NURS1921 Exam IV Cardiovascular and Peripheral Vascular System Assessment

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JARoberts
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111611
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NURS1921 Exam IV Cardiovascular and Peripheral Vascular System Assessment
Updated:
2011-10-23 22:12:48
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NURS1921 Exam IV Cardiovascular Peripheral Vascular System Assessment
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Based on lecture by Mrs. Pijut
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  1. What techniques are used when assessing the cardiovascular system?
    • Interview
    • Inspection
    • Auscultation
    • Palpation
  2. When assessing the heart, what general appearance is being assessed?
    • Skin color and moisture
    • Mentation - Awake, Alert & Oriented
    • Posture
    • Respiratory Pattern
    • Precordium - Heaves, Lifts or Pulsations (aortic pulse)
    • Neck Veins - JVD (right side heart failure)
  3. What risk factors should be identified during the interview of a cardiovascular assessment?
    • Medications
    • Cardiac Hx - murmurs, rheumatic fever, heart Sx
    • Family history of HTN, CAD, DM or Hyperlipidemia - Cannot change your genes/opprotunity to educate patient on modifying risk factors within their control.
    • Hx of smoking or alcohol abuse
    • Diet and exercise habits
    • Hx of blood clots, leg pain or sores on legs that do not heal - signs of poor circulation
    • Signs and Symptoms - Why are they at the hospital or being seen?
  4. What should be inspected when assessing the peripheral vascular system?
    • Skin color, moisture and integrity
    • Edema
    • Hair quantity and distribution
    • Varicosities
    • Nail color & integrity
  5. What should be palpated when assessing the peripheral vascular system?
    • Skin temp and moisture
    • Capillary refill time - delayed when < 2-3 seconds
    • Peripheral Pulses - rate, rhythm & quality
    • Edema - Pitting or non pitting
  6. What would be some age related (pediatric) variations when performing a cardiovascular & peripheral vascular system assessment?
    • Visible pulsation r/t thin chest wall
    • Sinus dysrhythmia - HR increases w/ inspiration and decreased w/ expiration
    • S3 present in 1/3 of all children
    • More rapid HR up to ~ age 8
  7. What would be some age related (geriatric) variations when performing a
    cardiovascular & peripheral vascular system assessment?
    • Apical & Distal pulses can be more difficult to palpate
    • Dilated proximal arteries
    • Varicosities more common
    • Increased BP
    • Widened pulse pressure
  8. What tests would be used to measure blood flow?
    • Angiogram
    • Doppler Flow Studies
    • Cardiac Catheterization
    • Red Blood Cell Count
  9. What tests would be used to visualize structures of the circulatory system?
    • CXR
    • Echocardiogram - ultrasound
  10. What test would be used to identify abnormal cells or infections?
    CBC
  11. What labs are commonly used when assessing the cardiovascular system?
    • Cardiac Markers
    • Hematology, chem & coag panels
    • Cholesterol & lipids
  12. Nursing Diagnoses
    • Altered tissue perfusion, cardiac, r/t decreased arterial blood flow
    • Altered tissue perfusion, peripheral, r/t decreased arterial blood flow
    • Pain r/t imbalace between oxygen supply and demand
    • Activity intolerance r/t insufficient oxygen to meet physiological needs

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