Cardiovascular Assessment Abormalities Flashcards
(29 cards)
Inspect-JVD
- distended jugular veins at 45 deg
- elevated R atrial pressure, R-sided HF
central cyanosis
- blue/purple tinge (tongue, conjuctivae, inner surface of lips)
- inadequate O2 sat of arterial blood r/t to cardiac/pulm disorders (congenital)
peripheral cyanosis
- blue/purple in extremeties or in nose & ears
- reduced blood flow r/t to HF, vasoconstriction, cold environment
splinter hemorrhages
- small red/black streaks under fingernails
- infective endocarditis (infection of endocardium-cardiac valves)
clubbing of nails
- obliteration of normal angle between base of nail and skin
- endocarditis, congenital defects, prolonged O2 deficiency
color changes in extremities with postural change
- pallor, cyanosis, mottling of skin after limb elevation/ reddish- blue, glossy skin
- chronic decreased arterial perfusion
ulcers
- venous-necrotic, crater, lower leg- slow wound healing r/t poor venous return, varicose veins, incomp venous valves
- arterial- pale, ischemic , well-defined edges; toes, heals r/t arteriosclerosis, DM
varicose veins
- visible dilated , discolored, tortuous vessels in lower extremities
- incompetent valves
bounding pulse
- sharp, brisk pounding pulse
- r/t hyperkinetic state (anxiety, fever), anemia, hyperthyroidism
thready pulse
- weak, slowly rising easily obliterated by pressure
- r/t blood loss , decreased CO, aortic valve disease, peripheral arterial disease
irregular pulse
- irreg/irreg or reg/irreg, skipped beats
- r/t cardiac dysryhthmias
pulsus alternans
- reg rhythm, but strength varies with each beat
- r/t HF, cardiac tamponade
absent pulse
-r/t atherosclerosis, trauma, embolus
thrill pulse
- vibration of vessel or chest wall
- r/t aneurysm, aortic regurgitation, arteriovenous fistula
pulse rigidity
- stiffness or inflexibility of vessel wall
- r/t atherosclerosis
Tachycardia > 100bpm
exercise, anxiety, shock , need for increased output. hyperthyroidism
bradycardia < 60 bpm
-rest or sleeping, SA or AV node dmg, athletic conditioning, SE of drugs, hypothyroidism
displaced pt of maximal impulse, apical
-cardiac enlargement r/t CAD, HF, cardiomyopathy
unusually warm extremities(hands, feet)
-possible thyrotoxicosis
cold extremities
- external covering necessary comfort
- intermittent claudication, peripheral arterial disease, low CO, severe anemia
pitting edema of the LE or sacral area
-interruption of venous return to the heart, R-sided HF
abnormal capillary refill
- blanching of nail bed ≥2 sec
- possible reduced arterial capillary perfusion, anemia
asymmetry in limb circumference
- measurable swelling of limb
- venous thromboembolism, varicose veins, lymphedema
pulse deficit
- apical exceeds peripheral
- r/t cardaic dysrhythmias, atrial fibrillation/flutter or prenmature ventricular contractions
