assessment of cardiac and peripheral vascular

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Prittyrick
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272042
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assessment of cardiac and peripheral vascular
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2014-04-26 21:22:16
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fundamentals of nursing
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  1. Location of the heart
    • - Mediastinum
    • - Between the lungs and above the diaphragm
    • -Top= base bottom= apex (opposite the lungs)
  2. Chambers of the heart
    • Four chambers
    • · Upper portion- atria= collects and pumps blood to the ventric
    • · Lower portion- ventricles= pumps blood to the lungs and the body
    • · Septum= separates the heart chambers
  3. Heart valves (prevent backflow of blood)
    • - Atrio-ventricular valves (AV)- between the
    • atrium and ventricles
    • · Tricuspid- 3 cusps on the right side
    • · Mitral- 2 cusps on the left side
    • - Semi lunar valves- SL
    • · Between the ventricles and arteries
    • · Pulmonic- right side
    • · Aortic- left side
  4. Layers of the heart
    • Epicardium- outer covering       
    • Myocardium- muscular wall pumping action
    • Endocardium- tissues lining the inner surface of the chambers and valves
    • Pericardium- encloses and protects the heart
    • (has a little bit of fluid to prevent friction rub)
  5. Blood flow/circulation
    • Pulmonary- goes thru lungs and provides O2 to go to the body
    • Cardiac/coronary- blood to heart
    • Systemic- O2 and nutrients to the body
    • Arteries- O2 and nutrients to the body
    • Veins- deoxygenated blood and waste away from the tissues
  6. Great Vessels of the heart
    • Super Vana Cava (SVC)- deoxygenated blood from the upper
    • body to the heart

    • Inferior Vana Cava (IVC)- deoxygenated blood from the lower
    • body to the heart

    Pulm A- De oxy blood from the RV to the lungs

    Pulm V- Oxy blood from the lungs to the LA

    Aorta- Oxy blood to the body
  7. Systemic Circulation
    • Supply tissues with O2 and nutrients       
    • Return waste to central circulation for
    • excretion
    • Jugular vein and carotid artery perfuse brain
    • SVC subclavian artery perfuse upper limbs
    • IVC and thoracic art perfuse lower limbs
  8. Blood Flow and Circulation
    • SVC/IVC and RA de oxy blood
    • Thru the tricuspid V to the RV
    • Pulmonary Art to the lungs
    • Lungs oxygenated blood
    • Pulmonary vein to the LA
    • LA thru mitral V to LV
    • LV to the Aortic V
    • Aorta to the body
  9. Cardiac Cycle
    • Systole- Ventricular contraction  
    • Diastole- Ventricle relaxation
    • Valves closes- sound
    • Valves open- silent
  10. Diastole
    • ventricle relaxes       
    • AV valve opens
    • Blood flows from the atria to the ventricles
    • Atria contracts to push the last 30% of blood to ventricles
  11. Systole
    • Closure of AV valve begins systole        
    • First heart sound S1 Lub
    • Ventricles contract
    • Closure of the SL valves
    • End of systole
    • Second heart sound Dub
  12. Cardiac Conduction System
    • SA nose (sinoartrial node, pacemaker)- keep
    • heart beat in normal range       
    • AV nose (atrioventricular nose)
    • Bundle of His- makes ventricles contract
    • Perkinjee fibers – makes ventricles contract
  13. Cardiac output Heart ability to pump
    • CO= SV x HR= amount of blood ejected from the
    • left ventricle each minute, 6L-8L/min
    •       
    • SV- Stroke Volume= amount of blood pumped in 1 heart beat

    HR- heart rate= number of beats per a minute
  14. Cardiac Landmarks
    Aortic-2nd ICS/RSB

    Pulmonic- 2nd ICB/LSB

    Tricuspid- 4th -5th ICS/LSB

    Mitral- 5th ICS Left MCL
  15. Cardiac Emergency- requires rapid assessment and
    intervention
    • S/S= Chest pain, abn BO, inadequate tissue
    • perfusion, arrhythmias, change of LOC, pulmonary edema, fluid volume overload       

    • Assess presenting Sx- location, onset,
    • intensity, alleviating, aggravating factors
    •        
    • Testing- EKG’s, Cxr, lab test (cardiac muscle
    • damage, electrolytes imbalance- low Na more dangerous can cause siezures)
    •        
    • Need to activate rapid response team
  16. Pulse Pressure
    • Assess difference between systolic and diastolic
    • (difference)
    •        
    • Information about SV and Peripheral Vascular
    • resistance
    •        
    • Normal- approx. 40 mmhg
    •        
    • How much heart puts out
    •        
    • In elderly this number might be elevated because
    • of decrease in elascity

  17. Inspection
    Neck and Precordium (front)- checking for visible pulsation

    • Assess for pulsation in the carotids, precordium, and
    • epigastric

    • Norms:
    •        
    • positive pulsations in the neck (carotid)       
    • positive pulsations at the 4-5th ics
    • mcl
    • positive pulsation in the mid abdomen 
  18. Palpation
    1. Neck (carotid)

    • · Symmetrical Equal pulsation felt in both
    • carotids

    · Strong smooth and regular

    · No changes noted with each pulsation

    2. Precordium (heart)

    ·  Palpate over each cardiac landmark

    • ·  Assess for location, size, thrills, lifts heaves
    • (rising of the chest)

    · Thrill- abnormal fine palpable rushing

    • · Lift/heaves- rise with each heart beat
    • (abnormal)

    Normal

    - No pulsation over the aortic and pulmonic areas

    • -  Positive palpation at the PMI (apical)usually
    • 1mm in size

    • -  No lifts, thrills, heaves (no rise or turbulent
    • blood flow)

    PMI (point of maximal impulse)

    PMI- pulsation felt at the apex of the heart

    • -       
    • Apex- mitral/left ventricular area 5th
    • ICS/MCL

    • -       
    • If difficulty palpating the PMI have pt lean
    • forward or have pt lay on the left side lateral position 
  19. Abdominal Aorta
    • - Assess in mid abdomen
    • Normal- slight pulsation especially in thin
    • people
    • Aneurysms- weaken of muscles
  20. Percussion (limited value for cardiac assessment)
    - Assess to locate cardiac borders

    - Assess from left of the chest to midline

    - Sound will change from resonance (hollow sound) to dullness at the MCL 3-6 ICS

    - Difficult to percuss right border of the heart because it is where the sternum is. 
  21. Auscultation
    • Systematic manner
    •        
    • Listening for sounds that identify valve
    • closures
    •        
    • Usually start at Aortic, pulmonic, tricuspid,
    • mitral
    •        
    • Focus on S1 and S2
    •        
    • Listen to the four cardiac landmarks for S1 and
    • S2
  22. S1
    • Lub
    •        
    • Closure of the mitral and tricuspid valves
    •        
    • Occurs with the onset of ventricular contraction
    •        
    • Best heard in the apical area
    •        
    • Described as low pitched and dull
    •        
    • Louder at tricuspid and mitral areas
  23. S2
    •        
    • Dub
    •        
    • Closure of the aortic and pulmonic valve
    •        
    • The end of systole
    •        
    • Best heard at the base
    •        
    • Described as a high pitched and shorter than S1
    •        
    • Louder at aortic and pulmonic areas
  24. Split S2
    • Aortic valves closes slightly earlier than the pulmonic
    • valve

    Heard best more on the right (on aortic side)
  25. abnormal sounds
    • 1. Murmur     
    • Caused my turbulent blood flow
    • Valve not opening and closing completely
    • Assess- where this is best heard and where it is on the cardiac cycle   
    • Graded from 1-6 (cards use this)
    • Significance can be seen as benign or serious
    • (may need to replace)
    • Constricted vessels trying to push blood flow

    • 2. Bruits     
    • Swooshing sound heard over a major vessel
    • Usually caused by an overextended or blocked vessel, turbulence
    • Can be heard over the carotid or abdominal
    • aortic area

    Pt with Fistula may have a bruit sound which is normal

    • 3. Pericardical Friction Rub     
    • Caused by inflamed pericardial tissue
    • Sounds like grating/rubbing sound
    • Need to tell the difference between pleural
    • friction rub

    4. S3 and S4 are abnormal sounds S3 however is normal in children and young adults
  26. Peripheral Vascular Assessment
    1. Assess blood pressure

    2. Circulation, sensation, movement (CSM)

    3. Assess temp, color, skin

    • 4.  Assess peripheral pulses (assess rhythm,
    • strength and amplitude size fullness. Do not have to count lower extremities.
    • Use the pad of your fingers and Doppler if need be.

    5. Always check both extremities to compare- equal and strong bilaterally.

    • 6.  Assess for edema
    •     
    • Assess the entire body       
    • Dependent areas (feet)
    • Edema with obscure bony prominences       
    • Pitting edema (grade it 1+ ect depending on how much you pushed in)  
    • Compare
    • Grade 1-4
  27. PVA cont
    • 1. Assess for phlebitis (inflammation of a vein)     
    • Calf circumstance
    •   
    • Color, warm, edema       
    • Normal- equal calf circumference, legs are warm,
    • equal consistent color, no swelling

    • Concerns about thrombosis especially in legs
    • cause this can travel

    • 2. Assess pain
    •      
    • Location, description (scale)what causes pain
    • and how long does it last, what relieve the pain?
    •        
    • Assess numbness tingling cramping, changes of sensation (indicative of lack of o2), better, worst sudden or gradual onset,
    • associated with activity?
    •      
    • When pts have surgery u expect pain but make sure pain is related to surgery and not circulation. Check CSM

    • 3. Lymph nodes
    •      
    • Cervical       
    • Supraclavicular
    • Axillary
    • Horizontal and vertical lymph nodes in the legs
    • Normal- nonpalpable, small, mobile, nontender, soft
  28. Diagnostic testing
    1. CXR- enlarged heart

    2. EKG- chest pain, MI, ischemia

    3. Echocardiogram- can tell u how the valves are working

    4. Cardiac stress test- treadmill

    5. Holter monitor- palpitations

    • 6. Cardiac enzymes, troponin- blood levels
    • determine muscle damage

    7. Lipid and blood sugar

    8. BNP- blood test indicative for heart failure

    9. ABGs – Ph, O2 and Co2 levels

    • 10.  Electrolytes-
    • cardiac function

    • 11.  Cardiac
    • cath- invasive test/treatment (stent)
  29. Nursing Dx
    -  Decreased cardiac output

    -  Activity intolerance

    -  Fatigue

    -  Fluid volume excess

    -  Ineffective peripheral tissue perfusion

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