Week 8 - CV, neck, peripheral and lympatic Flashcards
Common cardiovascular symptoms
Chest pain Dyspnea, orthopnea, cough Diaphoresis Fatigue Edema Nocturia Palpitations
How to check for jugular vein distention
Position the patient with the head of the bed at 30-45 degrees to promote visibility of the pulsation.
Right-side is easier to see.
S3 and S4 sounds are commonly called what?
Gallops
Extra heart sound: “venous hum”
continuous, rough, noisy, occasionally accomp by high-pitched whine. May be louder during diastole. It’s low pitched; heard best w/ bell above the medial third of the clavicles.
Normal in children and pregnancy
Extra heart sound: “Pericardial Friction Rub”
Triple phased during midsystole, mid-diastole, and presystole.
A scratchy, leathery quality results from the parietal and visceral pleura rubbing together.
Sound increases on leaning forward and during exhalation. It is heard best in the 3rd left ICS at the sternal border
Extra heart sound: “summation gallop”
This is the same as the quadruple rhythm but with a faster rate. S3/S4 merge to create one sound.
Extra heart sound: “opening snap”
Indicates mitral valve is mobile & “snaps” during early diastole from high atrial pressure, such as with mitral stenosis
Ejection click
results from an open valve that moves during the beg of systole. Heard best w/ diaphragm of stethoscope-audible over the aortic or pulmonic areas
How to describe intensity (loudness) of murmurs (6 levels)
I. Faint; heard only with special effort
II. Soft but readily detected
III. Prominent but not loud
IV. Loud; accompanied by thrill
V. Very loud
VI. Loud enough to be heard with stethoscope just removed from contact with the chest wall
edema can cause asymmetry in ONE upper exremity when issue is related to ______
Lymph
edema can cause asymmetry in ONE lower exremity when issue is related to ______
DVT
when edema is in BOTH lower extremities, issue could be related to
kidney or CHF
A radial pulse could be weak and thready due to
shock, PAD, hypothyroidism
A radial pulse could be bounding due to
exercise, anxiety, fever, anemia, hyperthyroidism
splenomegaly could be related to
mono, issues with RBC breaking down, sickle cell patients have blood that can clog up at lymphs
Sinus arrhythmia in children is a NORMAL finding - true/false
TRUE
what is sinus arrhythmia
HR changes on inspiration (faster) and expiration (slower)
In children, it is NORMAL to have extra S sounds (splitting, S1 S2) - true/false
TRUE
In older adults, why might extra S sounds be present?
Bc heart isn’t as compliant, doesn’t expand/contract like it used to
in older adults, atherosclerosis can lead to
poor perfusion
in older adults, a carotid or abdominal bruit can put organs such as _______ in danger
kidneys
Umbilicus appearance:
o Elevated could mean:
ascites, hernia
Umbilicus appearance:
-Sunken could mean:
this is seen in obese patients
Umbilicus appearance:
-Blueish could mean:
cullen sign (internal bleeding)
Umbilicus appearance:
-excessive abdominal aorta pulsations could mean:
if very bounding, could indicate aneurysm
In distension d/t FECES, auscultation is ______ and percussion is _______over feces
normal, dull
What is a “thrill”
palpable, rushing vibration from turbulent blood flow (cat purr) w/incompetent valves, pulmonary HTN, septal defects, AV fistula
the “lub” heart sound indicates:
S1, systole (AV valves (mitral and tricuspid) close)
the “dub” heart sound indicates:
S2, diastole (SL valves (pulmonic and aortic) close)
S3 heart sound
ventricular gallop “Ken-tuck-y”
Causes: fluid overload, HF
May be normal in youth and pregnancy
S4 heart sound
atrial gallop, “Ten-nes-see”
Causes: coronary artery disease
Point of maximal impulse (PMI)
area where the apical pulsation can be seen or palpated
The amount of blood that is ejected from the heart with each BEAT is the
stroke volume
cardiac output =
CO=HR x SV
congestion on the LEFT side of heart causes backup into
lungs
congestion on the RIGHT side of heart causes backup into
body, especially legs and feet
SOB, weight gain, and swollen ankles with decreased cardiac output are s/s of
heart failure
Volume in the right atrium at the end of diastole
preload (an indicator of how much blood will be forwarded to and ejected from the ventricles)
the amt of pressure the heart has to work against in the wall of the left ventricle during ejection
afterload
severe SOB and coughing at night (fluid coming to lungs from edematous legs)
paroxysmal nocturnal dyspnea (PND)
swooshing sound, audible when an artery is partially obstructed
bruit
hepatojugular reflux test is highly sensitve and specific for
right ventricular fluid overload
a “venous hum” heart sound is normal in what populations
This continuous sound is normal in children and during pregnancy.
S1 is louder heard at the _____of the heart
apex
S2 is louder heard at the ______ of the heart
base
S3 may be normal in who?
children, young adults, pregnant women in 3rd trimester
an innocent murmur is
a murmur w/ no underlying pathology. Occurs in systole (except for venous hum)
an abnormal murmur sounds like
a breath sound or is harsh or blowing. Signifies regurgitation and pathology.
what is “Coarctation of the aorta”
congenital narrowing of aorta (high arm BP and low thigh BP d/t restricted blood supply below the narrowing)
What is jugular vein distension indicative of?
heart failure (most common), fluid overload, tricuspid regurgitation
Orthopnea
SOB when lying flat
For carotid pulses and bruits, use _____ of stethescope
bell
Precordium inspection: heaves/lifts/pulsations indicate
cardiac hypertrophy of R or L ventricle. The enlarged heart displaces the PMI laterally and inferiorly.
A “heave” or “lift” seen on the precordium appears as
a forceful thrusting on the chest and is the result of an enlarged ventricle.
A right ventricular heave is observed at the lower left sternal border; a left ventricular heave is observed at the apex.”
Erb’s point is where the valves usually are _______ audible; this site is esp effective for taking the _______pulse
equally
Apical (but most effective is the mitral area for the apical)
For heart auscultation in obese or barrel chested PTs, auscultation is improved by:
placing the PT in the left lateral decubitus position or asking the PT to lean forward (this displaces heart more closely to thoracic wall)
The difference btwn radial and apical pulse is known as the
pulse deficit
Pulse deficits are common in:
people with irregular heart beats (e.g. with aFib)
aortic stenosis
thickening of aortic valve leaflets with age (common in older adults–can cause systolic murmurs)
The most common diastolic murmurs are
aortic insufficiency and mitral stenosis
The semilunar valves separate the ______ from the ______
The semilunar valves separate the ventricles from the arteries
The component of the conduction system referred to as the pacemaker of the heart is the:
sinoatrial (SA) node
During an assessment of a healthy adult, where would the nurse expect to palpate the apical pulse?
Fifth left intercostal space at the midclavicular line
During a cardiovascular assessment, the nurse knows that a “thrill” is:
vibration that is palpable (like a cat’s purr)
Claudication is caused by:
arterial insufficiency/obstruction of arteries
pain brought on by exertion and relieved by rest is called
intermittent claudication
How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient?
1+
Pacemakers are on which side?
can be on L or R side
What are normal heart variations in children?
- sinus arrhythmia (very common and normal)
- spliting S1 and S2 (common in young children)
Cardiac output
amount of blood pumped each minute (typically 4-8 L at rest)
The nurse is planning discharge teaching for a PT diagnosed with PVD. It is MOST important for the nurse to address which of the following?
- the PT drinks socially
- the PT walks 2 miles/day
- the PT takes vitamins daily
- the PT smokes heavily
-the PT smokes heavily (a predisposing factor for arterial PVD)
The nurse knows which of the following occurrences initiates the changes that take place in the newborn circulatory system after birth?
the infant begins pulmonary ventilation
The nurse knows that a cyanotic congenital heart defect is associated w/ which symptoms?
finger clubbing, costal retractions, and failure to thrive
If taking BP on a PT’s lower extremities, place PT in what position?
position PT on their abdomen, place BP cuff around thigh, use stethoscope at popliteal artery
Average BP for a newborn
60-80/40-50mmHg
Average BP for child 1-4 yrs
90-99/60-65mmHg
The nurse cares for the PT being evaluated for aortic stenosis. Which assessment data will the nurse expect to find?
- dyspnea
- HTN
- cyanosis
- respiratory acidosis
dyspnea
clients experiencing aortic stenosis are at risk for
fluid volume excess as a result of heart failure
In aortic stenosis, the PT often experiences:
decreased BP, decreased pulse pressure, and has a S4 murmur
pulse pressure
difference between systolic and diastolic pressure readings
characteristic signs of HF include
tachycardia and increased respirations
heart failure PTs are most comfortable in what position?
upright (not laying flat), high fowler’s
The nurse cares for a PT diagnosed w/ a recent MI. Which assessment data might alert the nurse that the client is developing left ventricular failure?
pulmonary crackles
The nurse recognizes that the type of edema r/t cardiac failure is usually
dependent edema (seen w/ R-sided heart failure and usually noted in the ankles and in the sacral region)
When auscultating heart sounds in the aortic area, where should the nurse place the stethoscope?
To the right of the sternum near the manubrium (aortic area)
A nurse cares for a PT with an AAA. Which post-op intervention should the nurse include in the PT’s plan of care?
perform circulation checks distal to the graft
- do NOT elevate legs–keep PT flat in bed w/o flexion of extremities to avoid compression of lower extremity arteries
- low fat diet is indicated for post-op AAA patients
The nurse understands that the MOST important factor to maintain adequate circulation is
blood volume
The nurse cares for a PT with arterial insufficiency. Which s/s should the nurse expect when obtaining the client’s Hx?
pain in hip, buttock, thighs, or calf.
Classic symptom of arterial disease is intermittent claudication
The nurse understands that the cause of essential HTN is
not known
The nurse knows that the priority observation for the post-op AAA patient is:
a. BP reading
b. blood chemistry lab report
c. intake/output measurements
d. rectal temp reading
-BP reading (patency of the aortic graft can be assured w/ maintenance of an adequate systemic BP
True/false: elevation of the leg exacerbates pain of arterial insufficiency
true
Which short term goal is appropriate for a PT with impaired arterial circulation in lower extremities?
The PT will report freedom from muscle pain while walking in the room
Over which anatomical area on the chest wall should the nurse place the stethoscope to MOST clearly auscultate the apical pulse?
mitral area
what are the 6 P’s (signs of acute arterial occlusion)
Pain, paresthesia, paralysis, poikilothermia, pallor, and pulselessness
A difference of more than ________in BP in limbs may indicate arterial disease
10 mmHg
Allen test assesses for
patency of the collateral circulation of the hands (perform PRIOR to radial cannulation)
An ankle-brachial index (ABI) of _______ indicates arterial insufficiency
0.90 or less
