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Nursing Fundamentals > Heart/Vasular w/ Breast and Axillae: 5 Questions > Flashcards

Heart/Vasular w/ Breast and Axillae: 5 Questions Flashcards

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1
Q

Central pulses are located where?

A

Carotid and Femoral=Adults

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2
Q

Pediatric central pulses are located where?

A

Brachial pulse under two

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3
Q

What is Cyanosis?

A

Blue lips and lack of oxygen.

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4
Q

What is JVD associated with?

A

Some form of Heart Failure

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5
Q

Adults with under 60 bpm?

A

Bradycardia

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6
Q

Baby under 60 bpm?

A

Is bad

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7
Q

How to assess the heart?

A

Inspect, auscultate, palpate

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8
Q

Heart failure

A

Mechanical Failure

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9
Q

Veins take blood where?

A

To the heart

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10
Q

Arteries take blood where?

A

Pump blood away from the heart

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11
Q

Indications of a patient with low fluid?

A

Cracked lips, skin turgor, and tachycardia

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12
Q

Jugular Vein Distention indicates what ?

A

Right Sided Heart Failure

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13
Q

What elevation do you set the HOB?

A

45-90 degrees

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14
Q

What is located for inspection for the heart?

A

Louis/sternal notch

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15
Q

How do you visualize the JVD?

A

With a flashlight to create shadows that highlight the venous pulse.

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16
Q

Do patient gain weight from acute right sided heart failure?

A

Yes

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17
Q

How do you document the inspection of the JVD?

A

Located the highest point along the vein where you see pulsations.
Measure distance from the sternal notch to the highest point

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18
Q

How do you expand JVD?

A

Chest pain or pressure, SHOB, pallor skin, Bluish coloration of lips or fingernails, profuse sweating, tachypnea, loss of strength

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19
Q

ALL
PIGS
EAT
TOO
MUCH

A

Aortic
Pulmonic
Erb’s Point
Tricuspid
Miteral

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20
Q

Location of the Aortic ?

A

2nd Right Intercostal Space

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21
Q

Location of the Pulmonic ?

A

2nd Left Intercostal Space

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22
Q

Location of the Erb’s Point ?

A

3rd Left Intercostal Space, Left Sternal Border

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23
Q

Location of the Tricuspid?

A

4th Left Intercostal Space, Left Lower Sternal Border

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24
Q

Location of the Mitral Area/Apex?

A

5th Left Intercostal Space, Mid Clavicular Line (Point of Maximum Inpulse)

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25
What pattern do you use for Auscultation?
Zig Zag
26
What heart sounds does S3 sound like?
Ken-TUCK-y
27
Who can have S3 Heart Sounds?
Young Children Adults under the age 40 Trained athletes
28
What heart sound is irregular for patients over 50 and up?
S3 Heart Sounds
29
What positions do you do for auscultation technique?
Supine, HOB 30-45 degrees Left Side Lying Sitting up, leaning forward slightly
30
Small part of the stethoscope ?
High frequency
31
Biggest part of the stethoscope?
Low frequency
32
What heart sounds do "normal" patients have?
S1 and S2
33
What should you check for blood clot possibility ?
Extremity Pain
34
If a patient looks diaphoretic, what is indicated?
Patient is SHOB
35
What level is concerning when it comes to hemoglobin levels (HBG) ?
Less than 8 can be concern for blood loss
36
What is common with a fever?
Tachycardia
37
What happens when the temperature comes down?
The heart rate also comes down
38
What side is usually lung issues?
Right Side
39
Indicates poor oxygenation and can involve the heart.
Clubbed Fingers
40
What should you not do to a fistula?
Put a blood pressure cup over it
41
What is the sound of Bruit ?
Blowing and Swishing sound
42
Results from turbulent blood flow in the carotid artery.
Bruit
43
How many sides should assess for Bruit?
One side at a time
44
Where should you place the stethoscope for Bruit ?
Lightly place bell over carotid artery
45
What is a Fistula ?
Artery and a Vein
46
What is a Thrill ?
Abnormal vibration
47
Can you palpate a thrill?
No
48
What is normal when assessing carotid vessels ?
Regular Rhythm; equal on both sides. S1 and S2
49
What does Thrill cause ?
Valvular Heart Disease, Congenital Heart Defects, Anemia, and Narrowing of the Arteries
50
What sound does an S4 heart sound make?
Ten-ne-see or A Stiff Wall
51
What is the frequency of S4?
Low-pitched, around 30 Hz
52
Indicates increased resistance to filling of the left or right ventricle. Myocardial Attack or Ischemia
S4
53
What position do auscultate Pericardial Rubs?
Patient sits upright, slightly forward
54
What sounds do hear while auscultate pericardial rubs?
S1 and S2
55
What does Pericardial Rubs sound like ?
Scratchy, rubbing sound
56
How do you differentiate between pericardial and pleural rubs?
Ask patient to hold breath (If it persists then it is pericardial) (If it ceases then it is pleural)
57
What tool do you use for assessing the vascular system ?
Doppler
58
What is a Doppler?
An Ultrasonic vascular device to detect weak pulses
59
What is palpation is grading pulse 0?
Absent
60
What is palpation is grading pulse 1+?
Weak
61
What is palpation is grading pulse 2+?
Normal
62
What is palpation is grading pulse 3+?
Increased
63
What is palpation is grading pulse 4+?
Bounding
64
What finger do you use for palpating for a pulse?
Index and Middle Finger
65
Loss of blood flow arterially, Pain out of proportion
Compartment Syndrome
66
Petal Pulse at the top of the foot
Arterial Insufficiency
67
~Decreased or absent pulses ~Skin cool, pale, shiny, decreased hair in blue spots. ~Pain possible in legs and feet ~Thick Ridged Nails ~Toe Ulcerations ~Deep red when dependent
Arterial Insufficiency
68
~Pitting Edema ~Pulses present, difficult to find ~Ankle Ulcerations ~Cyanotic when dependent ~Brown pigmentation
Chronic Venous Insufficiency
69
What can edema indicate ?
Heart Failure or Venous Insufficiency Varicosities or Thrombophlebitis
70
How long do you press finger against swollen area of pitting edema?
5 seconds
71
Pressure forces fluid into underlying tissues.
Pitting Edema
72
What depths measured in centimeters in Pitting edema?
1+ 2+ 3+ 4+
73
Skin feels unusually tight and firm, shiny appears.
Non-pitting edema
74
"Stasis Ulcer" Results from Venous HTN Lower Leg
Venous Ulcers
75
~"Ischemic Ulcer" ~Result from progressive atherosclerosis or emboli ~Insufficient blood flow to tissue ~Blue Skin ~Distal ends of arterial branches
Arterial Ulcers
76
~Secondary to Lymphedema ~Capillaries are compressed by thickened tissues ~Occludes blood flow to skin
Lymphatic Ulcers
77
Why is the right side harder to percuss?
Because of the liver
78
~EKG (Usually 12 Lead) ~5 lead/3 lead/2 lead ~Troponin (MI with non-STEMI) ~Cardiac Stress Test ~Ultrasound
Cardiac Labs
79
~Blood Pressure Meds (Beta Blockers "olol" ~Diuretics (Fluid meds; Lasix, HCTZ) ~Anti-Dysthymia Meds (Amiodarone, Cardizem, Adenosine) ~Aspirin, Nitroglycerin, Oxygen,Morphine ~TNKase
Cardiac Medications
80
Circular Wedged Vertical Strip
Breast Palpations
81
Breast/Axillary Labs
CBC
82
Breast/Axillary Medications
Hormone Therapy (ifen/ifene)
83
What should you avoid with a neutropenic fever?
Avoid fresh fruits and vegetables

Nursing Fundamentals (10 decks)

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