Cardiac Objective
A nurse auscultates a client's heart sounds and obtains a rate of 126 beats per minute. How should this rate be documented by the nurse?
Tachycardia
A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?
Apical heart rate 70 beats per minute
No current medications or treatments
No edema of extremities noted
Apical impulse palpated at 5 intercostal space on left
Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client.
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client’s electronic medical record?
2+
Arteries move blood ____
Veins move blood ____
Arties move blood_away from the heart___
Veins move blood___back to the heart_
The nurse is preparing to assess a client's point of maximal impulse. The nurse would palpate at which location?
The fifth intercostal space at the left midclavicular line.
The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?
Palpate each artery individually to compare.
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1
The posterior tibial pulse can be palpated where?
The posterior tibial pulse can be palpated behind the medial malleolus of the ankle.
What medication should we ask women about?
Birth Control
Afterload is....
The amount of pressure the heart has to work against to pump blood to the body
What does a heave or lift indicate?
Heaves or lifts are visible elevations of the chest wall and indicates increased workload on the heart.
List two risk factors for Cardiac disease
HTN
Smoking
Serum cholesterol
Physical activity
Sedentary lifestyle
Processed foods, high sodium, high fat diet
The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?
Venous insufficiency
Women with history of breast cancer: what would the nurse ask about in regards to a peripheral vascular assessment?
-Upper extremity lymphedema (use unaffected arm for BP measurements or IV insertion)
-Were lymph nodes removed or irradiated
-Compare both arms for circumference, color, temperature, pulses, edema, skin changes, and range of motion.
_____ is the amount of blood ejected from the left ventricle each minute
cardiac output
What are the names of the landmarks where we auscultate the heart?
aortic, pulmonic, Erb's, tricuspid, mitral (apical)
Give 4 subjective cardiac questions
Taking any medications for the heart, HTN, or high cholesterol?
Do you have chest pain? Pain in the jaw or arm? Cough?
Do your feet and ankles swell?
Do you smoke? Drink? Use recreational drugs?
What is your dietary pattern? Do you exercise?
Any family history of cardiovascular disease?
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable.
Ask 4 questions to gather subjective data.
Any Leg pain or cramps
Skin changes on arms or legs
History of Swelling
History of Lymph node enlargement
Medications
Smoking history
Family history of PV disorders
A client asks the nurse about the function that the lymphatic system plays in the body. What two functions would be most appropriate for the nurse to say when responding to the client?
A part of our immune system where it helps fight infection and maintains fluid and protein balance by bringing lymph back to the bloodstream.
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?
Bruits
The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?
"Do you have any pain or discomfort in your chest?"
May be indicative of myocardial infarction (MI) or heart attack
List 3 objective findings for a patient with peripheral artery disease.
Cool extremity
Pallor
Decreased/absent peripheral pulses
Delayed capillary refill
Shiny skin/hair loss
What are 3 priority risk factors for peripheral arterial disease with a client?
Smoking
Hypertension
Diabetes
High cholesterol
•Systole: the ventricles _____ and the ___ valves are open
•Diastole: the ventricles _____ and the ___ valves are open
Contract/semilunar valves (aortic and pulmonic)
Relax/AV valves (tricuspid and mitral)