Heart & Peripheral Vascular System

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Author:
kreed
ID:
71460
Filename:
Heart & Peripheral Vascular System
Updated:
2011-03-07 21:26:49
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Abnormal Findings
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Description:
Health Assessment
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  1. Abnormal findings assessed during inspection of the patient's general appearance (skin color, and breathing effort)
    • Dyspnea
    • Cyanosis
    • Pallor
    • Use of accessory muscles to breathe
  2. ASSESS THE PERIPHERAL VASCULAR SYSTEM
    Abnormal findings assessed while palpating temporal & carotid pulses for amplitude:
    • Tenderness
    • edema
  3. Abnormal findings when palpating pulses:
    • Rates >100 beats/min (tachycardia)
    • Rates<60 beats/min (bradycardia)
    • Irregular rhythms w/out any pattern
    • Coupled beats (two beats that occur close together)
    • Exaggerated or bounding upstroke
    • pulses that are weak, small, thready
  4. Abnormal findings when inspecting the jugular vein for pulsations:
    • fluttering or oscillating
    • irregular rhythms
    • unusually prominent waves (which may indicate right-sided heart failure)
  5. Abnormal findings found when measuring blood pressure:
    • elevated systolic or diastolic pressures (hypertension)
    • lowered systolic or diastolic pressures (hypotension)
    • pulse pressure should not vary more than 5-10 mm Hg between the two arms
  6. Abnormal findings associated w/bp from the supine position to standing:
    A decrease in systolic BP >20mm Hg & symptoms such as dizziness indicate orthostatic (postural hypotension) may be due to fluid volume deficit, drugs, prolonged bed rest)
  7. Abnormal findings when inspecting & palpating upper & lower extremities for skin turgor
    • Tenting (when skin doesn't immediately fall back into place)....indication of fluid volume deficit
    • Pitting edema (indention of fingers remains in skin.....indication of excess fluid
  8. Abnormal findings when inspecting & palpating upper extremities for symmetry
    One arm is larger in circumference than the other.....lymphedema
  9. Abnormal finding when inspecting & palpating upper extremities for skin integrity, color and temperature:
    • Thickening skin, skin tears, ulceration
    • Arterial insufficiency may cause cold extremities in a warm environment
    • Pallor or mottling when the extremity is elevated
  10. Abnormal findings when inspecting & palpating upper extremities for capillary refill, color and angle of nail beds
    • capillary refill time >2 seconds....indicates poor perfusion
    • Clubing of fingers (angle of nail disappears, becoming >160 degrees).....indicating chronic hypoxia
  11. Abnormal findings when inspecting & palpating lower extremities:
    Use the 5 P's to remember abnormal findings: pulseless, pale, paresthesia, pain and poikilothermia (cold)
    • Decrease in lack of hair peripherally, skin that appears thin, shiny & taunt.....indicates arterial insufficiency
    • stocking anesthesia (where legs feel numb in a pattern resembling stockings
    • distended veins in the anteromedial aspect of thig & lower leg or calf from knee to ankle
    • edema....impaired venous blood flow
    • >thigh circumference (immobile clients w/reduced sensation).....deep vein thrombosis
  12. Abnormal Findings when inspecting the anterior chest wall for contour, pulsations, lifts, heaves & retractions
    • Sternal depression or asymmetry
    • Retraction(when some of the tissue is pulled into the chest on the precordium).Marked retraction of apical space.....indicates pericardial disease or RV hypertrophy
    • Apical pulsation observed after exertion....hyperthyroidism or LV hypertrophy
    • Displaced pulsations.....cardiac anomalies or change in heart size
  13. Abnormal findings when palpating apical pulse for location
    • PMI moved laterally....vetricular hypertrophy or myocardium enlarged
    • Displaced PMI downward & to the right....chronic obstructive lung disease or overinflated lungs
  14. Abnormal findings when ausculating heart sounds for rate
    • Rates >100
    • Rates <60
  15. Abnormal findings when ausculating heart sounds for rhythm:
    1st hear sound seems accented, diminished or muffled or when intensity varies w/different beats
  16. Abnormal findings when ausculating heart sounds for splitting:
    • When the mitral & tricuspic valves do not close at the same time S1 sounds as if it were split into two sounds instead of one
    • systolic & diastolic murmurs are also abnormal
  17. Abnormal findings when ausculating the carotid artery:
    bruits......occlusion of the vessel
  18. Abnormal findings when estimating jugular venous pressure for pulsations:
    Jugular venous pressure exceeds 1" above the level of the manubrium
  19. Abnormal findings when palpating epitrochlear lymph nodes for size, consistency, mobility, boarders, tenderness, and warmth
    • enlarged, firm, warm, moveable & tender nodes......infection of the ulnar aspect of the forearm & 4th & 5th fingers
    • One arm is larger in circumference than the other....lymphedema
  20. Abnormal findings when palpating inguinal lymph nodes for size, consistency, mobility, borders, tenderness and warmth
    • Enlarged, tender, firm, warm, freely moveable nodes.....inflammatory process distal to these nodes such as in the leg, vulva, penis or scrotum
    • Circumference of one leg is larger than other....lymphedema
  21. Abnormal findings when calculating the ankle brachial index to est. arterial occlusion
    • An ABI <0.9.....indicates peripheral vascular disease
    • An ABI <0.6.....associated w/ intermittent claudication
    • ABI <0.2 reflects sever ischemia leading to gangrene
  22. Abnormal findings when performing Trendelenburg's test to evaluate competence of venous valves in client's w/varicose veins
    veins fill rapidly, valves may be imcompetent & varicose veins may be present
  23. ...Abnormal findings when palpating the precordium for pulsations, thrills, lifts & heaves
    Chest seems to lift or heave w/heart beat....indicates LV enlargement
  24. Abnormal findings when palpating base of heart
    • Pulsations....indicate aortic aneurysm
    • Thrill....associated w/a murmur for a disorder of the aortic or pulmonic valve
  25. Abnormal findings when palpating left sternal boarder:
    • Sustained lifts or palpatons....indicate RV hypertrophy
    • Pulsations....indicate pulmonary hypertension
    • Thrill....associated w/pulmonic valve stenosis
  26. Abnormal findings when palpating the apex of heart at the 5th ICS
    • Forceful pulsation, displaced laterally or downward....associated w/increased cardiac output or LV hypertrophy
    • Thrill.....indicates murmur
  27. Abnormal findings when palpating the epigastric area for pulsations
    bounding pulsations....indicate abdomial aortic aneurysm or aortic valve regurgitation

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