Flashcards in WEEK 8- HEART Deck (68):
1
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!
2
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
3
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
4
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
5
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
6
which groups of people are at an increased risk for heart issue
Mexican americans, AA, Asian, Native Americans
7
what are some disorders which are linked to cardiovascular disease
- high C reactive proteins
-hyperthyroid
- arterial fibrillation
-high cholesterol
8
Asking for a health history for peripheral diseases what should you ask?
- history of PVD
- varicose veins
-DVT
-claudacation
9
do we record positive and negative finds or just positive?
-record both positive and negative
-for positive findings do OLDCARTS
10
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
11
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
12
sleeping disturbances in women prior to an MI
- 50% of women have difficulty sleeping from up to a month prior to having an MI
13
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
14
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?
15
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)
16
apical heart sounds
-S3,S4 murmurs, gallop., rub = all abnormal sounds
-could be heard mid clavicular 5th intercostal space
17
capillary refill
-check bilaterally, hand and pedal, should be brisk
18
bruits
abnormal sounds, carotids, abdominal
use the bell
19
5 things to assess for when you are doing a cardiovascular/peripheral vascular assessment
- pulses
- apical heart
-bruits
- edema
20
5 abnormalities found on inspection and palpation
- tenderness
-enlargement
-lumps
-edema
-drainage
21
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
22
Cardiovasular assessment-palpating the neck
-only do one side at a time
-carotid arteries on both sides rate form 0 (absent) -3 (bounding)
23
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
24
Percordium assessment - inspection
-inspection- skin color and lesions
-do you see pulsations
25
where is the PMI
-point of maximal impulse
-between the 4th and 5th intercostal space in the mid clavicular line
-this is where the apex of the heart is
26
Abnormal findings in the precordium
-heaves- right ventricle heave is in the lower sternal border and the left ventricle heave is at the apex of the heart if present
-lifts- forceful thrusting on the chest caused by an enlarged ventricle
-pulsations
-anything other than the normal apical pulse indicated cardiac hypertrophy of the left or right ventricle
-cardiomegaly which moves the PMI laterally and inferiorly
-is there a pacemaker?
27
Palpation of the precordium
-thrill- turbulent blood flow that can be felt
-vibration
-fell the apex of the heart aka the PMI if this spot has moved laterally and inferiorly then there is enlargement of the heart . assess for size, location, amplitude and duration of the PMI/apical pulse
28
auscultation of the percordium
- most important technique for the cardiovascular system assessment
-use both the diaphragm and the bell
-listen for 30 sec and X 2 if the rate is normal
-note rhythm
-listen for normal heart sounds
if breathing sounds interfere with the heart sounds, ask the person to hold their breath
- S1 and S2 are normal
29
what is S1 AND S2 sounds
-S1- AV valves closing
AV valves are the tricuspid and the mitral valves
they close during the systole
-S2- SL valves closing
SL pulmonary and aortic valves closing end of diastole
30
how do you listen to the cardiac cycle and heart sounds
-listen to the lubb- dubb sound and determine whether its normal
-LUBB is beginning of the beginning of the systole aka S1
-DUBB is the beginning of the of the diastole and called S2
-LUBB and DUBB is one complete heart sound
-heart sounds could be regular, irregular or regular irregular (when there is a regular pattern of a abnormal sounds)
31
pulse deficit
difference between the apical and the radial pulses
32
cardiac output
stroke volume (mL/min) X heart beat
33
where can we assess the S1 and S2
Erbs point
34
spilt S1
-heard at the tricuspid area
abnormal
35
spilt S2
-heard at the tricuspid area and is a normal occurrence
-happens when the pulmonic valve closes slighlty after the aortic valve
36
sinus arthhymias
normal variation
when HR inc during inspiration and dec with expiration
37
5 important heart sounds
- Aortic
-Pulmonic
-Erbs
-Tircupsid
-Mitral
APE TO MEN
38
Location of aortic
-2nd intercostal space near the sternum
39
Location of the Pulmonic
-2nd intercostal space on the left side
40
Location Erbs Point
-left of the sternum in the 3rd intercostal
41
Location of the Tricuspid
-left of the sternum
-according to the 4th or 5th intercostal
42
Location of the mitral
-mid clavicular line on the left side on the 5th intercostal this is the point of max impulse
43
What motion do you use when assessing
- Z formation to assess the heart
44
Murmurs
- graded from 1-6
-1 only heard with special effort
-2 soft
-3 prominent sound not loud
-4 loud with a thrill usually -5 very loud
-5 very loud
-6 loud enough to hear it quickly with a stethoscope
- occur because of congenital defects of valvular defects
-timing (related to S1 and S2)- I systole=swosh- Dubb and falls between S1 and s2 or in diastole = dubb swoosh AND falls after S2 and before S1
-quality- harsh, raspy, muscial, rumbling, blowing
-location- on the predordium
-
45
S3
where does is happen diastolye or systole
-occurs in diastole
-normal for altheles and people under 40. ABNORMAL in people over 40
-sign of HF and fluid overload
-valvar regeneration
-(ken-tuck-y)
46
S4
what does it sound like
what casues it
-happens with PT with CAD happens with late diastole
-before the S1 sound
LUBB LUBB DUBB
-due to a noncompliant ventricle bc fibrosis and hypertension called an atrial gallop (ten-nes-see)
47
what kind of inspection do you do for peripheral vascular disease
-look at the upper and lower extremities- they should be symmetrical- look for hypertrophy or atrophy
-skin color- note the venous pattern- abnormal venous (arterial insufficiencies), erethymia (thrombothities), DVT (warmth, edema, pain)
-check for hair distribution
-varicosities
48
what do we do if someone has a DVT
what happens if we don't do anything
-prescribe anticolagutins
-PE could happen- life threatening, chest pain and dyspnea
49
suppose on an peripheral assessment you find:
-atrophy on one side
-symptoms of occulation
-assess for the 6P ASAP
-pallor
-poikilothermia
-pulselessness
-paralysis
-parasthesia
pain
50
9 different areas to asses for a pulse
1. temporal
2. facial
3. carotid
4. brachial
5. femoral
6. posterior tibal artery
7. dorsailas pedias
51
peripheral vascular assessment- palpation
-Edema and explain the different types and implications
-edema
this could be non-pitting or pitting
pitting edema is rated 1+ to 4+
+1: disappears rapidly 2MM
+2: 10-15 seconds to disappear 4MM
+3: imprint lasts more then one minute 6MM- increases the person's risk for falls bc they cant walk correctly
+4: imprint lasts 2-5 minutes 8MM fluid is totally trapped very bad
52
peripheral vascular upper extremities- abnormal findings
-needle tracks- drug user
-lymphatic obstruction- occurs in people who have had breast surgery so rmbr not to take BP in that arm
-sluggish cap refill- indicated dec cardiac output, hypothermia, vasoconstriction
-weak or bounding pulses
53
peripheral vascular lower extremities abnormal findings
- color- pallor indicating vasoconstriction, erretheymia with vasodilation
-think, shiny skin and hair loss- malnutrition and arterial insufficiency
--edema
-lymphodema - blocking of the lymph vessels with entrapment of the lymph in soft tissue
54
4 components of the lymphatic system
-lymphatic vessels
-spleen
- thymus
- tonsils
55
8 specific parts of the lymphatic system from image
- adenoids- patch of tissue preventing you from getting sick at the back of the nasal cavity
-palatine tonsils
- lingual tonsils
- nodes
- thymus gland
- spleen
- appendix
- peyer patches in intestine
56
functions of the lymphatic system
-functions alongside the immune system to fight infection
-Maintains the fluid and protein balance in the body
57
what happens when lymph get inflamed and nothing is done
- you can develop lymphedema- where lymph gets trapped in the soft tissue and cause edema and damage
58
normal variation in child's pulse
- pulse may inc on inspiration and dec on expiration
59
sinus dysthymia
- normal in childhood but document it so it an be monitored
- it is a HR with a varying rythm by more then 10 beats
60
abnormal childhood observations
- swatting position- similar to adults with COPD who use tripod positioning to breath better
-indicates the child is having trouble breathing
-cynosis- usually due to congenital heart defects
61
what are signs of poor child treatment
-has edema on their ankles and crying and cyanosis
-labored breathing while eating- baby should not have to stop while they are eating to take a breath
62
weak or absent femoral pulse in children could indicate what
- congenital condition known as coatoriation in which the aorta cortical pulse is abnormal
63
adolescent assessment for cardiovascular system
-same as the adult one
64
in the older population what heart sound variations exist
-apotonic beats are normal
S4 sound is common and associated with decreased LEFT venatical compliance
65
cardiovascular nursing diagnosis
6
1. activity intolerance
2. dec cardiac output
3. fatigue
3. sedentary lifestyle
4. risk for dec cardiac tissue perfusion
5. acute pain
66
peripheral vascular nursing diagnosis
1. ineffective peripheral tissue perfusion
2. risk for ineffective renal perfusion
3. risk for bleeding
4. risk for ineffective cerebral tissue perfusion
5. activity intolerance
6. chronic pain- claudication
7. risk for falls
8. risk for impaired skin integrity
67
what kind of health promotion are we telling our PT
- weight management
-balanced deit
- dont smoke
-regular check up
68