Health assessment chapter 5, 20, 21

Heart Sounds

  • S1 (First Heart Sound): Closure of the AV valve, marks the beginning of systole.

  • S2 (Second Heart Sound): Closure of the semilunar valves, signals the end of systole.

  • S3 (Third Heart Sound): Occurs right after S2, associated with rapid ventricular filling; may indicate heart failure in older adults.

  • S4 (Fourth Heart Sound): Occurs at the end of diastole, following atrial contraction; associated with hypertensive heart disease.

Murmurs

  • Definition: Abnormal sounds caused by turbulent blood flow.

  • Causes: Increased blood velocity, decreased blood viscosity, structural vascular defects.

    • Grading Murmurs (1-6):

      • 1: Barely audible, heard only in quiet rooms.

      • 2: Clearly audible but faint.

      • 3: Moderately loud, easy to hear.

      • 4: Loud, associated with a thrill.

      • 5: Very loud, can be heard with a stethoscope barely touching the chest.

      • 6: Loudest, can be heard without a stethoscope.

Cardiac Assessments

  • SA Node: The heart's natural pacemaker.

  • Cardiovascular Health Questions: Nurses ask about previous heart surgeries, pain during exertion, shortness of breath, history of hypertension, heart disease, family history, and lifestyle factors (smoking).

  • Blood Pressure: Normal <120/80 mmHg; elevated values need evaluation, especially in patients with obesity or diabetes.

Heart Function and Blood Flow

  • Systolic Dysfunction: Heart's inability to pump effectively during systole.

  • Diastolic Dysfunction: Heart's inability to fill properly during diastole.

  • Heart Failure Signs: Swelling (edema), shortness of breath, nocturnal dyspnea, and orthopnea (pillow use for sleep).

Heart Sound Locations (Mnemonic: APE to MAN)

  • Aortic Valve: 2nd right intercostal space.

  • Pulmonic Valve: 2nd left intercostal space.

  • Tricuspid Valve: Left lower sternal border.

  • Mitral Valve: 5th intercostal space, midclavicular line.

Risk Factors for Cardiac Disease

  • Primary Risk Factors: Smoking, high LDL cholesterol, obesity, hypertension.

  • Demographics: Higher prevalence of hypertension in African American populations, differ by age and gender.

Edema Assessment

  • Pitting vs Non-Pitting Edema:

    • Pitting Edema: Fluid accumulation where an indentation remains after pressure is applied; often indicates heart failure.

    • Non-Pitting Edema: Typically results from lymphedema or certain solid organ issues.

  • Measurement: Assess leg circumference for edema comparison and categorize per the scale (0 to 4+).

Peripheral Arterial Disease (PAD)

  • Symptoms: Claudication pain, wounds that are non-healing; ABI (Ankle-Brachial Index) test indicates severity.

  • Risk Factors: History of smoking, high cholesterol, diabetes, obesity.

  • Interventions: Walking programs recommended for claudication relief.

Neurological Assessments

  • Mental Status Examination (A&O times 3): Evaluates alertness and orientation (person, place, time).

  • Cognitive Tests: MMSE, GAD-7, PHQ-9 for anxiety and depression screening.

  • Aphasia Types:

    • Broca's Aphasia: Understanding is intact, but producing language is impaired.

    • Wernicke's Aphasia: Speech production is fluent but lacking meaning.

Syncope and Dizziness Assessment

  • Symptoms: Determine if the patient experiences dizziness, fainting, or episodes of loss of consciousness; evaluate history.

Overall Management and Important Conditions

  • Heart Failure: Manage sodium and fluid retention leading to symptoms of backing up in circulation causing edema.

  • Aneurysms: Risks include hypertension; can rupture and cause internal bleeding.

  • Diabetes and Neuropathy: Long-standing diabetes can lead to peripheral neuropathy; patients may have numbness in extremities.

Important Terms and Concepts

  • Arteriosclerosis: Thickening of arterial walls.

  • Atherosclerosis: Narrowing of arteries due to plaque buildup.

Lymphatic System

  • Function: Returns excess fluid to the bloodstream, important in immune response; track any lymphedema following surgeries that involve lymph node removal.