TEST 2 Flashcards
1
Q
CULTURE AND GENETICS
NUTRITION
A
Foods Choices and Eating Patterns are Heavily Influenced by Culture
Newly Arrive Immigrants May be at Increased Nutritional Risk
Religious Dietary Practices- Can affect food choices and eating patterns
2
Q
types of nutrition screenings
A
- Admission nutrition screening tool
*If risk is identified complete comprehensive nutritional assessment - 24 hour diet recall
- Food frequency
- Food diaries
- Direct observation
3
Q
2015-2020 dietary guidelines for americans
A
*Make small shifts in your daily eating habits to improve health over the long run
*Healthy eating patterns along with regular physical activity has been shown to help people reach and maintain good health and reduce chronic disease risk
4
Q
healthy eating patterns focus on
A
◦ Variety of vegetables
◦ Fruits, especially whole fruits.
◦ Grains, primarily whole grains
.◦ Fat-free or low fat dairy
◦ Variety of Protiens
◦ Limit Salt, Saturated and Trans Fats, and Added Sugars
5
Q
health history questions
nutritional subjective data
A
- Eating patterns
- Usual weight
- Changes in appetite, taste, smell, chewing, swallowing
- Recent surgery, trauma, burns, infections
- Chronic illness
- Vomiting, diarrhea, constipation
- Food allergies
6
Q
health history questions
nutritional subjective data- continued
A
- Medications and/or nutritional supplements
- Self-care behaviors
- Alcohol or illegal drug use
- Exercise and activity patterns
- Family history
7
Q
clinical signs of malnutrition
A
◦ Skin- Should be smooth, no bruises, rashes, or flaking
◦ Hair- Should be shiny, scalp intact and without lesions, does not fall out easily
◦ Eyes- corneas clear & shiny, membranes pink and moist, no bumps or sores
◦ Lips- Should be smooth, not chapped, cracked, or swollen
◦ Tongue- Should be red, not swollen or abnormally smooth, no lesions
8
Q
clinical signs of malnutrition
continued
A
Gums- Should be pink and moist, no swelling or bleeding
◦ Nails- Smooth, pink
◦ MS- Erect posture, good muscle tone, ambulates without pain
◦ Neuro- Appropriate affect, normal reflexes
9
Q
derived weight measures
A
- Body weight as percent of ideal bodyweight
- Percent usual body weight-
- Recent weight change
10
Q
body mass index
A
marker of optimal weight for height and indicator for obesity & protein-calorie malnutrition
BMI = weight (kg)/height (m)2
or
BMI = weight (lb)/height (inches)2 x 703
11
Q
bmi ranges
A
under 18.5 Underweight
18.5-24.9 Normal weight
25.0-29.9 Overweight
30.0-39.9 Obesity
>40 Extreme obesity
12
Q
Assessment of body fat distribution and indications of health risks
A
Waist-to-hip ratio = waist circumference / hip circumference
Indication of upper body obesity “android”:
Ratio of > 1.0 in men or > 0.8 in women* Increased risk for obesity-related diseases & early mortality
13
Q
total arm span or total arm length
A
roughly equal to height
14
Q
what do hemoglobin and hematocrit show
A
indicators of iron status
15
Q
what are the indicators of cardiovascular risks
A
cholesterol with triglycerides, ldl, and hdl levels
16
Q
malnutrition classifications
A
obesity
marasmus
kwashiorkor
17
Q
marasmus
A
protein calorie malnutrition
18
Q
kwashiorkor
A
protein malnutrition
19
Q
layers of skin
A
epidermis
dermis
subcutaneous
20
Q
epidermis
A
- Replaced every 4 weeks
◦ Outermost layer; thin but tough; houses keratin
21
Q
dermis
A
◦ Inner supportive layer; consists of connective tissue (collagen); contains elastic tissue
◦ Nerves, sensory receptors, blood vessels, & lymphatics housed here
22
Q
subcutaneous
A
◦ Aka Adipose tissue
◦ Stores fat for energy, provider insulation for temp control, and cushions/protects
23
Q
FUNCTIONS OF SKIN
A
protection
perception
temp regulation
identification
communication
wound repair
absorption/excretion
vitamin d production
24
Q
protection
functions of skin
A
◦ Thermal
◦ Physical
◦ Chemical
◦ UV
◦ Microorganisms
25
perception
| functions of skin
Houses neurosensory end-organs for touch, pain, temperature, and pressure
26
temp regulation
| functions of skin
Heat dissipation thru sweat glands
Heat storage thru subcutaneous tissue
27
identification
| functions of skin
Facial characteristics, hair, skin color, & fingerprints
28
communication
| functions of skin
blushing, blanching, expressions
29
vitamin d production
| functions of skin
uv light converts cholesterol into vitamin d
30
infants
| developmental care- hair/skin/nails
Lanugo- Fine hair
Vernix caseosa- white, cheesy substance
High risk for fluid loss
Poor thermal regulation
31
pregnancy
| developmental care - hair/skin/nails
◦ Increased sweat and sebaceous glands
◦ Increased fat deposits primarily in buttocks and hips
◦ Linea nigra- mid-abdominal dark line
◦ Melasma (Chloasma)- increased pigment in face
◦Striae gravidarum- aka stretch marks (abd, thighs, breasts)
32
older adults
| developmental care - hair/skin/nails
◦ Thin epidermis, ↓ elasticity, ↑ dryness
◦ Less protective mechanisms (functioning decreases)
33
melanin
ncreased in Indians and African Americans therefore increased protection from UV rays. Caucasians 20x more likely to develop melanoma (deadliest form of skin cancer)
34
keloids
scars with increased height and width
35
pigmentary disorders
increased incidence of pigment problems in african americans
36
pseudofolliculitis
razor burn/bumps, ingrown hairs
37
melasma
mask of pregnancy
patchy tan to dark brown discoloration of face
38
subjective data
| hair, skin, nails
Hx skin dz
pigmentation
mole (size color) = ABCDE
Excessive dryness (xerosis) or moisture (seborrhea)
Pruritis
Bruising
39
subjective data
| hair/skin/nails (cont.)
Rash, lesion
Meds
Hair loss
Nails
Environmental/ occupational exposures noteworthy
Self-care behaviors
40
what should you assess first
| hair/skin/nails
hands
41
what areas must you not forget to assess
| hair/skin/nails
intertriginous areas (skin folds)
42
color
| objective assessment of hair/skin/nails
nevus
pallor
erythema
cyanosis
juandice
43
nevus
mole
abcde
44
pallor
white, anemia, shock, arterial insufficiency, anxiety, fear, exposure to cold, cigarette smoke
45
erythema
redness, fever, local inflammation, blushing
46
cyanosis
blue, low perfusion, unoxygenated hgb
47
juandice
yellow, excessive bilirubin, sclera and hard and soft palate of mouth
48
in darker skinned people, where may you be better able to assess color changes
tongue, buccal mucosa, palpebral conjunctiva, sclera
49
external variable influencing skin color
emotions
environment
physical
50
emotions
| influence on skin color
◦ Fear, anger= peripheral vasoconstriction= pallor
◦ Embarrassment- facial/neck flushing= erythema
51
environment
| influence on skin color
◦ Hot room= vasodilation= erythema
◦ Chilly/air conditioned room= vasoconstriction= pallor
◦ Cigarette smoke= vasoconstriction= pallor
52
physical
| influence on skin color
◦ Prolonged elevation- decreased arterial perfusion= pallor, cool
◦ Dependent position= venous pooling = redness, warmth, distended veins
◦ Immobilization = slowed circulation = pallor, coolness, prolonged capillary filling time
53
temperature
| objective assessment of hair/skin/nails
◦ Dorsa
◦ Hypothermia
◦ Hyperthermia
54
moisture
| objective assessment of hair/skin/nails
◦ Dry vs. diaphoretic
◦ Dehydration- locations: mucous membranes, lips, sunken fontanel, turgor
55
texture
| objective assessment of hair/skin/nails
smooth, firm, even surface
56
thickness
| objective assessment of hair/skin/nails
◦ Mostly thin
◦ Some callus (overgrowth of epidermis)- normal on palms & soles
57
edema
| objective assessment of hair/skin/nails
accumulation of fluid in intercellular space
Most evident dependent parts of body (feet, ankles, sacral)
58
how to check for edema
place thumbs on ankle malleous or tibia to check
59
anasarca
generalized edema
60
edema scale
1+ = mild, 2+ = moderate, 3+ = deep, 4+ = very deep
61
mobility and turgor
| objective assessment of hair/skin/nails
Mobility= how easy the skin rises when pinched
Turgor= how quickly returns to its place when released
◦ Mobility + Turgor= Elasticity
62
how to check mobility and turgor
| objective assessment of hair/skin/nails
Pinch up a large fold of skin on the anterior chest under the clavicle
63
what are some causes of poor turgor
dehydration, weight loss, change with aging (decreased elasticity)
64
scleroderma
hard skin
chronic connective tissue disorder
makes it hard to asses turgor
65
vascularity or bruising
| objective assessment of hair/skin/nails
cherry angioma
ecchymosis
tattoo marks
bruising at venous access points (drug use)
66
cherry angioma
bright red dots
67
ecchymosis
bruising
68
lesions
| objective assessment of hair/skin/nails
primary vs secondary
69
hair
| objective assessment of hair/skin/nails
Color-Common to gray as we age
*Texture-Shiny and soft
*Distribution-Lesions
70
profile of the nail bed
| objective assessment of nails
◦ 160° = Normal
◦ < 160° = Curved
◦ 180° = Early clubbing- Caused by disrupted pulmonary circulation
◦ > 180°= Late clubbing
◦ Nail base feels spongy (feel your nail bases
71
consistency
| objective assessment of nails
◦ Smooth, regular, firm to palpation
◦ Pits, transverse grooves, or lines= nutrient deficiency or may accompany some acute illnesses
72
color
| objective assessment of nails
even
pink
cyanosis
brown linear streaks- suddent onset could be melanoma
73
capillary refill
| objective assessment of nails
◦ < 3 seconds= normal
◦ > 3 seconds = sluggish refill = CV or pulm prob
74
What are the skin changes that accompany pregnancy/newborn time period?
Pregnancy: Linea nigra, melasma, striae gravidarum, increase in sweat glands, redistribution of fat
Newborn- lanugo, vernix caseosa, very thin skin, more permeable
75
What are the skin changes that occur with an older adult?
oses elasticity, thinning of the epidermis, wrinkles become more noticeable, fewer sweat/sebaceous glands leads to dryer skin, less collagen makes skin more prone to tearing
* Palpate for temperature and texture
76
nevus assessment
* ABCDEF
* A-Asymmetry
* B-Border Irregularity
* C-Color Variation
* D-Diameter
* E-Elevation or Evolution
* F-Funny looking
77
what tool is used to assess risk of skin breakdown in patients
braden scale
78
This can slow as you age, contributes to constipation and indigestion
GI MOTILITY
79
Dry flaky skin; dull dry hair; dry cracking lips
MALNUTRITION
79
Cholesterol that is bad
LDL
80
Factor that has a huge impact on food choices/accessibility
FINANCES
81
A form of malnutrition (imbalanced nutrition) arising from excessive intake, leading to accumulation of body fat that impairs health
OVERNUTRITION
82
Lack of proper nutrition, caused by not having enough food or not eating enough food containing substances necessary for growth and health
UNDERNUTRITION
83
This value is derived by looking at both height and weight
BMI
84
This nutrition status means that a person is receiving and using the essential nutrients to maintain health and well-being at the highest possible level
OPTIMAL
85
his tool can be used to help understand what a patient's dietary habits are like over a 3 day period
DIARY
86
This varies from people group to people group, but always influences diet
CULTURE
87
HgbA1C is a chronic indicator of this disease process
DIABETES
88
cholesterol that is considered "good"
HDL
89
STERNUM
consists of 3 parts:
manubrium
body
xiphoid process
90
ribs
12 pair
1-7 attached to sternum
8-10 attached to costral margin
11-12 floatin
91
thoracic vertebra
12
92
diaphragm
a musculotendinous septum
93
anterior thoracic landmarks
suprasternal notch
sternum
manubriosternal angle (angle of louis)
intercostal spaces
costal angle
94
posterior thoracic landmarks
vertebra prominens
spinous processes
inferior border of scapula
twelfth rib
95
reference lines
midsternal
midclavicular
anterior axillary
mid axillary
posterior axillary
scapular
vertebral
96
mediastinum
| thoracic cavity
middle section
contains esophagus, trachea, heart and great vessels
97
pleural cavities
| thoracic cavity
located on either side of the mediastinum
98
lungs
| thoracic cavity
right lung: RUL, RML, RLL
left lung: LUL, LLL (no middle lobe)
99
pleurae
| thoracic cavity
visceral and parietal
100
where is the trachea located
in the thoracic cavity
101
bronchial tree
| thoracic cavity
right is wider and more vertical
trachea and bronchi transport air
dead space- contains air not involved in gas exchange
102
acinus
| thoracic cavity
functional respiratory unit
includes bronchioles, alveolar ducts, alveolar sacs, and alveoli
103
the anterior chest contains what
mostly the upper and middle lobe, very little lower lobe and that the apex extends 3-4cm above the inner third of the clavicles.
104
what does the posterior chest contain
almost all of the lower lobe
105
what are the functions of respiration
1. Supplying oxygen
2. Removing carbon dioxide
3. Maintaining acid-base balance
4. Maintaining heat exchange
106
hypoventilation
slow, shallow breathing
increased CO2 in the blood
107
hyperventilation
deep, rapid breathing
decreased co2 in the blood
108
respiration control
respiration center in the brain stem is the pons and medulla
109
what is the normal stimulus for breathing
co2, not o2 like you would think
110
infants and children
| respiration developmental considerations
- Foramen ovale closes after birth
- Ductus arteriosus closes hours later
- Smaller & immature resp. system = ↑ of respiratory infections
111
pregnant female
| respiration developmental considerations
effects of increased estrogen
- Elevation of diaphragm (elevates 4cm ↓ vertical diameter of thoracic cage
112
explain the relaxation of the rib cage in a pregnant female and its relation to respiration
circumference is increased by 2cm with the widening of the costal margin
there is an increaased tidal volume with deeper breathing that may be mistaken as dyspnea
113
apgar scoring system
used for the newborn’s initial respiratory assessment
* 1-minute score of 7-10: indicates newborn in good condition
* 1-minute score of 3-6: indicates moderately depressed newborn requiring more resuscitation
* 1-minute 0-2: indicates severely depressed newborn requiring full resuscitation
114
older adults
| respiratory considerations
- Decreased mobility of thorax from calcified cartilage
- Decreased muscle strength
- Decreased elasticity of lungs
- Decreased vital capacity (max exhalation)
- Increased residual volume (what’s left over after exhale)
115
older adults
| respiratory considerations (cont)
- Histologic changes with loss of intra
- lveolarseptum & number of alveoli leading to decreased surface area for gas exchange
- Increased risk of dyspnea & pulmonary complications
116
asthma
most common chronic disease in childhood
117
tuberculosis TB
higher incidence in asian americans
peaks in the first 2 months immigrating to the us
118
cough
| respiratory subjective data
sudden or gradual onset, frequency, duration, dry or productive with sputum (color & consistency), hemoptysis, congested, precipitating factors, associated symptoms, any treatment
119
shortness of breath
| respiratory subject data
orthopnea, paroxysmal nocturnal dyspnea, diaphoresis, cyanosis, precipitating factors, any effect on ADLs, increasing, the same or getting better
120
smoking history
| respiratory subjective data
type
packs per day
note in packs per year
121
other respiratory subjective data
Hx
respiratory infections
asthma
122
environmental exposure
| respiratory subjective data
works in factory, chemical plant, coal mine, farming, in heavy traffic area, x-ray exposure
123
self care behaviors
| respiratory subjective data
last TB test, chest x-ray, pneumonia or flu immunizations
124
children
| subjective respiratory assessment
◦ 4-6 URI per year is acceptable in early childhood
◦ Consider new foods or formula as possible allergens
◦ Child proofing the home to px inhalation/consumption of poisons
◦ Environmental smoke increases risk of ear and respiratory infections
125
older adults
| respiratory subjective data
◦ Decreased functional reserve- takes them longer to recover from activity
◦ Decreased vital capacity
◦ Decreased surface area for gas exchange
◦ Pain response is reduced in older adults- this is a risk factor
126
respiratory inspection
| objective data
thoracic cage
respirations
skin color/condition
position of the person
facial expression
loc
127
inspection of the thoracic cage
| respiratory objective data
for shape and configuration, compare anteroposterior to the transverse diameter (normal ratio is 1:2 or 5:7)
* Abnormal finding: barrel chest (anteroposterior = transverse diameter)
128
respirations
| respiratory objective data
assess rate, depth, effort, use of accessory muscles
129
normal respiratory pattern of adult
10-20 breaths per minute, even & unlabored, depth of 500-800ml
130
sigh
| respiratory pattern
punctuate the normal breathing pattern; if frequent, can result in hyperventilation & dizziness
131
tachypnea
rapid, shallow breathing
132
bradypnea
slow, regular breathing
133
chyne-strokes respirations
cyclic gradually wax and wane in regular pattern with periods of apnea
134
hyperventilation
increase in rate and depth
135
hypoventilation
irregular shallow pattern
136
biot's respirations
irregular pattern with periods of apnea
137
chronic obstructive breathing
normal inspiration with prolonged expiration (from increased airway resistance)
138
Barrel chest
anteroposterior-to-transverse diameter is equal (with aging, emphysema, asthma)
139
pectus excavatum
funnel chest
sunken sternum
140
pectus carinatum
pigeon breast
forward protrusion of sternum
141
scoliosis
lateral s shaped curvature of the thoracic and lumbar spine
142
kyphosis
exaggerated posterior curvature of the thoracic spine
humpback
143
palpate for symmetric expansion of the thorax
note any lag in expansion
* Abnormal finding: unequal chest expansion (present with atelectasis, pneumonia, trauma, or pneumothorax)
144
palpate the thorax for tactile fremitus
is a palpable vibration, produced by the larynx and transmitted through patent bronchi & lung tissue to the chest wall
145
decreased fremitis
occurs with any obstruction of vibration (obstructed bronchus, pleural effusion, pneumothorax or emphysema)
146
increased fremitus
occurs with compression or consolidataion of lung tissue
indicates increased density of lung tissue (must have a patent bronchus)
147
palpation of the entire chest wall
or tenderness, skin temperature, moisture, superficial lumps, crepitus (indicates air escaping from the lung into the subcutaneous tissue)
148
pleural friction fremitus
esults from inflammation of the pleura (visceral or parietal) with decrease in the normal lubricating fluid
149
percussion of the lung fields
percuss in the intercostal spaces, starting at apices, compare from side to side moving down the lung region
* Normal finding: resonance for adult lung; hyperresonance for the young child
150
what does hyperresonance over an adult lung indicate
emphysema or pneumothorax
151
diaphragmatic excursion
maps out the lower lung border in inspiration and expiration by use of percussion
* Difference between inspiration and expiration should be equal bilaterally and be 3-5cm (can be 7- 8 in a physically fit person)
152
auscultate breath sounds
listen to full breath at each location using the diaphragm of the stethoscope
* Compare from side-to-side
153
characteristics of normal breath sounds
bronchial (tracheal)- at the trachea
bronchovesicular - at the sternum
vesicular- outside of chest
154
adventitious breath sounds
crackles
rhonchi
friction rub
wheezes
155
crackles
high pitched popping sounds
156
rhonchi
long low pitched, coarse, gurgling sounds
157
friction rub
harsh grating sound
158
wheezes
high pitched whistling sound
159
bronchophony
have pt. say “99” (increased transmission of voice sound with increased lungd ensity or consolidation)
160
egophony
have pt. say “ee” (sounds like “a” with consolidation)
161
whispered pectoriloquy
have pt. whisper a phase (one, two, three) normally faint, muffled increased with consolidation)
162
pulse oximeter
noninvasive procedure
assesses arterial o2 saturation
normal 97-98%
163
12 or 6 minute distance walk
12 md
- measures functional status of O2 arterial saturation
- used for patients with chronic obstructive pulmonary disease (COPD)
164
common respiratory disorders
atelectasis
bronchitis
copd
asthma (restrictive airway disease)
pneumothorax
pulmonary embolism
pleural effusion
heart failure
165
cardiovascular system
heart and blood vessels
166
2 circulatory types in the body
pulmonary circulation
systemic circulation
167
the heart is really what
2 pumps, each consisting of an atrium and a ventricle
168
precordium
region on the anterior chest, over the heart and great vessels
169
mediastinum
the middle third of the thoracic cavity between the lungs, contains the heart and the great vessels
170
base of the heart
top
171
apex of the heart
bottom
172
great vessels
superior/inferior vena cava
aorta
pulmonary veins
pulmonary artery
173
4 chambers of the heart
Right atrium
right ventricle
Left atrium
Left ventricle
174
4 valves of the heart
- Two atrioventricular (AV) valves:
* Tricuspid
* Mitral
- Two semilunar valves:
* Pulmonic valve
* Aortic valve
175
s1 is the sound of the closure of what
tricuspid and bicuspid
176
s2 is the sound of the closure of what
pulmonic and aortic valves
177
p wave
depolarization of the atria
178
pr interval
from start of p wave to beginning of qrs
179
qrs
depolarization of ventricles
180
t wave
repolarization of ventricles
181
qt interval
electrical systole of the ventricles
182
effect of respiration of the heart
inspiration -->decreased intrathoracic pressure -->increased venous return to right side of heart-->increased right ventricular stroke volume-->aortic valve closes earlier--> normal split S2
183
moRe to the Right heart, Less to the Left
more venous return to the right side on inspiration
184
s3
third heart sound
“ventricular gallop”
- caused by ventricles being resistant to filling during the rapid filling phase (systolic heart failure)
- heard right after S2, sounds like “Kentucky”
185
s4
fourth heart sound
“atrial gallop”
- present at the end of diastole with resistance of the ventricles to filling (diastolic heart failure)
- sounds like “Tennessee”
186
murmurs
* Result from turbulent blood flow caused by:
- Increased velocity
- Decreased viscosity
- Structural defects
187
heart sounds are descibed by
Frequency or pitch
Intensity or loudness
Duration (early, late, pan (continuous))
Timing (systolic or diastolic)
188
when to use the bell side of the stethoscope
Use the bell for soft, low pitched sounds
(murmurs & extra heart sounds)
189
cardiac output
is 4-6L/min
* Stroke volume X heart rate = CO
190
preload
venous return, the volume of blood in the ventricle at the end of diastole
* Amount of stretch prior to systole
* Frank-Starling law: the greater the stretch, the stronger the cardiac contraction
191
afterload
* The resistance the heart has to pump against
192
carotid arteries
lies between the trachea and the sternomastoid muscle (medial to this muscle)
193
jugular venous pulse and pressure
reflect the filling pressure & volume in the right side of heart
194
internal jugular
larger, located deep & medial to the sternomastoid, generally not visible, diffuse pulsation may be visible in the sternal notch muscle in supine position
195
external jugular
more superficial, located lateral to the sternomastoid muscle
196
fetal circulation is rerouted to bypass what
the nonfunctional lungs
197
foramen ovale
opening in the atrial septum
closes within 1st hour after birth
198
ductus arteriosus
opening between the aorta and pulmonary artery
closes within 10-15 hrs after birth
199
describe an infants heart
Heart more horizontal & apex is higher, located at 4th left intercostal space
200
cardiovascular considerations of a pregnant female
- Increased blood volume by 30%-40%
- Increased stroke volume & cardiac output
- Increased heart rate
201
when is the arterial blood pressure decreased to its lowest point during pregnancy
during the 2nd trimester
202
hemodynamic changes
| older adults considerations in the vascular system
- Increased systolic BP
- Left ventricule (wall) thickens
- Heart rate: unchanged at rest
- Cardiac output: unchanged at rest
* Decreased adaptation to exercise
203
dysrhythmias
| older adult considerations for the vascular system
supraventricular & ventricular
Increased cardiovascular diseases
204
CAD
CVD (Cardiovascular Disease) is the number one cause of death worldwide
* influenced by genetics and lifestyle factors
*CAD-Coronary Artery Disease
205
risk factors of cad
Hypertension
Smoking
Serum cholesterol
Overweight/Obesity
Physical inactivity
Diabetes
Age
Poor nutrition
Family history of premature CAD
206
chest pain or tightness
| vascular subjective data
note onset, character (crushing, stabbing, burning, duration, precipitating factors (activity, emotional upset), associated symptoms (sweating, pallor, SOB, heart beat skipping, N & V, diaphoresis), radiates, relieved by rest or nitroglycerin
* Need to differentiate between cardiac and non cardiac origin!
* “Clenched fist” characteristic sign of angina
207
dyspnea
| vascular subjective data
shortness of breath (on exertion or at rest), paroxysmal, constant or intermittent, paroxysmal nocturnal dsypnea “PND” (a sign of heart failure)
208
orthopnea
| vascular subjective data
note how many pillows are needed to improve breathing
209
cough
| vascular system subjective data
Note duration, frequency, dry or productive, mucus (color, odor, blood tinged), hemoptysis, precipitating factors
210
fatigue
| vascular subjective data
onset, sudden or gradual
* From cardiac dysfunction – fatigue worse in evening
* With anxiety or depression - worse in morning or present all day
211
edema
| vascular subjective data
unilateral or bilateral, dependent edema with heart failure (bilateral, increases in the evening, decreases with elevation of legs)
212
nocturia
| vascular subjective data
recumbent position-->increased fluid reabsorption & excretion (with heart failure)
213
past cardiac Hx
| vascular subjective data
HTN, elevated cholesterol levels, rheumatic fever, anemia, recurrent tonsillitis, meds, heart surgery, last ECG, stress test
214
family cardiac Hx
| vascular subjective data
HTN, obesity, diabetes, CAD, sudden death at younger age
215
personal habits for risk cardiac factors
| vascular subjective data
nutrition (diet), smoking, alcoholic intake, exercise, drugs
* Hormonal replacement therapy (HRT) is no longer used for prevention of CAD
216
infants and children
| vascular subjective data
note fatigue, poor weight gain, cyanosis, limitations with exercise, frequent respiratory infections
217
pregnant female
| vascular subjective data
hypertension, protein in urine, swelling (in feet, legs or face), excessive weight gain
218
aging adult
| vascular subjective data
heart or lung disease, HTN, CAD, COPD, meds, noncompliance with meds, limitations with ADLs
219
order of regional cardiovascular assessment
1. Pulse and BP
2. Extremities
3. Neck vessels
4. Precordium
220
palpate the carotid arteries
| cardiovascular objective data
(medial to the sternomastoid muscle): avoid excessive vagal stimulation (decreases heart rate) by using gentle pressure over the lower part of the neck, palpate only one carotid artery at a time (avoids cerebral ischemia with syncope)
* Note contour & amplitude - normal is 2+ and equal bilaterally
* Diminished pulse (small & weak) - decreased stoke volume
* Increased pulse (full & strong) - hyperkinetic states
221
auscultate the carotid arteries for bruits
| cardiovascular objective data
for persons > 40 age or have S/S of CV disease
Use the bell side of the stethoscope for bruits
222
bruits
Bruit: blowing, swishing sound, indicates turbulent blood flow from a local vascular cause; audible when the lumen is occluded by ½ to 2/3
Absence of bruit does NOT necessarily exclude partial occlusion
223
unilateral distension of the external jugular veins
| cardiovascular objective data
indicates local cause (aneurysm or kinking)
224
bilateral distension of the external jugular veins
| cardiovascular objective data
above 45 degrees indicates increased central venous pressure (CVP) from systemic disorder such as heart failure
225
estimate the jugular venous pressure
| cardiovascular objective data
“reading” the CVP at the highest level of venous pulsations
* Place pt. in supine position with HOB elevated 45 degrees
* Elevated pressure indicated by level of pulsation is > 3 cm with HOB elevated at 45 degrees
*Look at illustration on page 481
226
inspect the anterior chest
| cardiovascular objective data
with tangential lighting
for any pulsations, heaves, liftss
227
heave or lift
(sustained forceful thrusting of ventricle during systole)
– indicates ventricular hypertrophy from increased workload
228
palpate the apical pulse
| cardiovascular objective data
(for the apex beat) and note its normal characteristics:
- Location: normally at 4 or 5th intercostal space at or medial to midclavicular line & only occupying one intercostal space
- Size: normally 1cm X 2cm
- Amplitude: normally a short, gentle tap
- Duration: normally occupies only one half of systole
229
left ventricular dilation
| cardiovascular objective data
(volume overload) – increases its size, displaces it more laterally, increases its duration & amplitude
230
palpate across the precordium for a thrill
| cardiovascular objective data
(palpable vibration)
* Note its timing if present auscultate or use carotid artery as a guide)
* Thrill: generally indicates a significant murmur
231
auscultate the precordium
| cardiovascular objective data
using the Z pattern technique from the base of the heart and down
Locations of the heart valves:
* Second right interspace – aortic valve
* Second left interspace – pulmonic valve
* Left sternal border – tricuspid valve
* Fifth interspace near the left midclavicular line – mitral valve
232
all pigs eat too much
aortic
pulmonic
erb's point
tricuspid
mitral
233
at what point does s1 and s2 the same loudness
erb's point
234
where is s2 the loudest
base
235
where is s1 the loudes
apex
236
With the apical pulse, start with the diaphragm part of the stethoscope and use the following routine
1. Note the rate & rhythm
2. Identify S1 and S2
3. Assess S1 and S2 separately
4. Listen for extra heart sounds
5. Listen for murmurs
237
what does s1 coincide with
the carotid artery pulse
the R wave
the upstroke of the QRS complex on the ecg monitor
238
s1 sound indicates what
from closure of the AV valves, indicates the beginning of systole
239
s2 indicates what
from closure of the semilunar valves, indicates beginning of diastole
240
splitting of the s2
normal physiological split occurs during inspiration only (not during expiration) in some people
241
what heart sound splits are abnormal
Fixed split (occurs in both inspiration & expiration) or a parodoxical split (occurs with expiration but not with inspiration)
242
grading murmurs
* Grade I - barely audible
* Grade II - clearly audible– most common
* Grade III - moderately loud
* Grade IV - loud with audible thrill
* Grade V - very loud
* Grade VI - loudest, can hear with stethoscope lifted off the chest
243
murmurs can be what
*Mid-systolic
*Pan-systolic
*Diastolic rumbles
*Early diastolic murmurs
244
ins and outs of s3 gallop
- Occurs in early diastole (during rapid filling phase)
- Low pitch, sounds like distant thunder
- Physiologic (normal): in children & some young adults, disappears
when pt. sits up
- Pathologic (abnormal): doesn’t disappear when pt. sits up
- Right ventricular S3 (right sided heart failure): heard at the left
lower sternal border with pt. in supine position
- Left ventricular S3 (left-sided heart failure): heard at the apex with
pt. in left lateral position
- Early sign of heart failure
- Results from volume overload, and also in high cardiac output
states (without cardiac dysfunction) such as with hyperthyroidism,
anemia , and pregnancy
245
ins and outs of s4 sounds
a ventricular filling sound, referred to as “atrial gallop” or “S4 gallop”
- Heard right before S1 (in late diastole)
- Soft, low-pitched sound
- Listen at the apex with pt. in left lateral position (right sided is less common, heard at the left lower sternal border)
- Results from decreased compliance of the ventricles
- Physiologic: in adults > age 40 or 50, especially after exercise
- Pathologic: from decreased compliance of the ventricles (CAD, cardiomyopathy, or increased afterload)
246
Patent Ductus Arteriosus (PDA):
| congenital heart defects
persistence channel between left pulmonary artery to aorta
247
Atrial septal defect (ASD):
| congenital heart defects
abnormal opening in the atrial septum
248
ventricular septal defect
vsd
| congenital heart defect
abnormal opening in the ventricular septum
249
tetrology of fallot
| congenital heart defect
*Right ventricular outflow obstruction
*VSD
*Right ventricular hypertrophy
*Over-riding aorta
250
Coarctation of the Aorta
Congenital Heart Defect
251
vascular system
Job is to circulate blood and lymph throughout the body
Comprised of arteries, veins, and lymphatics
252
arteries
Arteries-deliver freshly oxygenated blood to body, strong, tough vessels that must withstand high pressure demands, expand and recoil with each heartbeat/pulse
253
veins
Veins-bring blood back to the heart go to through lungs to be oxygenated, lie closer to the skin surface than arteries, are more elastic/distensible, contain valves so blood cannot flow backwards
254
lymphatics
Lymphatics-made up of vessels, nodes, ducts, some organs
Bring excess fluid and plasma proteins back to the bloodstream from the interstitial space
Major part of the immune system
Absorb lipids from the small intestine
255
know location of arteries listed
Temporal artery
Carotid artery
Brachial artery
Radial artery
Ulnar artery
Femoral artery
Popliteal
Posterior tibial
Dorsalis pedis
256
know the location of the veins listed
Deep veins in the legs:
- Femoral
- Popliteal
Superficial veins in the legs:
- Great saphenous
- small saphenous
257
know the location of the lymph nodes listed
cervical
axillary
epitrochlear
inguinal
258
cervical nodes
drain head and neck
259
axillary nodes
drain breast and upper arm
260
epitrochlear nodes
drains the hand & lower arm; located in the antecubital fossa
261
inguinal nodes
drain the lower extremities, the external genitalia, & the anterior abdominal wall
262
vascular considerations of the pregnant female
increased estrogen levels vasodilation & drop in BP; uterus exerts pressure on iliac veins & inferior vena cava resulting in:
- Edema (diffuse, bilateral, pitting) in the
lower extremities
- Varicose veins
263
vascular considerations for the aging adult
- Arteriosclerosis from increased rigidity
of the peripheral blood vessels
- Increased risk for deep vein thrombosis
- Decreased lymphatic tissue
264
leg pain or cramps
| vascular subjective data
note location, type, precipitating factors, claudication distance, relived by rest walking, rubbing, night pain, recent change in exercise, past history of vascular problems
* Note any sudden worsening of
claudication (decrease in claudication
distance) & pain suddenly not relieved
with rest
265
skin changes on arms or legs
| vascular subjective data
discolorations (redness, pallor, blueness, brownish), varicose veins, coolness, sores or ulcers
266
swelling in the arms or legs
| vascular subjective data
in one side or both, worse in the morning or evening, constant or intermittent, precipitating & relieving factors, associating factors (pain, heat, redness, ulcers, hardened skin)
* Bilateral edema indicates a systemic problem
* Unilateral edema indicates an obstruction or inflammation
267
lymph node enlargement
| vascular subjective data
location, duration, any recent changes, presence of pain or infection
* Enlarged nodes indicate infection, immunologic disease or malignant disease
268
medications
| vascular subjective data
oral contraceptives or hormonal replacement (increased risk for thrombosis)
269
capillary refill
| vascular objective data
index of peripheral perfusion & cardiac output
* Abnormal finding- refill lasting more than 1 or 2 seconds (indicates vasoconstriction or decreased cardiac output)
270
vascular objective data
temperature
symmetry or presence of edema
Presence of any lesions, scars, needle tracks in antecubital fossa (indicates intravenous drug use)
271
nailbeds
| vascular objective data
for pallor, cyanosis, clubbing (enlargement of
terminal phalanges) indicates chronic hypoxia
* Normal angle is 160 degrees
272
skin color
| vascular objective data
(pale, erythema, cyanosis), texture, turgor
* Pallor with vasoconstriction, erythema with vasodilation
273
how to assess radial pulse
assess both for rate rhythm and amplitude
274
palpate the following pulses for amplitude and elasticity
- Radial
- Ulnar (usually not palpated)
- Brachial
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis
275
Three-point scale for grading the amplitude(Force)
3+ Increased, full, bounding
2+ Normal
1+ Weak
0 Absent
276
what does a full bounding pulse indicate
hyperkinetic states (exercise, anxiety, fever & hyperthyroidism)
277
what does a weak thready pulse indicate
shock and peripheral arterial disease
278
inspect and palpate extremities for
Hair distribution
Venous pattern
Lesions/ulcers
Size, swelling, atrophy
279
what does an enlarged lymph node indicate
infection of the draining area
280
assessing edema
- location
- pitting or nonpitting
- measurement
281
Signs of malnutrition:
thin, shiny, atrophic skin, thick-ridged nails, loss of hair, ulcers, gangrene
282
signs of arterial insufficiency
pallor, coolness, diminished pulse strength
283
unilateral vs bilateral swelling
Unilateral swelling signifies a local problem
*If asymmetry of the calves is > 1 cm, refer
the pt. (possible deep vein thrombosis)
Bilateral swelling of legs indicates a systemic
problem
284
brownish skin discoloration
Brownish discoloration: indicates chronic venous stasis
285
venous ulcers
generally located on the medial malleolus
286
location of arterial ulcers
located on tips of toes, metatarsal heads, or lateral malleoli
287
what does a bruits indicate
turbulent blood flow from partial occlusion
288
modified allen test
evaluates the adequacy of collateral circulation prior to cannulating the radial artery
* Persistent pallor or sluggish return of color indicates occlusion of collateral circulation
289
doppler ultrasound stethoscope
use to detect a weak peripheral pulse
* Presence of a swishing, whooshing sound indicates a pulse
290
Lymphedema
- Impediment of lymph drainage
- Unilateral
- Lymphedema is nonpitting edema, unilateral, overlying skin is indurated and brawny
291
raynaud's syndrome
292
Chronic Arterial Insufficiency:
- deep muscle pain
- pain with walking “claudication”
- coolness, pallor
- diminished pulses
- thin, shinny skin
- absence of hair
- necrotic ulcers on toes, heels, lateral
malleolus
293
Chronic Venous Insufficiency:
- dull ache, heaviness in lower leg pain
- pulses present
- thick brawney, edematous skin
- brown pigmentation
- weeping ulcers on medial malleolus
294
Chronic Venous Stasis:
- aching, heaviness, night leg or foot cramps
- dilated, tortuous veins
295
acute venous thrombosis
- sudden onset pain
- increased warmth, swelling, redness
* Homan’s sign – not diagnostic
296
Grade pitting edema on the following scale:
1+ Mild
2+ Moderate
3+ Deep pitting
4+ Very deep pitting
