Nurs 225 QUIZ 2

Function of CV system

• circulates O2,removes CO2

• removes waste from metabolism

  provides cell w/ nutrients

Precordium

chest walls that overlay the heart area

Base of the heart

THE TOP OF THE HEART

• Left atrium

• Small portion of right atrium

• superior/inferior venae cavae

• pulmonary veins

Apex of heart

BOTTEM OF HEART

• Right & Left Ventricle

Point of Maximal Impulse (PMI)

the location where cardiac impulse can be best palpated on the chest wall

• @ 5th intercostal space (L. mid clavicular line)

What are the 3 layers of the heart

• epicardium (outer layer)

  • contains: blood vessels

• myocardium (mid-layer)

  • contains: contractile tissue

• endocardium (innermost layer)

  • contains: vessels and nerves

How does blood flow through the heart

thru R. atrium → R. ventricle and is pushed into pulmonary arteries in the lungs →after getting O2 → blood goes back to the heart thru pulmonary veins → L. atrium → L. ventricle → to the rest of the body.

Systole

HEART MUSCLE CONTRACTS

• blood pumps from chambers → arteries

  • S1: max. point of contraction

Diastole

HEART MUSCLE RELAXES

• allows chambers to fill with blood

  • S2: relaxed phase/refills with blood

S1

mitral & tricuspid closure (LUB)

• heard at the apex

• max. point of contraction

S2

aortic & pulmonary closure (DUB)

• heard at L. sternal border

• relaxed phase/refills with blood

S3

EARLY DIASTOLE

• MITRAL MURMUR

• indicates Heart Failure

• heard after S2

S4

LATE DIASTOLE

• MITRAL MURMUR

• indicate hypertension/vascular resistance

• heard before S1

CV concerning symptoms

• chest pain

• dyspnea (shortness of breath)

• pain in LEFT shoulder/back/arm

• pallor

• arrhythmia

NORMAL CV findings

• NO murmurs

• chest appears w/o lifts, heaves, thrills

• PMI is visible & palpable (@ 5 ICS)

• heart rate & rhythm is normal

ASSESSMENT OF NECK VESSELS

• Inspect

jugular & carotid artery for pulsation

Palpation of Carotid Artery

1 side at a time

• +2 Normal

Abnormal finding in carotid artery

Thrills

• turbulent blood flow

Bruit (when auscultating)

Auscultate Carotid artery

USE BELL

• have patient hold breathe (so you don’t hear breathe sounds)

ASSESSMENT OF PRECORDIUM

• Inspect for…

Pulsations ( towards R. side of chest)

ASSESSMENT OF PRECORDIUM

• normal finding

pulsation at the PMI

ASSESSMENT OF PRECORDIUM

• abnormal findings

heaves or lifts (abnormal contraction)

ASSESSMENT OF PRECORDIUM

• palpate for…

lifts, heaves, thrills, PMI, pulsations

6 areas of palpation/auscultation of precordium

1. 2nd ICS right sternal border (aorta)

2. 2ns ICS left sternal border (pulmonic)

3. 3rd ICS left sternal border (Erb’s point)

4. 4th or 5th ICS lower left sternal border (tricuspid)

5. 5th ICS left mid clavicular (mitral)

6. Epigastric (subxiphoid)

   • @ the bottom of breastbone

PV system concerning symptoms

• leg pain/cramps

• swelling in arms/ legs with redness & tenderness

• numbness/coldness

• pallor

• INTERMITTENT CLAUDIFICATION

Intermittent Claudification

pain in leg when you exercise

PV SYSTEM ASSESSMENT (legs & arms)

• Inspect/note

• symmetry

• color of skin

• nail beds → color, texture, clubbing?

• lesions/masses

• hair distribution

PV SYSTEM ASSESSMENT

• palpating arms

asses capillary refill

• NORMAL: color returns in under 2 seconds

Peripheral Pulse Sites

• radial

• brachial

• femoral

• popliteal

• posterior tibal

• dorsalis pedis

PV SYSTEM ASSESSMENT

• Assess peripheral pulse

• rate, rhythm, equality, amplitude BILATERALLY

  • +2 = normal

Grading scale for amplitude of peripheral pulses

0: absent

1: diminished/ weak

2: normal/brisk/expected

3: bounding

What is the purpose of the Allen test?

find out which side of PT body has better perfusion/arterial flow

How do you preform Allen Test ?

1. Occlude BOTH ulnar and radial artery in ONE HAND

2. ask PT to make a fist several times

3. have PT open hand

4. release ULNAR artery pressure only

Normal finding for Allen test

hand regains blush within 2-5 seconds

• indicates NORMAL CIRCULATION

When do we evaluate Arterial Supply to Legs?

we evaluate if we suspect arterial deficit

How to evaluate Arterial Supply to Legs?

1. place PT lying down with BOTH LEGS about 60° up (until max. pallor of feet develop)

2. have PT flex ankles UP AND DOWN to drain venous blood

3. ask PT to sit up and dangle legs over side of bed

4. compare BILATERALLY

Normal finding for Evaluation of Arterial Supply to Legs

return of pinkness → 10 seconds

filling of veins in feel and ankle → 15 seconds

Abormal finding for Evaluation of Arterial Supply to Legs

• slow return of color & filling of veins

• RUBOR (arterial insuffenciency)

Common CVPV Nurs. Diagnosis

• decrease cardiac output

• ineffective tissue perfusion

• risk for shock

• impaired skin integrity

CVPV Nurs. Implementations

• promote circulation

• prevent clots

• decrease risk factors

• administer meds

IAPP

inspect, auscultate, percuss, palpate

what organs are in the RLQ

• appendix

• cecum

• iliac artery

• ascending colon

• bladder

• small intestine

• rectum

• ovary, fallopian tubes, uterus

• prostate

• ureter (R)what organs are in the

what organs are in the RUQ

• ascending colon

• duodenum

• gallbladder

• (R) kidney

• liver

• pancreas (head)

• transverse colon

• ureter (R)

what organs are in the LUQ

• descending colon

• (L) kidney

• pancreas (body & tail)

• spleen

• stomach

• transverse colon

• (L) ureter

what organs are in the LLQ

• bladder

• descending colon

• ovary, fallopian tubes, uterus

• prostate

• small intestine

• sigmoid colon

• ureter

Visceral Pain

organ specific pain/internal organ pain

• hard to localize

• cramping/burning/aching

Parietal Pain

inflammation of peritoneal lining (peritonitis)

• steady aching pain

• more precisely located

• worse than visceral

ALARM

???

Assessing ACUTE UPPER abdominal pain

just OLDCART it!

Assessing CHRONIC UPPER abdominal pain

could indicate:

• heart burn

• dyspepsia (indigestion)

• atypical respirations

• ALARM symptoms (dysphagia, vomiting)

Assessing ACUTE LOWER abdominal pain

• right lower

• sharp?

• continuous?

• intermittent?

• cramping?

Assessing ACUTE LOWER abdominal pain

• left lower

is the pain diffusing?

Assessing CHRONIC LOWER abdominal pain

• is there a change in bowel habits?

• change in stool?

• diarrhea? or constipation?

• intermittent pain w/ relief from shitting

Why do you ask patient to void B4 assessment?

pushing down on abdomen can cause PT to pee themself during assessment

What way do you position a PT for and abdominal assessment?

supine with knees flexed over a pillow

• to ensure abdominal relaxation

what side of PT do you stand on during abdominal assessment

right side

GI ASSESSMENT

• inspect/observe

• size, symmetry, contour

• skin condition (consistent) & color

• check for bulges & distension

• involuntary abdominal movements

  • peristalsis

  • pulsations

Peristalsis

involuntary constriction/relaxation of the muscles of the intestine

inspection landmarks

• epigastric

• umbilical

• suprapubic

GI ASSESSMENT

• auscultate abdomen

USE DIAPHRAGM

• listen to all 4 quadrants in different spots

• NOTE: pitch, frequency, intensity

Normal bowel sounds

• clicks/gurgles

• high pitch

• heard 5-34 per min

GI ASSESSMENT

• auscultation order

RLQ, RUQ, LUQ, LLQ (move clockwise)

Hypoactive Bowel Sounds

heard LESS frequently (> 5x a min)

Hyperactive Bowel Sounds

heard MORE frequently (<35x a min)

Absent Bowel Sounds

NO Bowel Sounds

• you MUST listen for 2 or more minutes b4 declaring bowel sounds are absent

borborygmi

stomach growling

• usually heard w/ hyperactive

GI ASSESSMENT

• auscultate abdominal arteries

• area of aorta

• renal→iliac→femoral

LISTEN FOR BRUIT

GI ASSESSMENT

• percussing abdomen

  • normal sound?

estimates the size of organs

• Normal sounds:

  • tympanic throughout abdomen

  • dullness over organs

GI ASSESSMENT

• Percuss CVA

CVA= costovertebral angle

• where the END of rib cage meets the SPINE

  • think posterior!!!

Abnormal finding

• percussing CVA

tenderness @ kidney

• could indicate: infection / musculoskeletal problem

GI ASSESSMENT

• palpate the abdomen

  • ASSESS FOR:

crepitus, tenderness, masses

Light palpation

press down lightly w/ fingertips

• 1-2cm

Deep palpation

using one or two hands use fingertips to press 5-8cm down

What technique do you use if a patient is ticklish?

“sandwich method”

GI ASSESSMENT

• how to palpate liver

Right hand → @ R. mid clavicular line

Left hand → under the back of the 11th and 12th rib

Press DEEPLY in & up

Normal finding

• palpating liver

NON palpable

Abormal finding

• palpating liver

hard/firm

• could indicate: cancer

when do we use Rebound Tenderness

for patients that complain of abdominal pain

How do you perform Rebound Tenderness

1. place hand perpendicular to stomach

2. press firm & slow then release quickly

** if pain increases when hand is released → peritoneal irritation

GI health promotion

• drink water

• eat more fruits and veggies

• good nutrition

• be active/exercise

GI health teaching

• screen for alcohol abuse

• Hep A, B, C prevention

• screen for colorectal cancer

• education on alleviating incontinence

What is incontinence?

loss of bladder control

What causes incontinence?

• nerve damage

• old age

• post-op

• pregnancy (stress incontinence)

dependent rubor

reddening/discoloration of the skin associated with peripheral artery disease.

findings in arterial diseases

• edema

• skin is red (DVT)

• skin is warm to touch

• thicker skin

findings in venous diseases

• NO swelling

• skin is cool to touch (due to low blood flow),

• pallor

• Low pulse

DVT possible findings

• blood clots

• skin is warm to touch

• reddness/tenderness/edema

usually @ the back of leg below the knee

Where can you check for edema

ankles, arms, legs, feet, hands

edema grading scale

+1: 2mm

+2: 4mm

+3: 6mm

+4: 8mm

Cardiac Output

volume of blood ejected from each ventricle in 1 minute

Stroke Volume

volume of blood ejected with each heart beat

Preload

initial stretching of the cardiac muscle cells

Afterload

force against which the heart has to contract to eject the blood

Myocardial Contractility

innate ability of the heart muscle to contract

Orthopnea

Discomfort when breathing while lying down flat

Dyspnea

shortness of breath

Hypervolemic

too much fluid volume in your body

Hypovolemic

body loses fluid, like blood or water