Cardiovascular.330.Ss.09
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Cardiovascular.330.Ss.09 Cardiovascular.330.Ss.09 Presentation Transcript

  • Cardio Vascular System Nursing 330 Shirley Comer
  • Pertinent History
    • Chest Pain Edema Known disease
    • Dyspnea Nocturia Family Hx
    • Orthopnea Diet Smoking
    • Cough Obesity Diabetes Mellitus
    • Fatigue ETOH use Exercise
    • Cyanosis or pallor
    • Past Hx ie Rheumatic fever, recent dental work
  • Neck Vessels
    • Keep neck in a neutral position
    • Locate and Palpate Carotid Arteries
      • One at a time
      • Rate amplitude 1+ to 4 +
  • 5 p of circulation
  • Neck Vessels cont
    • Auscultate the Carotid-normally no sound
      • Bruit - blowing or swishing sound indicating turbulent blood flow
        • Use bell of stethoscope
        • Auscultate at 3 positions
      • Thrill – Palpable vibration accompanying bruit
    • A loud aortic heart murmur may radiate to neck
  • Jugular Venous Assessment
    • Position client supine at 30 to 45 degree angle
      • Always be aware of client comfort
      • Turn client’s head slightly away
    • Note the external and internal Jugular vein distention (if any) and record the level in relation to the clavicle(normal less than 2 cm)
      • Observe for pulsations (if any)
      • Unilateral distension=kinking or aneurysm
      • Bilateral distension=increased CVP
  • Jugular Vein Drawing
  • The Precordium (chest wall)
    • Inspect
      • Heave(lift)=sustained forceful thrust of ventricle against chest wall=ventricular hypertrophy
      • Apical pulse may be visible in thin adults and children
    • Palpate the Apical Pulse
      • Sometimes called PMI (point of maximum impulse)
      • Note
        • Location
          • should be at or near 5 th intercostals space
          • LV dilatation (fluid overload) displaces down and to the left and increases size
  • Apical Pulse cont
        • Size
        • Amplitude- 1+ to 4+
          • Increased in LV hypertrophy (pressure overload)
        • Rate and Rhythm
          • Regular irregularity or irregular irregularity
          • Compare irregular apical pulse to radial
          • Sinus arrhythmia common in children and young adults related to the respiratory cycle
          • Premature Beat- more common in elderly
    • Palpate the Precordium
      • Use palm
      • Normally thrill or mass not felt
  • 5 areas for listening to the heart
  • Auscultate Heart Sounds
    • Auscultation sites
      • 2 nd right intercostal space (aortic value)
      • 2 nd left intercostal space (Pulmonic Value)
      • Left lower sternal border (Tricuspid Valve)
      • Apex (Mitral Valve)
      • Continue auscultation in Z pattern
  • Blood Flow through Cardiac Valves
  • The Stethoscope
  • Auscultation Heart sounds
  • Auscultation cont
    • Use Diaphragm of Stethoscope
    • Identify S1 and S2
      • S1 is loudest at apex
        • closure of AV valves
        • Beginning of systole
      • S2 is loudest at base
        • Closure of semilumar valves
        • Beginning of diastole
      • S1 coincides /c carotid pulse and R wave on ECG
  • S1, S2
  • Extra Heart Sounds
    • Split S2
      • Normal phenomenon
      • Occurs at end of inspiration
      • Semilumar valves don’t close at the same time
      • Heard best at left 2 nd ICS
      • Can be fixed or paradoxical
  • Extra Heart sounds cont
    • S3 – Ventricular Gallop
      • Early in diastole during rapid filling
      • Heard best at apex using bell of stethoscope
      • Doesn’t vary /c resp like Split S2
      • Indicates decreased ventricular compliance
      • In children and young adult may be innocent and disappear when pt sits
      • May be earliest sign of heart failure
      • Heard /c increased CO ie hyperthyroidism,
  • Extra Heart Sounds cont
    • S4- Atrial Gallop
      • Ventricular filling sound
      • Occurs late in diastole immediately before S1
      • Heard when atria contract
      • Very soft, low pitched sound
      • Heard best at apex /c pt in left lateral position /c bell
      • Can occur /p exercise at 40 yr old
      • Occurs /c systolic overload, hypertension and aortic stenosis
  • Extra Heart Sounds cont
    • Friction Rub
      • Occurs r/t inflammation of the pericardial membranes
      • Occur in both systole and diastole
      • Hear best at apex
      • Common in 1 st week following Myocardial Infarction and pericarditis
  •  
  • Heart Murmurs
  • Murmurs
    • Blowing, swooshing sound
    • Indicates abnormal turbulent blood flow
    • A murmur outside the heart is called a bruit
    • Are either systolic or diastolic
    • Systolic murmur may occur innocently in children and young adults r/t increased force of contraction
  • Assessment of Murmurs
    • Timing - systolic or diastolic
    • Loudness -Grade I thru VI
    • Pitch- high or low
    • Pattern- Crescendo, decrescendo, plateau, diamond
    • Quality- Musical, blowing, harsh or rumbling
    • Location- Where is it loudest?
    • Radiation- Is it audible in other parts of precordium
    • Posture- Is it present or louder only in certain position
  •  
  • Age Specific Considerations
    • Infants
      • Use appropriate size stethoscope
      • May be irregular
      • Murmurs may be present r/t congenital fetal circulation remnants
    • Children
      • May have visible apical pulses r/t thin chest wall
      • May have innocent murmurs-always note presence of murmur
  • Age Specific Consideration cont
    • Pregnancy
      • Increased pulse rate
      • Exaggerated S2 splitting
      • Easily heard S3
      • Systolic murmur may be present-should disappear /p delivery
    • Elderly
      • S4 even /s Hx of CAD
      • Irregular pulse more common
  • Practice Exam Question
    • You are assessing a 7 year old child upon admission to the pediatric unit. The child has a soft systolic murmur. His Mother states he has always had this murmur and the doctor is aware of it. How should you document your finding?
      • A. No need to document it as it is an innocent murmur.
      • B. Describe murmur location, pitch and loudness in the nurses notes but no need to mention it to the Doctor.
      • C. Document your finding in the nurses notes and mention your finding to the Doctor.
      • D. Document you findings on the graphic sheet.
  • Rationale
    • C is the correct answer as the murmur is an abnormal finding
    • A is incorrect because you always document an abnormal finding
    • B is incorrect because the Physician should be aware of all abnormal findings
    • D is the wrong form
  • Peripheral Vascular system and Lymphatics Nursing 330 Governors State University Shirley Comer
  • Anatomy in Peripheral Vascular
    • Arteries- carry oxygenated blood to tissues
      • Thick muscular walled
    • Veins - carry deoxygenated blood to tissues
      • Thin walled
    • Lymphatics- separate vessel system which retrieves excess fluid and plasma proteins and returns them to blood stream
      • Major player in immune system
      • Contains nodes that drain body areas
  • Assess Arms
    • Note color of skin and nails, temperature, texture, turgor, hair distrubuiton
    • Note lesions, edema or clubbing
    • Assess capillary refill
    • Assess radial and antecubital pulse (0 to 4+)
    • Palpate antecubital and axillary lymph nodes
    • All finding should be bilateral
    • Edema indicates lymphatic obstruction (lymphedema)
  • Pulse Assessment
    • Pulses are rated 0 to 4+
    • 3+ is normal
    • Note rate, amplitude and rhythm
    • Documenting in the physical assessment
    Pulse Radial Carotid Brachial Apical Femoral Pop Post Tib Dorsal Ped Left 3+ 3+ 3+ n/a 2+ 2+ 1+ 1+ Right 3+ #+ 3+ n/a 2+ 2+ 1+ 0
  • Assess the legs
    • Inspect skin
      • Note: color, hair distribution, venous pattern, size, edema, lesions, temperature, turgor, texture
      • Should be symmetrical
    • Venous pattern
      • Normally flat and barely visible
      • Vericose vein-enlarged surface vein, tortuous, prone to clots
      • Note angiomas, petichia, purpuras, brusing ect
  • Assess the Legs cont
    • Palpate Inguinal lymph nodes
    • Palpate Peripheral pedal pulses- use doppler if unable to find
      • Femoral pulse
      • Popliteal pulse-can be difficult to locate
      • Posterior Tibial pulse- behind medial malleolus
      • Dorsal pedis pulse- lateral to extensor tendon of great toe- use light touch
  • Edema
    • Pretibial-
      • Firmly press over skin of tibia or medial malleolus for 5 seconds and release.
      • If indentations are left pt has pitting edema.
      • Scale 0 to 4+
    • Unilateral edema may indicate venous thrombosis, lymph obstruction, injury or dependant positioning
  • Practice Exam Question
    • Your patient has a history of a mastectomy on the right side. You note her right arm is twice the size of the left. What nursing intervention would you use to decrease the size of this arm?
    • A. elevate arm on pillow
    • B. encourage ROM exercises
    • C. discouarage constricting clothing
    • D. all of the above
  • Rationale
    • D is the correct answer. The pt is experiencing lymphedema as a result of her mastectomy and all the interventions listed are appropriate.