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cardiovascular
Health Assessment
| Question | Answer |
|---|---|
| MSL | midsternal line |
| MCL | midclavicular line |
| RSB | right sternal border |
| LSB | left sternal border |
| AAL | anterior axillary line |
| MAL | midaxillary line |
| PAL | posterior axillary line |
| ICS | intercostal space |
| anatomical location of the heart | in the mediastinum in the middle third of the thorax from RSB to L MCL and 2-5 ICS |
| Perichordium | front side of chest overlying heart and vessels |
| sternal notch (jugular notch) | concave depression found at the most superior point of the manubrium |
| Angle of Louis (sternal angle) | manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib |
| costal angle | the angle between the ribs at the costal margins, should be <90 degrees |
| three layers of the heart | epicardium, myocardium, endocardium |
| chambers of the heart | R/L atria and R/L ventricles |
| 4 valves of the heart | tricuspid, pulmonary, mitral, aortic |
| what brings deoxygenated blood into the R atrium? | vena cava |
| where are the great vessels bunched? | above the base of the heart |
| what are the great vessels? | Superior and inferior vena cava, pulmonary artery(splits into 2), pulmonary veins(2 on each side), aorta |
| pericardium | tough, fibrous, double-walled sac that surrounds and protects the heart |
| how much pericardial fluid does the pericardium contain to prevent friction and reduce heat? | 2mL |
| myocardium | the layer that a actually does the pumping |
| endocardium | thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves |
| AV valves are open during which phase? | diastole- allows the ventricles to fill with blood |
| which valves are closed during systole? | AV valves- prevents back flow of blood into the atria |
| which valves are open during systole? | semilunar valves- allows blood to be ejected from the heart |
| what is the function of heart valves? | prevent backflow of blood |
| cardiac cycle | one complete heart beat: diastole and systole of both atria and ventricles |
| diastole | when ventricles are relaxed and filling with blood; constitutes 2/3 of cardiac cycle |
| systole | when the ventricles are contracting |
| cardiac output | amount of blood volume circulated in one min; determined by stroke volume CO = HR x SV |
| stroke volume | amount of blood ejected with each heart beat |
| stroke volume is determined by: | preload: blood volume in. ventricle at end of diastole_ arterial pressure heart must pump against _the ability of the heart to. contract |
| pacemaker of the heart | SA node (60-100 bpm) |
| if the SA node fails, what can act as a backup? | AV node at 40-60BPM |
| AV node prevents | excessive atrial impulses |
| P wave represents | atrial depolarization |
| QRS complex represents | ventricular depolarization and also atrial depolarization |
| T wave represents | ventricular repolarization |
| normal heart sounds | S1 and S2 created by closure of valves |
| S1 lub sound | ventricles contract, closing tricuspid and mitral valves (begins systole) |
| S2 dub sound | when ventricles are nearly empty, the pulmonic and aortic valves close (begins diastole) |
| Diastole makes up how much of the cardiac cycle? | 2/3 |
| where. is S1 loudest? | apex |
| where is S2 loudest? | base |
| S3 | ventricular gallop- rapid ventricular filling: CHF, fluid overload: vibrations from resistance to ventricular filling heard over chest can be normal in children and athletes |
| S4 | atrial gallop- non-compliant ventricle: CAD, hypertension, cardiomyopathy- at the end. of. diastole just before S1 |
| summation gallop | both pathological sounds occur |
| split heart sound | audible heart sound that occurs when the valves close at slightly different times inspiration shifts more blood to right side of heart which speeds closure of aortic valve and delays closure of pulmonic valve |
| heart murmurs | Turbulent blood flow with a swooshing or blowing sound when doing auscultation |
| causes of heart murmurs | - increased blood velocity (exercise, thyrotoxicosis), narrow or incompetent valves, decreased blood viscosity, abnormal chamber openings |
| grade I heart murmur | difficult to hear; experienced examiner and quiet environment are needed |
| Grade II heart murmur | is not readily heard upon laying stethoscope on chest; examiner must listen closely |
| Grade III heart murmur | requires no effort to hear; is readily heard when stethoscope is placed on chest |
| Grade IV heart murmur | Loud with thrill |
| Grade V heart murmur | very loud, and a thrill is easily palpable |
| Grade VI heart murmur | audible with stethoscope only near chest |
| are nurses responsible for grading murmurs? | no, typically a physician/cardiologist |
| how to document a murmur | location, timing(where in cardiac cycle), grade, pitch(high, medium, low), quality(harsh, rasp, mechanical blowing) |
| subjective data health history | chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis/pallor, edema, nocturia, cardiac history, family cardiac history, personal habits |
| lifestyle risk factors for heart disease | nutrition, smoking, alcohol, exercise, drugs mainly: hypertension, smoking, cholesterol |
| objective data of assessment | BP, count apical and radial pulse, assessor pulse deficit, note color |
| where do you stand to inspect the anterior chest? | on PT's R side, HOB elevated between 30-45 degrees |
| in a very thin Pt, which pulse may be seen? | apical. pulse at the apex at the. 4th-5th ICS at L MCL |
| what position should your client be in to palpate the anterior chest? | supine |
| what are you palpating for? | heaves, lifts, thrills |
| heave/lift | sustained, systolic outward movement of the pericardium, due to heart failure |
| a right ventricular heave or lift is best palpated at: | 3rd or 4th ICS LSB |
| left ventricular heave or lift best palpated at: | apex |
| thrills | turbulence of blood flow, -can be seen with >grade 4 murmur |
| S1 coincides with which pulse? | carotid artery pulse |
| Sinus Arrhythmia | HR increases with inspiration and decreases with expiration |
| auscultating heart valves acronym | APETM (aortic, pulmonic, Erb's point, tricuspid, mitral) |
| Aortic area auscultation | 2nd intercostal space, right sternal border |
| Pulmonic area auscultation | 2nd intercostal space, left sternal border |
| Erb's point auscultation | 3rd intercostal space, left sternal border |
| Tricuspid area of auscultation | 4th intercostal space, left sternal border |
| Mitral area auscultation | 5 ICS left midclavicular line |
| positions for auscultation of heart sounds | supine at 45 degrees, lying on left side, sitting. up while leaning forward |
| how many times should you listen to each location? | at least two times, once with diaphragm for S1 and S2 and once with bell for S3 and S4 murmurs count apical rate for one minute |
| infant HR | rapid HR makes it harder to evaluate heart sounds |
| children | murmurs can be common and innocent but be aware of signs of heart disease such as poor weight gain, tachycardia, clubbing, etc. |
| aging adult | gradual rise in systolic blood pressure and thickening. of left ventricle wall is common apical pulse maybe difficult to palpate due to increased AP chest diameter |
| angina | ischemia of heart- reduced blood flow |
| angina pectoris | pressure-like discomfort like tightness or squeezing; often resolves with rest |
| acute unstable angina | Heavy or crushing discomfort lasting 20 mins to hours. Doesn't resolve with rest |
| myocardial infarction | reduced blood flow to coronary artery due to occlusion MOAN to help: morphine, oxygen, aspirin(anticoagulant), nitroglycerin(vasodilator) |
| left side heart failure signs | respiratory issues |
| right side heart failure signs | swelling |
| jugular venous pulsations inspection | - stand on R side of PT, have them turn head slight to L and shine light on neck, look for pulsations of jugulars distension at >45 degrees = inc central venous pressure and reflects right atrial pressure |
| How to measure jugular venous pressure? | - use angle of Louis as reference point, vertical ruler at sternal angle, align horizontal straight edge at level of pulsation normal = 2cm or less above sternal angle and state person's position |
| hepatojugular reflux | sustained distention of jugular veins observed when during phys exam you press just under the liver for 20-30 secs |
| carotid artery assessment | - palpate one at a time. auscultate for bruits with bell by having PT exhale and hold breath |
| normal finding for amplitude of pulse | 2+ or moderate |
| are the vascular and lymphatic systems connected? | no, they are completely separate systems |
| arteries | carry oxygenated blood away from the heart to body. tissues, high pressure system, each beat creates pulsations that can be felt at certain locations |
| pressure wave is another term for | pulse |
| pressure wave can only be felt at: | body sites where artery lies close to skin and over bone |
| complete arterial blockage= | death of distal tissue |
| partial arterial blockage= | ischemia (reduced blood flow) |
| veins | drain deoxygenated blood and wastes from tissues to heart, low pressure, no pump (valves) |
| lymphatic ducts | drain excess fluid from tissue spaces and return it to blood stream- part of. immunity drain a subclavian veins |
| objective data for peripheral vascular assessment | inspect arms, look for clubbing, color, temp, capillary. refill, symmetry, lesions, radial/ulnar pulse, brachial pulse same for legs but also femoral, popliteal, posterior tibial, and dorsals pedis pulse and edema |
| modified Allen test | client makes fist, nurse holds radial and ulnar pulse at same time until turns white then release ulnar and color should return |
| edema in only one leg could be indicative of: | deep vein thrombosis |
| Palpate epitrochlear lymph nodes | - Flex the client's arm to a 90 degree angle and palpate below the elbow posterior to the medial condyle of the humerus no palpable lymph nodes (assessing for infection in hand/forearm) |
| dorsalis pedis pulse | top of foot lateral to extensor tendon of big toe |
| posterior tibial pulse | inner ankle- fingers anchor medial malleolus |
| popliteal pulse | Pulse felt at the back of either knee; lower part of femoral artery |
| doppler ultrasonic probe | used to detect weak peripheral pulses |
| Ankle Brachial Index | Comparison of the blood pressure in the leg vs. the arm; normal ratio is about 1-1.2: if less than this it may be indicative of peripheral artery disease |
| arterial insufficiency | narrowing of the arteries, commonly the pelvis & legs peripheral artery disease |
| venous insufficiency | inadequate return of venous blood from the legs to the heart, peripheral vein disease |
| Aging Adult Trophic Changes | associated with arterial insufficiency thin, shiny skin, thick, rigid nails, loss of hair |
| arterial ischemic ulcers | does not bleed, has a necrotic black crust, defined edges, pallor, dry skin, metatarsal heads/ankles |
| venous assessment | observe for varicosities while pt stands, look for lesions or homan's signs |
| Homan's sign | pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis no longer used because it could release clot |
| pitting edema | indentation left after examiner depresses the skin for five sec over swollen edematous tissue scale of 0-4+ |
| venous stasis ulcer | ulcer caused by venous insufficiency and stasis of venous blood; usually forms near the ankle irregular boders, shallow wounds, granulation tissue, wavy with itchy skin 40% of all ulcers |
| lymphedema | lymph builds up in interstitial tissue TX: exercise, noon-elastic wrapping, compression garments |
| Raynaud's disease | change of fingers in response to cold, vibration, or stress |
| varicose veins | veins in legs dilated bc chronic increased venous pressure |
| deep vein thrombosis (DVT) | notable swelling, emergency due to risk of pulmonary embolus, (from lying too long) signs: calf pain, edema, warmth |
Created by:
AV25
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