Module 9 Heart & Vessels PDF

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Heart Sound Locations: https://quizlet.com/516427121/5-areas-for-listening-to-the-heart-flash-cards/?new ● Thorax, Lung and Heart Assessment: Looking underneath the skin, where is the sound and how to describe it ● Cardiac output = stroke volume (how much blood is being pushed outside of the heart) x heart rate (how fast is the heart pumping) ● If you hear a bruit in the carotid artery, there is an obstruction there

1. Describe the normal and abnormal heart sounds that you might hear on a cardiac assessment and explain what causes them S1, S2 Systole: Heart filling up with blood. Heart sounds normally happen very quickly. The first heart sound (S1) is the result of closure of the AV valves: the mitral and tricuspid valves. As mentioned previously, S1 correlates with the beginning of systole (see Box 21-2 for more information about S1 and variations of S1). S1 (“lub”) is usually heard as one

sound but may be heard as two sounds. If heard as two sounds, the first component represents mitral valve closure (M1) and the second component represents tricuspid closure (T1). With ventricular emptying, the ventricular pressure falls and the semilunar valves close. This closure produces the second heart sound (S2), which signals the end of systole. After closure of the semilunar valves, the ventricles relax. Diminished S1= valve not fully open, mitral valve deficiency S3 and S4 are referred to as diastolic filling sounds, or extra heart sounds, which result from ventricular vibration secondary to rapid ventricular filling. 2. How do you examine the carotid pulse? Located in the groove between the trachea and the right and left sternocleidomastoid muscles. Slightly below the mandible, each bifurcates into an internal and external carotid artery. The carotid artery pulse is a centrally located arterial pulse. Because it is close to the heart, the pressure wave pulsation coincides closely with ventricular systole. The carotid arterial pulse is good for assessing amplitude and contour of the pulse wave. The pulse should normally have a smooth, rapid upstroke that occurs in early systole and a more gradual downstroke. 3. What is capillary refill? How do you assess it? It is used to monitor dehydration and the amount of blood flow to tissue.Test capillary refill in nail beds by pressing the nail tip briefly and watching for color change 4. What is the proper sequence for auscultating heart sounds? Cover the entire precordium. As you auscultate the aortic area, pulmonic area, left atrial area, right atrial area, left ventricular area, and right ventricular area. Concentrate on systematically moving the stethoscope from left to right across the entire heart area from the base to the apex (top to bottom) or from the apex to the base (bottom to top). 5. How do you grade pulses, edema, murmurs? 0 = Absent 1+ = Weak, diminished (easy to obliterate) 2+ = Normal (obliterate with moderate pressure) 3+ = Strong (obliterate with firm pressure)

4+ = Bounding (unable to obliterate) 6. How do you grade edema? Pitting, documented as:

1+ = slight pitting 2+ = deeper than 1+ 3+ = noticeably deep pit; extremity looks larger 4+ = very deep pit; gross edema in extremity 7. How do you grade murmurs? Grade 1: Very faint, heard only after the listener has “tuned in”; may not be heard in all positions Grade 2: Quiet, but heard immediately on placing the stethoscope on the chest Grade 3: Moderately loud Grade 4: Loud Grade 5: Very loud, may be heard with a stethoscope partly off the chest Grade 6: May be heard with the stethoscope entirely off the chest 8. What are the terms that describe normal heart characteristics? Rate, sounds, vibrations Rate should be 60–100 beats/min, with regular rhythm. A regularly irregular rhythm, such as sinus arrhythmia when the HR increases with inspiration and decreases with expiration, may be normal in young adults. S1 and S2 heart sounds are normally present. S1 is louder and S2 may be split The S2 sound depends on the closure of the aortic and pulmonic valves. Closure of the pulmonic valve is delayed by inspiration, resulting in a split S2 sound. The apical impulse is palpated in the mitral area and may be the size of a nickel (1–2 cm).Amplitude is usually small—like a gentle tap. The duration is brief, lasting through the first two-thirds of systole and often less. In obese clients or clients with large breasts, the apical impulse may not be palpable.

9. What are the terms that describe abnormal characteristics? Rate, sounds, vibrations, palpations? Bradycardia (less than 60 beats/min) or tachycardia (more than 100 beats/min) may result in decreased CO2. A pulse deficit (difference between the apical and peripheral/radial pulses) may indicate atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block Pulsations, which may also be called heaves or lifts are abnormal findings Ejection sounds or clicks (e.g., a mid-systolic click associated with mitral valve prolapse). The apical impulse may be impossible to palpate in clients with pulmonary emphysema. If the apical impulse is larger than 1–2 cm, displaced, more forceful, or of longer duration, suspect cardiac enlargement. 10. What is the difference between a thrill, bruit, and murmur? Where might you find them and what would they look or feel like? THRILL-Palpable vibration over a murmur A thrill is palpated over the second and third ICS; a thrill may indicate severe aortic stenosis and systemic hypertension. A thrill palpated over the second and third left ICSs may indicate pulmonic stenosis and pulmonic hypertension. Bruit- Auscultated sound over a vessel (carotid artery, aortic artery)Turbulent sound associated with occlusion (turbulent sound due to narrowed vessel) SWOOSH Murmurs-Auscultated sound over a valve Turbulent blood flow in which a swooshing or blowing sound may be auscultated over the precordium. ALSO SWOOSH

11. How would you locate the mitral area of the heart? Fifth Intercostal space (ICS), left mid-clavicular line 12. Where is the pulmonic valve auscultated? Second left intercostal space (ICS), left sternal border 13. A client comes to the clinic and states that he was told that he has peripheral vascular disease. He asks the nurse " What does this mean?" How will the nurse answer this client? What should the nurse teach the client about self care related to health promotion and prevention? What are some risk factors that the nurse needs to discuss with the client? PVD is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm. This can happen in your arteries or veins. PVD typically causes pain and fatigue, often in your legs, and especially during exercise. Symptoms: heaviness of legs, aching sensation in legs aggravated by standing or sitting for long periods of time, leg edema, or varicosities

Treatment consists of self care and blood thinners. Tobacco cessation, exercise, and a healthy diet are often successful treatments. When these changes aren't enough, medications or surgery can help.

14. What physical findings would the nurse expect to see in a client with PVD? What causes these findings?

Color of skin: pallor & rubor, especially when the legs are elevated suggests arterial insufficiency Edema:Bilateral edema may be detected by the absence of visible veins, tendons, or bony prominences. Bilateral edema usually indicates a systemic problem, such as heart failure, or a local problem, such as lymphedema, but lymphedema is always unilateral unless elephantiasis is diagnosed or prolonged standing or sitting (orthostatic edema).Unilateral edema is characterized by a 1-cm difference in measurement at the ankles or a 2-cm difference at the calf, and a swollen extremity. It is usually caused by venous stasis due to insufficiency or an obstruction. It may also be caused by lymphedema. A difference in measurement between legs may also be due to muscular atrophy. Muscular atrophy usually results from disuse due to stroke or from being in a cast for a prolonged time. Peripheral edema (swelling) results from an obstruction of the lymphatic flow or from venous insufficiency from such conditions as incompetent valves or decreased osmotic pressure in the capillaries. It may also occur with deep vein thrombosis (DVT). Risk factors for DVT include reduced mobility, dehydration, increased viscosity of the blood, and venous stasis. With leg or foot ulcers, edema can reduce tissue perfusion and wound oxygenation Peripheral ulcers: Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle.

15. What impulse causes the contraction of the heart electrical impulses by specialized sections of the myocardium regulate the events associated with the filling and emptying of the cardiac chambers. The process is called the cardiac cycle.

Electrical impulses, which are generated by the SA node and travel throughout the cardiac conduction circuit, can be detected on the surface of the skin. This electrical activity can be measured and recorded by electrocardiography (ECG, also abbreviated as EKG), which records the depolarization and repolarization of the cardiac muscle. 16. What physical findings would the nurse expect to see on a client with a history of chronic arterial insufficiency? What causes these findings? Pallor, arterial ulcer

17. What is the difference between arterial and venous insufficiency? What are the symptoms of each? Arterial insufficiency your arteries have trouble sending blood from your heart to peripherals. ● Pain: Intermittent claudication (cramping) to sharp, unrelenting, constant ● Pulses: Diminished or absent ● Skin characteristics: Dependent rubor ● Elevation pallor of foot ● Dry, shiny skin ● Cool-to-cold temperature ● Loss of hair over toes and dorsum of foot ● Nails thickened and ridged Ulcer characteristics: ●

Location: Tips of toes, toe webs, heel or other pressure areas if confined to bed

● ● ● ● ●

Pain: Very painful Depth of ulcer: Deep, often involving joint space Shape: Circular Ulcer base: Pale black to dry and gangrene Leg edema: Minimal unless extremity kept in dependent position constantly to relieve pain

VENOUS INSUFFICIENCY ● ● ● ● ● ● ● ● ● ● ● ● ●

Pain: Aching, cramping Pulses: Present but may be difficult to palpate through edema Skin characteristics: Pigmentation in gaiter area (area of medial and lateral malleolus) Skin thickened and tough May be reddish-blue in color Frequently associated with dermatitis Ulcer characteristics: Location: Medial malleolus or anterior tibial area Pain: If superficial, minimal pain; but may be very painful Depth of ulcer: Superficial Shape: Irregular border Ulcer base: Granulation tissue—beefy red to yellow fibrinous in chronic long-term ulcer ● Leg edema: Moderate to severe

18. How do venous wounds differ from arterial wounds? Why?

Venous Wounds Location: Venous leg ulcers usually develop on the inner lower leg, above the medial malleolus, gaiter area. Size and shape: Wounds are often shallow, but large, and typically have irregular edges that may also slope. Color: Typically, venous wounds appear ruddy red, with granular tissue. There may also be discoloration with yellow slough present. Appearance: Surrounding skin may be shiny, warm or scaly. Tunneling is uncommon. Exudate: These wounds often have a moderate to heavy amount of exudate, causing them to appear “wet.” Pain level: Individuals often describe a dull, aching pain. This pain is likely more related to venous hypertension and resulting edema rather than from the wound itself. Other distinguishing characteristics: In the case of infection, there is often an accompanying foul odor, and may be purulent. Venous ulcers are the most common form of lower extremity wound, accounting for 80% – 90% of all leg ulcers.1 Arterial wounds Location: Arterial wounds occur most often on the foot, in between or at the tips of the toes, at pressure points from foot wear, on the heels and around lateral malleolus (the bone on the outside of the ankle joint). Size and shape: Most likely round, with a “punched out” appearance. They may range in size from small to large, with well-defined edges. Color: Often occur yellow, brown or black in color. Skin may also appear pale and non-granulating. Appearance: Arterial ulcers are often deep, but may also appear shallow in early stages. Skin surrounding the wound is often thin, smooth, taut and dry. Loss of hair on the leg is also common.

Exudate: Unlike venous ulcers, arterial ulcers are often dry due to minimal drainage. Pain level: Reportedly very painful. Elevating the leg can increase this pain. Other distinguishing characteristics: Toenails often appear brittle, yellow, deformed, thick and dry. A patient’s pulse may be indistinguishable around the site of the wound. The area around the wound is likely cool or cold to the touch due to minimal blood circulation.

19. Describe the proper technique for listening to heart sounds. Position yourself on the client’s right side. The client should be supine, with the upper trunk elevated 30 degrees. Use the diaphragm of the stethoscope to auscultate all areas of the precordium for high-pitched sounds. Use the bell of the stethoscope to detect (differentiate) low-pitched sounds or gallops. Apply the diaphragm firmly to the chest, but apply the bell lightly. Focus on one sound at a time as you auscultate each area of the precordium. Start by listening to the heart’s rate and rhythm. Then identify the first and second heart sounds, concentrate on each heart sound individually, listen for extra heart sounds, listen for murmurs, and finally listen with the client in different positions

20. Explain what is happening during S1 and S2 heart sounds. S1 (lub), marks the beginning of systole and the closure of the mitral and tricuspid valves. Loudest at the apex S2 (dub), marks the end of systole (beginning of diastole) and the closure of the aortic and pulmonic valves. Loudest at the base. 21. It is important for the nurse to have a complete understanding of what PVD is, what causes it, what its symptoms are, how it is assessed on a physical exam, and what is done to treat it. The purpose of the peripheral vascular assessment is to identify any signs or symptoms of PVD including arterial insufficiency, venous insufficiency, or

lymphatic involvement. This is accomplished by performing an assessment first of the arms then the legs, concentrating on skin color and temperature, major pulse sites, and major groups of lymph nodes. ● ● ● ● ● ● ● ●

Observe arm size and venous pattern; also look for edema. Palpate the client’s fingers, hands, and arms, gand note the temperature. Palpate to assess capillary refill time. Palpate the popliteal and femoral pulses. Palpate the radial and ulnar pulses. Inspect legs for distribution of hair, temperature, lesions, ulcers, or edema. Palpate the dorsalis pedal, and posterior tibial pulses. Inspect for varicosities (varicose veins) and thrombophlebitis. Although peripheral venous disease (PVD) is not as common as peripheral arterial disease (PAD), it often occurs with PAD but can occur in isolation. Symptoms of PVD include: heaviness of legs, aching sensation in legs aggravated by standing or sitting for long periods of time, leg edema, or varicosities. PVD is often associated with delayed wound healing. Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle. A history of prior PVD increases a person’s risk for a recurrence. Symptoms such as an absence of a prior palpable pulse; cool, pale legs; thick and opaque nails; shiny, dry skin; leg ulcerations; and reduced hair growth signal peripheral arterial occlusive disease These disorders or abnormalities tend to be hereditary and cause damage to blood vessels. An essential aspect of treating PVD is to identify and then modify risk factors. Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, decreasing the risk for developing PVD. Drugs that inhibit platelet aggregation, such as aspirin (ASA) and/or clopidogrel (Plavix), may be prescribed to increase blood flow. Aspirin also prolongs the time it takes for blood to clot and is used to reduce the risks associated with PVD. Abnormal (ankle-brachial index) ABI findings, indicating PVD, are associated significantly with poorer walking endurance. For the  most reliable physical

findings of PVD are diminished or absent pedal pulses, the presence of femoral artery bruit, abnormal skin color and/or cool skin. 22. Arterial insufficiency is? What causes it, what its symptoms are, how it is assessed on physical exam and what is done to treat it? Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. It is one of the signs of PVD. Smoking significantly increases the risk for chronic arterial insufficiency Palpate the brachial pulses if you suspect arterial insufficiency. Perform position change test for arterial insufficiency. Perform the Allen Test: The Allen test evaluates patency of the radial or ulnar arteries. An Allen test is essential before arterial sampling (arterial blood gas) or arterial line insertion/placement. It is implemented when patency is questionable or before such procedures as a radial artery puncture. The test begins by assessing ulnar patency. Have the client rest the hand palm side up on the examination table and make a fist. Then use your thumbs to occlude the radial and ulnar arteries. Continue pressure to keep both arteries occluded and have the client release the fist. Note that the palm remains pale. Release the pressure on the ulnar artery and watch for color to return to the hand. To assess radial patency, repeat the procedure as before, but at the last step, release pressure on the radial artery Pallor, especially when elevated, and rubor, when dependent, suggests arterial insufficiency. Dark-colored toes and blisters are seen with arterial insufficiency.Loss of hair on the legs suggests arterial insufficiency. Often thin, shiny skin is noted as well.Ulcers with smooth, even margins that occur at pressure areas, such as the toes and lateral ankle, result from arterial insufficiency. Perform position change test for arterial insufficiency. If pulses in the legs are weak, further assessment for arterial insufficiency is warranted. The client should be in a supine position. Place one forearm under both of the client’s ankles and the other forearm underneath the knees. Raise the legs about 12 in above the level of the heart. As you support the client’s legs, ask the client to pump the feet up and down for about a minute to drain the legs of venous blood, leaving only arterial blood to color the legs ● Marked pallor with legs elevated is an indication of arterial insufficiency (Fig. 22-23C). Return of pink color that takes longer than 10 seconds and

superficial veins that take longer than 15 seconds to fill suggest arterial insufficiency. Persistent rubor (dusky redness) of toes and feet with legs dependent also suggests arterial insufficiency

23. Edema is a significant finding on an exam that indicates an alteration in cardiac function. Where would the nurse expect to find edema? How is it assessed? How is it measured? How is it documented? Palpate edema. If edema is noted during inspection, palpate the area to determine if it is pitting or nonpitting. Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present. Pitting edema is associated with systemic problems, such as heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insuffic...