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Assessment
Test 3
| Question | Answer |
|---|---|
| Cardiovascular System | -Highly complex -Includes heart and closed system of blood vessels |
| Heart | -Extends: vertically from L second to L fifth intercostal space -Extends: horizontally from R edge of sternum to L midclavicular line -Precordium: anterior chest area overlying heart and great vessels -Mediastinum: space where heart sits |
| Layers of the Heart | -Pericardium: Heart's outermost layer (covering) -Myocardium: Heart's muscular layer, biggest and thickest part, most of heart -Endocardium: Heart's innermost layer |
| Cardiac Cycle | -Refers to the filling and emptying of the heart's chambers -Two phases: Diastole (relaxation or the ventricles, filling); Systole (contraction of the ventricles, emptying) |
| Heart Valves | -Atrioventricular b/w the atrium and the ventricle -R=tricuspid -L=bicuspid (mitral) -Semilunar located at the exit of the ventricles and beginning ofthe great vessels -R=pulmonic -L=aortic |
| Heart Sounds | -Produced by valve closure -Opening=silence -2 normal heart sounds: S1 & S2 -S1-closure of the AV valves, lub -S2-closure of the semilunar valves, dub |
| Phases of ECG | -P -Q -R -S -T |
| Extra Heart Sounds | -S3 and S4 referred to as diastolic filling sounds/extra heart sounds -Result of ventricular vibration secondary to rapid ventricular filling |
| S3 | -Ventricular Gallop, can be heard early in diastole after S2 -Best heard using bell @ apical area -Rhythm=Kentucky -Extra beat@end -Normal in young children,and pregnancy -Rarely normal in ppl over 40 -Associated w/CHF,myocardial failure, volume ov |
| S4 | -Atrial gallop heard late in diastole, just b/f S1 -Best heard using bell over apical area w/patient supine or L lateral -Rhythm=Tennessee -Extra beat @beginning -Can be normal in trained athletes -usually an abnormal finding associated with CAD,HTN |
| Murmur | -Swishing sound caused by turbulent blood flow through the heart valves/great vessels -Pan-Means all throughout |
| Physiologic Murmur | -Caused by temporary increase in blood flow. Can occur with anemia, pregnancy, fever and hyperthyroidism |
| Innocent murmur | -Not associated w/any physiologic abnormality,they occur when the ejection of blood into the aorta is turbulent, very common in kids and young adults |
| Pericardial Friction Rub | -Caused by inflammation of the pericardial sac -Best heard w/diaphragm over the 3rd ICS L of sternum -High pitched,scratchy, scraping sound -For best results have patient sit up, lean forward,exhale & hold breath -Commonly heard during the 1st after a |
| Cardiac Output | -The volume of blood expelled by the ventricles of the heart with each beat -CO=HR X SV |
| Coronary Artery Disease: Risk Factors | -Age -Family Hx -Ethnicity -Metabolic syndrome -Obesity -HTN -High LDL and fibrinogen -Diabetes -Smoking -Inactivity -Alcohol -Stress |
| Myocardial Infarction Signs and Symptoms | -Chest pain,Squeezing pressure in chest -Anxiety -Pain in L arm -Sweating -Shortness of Breath |
| Jugular Veins | -Internal and External veins -Internal-lie deep and medial to the sternocleiomastoid muscle -External-superficial, lie lateral to the sternocleidomastoid muscle above the clavicle -Both return blood to the heart from the head to neck by the SVC |
| Jugular Venous pressure | -Asst- of venous pulse helps determine the hemodynamics of the right side of the heart -R sided HF raises pressure and volume, raises jugular venous pressure -Decreased jugular venous pressure occurs w/reduced L ventricular output or reduced blood volum |
| Pulse Amplitude | 0=Absent 1+ = Weak 2+ = Normal 3+ = Increased 4+ = Bounding |
| Location of Heart sounds | -Aortic-2nd ICS @ R Sternal border (base) -Pulmonic-2nd ICS @ L sternal border -Erb's point-3rd ICS near L midclavicular line -Tricuspid-4th/5th ICS @ L lower sternal border -Mitral-5th ICS near L midclavicular line (apex) |
| Observe Jugular Venous Pulse | -Stand on R side of client -Client in supine @ 45* -Client turn head to L slightly -Inspect suprasternal notch for pulsations -Not normally visible w/client sitting upright, this position fully distends vein |
| Abnormal finding-Jugular Vein Distention | -Indicates increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade |
| Abnormal-Neck Vessels | -Distention,bulging, or protrusion at 45,60,or90*may indicate R HF -Clients w/ OPD may have elevated venous pressure only during expiration -An increase in venous pressure (Kussmaul's sign) may occur w/severe constrictive pericarditis |
| Abnormal-Auscultation Neck Vessels | -Bruit (a blowing ow swishing sound caused by turbulent blood flow through a narrowed vessel) -Indicative of occlusive artery disease -If artery is more than 2/3 occluded a bruit may not be heard |
| Abnormal-Palpation Neck Vessels | -Pulse inequity-arterial constriction or occlusion in one carotid -Weak pulses may indicate hypovolemia, shock or decreased CO -Loss of elasticity-arteriosclerosis -Thrills-abnormal tremor accompanying a vascular/cardiac murmur,narrowing of artery |
| Abnormal-Palpation Heart | -Pulsations which may be called heaves or lifts other than the normal apical pulse -May occur as the result of an enlarged ventricle from an overload of work |
| Abnormal Apical Pulse | -If apical impulse >1-2cm, displaced, more forceful or longer in duration, suspect cardiac enlargement |
| Auscultate S1 and S2 | S1-corresponds with each carotid pulsation and is loudest at the apex of the heart S2-immediately follows after S1 and is loudest at the base of the heart -Concentrate on each sound indiv. |
| Peripheral Vascular System | -Arteries and veins of arms and legs -Lymphatic system -Capillaries |
| Arteries | -Carry oxygenated, nutrient-rich blood to capillaries -High pressure system -Thick,layered walls -Pulse=force of blood against arterial walls felt w/heart beat |
| Major Arteries | Arm: Brachial, Radial, Ulnar Leg: Femoral, Popliteal, Dorsalis pedis, posterior tibialis |
| Veins | -Carry deoxygenated, nutrient depleted, waste-laden, blood from the tissues back to the heart -No force that propels blood flow -Low pressure system |
| Propel Blood Back to Heart | 3 Mechanisms: Valves,Muscular contraction,Pressure Gradient -Failure can result in impeded venous return, venous stasis -Types: deep,superficial,perforator |
| Lymphatic System | -Component of circulatory system -Complex system composed of lymphatic: capillaries and vessels, nodes -Function: drain excess fluid and plasma protein from bodily tissue and return them to venous system; prevent edema;produce lymph |
| Lymphatic nodes | -Somewhat circular or oval and tend to be grouped together -Vary in size from non-palpable to 1-2 cm in diameter -Many located near major joints |
| Peripheral Vascular Disease | Includes 5 vascular disorders: -Aortic Aneuryism -Cerebrovascular disease -Deep vein thrombosis (clot) & pulmonary embolism -Peripheral arterial occlusive disease -Varicose veins |
| Deep Vein Thrombosis | -Conditions that increase blood clotting:Inherited,injury,surgery,Ca, pregnancy -Varicose veins -Immobility, immobilization -Age >60 more common -Overweight -BC,hormone therapy/replacement -Central venous catheter in a vein |
| Abnormal Findings-Arm Inspection | -Lymphedema-blocked lymphatic circ caused by breast surgery -Usually affects one extremity, nonpitting edema -No BP done on that arm -Prominent venous patterning w/ edema may indicate venous obstruction |
| Abnormal Finding-Coloration of Hands | -Raynaud's disease is a vascular disorder caused by a vasoconstriction or vasospasm of fingers or toes -Characterized by rapid changes in color |
| Abnormal-Palpation Arms | -A cool extremity may be a sign of arterial insufficiency |
| Capillary Refill | -If exceeds 2 seconds may indicate vasoconstriction,decreased cardiac output,shock,arterial occlusion or hypothermia |
| Abnormal-Radial pulse | -Diminished or absent pulse suggests partial or complete arterial occlusion |
| Abnormal-Ulnar Pulse | Normally ulnar pulse may not be detectable -Lack of resilience may indicate arteriosclerosis |
| Abnormal-Brachial pulse | -Brachial pulses are increased, diminished, or absent |
| Abnormal Findings-Legs | -Pallor, especially when elevated, and rubor when dependent, suggests arterial insufficiency -Cyanosis when dependent suggests venous insufficiency -A rust or brownish pigmentation around ankles indicates venous insufficiency |
| Abnormal Findings-Leg Hair | -Hair loss could indicate arterial insufficiency |
| Abnormal findings-Leg lesions, ulcers | -Ulcers w/smooth,even margins that occur @pressure areas,toes and lateral ankle, result from arterial insufficiency -Ulcers w/irregular edges,bleeding and possible bacterial infection that can occur on the medial ankle, result from venous insufficiency |
| Abnormal Findings-Edema | -Pitting edema is associated w/systemic problems such as CHF,hepatic cirrhosis and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sitting -4+ most severe |
| Abnormal Findings-Legs Palpation | -Generalized coolness in one leg or a change in temperature from warm to cool as you move down the leg suggests arterial insufficiency -Increased warmth in the leg may be caused by superficial thrombophebitis |
| Homan's Sign | -Screening for thrombophebitis -Client supine -Flex knee about 5* -Place hand under calf musc, and dorsiflex of foot -Pain or tenderness? -No pain or tenderness=negative |
| Other tests for Leg | -ABPI-ankle brachial pressure index to screen for arterial occlusion -Manual compression and Trendelenburg tests to screen for incompetent valves |
| Breasts | -Paired mammary glands -To produce and store milk that provides nourishment for newborns -To aid in sexual stimulation |
| Breast: Anatomy | -Nipple;areola -Montgomery glands -Four quadrants -Glandular (produce milk, functional tissue), fibrous(support breasts), and fatty tissue, major axillary lymph nodes -Axillary tail of spence-where tumors are found, upper outer quadrant |
| Risk Factors: Breast Cancer | -Most common cancer among women -Age -Genes -Family Hx -Personal Hx -Early menarche/Late Menopause -No natural kid -1st child >30 -BC -Alcohol -Education -Hormone replacement -Wet ear wax -Smoking -Chest exposed to radiation as child |
| Ways to reduce Breast Cancer | -Breast-Feed -Monthly Breast self exam -Stay active -Avoid weight gain -Maintain regular sleep sched. 9hrs in dark room -Avoid exposure to bright light @ night, and night shift |
| Physical Examination: Breast | -Inspection:skin,aerolas,nipples for size shape rashes dimpling swelling discoloration retraction asymmetry -Palpation: swelling lumps masses warmth or inflammation tenderness |
| Masses or Lumps | -If malignant: usually upper outer quadrant,, irregular poorly defined borders, hard nontender, fixed to underlying tissue |
| Fibroadenomas | -1-5cm round,oval,mobile,firm,solid,elastic,nontender, unilateral or bilateral -Fibrosystic Breast Disease: round elastic,defined, tender, mobile systs,most common 30yrs old-menopause about 50 |
| Male Breasts | -Inspect and palpate the breasts ,areolas,nipples,and axillae -No swelling,nodules, or ulceration should be detected -Gynecomastia-enlargement of breasts-puberty |
| Axillae: Breasts | -Inspect and palpate -No rash or infection -No palpable nodes or one to two small discrete non-tender, movable nodes in the central area |
| Male Genitalia | -Penis: used for urination and reproduction -Components: shaft, gians, scrotum, scrotal sac -Internal: spermatic cord, testes(produce sperm,testosterone),epididymis, vasdeferens |
| Inguinal area | -Located b/w the anterior superior iliac spine laterally and symphysis pubis medially -Frequent site of hernia development |
| Adult HIV/AIDS:Risk Factors | -Anal intercourse -Intravenous drug use -Heterosexual transmission -Exchange of blood or body fluids -Mother to infant transmission during pregnancy or delivery |
| Adult HIV/AIDS:Reduce Risks | -Abstinence -Use condoms -Double glove when handling sharp objects -Single glove with bodily secretions -Avoid: IV drug use,sex w/multiple partners,mixing sex w/alcohol and drugs, anal intercourse |
Created by:
prettyinpink7
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