cardiac and peripheral

heart

has 2 pumps

2 pumps

pulmonary and systemic

arterial system

oxygenated

venous system

oxygen poor/deoxygenated

top of heart

base

bottom of heart

apex

where to locate the heart

2nd to 5th intercostal space (ICS)

right sternal border to the LEFT mid clavicular line (MCL)

layers of the heart wall

pericardium

myocardium

endocardium

pericardium

outer layer

myocardium

muscle layer

endocardium

thin inner layer

4 chambers of the heart

right atrium (RA)

left atrium (LA)

right ventricle (RV)

left ventricle (LV)

heart valves

atrioventricular

semilunar

atrioventricular (AV)

tricuspid (RA-RV)

mitral (LA-LV)

semilunar (SL)

pulmonic (RV- Pulmonary Art.)

aortic (LV-aorta)

vital signs

a thoughtful, scientific assessment

-nursing judgement

-delegation

-how often? anytime of the day

pulse

wave of blood created by contraction of the left ventricle; the amount of blood entering the arterial system

the pulse is useful for

rate and rhythm

artery condition

Rate

60-100 beats per min

varies with age and gender

<60

bradycardia

>100

tachycardia

Rhythm

even tempo

reg. or irregular

rhythm scale

3+ full, bounding

2+ normal

1+ weak, thready

0 absent

elasticity

vessel expansion

springy, straight & resilient

aging: inelastic or coiled

blood pressure

measure of pressure exerted by blood as it flows through the arteries; blood moves in waves

2 measures

systolic and diastolic

systolic

ventricular contraction; top number

diastolic

ventricles resting ; bottom number

record blood pressure in

millimeteres mercury (mmHg)

physiologic factors effecting artierial BP

cardiac output

peripheral vascular resistance

blood volume

blood viscosity

elasticity of the vessel

non-physiologic factors

age

-increases

exercise

-increases

-within 5 min, should return to baseline

stress & pain

-vasoconstriction

vasoconstriction

vessels tighten, BP goes up

factors affecting BP

race

-African Americans > risk

gender

-females < males

-menopause

medications

caffeine

factors affecting BP

obesity

-childhood

time of day

-lowest in the am

-peaks late pm, early evening

disease

-social determinant of health

-vessel & kidney disease

modifiable

can change

ex: smoking, weight, stress

non-modifiable

cannot change

ex: race, age, family history

hypotension

bp below normal

systolic reading <90/60

asymptomatic or symptomatic

dizzy, faint, sweaty

orthostatic hypotension

bp falls upon sitting/standing

blood leaves the central organs & heads to the periphery

systolic drop >20 mmHg

diastolic drop >10 mmHg

bleeding, medications, injury

bp cuff assessment

bladder too narrow; falsely high

bladder too wide/larger ; falsely low

width: 40% arm circumference

length: 80%

more bp pitfalls

arm too high

leg positon

pain/stress

failure to use the same arm

****extremity restriction

iv sites

examiner bias

manual vs electronic

Palpate bp when

bp is too weak to be heard

cardiac cycle

rhythmic movement of blood through the heart

happens simultaneously on the L&R side of the heart

cardiac cycle sounds

produced by valve closure

s1 & s2

s1

systole/contract

AV valves shut

SL valves open

s2

diastole/relax

AV valves open

SL valves shut

systole

the time between s1 to s2

diastole

the time between s2 & the next s1

cardiac assessment

any chest pain or tightness

radiate

quality

other symptoms

cardiac assessment cont.

shortness of breath DYSPNEA

dyspnea on exertion

paroxysmal

constant or intermittent

orthopnea

cough

Dys

bad or difficult

dyspnea

difficulty breathing

paroxysmal

sudden or out of nowhere

orthopnea

have trouble breathing in different positions

pnea

breathing

assessment

fatigue

cyanosis or pallor

edema

nocturia

nocturia

nighttime urination

assessment

past history

-cardiac related

hypertension

hyperlipidemia

heart murmur

myocardial infarction

congestive heart failure

background assessment

family cardiac history

personal habits

-nutrition

-smoking (PPD)

-alcohol

-exercise

-drugs (prescription,OTC, street)

Precordium

area on the anterior chest overlying the heart & the great vessels

inspection

may or may not see the apical impulse (4th or 5th ICS space only)

heave or lift

forceful thrusting of the ventricle during systole

auscultation

2nd ICS Rt. sternal border- aortic

2nd ICS Lt. sternal border- pulmonic

3rd ICS Lt. sternal border- erb’s

5th ICS Lt. sternal border- tricuspid

5th ICS Lt. MCL- Mitral (apical pulse)

A PET M (onkey)

Aortic & Pulmonic

best to hear valves closing

MCL

mid clavicular line

rules for auscultation

educate

concentrate

sounds are produced by the second

do not listen over clothes

advise pt to breathe normally

diaphragm

used to hear s1 & s2

bell

relatively low pitched sounds; place lightly on skin

positions

left lying, sitting up leaning forward, supine

auscultation rhythm & rate

rate

rhythm

assess s1 & s2 (lub-dup)

any extra sounds

apical: 1 FULL MINUTE

s1 systole

closure of the AV valves

“lub” of the “lub-dup”

louder at apex

softer at base

coincides w/ carotid pulse

s2 diastole

closure of the SL valves

loudest at base

softer at apex

“dup” in “lub-dup”

murmurs

faulty valve

blowing, swooshing sound

turbulence

timing

grading (1-6)

Timing

is it systole or diastolehan

changes in elderly

HTN (vessel changes)

Incr. in rhythm disturbances

Incr. in CV disease

apical impulse difficult to palpate

electrolytes that impact the heart

(K) Potassium

Potassium

major intracellular cation

K+

transmission and conduction of nerve impulses

esp. in cardiac and skeletal muscles

regulated and balanced thru the renal system

normal range: 3.5-5.0

hypokalemia

hyperkalemia

foods rich in K

fruit- cantaloupe, oranges, bananas

dried fruits

carrots, tomatoes, and potatoes

salt substitutes

nuts/seeds

chocolate

transmitter for neuromuscular activity- assists with contraction of the heart

intracellular

normal range 1.5-2.0

hypomagnesemia

hypermagnesemia

foods- seafood, PB, dried beans, green leafy veggies

bifurcates

to split

subject assessment

Claudication (leg cramps)

any skin changes

swelling

medications

smoking

objective data

arms- inspect & palpate

skin color & nailed (CRT)

temp, texture, & turgor

lesions

edema

clubbing

pulses

amplitude

symmetry

carotid locations

neck

central pulse

palpate seperately

vagal stimulation

locations cont.

brachial

radial

ulnar

brachial

medial

radial

thumb side

ulnar

pinky side

femoral

just below the inguinal ligament halfway between the pubis and anterior superior iliac spines

popliteal

behind the knee

dorsalis pedis

very light touch

normally it is just lateral to and parallel with the extensor tendon of the big toe

posterior tibial

press softly

will feel the tapping right behind it in the groove between the malleolus and the achilles tendon

peripheral assessment

edema 1+ to 4+

dorm of feet

behind medial malleolus

shins

sacrum

arterial

color: rubor- dependence pallor- elevation

skin: shiny; no hair

nails: thick

edema: none

temp: cool

pulses: diminished

venous

color: brawny- bronze or brown

skin: -

nails: -

edema: edema

temp: normal

pulses: normal

arterial ulcers

buildup of fatty plaque on intimate, hardening, calcification, of arterial wall

occur at toes, metatarsal heads, heels, and lateral ankle

arterial insuff

thick toe nails

venous ulcer

after acute DVT or chronic incompetent valves in deep veins

occur at medial malleolus and tibia; characterized by bleeding, uneven edges

venous assessment

inflammation

redness, pain, tenderness, edema

venous pattern

deep vein thrombosis (DVT)

venous stasis

risk factor for clots

bedrest (prolonged)

immobility

driving (long hours)

flying (long hours)

changes in elderly

atherosclerosis

decrease in arterial perfusion

varicosities

atherosclerosis

build up in vessels