WEEK 8- HEART Flashcards
(68 cards)
When assessing the heart rate of a PT the nurse identifies a change from 86 to 56, what should the nurse do first?
A. Wait half and hour and retake the pulse
B. Obtain other vital signs
C. Ask about recent activity
D. Tell the charge nurse
- obtain the other vitals!
In assessing the carotid in an older PT with cardiovascular disease the nurse would:
A. Palpate the artery to determine the occultation pressure
B. Listen with the bell to assess for bruits
C. Palpate both arteries simultaneously to compare
D. Instruct the PT to take slow deep breaths
B- assess for the bruit
The function of which part of the anatomy is primarily being assessed with the nurse takes a pedal pulse
A. Veins
B. Heart
C. Arteries
D. Blood
C-Arteries
The nurse is assessing for a pulse in a PT who has hyperthyroidism, the nurse should expect to find an
A. Bounding pulse
B. Weak
C. Thready
D. Normal
A- bounding
subjective data for the cardio system
- do you have a history of high cholesterol, HTN, DM, heart murmur
- do you have a family history of high cholesterol, HTN, heart disease, obesity
which groups of people are at an increased risk for heart issue
Mexican americans, AA, Asian, Native Americans
what are some disorders which are linked to cardiovascular disease
- high C reactive proteins
- hyperthyroid
- arterial fibrillation
- high cholesterol
Asking for a health history for peripheral diseases what should you ask?
- history of PVD
- varicose veins
- DVT
- claudacation
do we record positive and negative finds or just positive?
- record both positive and negative
- for positive findings do OLDCARTS
subjective data for the heart
- what do you assess about location?
- what other symptoms do you ask about
- precordial (middle)
- retrosternal (behind the sternum)
- do you feel palpitations?
- fatigue
- fainting
- dizziness
- dyspnea- does it happen on exertion, if so, how much?
- orthopnea- does the patient sleep with a lot of pillows
- paroxysmal nocturnal dyspnea - happens alot in people with HF when blood gets pushed back into the lungs
- cyanosis
- edema
If someone has chest pain what kind of questions do you ask them?
- is it relieved by Nitro
normally if it is relieved with this then you are having angina if it is not relieved then you might be having an MI
sleeping disturbances in women prior to an MI
- 50% of women have difficulty sleeping from up to a month prior to having an MI
subjective data- what things would you like to know for a peripheral review of systems?
- coldness
- numbness
- tingling
- swelling of legs (when does it happen, how much activity do you do before it happens)
- discoloration of hands or feet: looking for cyanosis, reddish colorization (could be reynaud’s disease)
- Claudication- could be intermittent, at rest? how much activity causes it? has this changed recently?
- do you have swollen glands
Questions specific to older adults
- do you know side effects of your medicines such a lightheadedness
- have you stopped taking your medications
- do you have stairs in your house, is it hard for you to use them?
how do you assess pulses?
-compare both sides
-note the rate
-note the rhythm
(diminished, can barely feel it), +2 (normal), +3 (full and brisk), +4 (bounding)
apical heart sounds
- S3,S4 murmurs, gallop., rub = all abnormal sounds
- could be heard mid clavicular 5th intercostal space
capillary refill
-check bilaterally, hand and pedal, should be brisk
bruits
abnormal sounds, carotids, abdominal
use the bell
5 things to assess for when you are doing a cardiovascular/peripheral vascular assessment
- pulses
- apical heart
- bruits
- edema
5 abnormalities found on inspection and palpation
- tenderness
- enlargement
- lumps
- edema
- drainage
cardiovascular neck assessment
-inspection
- inception: jugular venous distention indicates fluid overload, right side heart failure
-we measure it by laying the person at a 45 degree angle and measure the elevated area and see if its greater than 3 cm -abnormal
75% of PT with this have right sided heart failure -fluid is being pushed back via the tricuspid valve and fluid volume overload
Cardiovasular assessment-palpating the neck
- only do one side at a time
- carotid arteries on both sides rate form 0 (absent) -3 (bounding)
Auscultation of the neck
- preformed when you inspect narrowing or inclusion (obstruction)
- happens to older adults alot bc they are increased risk for carotid artery disease
- listen for bruits which is turbulent blood flow
- use the bell to listen
- normally you should hear nothing
- 3 places to listen for bruits
- # 1 under the jaw
- # 2 the neck near the trachea side
- # 3 clavicle
Percordium assessment - inspection
- inspection- skin color and lesions
- do you see pulsations