Nursing 101 - exam 3 part 1 (1st semester)

What part of the stethoscope do we use to listen for vital signs?

diaphragm - used for high frequency sounds

What type of data do you collect first?

subjective data

what the the blood flow of the heart?

-oxygen poor blood from inferior and superior vena cava enters Right Atrium

- blood goes thru Tricuspid Valve into Right Ventricle

-Right Ventricle is full and squeezes which closes tricuspid valve and opens Pulmonary Valve.

- Blood goes thru Pulmonary Artery to lungs to get oxygenated.

- Oxygen rich blood travels from lungs to Left Atrium thru L/R Pulmonary Veins

-Left Atrium to Left Ventricle thru Mitral Valve

- Left Ventricle is full, squeezes which closes Mitral valve

- Aortic semilunar valve opens

- blood goes into Aortic Semilunar Valve to Aorta to go through the body and start over again.

When do you use the Bell on your stethascope?

when looking for a LOW frequency sound

Bruit

abnormal blowing or swishing sound heard during auscultation of an artery or organ

what should you hear when listening to a carotid artery?

nothing

What is a bruit?

blood flow turbulence, generated by a wave

what causes the wave in Bruit usually?

carotid artery narrowing

what causes carotid artery narrowing?

plaque buildup

teaching pt when taking carotid artery assessment?

have pt hold their breathe because you may hear the larynx or pharynx otherwise because of their breathing

- have pt exhale first and then hold breath

assessment areas of carotid artery

upper carotid

middle carotid

lower carotid

if patients heart is beating 80 bpm how many waves are being produced per minute?

- bruits per minute?

- pulses per minute?

80

first thing we do with assessment of the chest?

inspection

inspection of the chest consists of?

- is it symmetry

- are there any lumps

- any pulsations or pulsating outside of chest

- look for Heave/Lift

- Thrills

Heave on chest means what?

a visible pulsation which is seen with hypertrophy of ventricle (enlargement of ventricle)

Palpate for thrills n chest

Using the ball or back of hand of the hand, palpate for thrills, (vibration) of turbulent flow transmitted to the chest wall surface by a damaged heart valve.

Palpate PMI (point of maximum impulse)

apical area

Whoosing sound heard on carotid auscultation?

Bruit

Right ventricular hypertrophy is seen how?

will observe heave or lift closer to the sternal board

left ventricular hypertrophy seen how?

observe heave or lift closer to the mid clavicular line

Auscultation of heart sounds 1st with?

diaphragm

Auscultation of heart sounds 2nd time with?

the bell

normal heart sounds are what?

high frequency sounds

S1 & S2 heart sounds are?

lubb dubb

low frequency heart sounds are heard with what?

bell of stethoscope

abnormal heart sounds are heard

by low frequency

Whoosing sound heard on heart auscultation?

murmur

whooshing/swishing sound in any of our peripheral vessels?

Bruit (sounds like brew-E)

whooshing/swishing sound in our heart is called

a murmur

"Lubb SHH Dubb" sound?

means a bruit or murmur is present

where do you place stethoscope when ausuctating heart sounds?

APETM

(APE-To-Man) aka Z pattern

exact body landmarks for placing stethoscope when ausuctating heart sounds?

1. A - second intercostal space RIGHT sternal border (AORTIC AREA)

2. P - second intercostal space LEFT sternal border (PULMONIC)

3. E - third intercostal space LEFT sternal border (ERBS POINT)

4. T - fifth intercostal space LEFT sternal border (TRICUSPID)

5. M - slide across to midclavicular line of that 5th intercostal space (MITRAL)

S2 is louder where?

base of the heart (higher point)

S1 is louder where?

apex of the heart (lower part)

S1

closure of AV valves, loudest at the apex

S1

beginning of systole

closure of AV valves

S2

- end of systole

-closure of semilunar valves

murmurs are caused by

turbulent blood flow (blood backflowing)

- incomplete closure of valves

- could be holes in-between the chambers of the heart

What is a nurses job when they hear a murmur? (as a 1st semester student)

to report/document that a murmur is heard, not diagnose.

if murmur sound comes after S1 or inbetween S1 and S2 what is it?

a systolic murmur

(Lubb SHH Dubb) - sound heard

if murmur sound comes after S2?

a diastolic murmur

(Lubb Dubb SHH) - sound heard

if murmur is present how is cardiac output being effected?

it is being decreased

Grade I murmur

barely audible, with difficulty

Grade II murmur

audible, but faint

Grade III murmur

moderately loud, easy to hear

Grade IV murmur

loud, thrill palpable on the chest wall

Grade V murmur

very loud, can hear with part of stethoscope off the chest

Grade VI murmur

loudest, can hear with stethoscope off the chest

What are modifiable risk factors for CAD and stroke?

diabetes

hypertension (both can be controlled dont have to be completely eliminated)

- obesity

- high cholesterol

what is the heart in one word?

Pump

heart failure =

pump failure

cardiac output

stroke volume x heart rate

4/6 liters

fluid from the body will go into what side of the heart?

Right / goes into right atrium

from right ventricle blood goes to ?

the lungs

heart failure presents with?

-lowered cardiac output

- low BP

- pulmonary congestion

-dyspnea

- extremity edema

- JVD

Left sided heart failure

respiratory symptoms

Right sided heart failure

backup into general circulation, edema, venous distention

if blood is backed up into the systemic system what side of the heart is failing?

Right side of the heart

if blood is backing up into the lungs what side of the heart is failing?

Left side of the heart

can patients have both Left and Right sided heart failure?

Yes. even though the failure of the heart started on either the left or the right eventually the hearts side that is functioning will have to compensate for the side that is failing and will eventually lead to Left and Right sided heart failure.

CHF (congestive heart failure)

Left sided heart failure

what sounds do you hear with CHF?

crackles, fluid accumulation, ect

if a patient has heart failure why are you told to "weigh the patient daily"?

to check for fluid retention

- with heart failure patient will have decreased cardiac output making the brain think you lost fluid.

- this tells the kidneys to retain fluid, retain sodium (as sodium is retained water follows and is retained as well.

Kidneys action in heart failure?

retain fluid, retain sodium (as sodium is retained water follows and is retained as well.

(fluid overload)

what does the brain do during heart failure/decreased cardiac output?

it thinks the body is bleeding out or going into shock and that you are losing fluid because cardiac output is decreased

treatment for patient who has excessive fluid and the kidneys that are retaining fluid?

will give diuretics

What do diuretics do?

tells kidneys to excrete.

Promote sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines.

what does your nursing note always start out with?

the date and the time

what do your nursing notes always end with?

your name and credentials

Peripheral vascular system

arteries, veins and lymphatic system

arteries

bring fluid to all of our peripheral tissues

veins

take fluid and bring it back to the heart

lymphatic system

the network of vessels through which lymph drains from the tissues into the blood. (general circulation)

- involved in immune system

lymph nodes will enlarge

in a localized area and will show sign of infection

arteries have what kind of system?

high pressure sysem

what makes the arteries have a high pressure system?

the left ventricle

Arteries supply what?

oxygen and essential nutrients to the tissues

arteries for examination

temporal

carotid

brachial

radial

femoral

popliteal

dorsalis pedis

posterior tibial

temporal artery

lies superior to the temporalis muscle; its pulsation is palpable anterior to the ear

carotid artery

artery on each side of the neck that supplies blood to the head

brachial artery

The brachial artery runs along the front part of your bicep. It's a continuation of the axillary artery in your armpit and shoulder. It ends at the cubital fossa (the indentation between your upper and lower arm, at the front of your elbow).

radial artery

runs on the inside of the forearm from the elbow to the thumb. The artery lies just under the surface of the skin. You may be able to see the blue or purple vein inside your wrist where the artery brings blood to the thumb.

femoral artery

is at the top of your thigh in an area called the femoral triangle. The triangle is just below your groin, which is the crease where your abdomen ends and your legs begin. The femoral artery runs to the lower thigh and ends behind the knee

popliteal artery

is located behind your knee and runs behind your knee pit. Below your knee joint, the arteries divide into the anterior tibial artery and the tibioperoneal (or tibiofibular) trunk. This trunk divides into smaller branches that carry blood to your fibula and to the back of your calf.

dorsalis pedis artery

The artery on the anterior surface of the foot between the first and second metatarsals.

posterior tibial artery

commences at the lower border of the popliteus as one of the two terminal branches of the popliteal arteries, the other being the anterior tibial artery. It supplies the back of the leg, i.e. the two posterior compartments and the sole of the foot.

Veins

Blood vessels that carry blood back to the heart

what is parellel to the arteries?

the veins

low pressure system

veins

what pushes things forward with veins?

muscles // contracting muscles

what prevents backflow of veins?

valves

low pressure system that is contracting skeletal muscles to milk blood proximally back towards the heart

vein system

breathing in and out

milks blood forward - causes a pressure gradient caused by breathing

problem with a patient who is on bedrest?

milking action is nonexistent and blood just sits in the body letting pt to become at risk for blood clots

inspiration

increases abdominal pressure and

decreases thoracic pressure

Intraluminal valves do what?

ensure unidirectional flow

veins for examination

Jugular veins

Subclavian

in the arm - Cephalic, Basilic, Median, Cubital

in the leg - Great Saphenous, Small Saphenous

lymphatic system

drains the fluid

Is the Lymphatic system a separate vessel system?

yes, but it runs parallel to arteries and veins

low pressure system that requires skeletal muscle contraction also?

Lymphatic system