Perfusion (exam 4)

PP & notes on perfusion

What is perfusion?

What is perfusion?

passage of blood, blood substitute, fluids through blood vessels/ channels in an organ or tissue

(process of oxygenated blood being delivered to the body’s tissues)

Which is the lower portion of the heart, Apex or Base?

Apex (lower left ventricle)

Which is the upper portion of the heart, Apex or Base?

Base (atrium)

True or False. An individuals heart is the size of their fist?

True

Normal Bpm?

60-100

(without rest)

True or false. The heart responds to both external & internal demands?

True

(exercise, temperature change, stress)

Why is adequate relaxation important for the heart?

For the heart to be efficient

What is the Cardiac Cycle?

a series of pressure changes that take place within the heart

What divides the cardiac cycle into 2 events?

Diastole & Systole

What does atrial contraction represent when taking BP?

Systole

What does ventricular relaxation represent when taking BP?

Diastole

What is cardiac output (CO)?

quantity of blood pumped by the heart in a given amount of time measured in liters per minute

What is the cardiac output for a normal heart?

4-5L per minute

How does a heart pump?

wringing & twisting

What factors impact cardiovascular health? (7)

1. stress

2. working long hours without rest

3. diet

4. weight

5. smoking

6. ETOH (alcohol)

7. family history

Does stress increase sympathetic?

YES

True or False. Working long hours without rest does not lead to heart disease?

False

It does lead to heart disease.

Does high fat diet lead to atherosclerosis?

Yes.

Atherosclerosis: thickening/hardening of arteries. due to buildup of plaque in the inner lining of an artery.

True or False. Does smoking injury the lining of arteries?

True

Who documents the patients health history in a hospital setting?

The Nurse

True or False. A Nurse does not have to ask about ADLs during a patients health history?

False.

Ask type, how often, change in ability, if tolerable to perform ADLs.

What should the Nurse ask about Medications when gathering the patients health history? (4 questions)

1. what?

2. How much?

3. How often?

4. For how long?

True or False. The Nurse should ask the patient about weight changes correlating with the patients health history?

True

What is cerebral palsy (CP)? And where should it be documented?

Cerebral= brain. Palsy= weakness with muscle

(affects ability to move, maintain balance, & posture)

Document: patient health history

True or False. Most common motor disability in childhood is cerebra palsy?

True

What is CAD?

Coronary artery disease

What makes coronary artery disease (CAD) occur?

coronary arteries struggle to supply the heart with enough blood, oxygen, & nutrients due to cholesterol deposits & plaque buildup

Is coronary artery disease (CAD) the most common heart disease?

Yes

What is diabetes mellitus (DM)?

inadequate control of blood levels of glucose

What is CHF?

Congestive heart failure

What occurs with congestive heart failure (CHF)?

heart is unable to pump blood

True or False. Peripheral vascular disease (PVD) is narrowing of peripheral blood vessels?

True

What causes narrowing of peripheral blood vessels with peripheral vascular disease (PVD)?

arteriosclerosis (high BP, cholesterol, diabetes) or buildup of plaque

True or False. Pulmonary edema is the most common condition that is caused by heart problems?

True

(if the heart is ill/damaged its unable to pump out enough blood therefore blood gets into the lungs)

What type of breathing is dyspnea?

shortness of breath (SOB)

What position would a patient be in if they are diagnosed with orthopnea?

Supine

(harder to breath due to fluid in your lungs)

What is sputum production?

coughing up thick mucus produced in the respiratory tract

True or False. Position should be associated with sputum production?

True.

Changing body position can help drain your lungs

What is Syncope?

fainting or passing out

What causes syncope?

decreased cerebra blood flow

What is the name for any condition that slows or stops the flow of blood through your arteries?

arterial insufficiency

What sensation would you feeling due to arterial insufficiency?

cramp/ pain / pins and needles sensation

What 4 equipment is needed for a cardiac examination/ assessment?

1. stethoscope

2. sphygmomanometer

3. penlight

4. pen/ pencil

Purpose of a penlight during a cardiac examination/ assessment?

illuminate jugular veins & inspect chest wall

Pulse Amplitude Rating Scale (0+ —> 4+)

0+: absent

1+: diminished, barely can feel

2+: normal

3+: full volume

4+: full volume, bounding

What are the peripheral pulses? (10)

1. superficial temporal

2. external maxillary

3. carotid

4. brachial

5. radial

6. ulnar

7. femoral

8. popliteal

9. posterior tibial

10. dorsalis pedis

Location of superficial temporal pulse?

Head/ temple location

Location of the external maxillary pulse?

at the side of the lower jaw

Location of the carotid pulse?

palpate along medial edge of sternocleidomastoid (3rd lower muscle of neck)

Can you feel both carotid pulses at the same time?

No.

Will reduce cerebra blood flow

How do you auscultate the carotid artery?

1. use bell of stethoscope

2. ask patient to hold breath when stethoscope touches neck

True or false is bruits (low pitch blowing sound) a normal sound heard when auscultate the carotid artery?

No.

No sound over carotids is normal

Location of the brachial pulse?

antecubital fossa (bend in the arm)

Location of radial and ulnar pulses?

Radial: thumb side of wrist

Ulnar: pinkie side of wrist

Location of femoral pulse?

Groin

(palpate the inguinal ring, midway between the symphysis pubis & anterior superior iliac)

Location of the posterior tibial pulse?

inner aspect of the ankle below/ behind the ankle bone

Location of the dorsalis pedis?

Top of foot

(over the dorsum of foot between extension tendons of first & second toe)

Location to identify PMI? What is the cm diameter?

apical pulse

no longer than 2-3cm diameter

Location of the apical pulse?

palpate over the apex of the heart at the 5th intercostal space. Left of midclavicular line

What should the Nurse be inspecting & palpating when assessment extremities? (5)

1. appearance

2. color

3. temperature

4. hair distribution

5. capillary refill

Purpose to detect normal hair distribution during an assessment on extremities?

normal distribution/ more hair = better perfusion

Damage to either 2 things could cause decrease hair growth?

Arterial/ venous injury

How long should capillary refill take to be normal?

2 seconds

What abnormal finding of finger nails could determine hypoxia?

clubbing

Purpose of a venous assessment?

diagnostic test used to check the circulation in the large veins in the legs (sometimes arms. This exam shows any blockage in the veins by a blood clot (thrombus)

Steps to a venous assessment? (4)

1. inspect jugular veins for pulsation (carotid pulse)

2. elevate HOB until venous pulsation is seen (30-45 degree)

3. evaluate leg veins distention or edema- document if edema present

4. evaluate for thrombophlebitis

True or False. Bedside measurement has now been replaced by hemodynamic monitors?

True

What is Homan’s sign?

sharp dorsiflex foot with knee slightly elevated to assess calf pain response

What diagnostic test do you use evaluate for thrombophlebitis (DVT)?

Homan’s Sign

What is thrombophlebitis?

inflammatory process that causes a blood clot to form & block one or more veins, closure to the skin surface

What is DVT (deep vein thrombosis)?

inflammatory process that causes blood clot to form & block one or more veins deep below the skin surface

What is the most common place thrombophlebitis is located?

Legs

Pitting edema scale (1+-4+) & (mm measurement)

1+: barely perceptible -2mm

2+: deep pit -4mm

3+: deeper, rebounds in 10-20 sec -6mm

4+: deeper pit, rebounds in greater than 30 sec -8mm

Precordium Assessment steps? (4)

1. inspection

2. palpation

3. auscultation

4. follow cardiac landmarks

How should the Nurse proceed in orderly fashion when completing a precordium assessment? A. base → apex B.apex→ base. C. A & B

C. A & B

as long as its in orderly fashion both ways can be used

What does it mean to follow cardiac landmarks?

use specific locations to know where the heart sounds are heard best

-not directly over valves

What are the 9 cardiac landmarks? (full names & abrev.)

1. ICS (intercostal space)

2. RICS (right intercostal space)

3. LICS (left intercostal space)

4. SB (sternal border)

5. RSB (right sternal border)

6. LSB (left sternal border)

7. MCL (midclavicular line)

8. RMCL (right midclavicular line)

9. LMCL (left midclavicular line)

Cardiac assessment steps? (6)

1. inspect anterior chest wall

2. look for symmetry

3. pulsation

4. palpate systemically from base to apex

5. auscultate

6. identify PMI

Oder of auscultation during a cardiac assessment? (3)

1. listen to all cardiac landmarks 2 times

2. 1st listen to S1 (lub) then S2 (dub)

3. 2nd listen for S3 (early diastole) & S4 (late diastole)

True or False. The epigastric area should be negative for pulsation when identifying PMI?

True

Auscultation of S1? (3 important facts)

1. 1st heart sound

2. starts systole (ventricular systole)

3. Lub sound

Auscultation of S2? (5 important facts)

1. 2nd heart sound

2. End of systole (ventricular systole)

3. closer of aortic & pulmonary valves

4. Best heard over the base of the heart (upper heart) at ICS & LSB

5. Dub sound

Auscultation of S3 & S4 (3 important facts)

abnormal heart sounds

S3: early diastole

S4: late diastole

What causes murmurs?

produced by turbulent blood flow over the valves

What are murmurs related to?

insufficiency or stenosis (narrowing of aortic valve)

Murmurs Scale (i-iv)

i. very faint

ii. faint- heard immediately

iii. moderate intensity

iv. loud

What does friction rub sound like?

sandpaper sound

What is friction rub related to?

pericarditis

(swelling/irritation of thin, saclike tissue surround the heart = pericardium)

Friction rub occurs due to what rubbing?

pericardium, epicardium, myocardium, or endocardium

True or False. With friction rub you do not need to rule out pulmonary pathology?

False

Is pleural friction rub a manifestation of pleural disease?

Yes

Purpose of a pulmonary pathology?

diagnosis of neoplastic & non-neoplastic disease of the lungs & thoracic pleura

What are the common alteration of cardiovascular system?

1. ischemia

2. MI

3. Valve disease

4. CHF

5. Ventricle hypertrophy

6. Septal defects

7. Electrical rhythm disturbance

8. angina

What is Ischemia?

inadequate blood supple to the heart

What does MI stand for and what is it?

Myocardial Infraction

heart attack—> decreased blood flow of myocardium

What is Valve disease?

multiple valves don’t function

What is CHF & what does the abbreviation stand for?

Congestive Heart Failure

(weakened heart/ fluid buildup)

What is Ventricle Hypertrophy?

increase in left ventricular myocardial mass by increased workload on the heart)

(heart wall thickening)

(die from a “big” heart)

What is septal defects?

hole in wall of septum divided by the upper chambers in the atria

What is electrical rhythm disturbance?

Slow, fast, or skips bpm (breaths per minute)