HESI Heart and Neck Vessels PDF

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HESI: Heart & Neck Vessels Patient has frequent periods of dyspnea, dizziness, and minor chest discomfort. What should the nurse assess for? o Determine if the client is currently experiencing any angina (heart pain) Cardiac telemetry monitoring = monitoring the electrical activity of the heart for an extended period of time Fatigue related to stress or depression may worsen in the morning or be present all day. Fatigue related to decreased cardiac output may worsen in the evening A left ventricular heave = a forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle is seen at the apex of the heart (5th intercostal space, left midclavicular line) Base of the heart is located at the right sternal border 2nd intercostal space (where the aortic site it located) o Remember the aortic and pulmonic site are located at the base just on 2 different sides Rolling half-way onto a patients left side when assessing the heart will bring the heart closer to the chest wall and allow to hear easier Chest percussion helps outline the boarders of the heart to detect enlargement o Heart enlargement is more accurately detected with a chest x-ray and echocardiogram You will hear S1 & S2 at the second intercostal space S1 typically goes along with the carotid artery pulse, so you can determine the S1 is then the sound that occurs with each pulsation Nurse hears a split S2 at the second intercostal space during inspiration o The nurse should document this as normal  A split S2 is a normal finding and is a result of a slightly asynchronous closing of the aortic and pulmonic valves  A split S2 is heard best during inspiration at the pulmonic site, the left second intercostal space Nurse hears swooshing sound the coincides with S1 what does this mean o Systolic murmur Presence of an S3 may be an early indicator of the onset of heart failure so the nurse should then assess for other signs of heart failure like JVD Heart murmurs are graded based on the intensity of the sound (ranges from 16) which can be heard when the stethoscope is lifted off the chest wall S3 is a low-pitched extra heart sound that is best heard at the apex of the heart with the bell (think about it, dull noise = use bell) Assessing for JVD includes… o...