Heart & Peripheral Vascular Assessment pt 1 (study alongside notes)

Where is the heart located?

In mediastinum

What are the four chambers of the heart?

left atrium and ventricle, right atrium and ventricle

The right side of the heart receives blood from…

the superior and inferior vena cava

The right side of the heart pumps blood through the…

pulmonary arteries to the pulmonary circulation.

Left side receives blood from…

the pulmonary veins

Left side pumps it through aorta into __________.

systemic circulation

Upper part of heart is _____.

base

Lower left ventricle of the heart is the _____.

apex

Heart lies behind _______ and above _______ in mediastinum.

sternum ; diaphragm

______ valve on right.

Tricuspid

_____ valve on left are termed ______ (AV) valves because they separate atria from ventricles

Mitral ; atrioventricular

_____ valve opens from left ventricle into aorta.

Aortic

______ valve opens from right ventricle into pulmonary artery.

Pulmonic

The aortic and pulmonic valves are termed __________ valves because of their half-moon shape.

semilunar

Closure of _____ and _____ valves produces the S1 sound.

mitral ; tricuspid

Closure of _____ and _____ valves produces the S2 sound.

aortic ; pulmonic

What is the correct order of assessment techniques for the heart?

Inspection, palpation, percussion (sometimes skipped), and auscultation

What is the correct order of blood flow through the heart

Right atrium → Right ventricle → Pulmonary arteries → Lungs → Pulmonary veins → Left atrium → Left ventricle → Aorta

The first step of a cardiovascular assessment is the __________ __________ interview.

health history

During a cardiovascular assessment, the neck vessels are inspected with the head of the bed elevated at a ____° angle.

30-45

When inspecting the neck vessels, the nurse observes the __________ veins and __________ arteries.

jugular; carotid

An expected finding when inspecting the neck vessels is __________.

no jugular vein distention.

Slight visible __________ in the carotid area are considered a normal finding.

pulsations

Bulging or bounding of the neck vessels is considered an __________ finding.

abnormal

Carotid arteries should be palpated __________ at a time.

ONE

Expected findings when palpating the carotid arteries include __________ strength and equal __________.

moderate; bilaterally

A __________ or __________ carotid pulse is considered an unexpected finding.

bounding; diminished

When inspecting the anterior chest during a cardiovascular assessment, the client should be positioned with the head of the bed elevated at a ____° angle.

30-45

An expected finding when inspecting the anterior chest is __________ chest movements.

symmetrical

Gentle, visible pulsations in the __________ area (___th intercostal space, midclavicular line) are considered normal.

PMI ; 5

The point of maximal impulse (PMI) may not be visible in clients who are __________ or very __________.

obese; muscular

A prominent, thrusting PMI, also called __________ or __________, is considered an unexpected finding.

heaves; lifts

When auscultating heart sounds, position the client with the head of the bed elevated at a ____° angle.

30

The apical pulse is normally between __________ and __________ beats per minute.

60; 100

A heart rate greater than 100 beats per minute is called __________.

tachycardia

A heart rate less than 60 beats per minute is called __________.

bradycardia

Additional abnormal heart sounds such as __________, __________, __________, or __________ (S3 or S4) are considered unexpected.

clicks; rubs; murmurs; gallops

A __________ __________ is a harsh, grating sound that can indicate pericardial inflammation.

friction rub

Heart sounds are produced by the __________ of the heart valves.

closure

Abnormal whooshing or blowing heart sounds caused by turbulent blood flow are called __________.

murmurs

The “lubb” sound, also called S1, is caused by the…

closure of the mitral and tricuspid valves at the beginning of systole.

The “dubb” sound, also called S2, is caused by the…

closure of the aortic and pulmonic valves at the beginning of diastole.

An __________ in blood velocity can contribute to the development of a heart murmur.

increase

Structural __________ defects or valve __________ can cause murmurs.

valve; malfunctions

Valve prolapse or __________ (narrowing) are examples of valve malfunctions that may lead to murmurs.

stenosis

When palpating the precordium, assess for __________, __________, __________, and __________.

pulsations; thrills; lifts; heaves

Percussion of the heart borders is done to estimate __________ __________.

heart size

When auscultating the carotid arteries, use the __________ of the stethoscope and listen for __________.

bell; bruits

Ask the patient to _____________ while you listen to the carotid arteries.

hold their breath

If a bruit is heard, lightly palpate the neck for __________, which are felt as pulsations or vibrations.

thrills

Jugular venous __________ measurement helps assess right-sided heart function.

distention

Disorders of the peripheral blood vessels impair blood flow __________ and __________ organs and tissues.

to; from

Arterial abnormalities disrupt the flow of __________ blood to tissues.

oxygenated

Signs of arterial disease include __________, pain, weak or absent __________, poor capillary refill, cool skin, and sores on the __________ or __________.

pallor; pulses; toes; feet

Chronic arterial insufficiency may cause __________ skin or __________ skin on the legs due to loss of hair.

shiny; hairless

Venous abnormalities interfere with blood __________ to the heart.

return

Common signs of venous disease include __________, brown skin __________, stasis __________, and __________ veins.

edema; discoloration; ulcers; varicose