heart and peripheral vascular system Flashcards

1
Q

heart purpose for pumping blood

A

transport oxygen
transport nutrients
carries metabolic waste products to kidneys and lungs

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2
Q

how does the cardiovascular system adjust to changing demands for blood/ perfusion?

A

constricting or dilating blood vessels

altering cardiac output

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3
Q

perfusion

A

the mechanism that either allow or prevent oxygenated blood to reach parts of the body
- all tissues require perfusion of oxygenated blood

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4
Q

what to inspect in a heart assessment

A
  • general appearance
  • skin color
  • nails (capillary refill)
  • edema
  • veins, jugular veins
  • moisture in the axillae and in skin folds
  • diaphoresis
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5
Q

what does brown pigmentation change with

A

poor circulation

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6
Q

the best place to detect color change

A
palms
soles of feet
lips
tongue
nail beds
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7
Q

pallor

A

loss of color
black skin tones: change to gray
location: face, conjunctivae, nail beds, palms, lips, buccal mucosa
Indication: could be a problem with the heart

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8
Q

cyanosis

A

bluish
darker skin tones: palms and soles
location: nail beds, lips, mouth mucosa, skin, palms
indication: hypoxia ( no oxygen in blood) or a problem with circulation due to the heart

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9
Q

what does capillary refill asses

A

circulation
apply firm pressure to nail bed to blanch it
result in brisk return of color

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10
Q

results from aging changes or blood vessel damage

A

spider angioma

cherry angioma

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11
Q

spider angioma

A

red center with radiating red legs

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12
Q

cherry angioma

A

red, round, possibly raised

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13
Q

spider vein

A

bluish, spider-shaped or linear, up to several inches in size

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14
Q

petechiae/purpura

A

deep reddish, purple, flat, petechiae

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15
Q

ecchymosis

A

purple fading to green or yellow over time, variable in size, flat

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16
Q

hematoma

A

raised ecchymosis

- collection of blood right underskin

17
Q

jugular veins

A

inspect when bed is at a 30-40 degree angle

normal: no neck vein distension

18
Q

insepct anterior chest wall for

A

contour, pulsations, and retractions

19
Q

aplical pulse

A

visible to the left midclavicular line at the fourth or fifth intercostal space
- on a woman have them displace their breast tissue

20
Q

edema

A

accumulation of fluid in the tissues

  • causes swelling with the skin appearing shiny and tight
  • asses for discoloration, location, and tenderness
21
Q

edema rating

A

1+ trace, 2 mm, rapid skin response
2+ mild, 4mm, 10- to 15- second skin response
3+ moderate, 6mm prolonged skin response
4+ severe, 8mm prolonged skin response

22
Q

pulses should be

A

symmetrical in quality and quantity on both sides of the body @ the same location

23
Q

what do you asses to evaluate the adequacy of the vascular system

A

strength and equality

24
Q

grade scale for pulsations

A
0 absent, unable to palpate
1+ diminished, weaker than expected
2+ brisk expected
3+ increased strong
4+ full volume bounding
25
what will be documented related to pulses
number, quality, strength, location
26
what do thicker more rigid peripheral blood vessel walls lead to
poor peripheral circulation, higher systolic BP
27
when listening to heart the nurse hears
heart sounds lub/dub S1, S2
28
what does the beginning of ventricular systole (contraction) produce
s1 sound | - place diaphragm of the stethoscope at the apex to hear "lub"
29
beginning of ventricular diastole (relaxation) produces
s2 "dub"
30
3 ways to listen to heart sounds
sitting, leaning forward lying supine turned towards the left side
31
when are murmurs audible
when blood in the heart is increased or its flow is impeded or altered
32
thrills
palpable vibration that can accompany murmurs
33
bruits
blowing or swishing sounds that indicate obstructed peripheral blood flow
34
use the bell to assess
murmurs thrills bruits