Unit 2 Nursing Skills

Blood Pressure/Cardiovascular Assessment

Diastole

The phase between each contraction of the heart when the ventricles are filling with blood.

Diastolic Pressure

The resting pressure of blood on the arteries between each cardiac contraction.

Hypertension

Elevated blood pressure over 130/80 mmHg in an adult.

Hypotension

Decreased blood pressure less than 90/60 mmHg in an adult.

Korotkoff sounds

The audible sounds of blood pressure named after Dr. Korotkoff who discovered them.

Orthostatic hypotension

A decrease in blood pressure by at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing from a seated or lying position.

Sphygmomanometer

A device used to measure blood pressure and is commonly referred to as a blood pressure cuff.

Systole

The phase of the heartbeat when the left ventricle contracts and pumps blood into the arteries.

Systolic blood pressure

The maximum pressure of blood on the arteries during the contraction of the left ventricle of the heart referred to as systole.

Atrial fibrillation

An irregular heartbeat that is often fast and increases the risk of heart attack or stroke.

Blanching

The whiteness that occurs when pressure is placed on tissue or a nail bed, causing blood to leave the area.

Bruit

A swishing sound when auscultating the carotid arteries. This indicates turbulence in the blood vessel due to atherosclerotic changes.

Capillary refill

The time it takes for color to return after pressure is applied to tissue causing blanching

Click

Clicking sound heard on auscultation of the precordium; often heard in patients with heart valve abnormalities.

Cyanosis

A bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.

Deep Vein Thrombosis (DVT)

A blood clot that forms in a vein deep in the body.

Ductus arteriosus

Shunt that connects the pulmonary artery and aorta in the developing fetus.

Dyspnea

A feeling of shortness of breath.

Heave or lift

Palpable lifting sensation under the sternum and anterior chest wall to the left of the sternum; it suggests severe right ventricular hypertrophy.

Jugular Vein Distension (JVD)

Occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of a person’s neck.

Murmur

A blowing or whooshing sound heard on auscultation of the

precordium that signifies turbulent blood flow in the heart often caused by a valvular defect.

Assess:

• Timing

• Location

• Radiation

• Pitch

• Intensity

• Quality

Orthopnea

A feeling of shortness of breath when lying flat.

Pallor

A reduced amount of oxyhemoglobin in the skin or mucous membranes. Skin and mucous membranes present with a pale skin color.

Paroxysmal nocturnal dyspnea

An attack of severe shortness of breath that generally occurs at night.

Perfusion

The amount of blood flow to tissue.

Peripheral edema

Swelling due to an accumulation of fluid in tissues perfused by the peripheral vascular system.

Pitting edema

An accumulation of fluid in tissue and causes an indentation when the area is pressed.

Pleural friction rub

Uncommon heart sounds produced when the parietal and visceral pericardium become inflamed, generating a creaky-scratchy noise as they rub together.

Precordium

The region of the thorax in front of the heart.

Pulmonary embolism

A blood clot that lodges in one of the arteries that go from the heart to the lung.

Sphygmomanometer

An instrument for measuring blood pressure typically consisting of an inflatable rubber cuff.

Syncope

A temporary loss of consciousness usually related to insufficient blood flow to the brain.

Thrill

A vibration felt with palpation of the precordium

Accessory muscles

Muscles other than the diaphragm and intercostal muscles that may be used for labored breathing.

Apnea

Absence of respirations.

Atelectasis

Alveoli or an entire lung is collapsed, allowing no air movement.

Barrel-chested

An equal AP-to-transverse diameter that often occurs in patients with COPD due to hyperinflation of the lungs.

Bradypnea

Decreased respiratory rate or slow breath less than normal range according to the patient’s age.

Bronchial breath sounds

High-pitched hollow sounds heard over trachea and the larynx.

Bronchovesicular sounds

Mixture of low- and high-pitched sounds heard over major bronchi.

Clubbing

A change in the configuration where the tips of the nails curve around the fingertips, usually caused by chronic low levels of oxygen in the blood.

Crackles

Also referred to as “rales”; sound like popping or crackling noises during inspiration. Associated with inflammation and fluid accumulation in the alveoli.

Crepitus

Air trapped under a subcutaneous layer of the skin; creates a popping or crackling sensation as the area is palpated.

Cyanosis

Bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.

Dyspnea

A subjective feeling of breathlessness.

Hemoptysis

Blood-tinged mucus secretions from the lungs.

Hypercapnia

Increased carbon dioxide levels in the blood.

Hypoxemia

Decreased levels of oxygen in the blood.

Kyphosis

Outward curvature of the back; often described as “hunchback.”

Orthopnea

Breathlessness or a feeling of shortness of breath when lying in a reclined position.

Pallor

A reduced amount of oxyhemoglobin in the skin or mucous membranes and causes skin and mucous membranes to present with a pale skin color.

Rales

Another term used for crackles.

Respiration

Includes ventilation and gas exchange at the alveolar level where blood is oxygenated and carbon dioxide is removed.

Retractions

The “pulling in” of muscles between the ribs or in the neck when breathing, indicating difficulty breathing or respiratory distress.

Stridor

High-pitched crowing sounds heard over the upper airway and larynx indicating obstruction.

Tachypnea

Rapid and often shallow breathing greater than normal range according to the patient’s age.

Ventilation

The mechanical movement of air into and out of the lungs.

Vesicular sounds

Low-pitched soft sounds like “rustling leaves” heard over alveoli and small bronchial airways.

Wheeze

High-pitched sounds heard on expiration or inspiration associated with bronchoconstriction or bronchospasm.

Borborygmus

Hyperperistalsis, often referred to as “stomach growling.”

Distention

An expansion of the abdomen caused by the accumulation of air or fluid. Patients often report “feeling bloated.”

Dysphagia

Difficulty swallowing.

Dysuria

Painful urination.

Guarding

Voluntary contraction of abdominal wall musculature; may be related to fear, anxiety, or presence of cold hands.

Hematochezia

Passage of bloody stool.

Hematemesis

Blood-tinged mucus secretions from the lungs.

Hyperactive bowel sounds

Increased peristaltic activity; may be related to diarrhea, obstruction, or digestion of a meal.

Hypoactive bowel sounds

Decreased peristaltic activity; may be related to constipation following abdominal surgery or with an ileus.

Melena

Stool dark in color and tarry in consistency.

Protuberant

Convex or bulging appearance.

Rebound tenderness

Pain when hand is withdrawn during palpation.

Rigidity

Involuntary contraction of the abdominal musculature in response to peritoneal inflammation.

Scaphoid

Sunken appearance.

Stiae

White or silver markings from stretching of the skin.

Urinary frequency

Urination every hour or two.

Urinary incontinence

Involuntary leakage of urine.

Urinary urgency

An intense urge to urinate that can lead to urinary incontinence.

*Base

Widest part of the heart

*Apex

Tip of the heart

*Atrioventricular valves

Valves separating the atrium and ventricles (mitral and tricuspid)

*Tricuspid

Valve separating right ventricle and right atrium

*Mitral valve

Valve separating left ventricle and left atrium

*Diastole

Ventricles relaxing or filling

*Semilunar valves

Valves separating ventricle to lungs or aorta

*Pulmonic valve

Valve from the right ventricle to the lungs

*Aortic valve

Valve from the left ventricle to the aorta

*Systole

Ventricles contracting

*S1

Lub

*S2

Dub

*Orthostatic hypotension

Result from low BP. Can make you dizzy going from sitting to standing. SLOW positional changes.

*Popliteal pulse

Pulse located behind the knee

*Posterior tibial pulse

Pulse located behind the ankle medially

*Dorsalis pedis pulse

Pulse located on the top lateral foot.

*Femoral pulse

Pulse located within the groin.

*Apical pulse

Left 5th intercoastal space, mid clavicular line under the nipple.

*Carotid pulse

Pulse felt in the right and left neck.

*Adventitious sounds

Adnormal lung sounds

*Cough/Deep breathe

Technique used to clear airway and improve respirations

*Incentive spirometer

Technique used through inhalation to expand the lungs to clear airway and improve respirations

*Peak Flow

maximum speed at which air can be blown out of the lungs after a deep inhalation