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Health Assessment > Cardiovascular > Flashcards

Cardiovascular Flashcards

(86 cards)

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1
Q

How to inspect the anterior chest apical impulse

A

Look for pulsations at the fifth ICS at midclavicular line

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2
Q

Expected finding for anterior chest apical impulse

A

Usually not visible, but seen easier in children and thin adults

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3
Q

If apical impulse is visible in an adult it may indicate ___

A

Ventricular hypertrophy (enlargement)

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4
Q

If a person isn’t orientated x3, they may not be ____

A

Getting enough oxygen to their brain

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5
Q

How to assess jugular vein distention

A

Inspect patient’s neck when they are sitting up at least 45°, and have them turn their neck

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6
Q

Expected finding for jugular vein distention

A

JVD is seen while patient is laying flat, but not seen when patient sitting upright

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7
Q

If you can see JVD when the person is sitting upright, they could have ____

A

Right sided heart failure

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8
Q

Mucous membranes of the eyes

A

Conjunctiva

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9
Q

Lack of oxygen in the blood

A

Hypoxemia

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10
Q

If a patient has pallor, they could be ___

A

Anemic

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11
Q

If patient skin and nail color is as expected, they have ___ ___

A

Adequate perfusion

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12
Q

How to perform apical impulse palpation

A

Turn patient on left side, place hand at the fifth intercostal, ask client to exhale, and feel for pulsation

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13
Q

Expected finding for apical impulse palpation

Not palpable in ___ or ___ people

A

You may feel it.

Not palpable in obese people or in thick chest-walled people

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14
Q

If we are able to feel the apical impulse during palpation, it may indicate what?

A

Enlargement of the heart

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15
Q

Name 7 pulses locations

A

Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

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16
Q

In the interior of the elbow lies which pulse?

A

Brachial pulse

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17
Q

What pulse is in the wrist closest to the thumb? 

A

Radial

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18
Q

What pulse is behind the knee?

A

Popliteal, and you’re not supposed to be able to feel it

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19
Q

Where does the posterior tibial pulse lie?

A

Inner ankle

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20
Q

Where does the dorsalis pedis pulse lie?

A

On top of the foot

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21
Q

When we are unable to palpate a pulse, we use the __

A

Doppler

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22
Q

When we use a Doppler, we cannot document ___

A

Amplitude

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23
Q

Force or pumping action of the blood

A

Amplitude

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24
Q

What is the number scale for amplitude and each number’s meaning?

A

3+ increased, full, bounding
2+ expected
1+ weak, thread (shock)
0 absent

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25
Expected finding for amplitude?
2+
26
What does an amplitude of 1+ tell me about my patient?
May have low blood pressure due to low blood volume or a narrow vessel
27
What does an amplitude of +3 tell me about my patient? Name 4
Patient may have increased blood volume, is anxious, has a fever, or they just exercise
28
Electrical conduction system of the heart
Rhythm
29
What does rhythm tell me about my patient’s heart rate?
If the heart rate is irregular
30
An irregular heartbeat can be caused by ___ ___, most common is ___ ___
Cardiac dysrhythmias; atrial fibrillation
31
Normal heart rate for an adult is
60-100 BPM
32
____ is an expected finding for the pulse, because we have 2 of each
Symmetry
33
What does symmetry tell me about my patient?
Patient’s vessels (vasculature) are the same on both sides, no narrowing on either side
34
Use backside of hands when assessing persons ___ ___
Skin temperature
35
How do you assess if the patient has good skin turgor?
Lightly pinch skin below clavicle, hold for a few seconds and do a quick release
36
What is the expected finding for skin turgor? 
Skin should snap back to its normal position
37
Used to test hydration status
Skin turgor
38
Patient is dehydrated and has poor skin turgor
Tenting
39
Depressing nail bed until it turns white during capillary refill assessment
Blanching
40
What tells me the most distal corporal perfusion is intact?
Assessing capillary refill. Patient is getting circulation all the way down to their fingertips
41
Fluid that seeps into the tissues and doesn’t return to the cardiovascular space
Edema
42
Indicates heart failure or liver disease
Edema
43
Edema scale 1+ (name 4)
Less than 2 mm indentation, slight pitting, no visible swelling, disappears rapidly
44
Edema scale 2+ (name 2)
2-4 mm indentation, takes 10-15 seconds to disappear
45
Edema scale 3+ (name 2)
4-6 mm indentation, 1 or more minutes to disappear
46
Edema scale 4+ (name 3)
6-8 mm indentation, 2-5 minutes or more to go away, grossly distorted
47
An extreme case of edema where the legs are very large, shiny, and taught (tight)
Anasarca
48
Extremity inspection (SEE)
Skin color/condition, edema, equal
49
Extremity palpation (PEET)
Pain, edema, equal, temperature
50
Lack of hair growth indicates what?
Lack of arterial blood flow to the hair follicle
51
Lack of arterial blood flow to the hair follicle is caused by what?
Narrow blood vessel
52
When assessing carotid bruit, use ___ of stethoscope. Name 3 places to auscultate
Bell; Angle of jaw, mid cervical area, and base of neck just above clavicle
53
Expected finding when auscultating for a carotid bruit
NO swishing sounds You would either hear nothing for a feint heartbeat
54
If you hear a carotid bruit, this means there is a narrowing in the carotid artery, maybe due to ___
Atherosclerosis
55
Patient is not getting sufficient blood to the brain and they are more likely to have a stroke if they have ___
Atherosclerosis
56
___ is not needed for the cardiac assessment
Percussion
57
Name 5 heart sounds
Aortic, pulmonic, erb’s point, tricuspid, mitral
58
Use the ___ of the stethoscope when auscultating the heart
Diaphragm
59
Systole, lub, loudest at apex
S1
60
Diastole, dub, loudest at base
S2
61
S1 is the closure of which valves?
Mitral and tricuspid
62
S2 is the closure of which valves?
Aortic and pulmonary
63
If heart rhythm is irregular, there is a ___ problem
Conduction
64
If you hear a swish sound on S1 or S2, this could be a ___ problem 
Valve
65
Unexpected findings when auscultating apical heart rate? (Name 3)
Bradycardia, tachycardia, or an irregular heartbeat
66
Auscultating the apical heart rate tells us if our patient has ___, ___, or ___
Bradycardia, tachycardia, or an irregular heartbeat
67
Stage one hypertension in adults
130-139 / 80-89 mmHg
68
Stage two hypertension in adults
Anything greater or equal to 140 (systolic) / 90 (diastolic)
69
High blood pressure
Hypertension (HTN)
70
Low blood pressure
Hypotension
71
Heart rate for infant
120 to 160
72
Heart rate for a toddler
90 - 140
73
Heart rate of a preschooler
80 - 110
74
Heart rate of a school-aged child
75 - 100
75
Heart rate of an adolescent
60 - 90
76
Heart rate of an adult
60 - 100
77
The younger the age, the ____ that the heart rate is
Higher
78
The school- aged child is also close to the ___ and the ___ age categories
Adolescent; adult
79
The adolescent heart rate range is most like which other age category?
Adult
80
When auscultating the apical pulse, which point do you use?
Mitral or erb’s point, whichever you hear best
81
Name two reasons a nurse should take an apical pulse
When patient is on a cardiac medication and it is mandatory to listen to a full minute and when a patient has an irregular heart rate
82
Left to ___, right to ___
Limbs; respiratory
83
If left side of heart is not working, there is a back up in the ____
Respiratory system (crackles)
84
If right side of heart is not working, there is a back up in
The limbs (edema, JVD)
85
Bilateral edema indicates
Heart failure
86
Unilateral edema indicates
Lymph edema or a blood clot

Health Assessment (15 decks)

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