health assessment.cardiac & pvs

8/10/2019 Health Assessment.Cardiac & PVS

http://slidepdf.com/reader/full/health-assessmentcardiac-pvs 1/56

heartchapter 19



blood flow

• know flow of blood &

anatomy• any questions about

flow of blood or

anatomy of heart?



cardiac cycle

• what is happening during s1, s2, s3 &

s4?• s1: systole-mitral & tricuspid valves

close

• s2:systole-aortic and pulmonic valvesclose

• s3: blood empties from atria to

ventricles; passive filling of ventricles-diastole

• s4:at end of diastole-atria contract and

push last of blood into ventricles (atrial

kick)



cardiac cycle

• s1 sound is created when AV valves

close-where is this sound heard loudest?

• at apex - where is this?

• s2 sound is created when SL

valves close-where is this sound

heard loudest?

• at base - where is this?• what is a split s1/s2?

http://www.blaufuss.org/arrow/S2.html


Clear explanation of heart sounds s1/s2, where they are heard & what is happening-follow links









extraneous heart sounds• **s3 when do we hear this? physiologic

& pathologic reasons• physiologic: young adults, children,

pregnancy

• patho: heart failure, regurgitation - V gallop• **s4 when do we hear this?

physiologic & pathologic

reasons

• physiologic: 45/50’s after exercise

• patho: heart dz, HTN - A gallop


Clear explanation of heart sound s4, where they are heard & what is happening-follow links






murmur• *be able to define

• how do we document these sounds? p

478

• timing

• loudness - graded

• pitch

• pattern

• quality

• location- where heard

• radiation - travel?

• position - of pt



precordium

• know & be able to define

heave/lift/pulsations/apical

impulse/thrill/murmur

• when/how you note these & when they willoccur (during inspection, palpation,

auscultation, etc)

• which part of the stethoscope will we use for

s1, s2, s3 and s4?

• which set of pts will we have a difficult time

palpating the apical impulse?



auscultation heart sound

locations

• **know location of each -

may have to draw on blank

picture & label

• **read over Z pattern on pg

475

• which pulse is associatedwith s1? carotid

• what is a pulse deficit?



other terms

• angina-we ask about chest “discomfort” here-pain is subjective-

this occurs when the hearts own blood supply cannot keep up

with metabolic demand

• DOE-dyspnea on exertion-shortness of breath-when does this

happen?

• PND-paroxysmal nocturnal dyspnea-occurs with heart failure-

lying down increases pressure on heart workload-pt feels short

of air

• nocturia-increased urinary frequency during the night-due to

fluid reabsorption when lying down occurring with heart failure

• pericardial friction rub-inflammation of pericardial sac

surrounding the heart-sounds like rubber against leather-best

heard pt sitting up and learning forward breath held on expiration



Cardiovascular DZ

• list modifiable vs non-modifiable risk

factors

• warning signs of hypoxia



neck vessel assessment

• why do we palpate carotid artery one at a

time?

• what is a bruit & what does it indicate?(*difference between bruit & murmur)

• be able to describe the inspection of the

jugular vein - slide 21/pg 472 - always read

specific inspection instructions in book if onslide r/t test questions



PVSchapter 20



PVS

• look over anatomy

• this HH is VERY similar to cardiacassessment questions except for HPI

• **VTE risk assessment (select all that

apply would be applicable here) knowdifferences between modifiable and

non-modifiable-slide 30 & pg



occlusion of

arteries vs veins

• slide 38, 40; chart on page 521

• veins=towards (deoxygenated)

• painful! • large veins, edema pitting/non, thick skin, warm, erythema,

thrombosis, etc

• homans sign

• arteries=away (oxygenated)

• 5 P’s - pain, pallor, pulseless, paresthesia, paralysis

• loss of hair, thick nails, thin skin, cap refill, cold extremities, etc

• allen test



signs

• be able to describe what the test is determining, the

process, and what a positive (or negative) sign

indicates

• allen test-evaluate the adequacy of collateral ARTERIAL circulation in the hand-read over steps on

pg. 509-POSITIVE test is when the blood flow does

NOT return to the hand within 2-5 seconds

• homans sign-may indicate DVT or superficialthrombophlebitis-read over steps on slide 40-

POSITIVE sign means potential for DVT or

thrombophlebitis



terms

• ischemia-deficient supply of oxygenated arterial blood to a

tissue caused by obstruction of a blood vessel-partial blockage

creates insufficient supply and ischemia may be apparent only

at exercise when oxygen needs increase (claudication occurs

with activity, relieved with rest) • edema-swelling-occurs in both extremities when right sided HF

is present-unilaterally when there is an obstruction

• orthostatic hypotension-drop in systolic BP >20 mmHg and

diastolic of >10 mmHg-results in feeling lightheaded or

dizziness-results primarily from blood pooling in lowerextremities which results in decreased venous return and

decreased cardiac output



A patient has been diagnosed with Right-Sided

Congestive Heart Failure and is confused about return

of deoxygenated blood from the tissue. To clarify the

confusion, which chamber of the heart receives blood

from systemic circulation?

• 1. Left atrium

• 2. Right atrium

• 3. Right ventricle• 4. Left ventricle



answer: 2 right atrium



nurse is listening to client's heartbeat & focusing on 2nd

heart sound, which heart valves produce this sound?

• 1. Pulmonic & Mitral

• 2. Aortic & Pulmonic

• 3. Mitral & Tricuspid

• 4. Tricuspid & Aortic



answer: 2. Aortic & Pulmonic

• S2



a nurse is performing a cardiac assessment on a 22

year old. the first heart sound can best be heard at

which of the following locations?

• 1. third or fourth intercostal space

• 2. the apex with the stethoscope bell

• 3. second intercostal space, left

midclavicular line

• 4. fifth intercostal space, leftmidclavicular line



answer: 4 fifth intercostal space,

left midclavicular line

• S1 can best be heard at the fifthintercostal space, midclavicular line.

• this is just knowledge of where heart

sounds can be heard-on powerpoint

h lt ti th h t hi h f th f ll i



when auscultating the heart, which of the following

characteristics or statements best describes the

first heart sound?

• 1. heard late in diastole

• 2. heard early in diastole

• 3. closure of the mitral and tricuspid

valves

• 4. closure of the aortic and pulmonicvalves

answer:3 closure of the mitral



answer:3. closure of the mitral

and tricuspid valves

S



A 12 year old client has an S3 heart

sound. The nurse knows:

• 1. she can document this as an

abnormal finding and continue the

assessment• 2. physiologic S3 is common in children

and young adults

• 3. she must contact the attendingphysician immediately, something is

wrong



answer:2. physiologic S3 is common in

children and young adults

• An S3 heart sound, also called a

ventricular gallop, occurs early indiastole when blood is flowing from the

atria into the ventricles and causes

vibrations. S3 is a physiologic heart

sound in children, young adults, andpregnant females

Which of the following risk factors for



g

coronary artery disease cannot be corrected?

(non-modifiable)

• 1. Cigarette smoking• 2. DM

• 3. Heredity

• 4. HTN



answer: 3 heredity

• Because “heredity” refers to our genetic

makeup, it can’t be changed. Cigarette

smoking cessation is a lifestyle changethat involves behavior modification.

Diabetes mellitus is a risk factor that

can be controlled with diet, exercise,

and medication. Altering one’s diet,exercise, and medication can correct

hypertension.

A murmur is heard at the second left intercostal



A murmur is heard at the second left intercostal

space along the left sternal border. Which valve

area is this?

• 1. Aortic• 2. Mitral

• 3. Pulmonic

• 4. Tricuspid



answer: 3 pulmonic

• Abnormalities of the pulmonic valve are

auscultated at the second left intercostal

space along the left sternal border. Aortic

valve abnormalities are heard at the second

intercostal space, to the right of the sternum.

Mitral valve abnormalities are heard at the

fifth intercostal space in the midclavicular

line. Tricuspid valve abnormalities are heard

at the third and fourth intercostal spaces

along the sternal border.

Wh i i h ld h l h h d f h b d i



What position should the nurse place the head of the bed in to

obtain the most accurate reading (in our case, to visualize it)of

jugular vein distention?

• 1. High-fowler’s • 2. Raised 10 degrees

• 3. Raised 30 degrees

• 4. Supine position



answer: 3. Raised 30 degrees

• 30-45 is ideal. Inclined pressure can’t

be seen when the client is supine or

when the head of the bed is raised 10degrees because the point that marks

the pressure level is above the jaw

(therefore, not visible). In high Fowler’s

position, the veins would be barely

discernible above the clavicle.

The client is diagnosed with pericarditis. When

i th li t th i bl



assessing the client, the nurse is unable

to auscultate a friction rub. Which action should the

nurse implement?

• 1. Notify the health-care provider.

• 2. Document that the pericarditis has

resolved.

• 3. Ask the client to lean forward and

listen again.

• 4. Prepare to insert a unilateral chest

tube



answer: 3. Ask the client to lean forward and

listen again.

• pericarditis is best heard when the

patient is sitting up and learning

forward

Two nurses are taking an apical radial pulse and note a



Two nurses are taking an apical-radial pulse and note a

difference in pulse rate of 8 beats per minute. The nurse

would document this difference as which of the following?

• 1. Pulse deficit • 2. Pulse amplitude

• 3. Ventricular rhythm

• 4. Heart arrhythmia



answer: 1. Pulse deficit

• when the apical heart rate and the

radial heart rate do not coincide, this is

termed pulse deficit



When evaluating a client's circulation the nurse should

include which assessments? Select all that apply.

• 1. Palpation of pulses

• 2. Skin temperature of bilateralextremities

• 3. Skin color

• 4. Moles & freckles• 5. Hair on the legs and feet



Answer: 1, 2, 3 & 5

• 1. Palpation of pulses

• 2. Skin temperature of bilateral

extremities

• 3. Skin color

• 5. Hair on the legs and feet

• These are indicative of circulation to

and from the extremities

A 65-year-old patient with a history of heart failure comes to



y p y

the clinic with complaints of "being awakened from sleep with

shortness of breath." Which action by the nurse is most

appropriate?

• 1. Obtain a detailed history of the patient's

allergies and history of asthma.

• 2. Tell the patient to sleep on his or her

right side to facilitate ease of respirations.

• 3. Assess for other signs and symptoms of

paroxysmal nocturnal dyspnea.

• 4. Assure the patient that this is normal

and will probably resolve within the next

week.



answer: 3. Assess for other signs and symptoms of

paroxysmal nocturnal dyspnea.

• The patient is experiencing paroxysmalnocturnal dyspnea: being awakened

from sleep with shortness of breath and

the need to be upright to achieve

comfort.

During an assessment of a 68-year-old man with a recent onset of

right sided weakness the nurse hears a blowing swishing sound



right-sided weakness, the nurse hears a blowing, swishing sound

with the bell of the stethoscope over the left carotid artery. This

finding would indicate:

• 1. a valvular disorder.

• 2. blood flow turbulence.

• 3. fluid volume overload.

• 4. ventricular hypertrophy



answer:2. blood flow turbulence.

• A bruit is a blowing, swishing sound

indicating blood flow turbulence;

normally none is present.

Th i i t lt t f h t



The nurse is preparing to auscultate for heart

sounds. Which technique is correct?

• 1. Listen to the sounds at the aortic,

tricuspid, pulmonic, and mitral areas.

• 2. Listen by inching the stethoscope in a

rough Z pattern, from the base of the heartacross and down, then over to the apex.

• 3. Listen to the sounds only at the site

where the apical pulse is felt to be the

strongest.

• 4. Listen for all possible sounds at a time at

each specified area.

answer:B) Listen by inching the stethoscope in a rough Z



pattern, from the base of the heart across and down, then

over to the apex.

• Do not limit auscultation of breath

sounds to only four locations. Sounds

produced by the valves may be heardall over the precordium. Inch the

stethoscope in a rough Z pattern from

the base of the heart across and down,

then over to the apex. Or, start at the

apex and work your way up.

When performing a peripheral vascular assessment on a patient



When performing a peripheral vascular assessment on a patient,

the nurse is unable to palpate the ulnar pulses. The patient's skin

is warm and capillary refill time is normal. The nurse should next:

• 1. check for the presence of claudication.

• 2. refer the individual for further evaluation.

• 3. consider this a normal finding and

proceed with the peripheral vascular

evaluation.

• 4. ask the patient if he or she hasexperienced any unusual cramping or

tingling in the arm.



answer:3. consider this a normal finding and proceed with

the peripheral vascular evaluation.

• It is not usually necessary to palpate

the ulnar pulses. The ulnar pulses are

often not palpable in the normal

person. The other responses are not

correct.



When using a Doppler ultrasonic stethoscope, the nurse

recognizes arterial flow when which sound is heard?

• 1. Low humming sound

• 2. Regular "lub, dub" pattern

• 3. Swishing, whooshing sound

• 4. Steady, even, flowing sound



answer:3. Swishing, whooshing sound

• When using the Doppler ultrasonicstethoscope, the pulse site is found

when one hears a swishing, whooshing

sound.

During an assessment of an older adult, the nurse should expect



to notice which finding as a normal physiologic change associated

with the aging process?

• 1. Hormonal changes causing vasodilation and a

resulting drop in blood pressure

• 2. Progressive atrophy of the intramuscular calfveins, causing venous insufficiency

• 3. Peripheral blood vessels growing more rigid with

age, producing a rise in systolic blood pressure

• 4. Narrowing of the inferior vena cava, causing lowblood flow and increases in venous pressure

resulting in varicosities

3 P i h l bl d l i i id ith



answer: 3. Peripheral blood vessels growing more rigid with

age, producing a rise in systolic blood pressure

• Peripheral blood vessels grow more

rigid with age, resulting in a rise in

systolic blood pressure. Aging

produces progressive enlargement of

the intramuscular calf veins, not

atrophy. The other options are notcorrect.

during a cardiovascular assessment the nurse finds a bluish

tinge on the clients lips fingers and toes what is the



tinge on the clients lips, fingers, and toes. what is the

appropriate documentation for this finding?

• 1. blue tinged extremities

• 2. central and peripheral cyanosis

• 3. bad circulation

• 4. central and peripheral pallor



ANSWER: 2. central and peripheral cyanosis

• inadequate blood flow to the peripherymay be due to several different things

but will result in central & peripheral

cyanosis

A Nurse assesses the client for the presence of homan's



A Nurse assesses the client for the presence of homan s

sign- which one indicates that this sign is positive?

• 1. no pain

• 2. pain on dorsiflexion of the foot

• 3. pain on plantar flexion of the foot

• 4. pain when bringing knee to chest

answer: 2.pain on dorsiflexion

f f t



of foot

• Homan’s sign has to do with pain in the

calf area indicating possible DVT/VTE

A client has a 1+/0-4+ dorsalis pedis pulse on the right. The

lower leg is cool pale and painful This description is most



lower leg is cool, pale, and painful. This description is most

consistent with:

• 1. venous insufficiency

• 2. arterial insufficiency

• 3. normal finding

t i l i ffi i



answer: arterial insufficiency

• Arterial insufficiency is inadequate

circulation in the arterial system, whichresults in diminished pulses; cool, shiny

skin; deep muscle pain; absence of hair

on the toes; pallor on elevation; and a

red color when dependent.

health assessment.cardiac & pvs

Documents