Assessment
What degree should you have the HOB for a CV assessment
45 degrees
When do S1 and S2 occur
S1- closure of AV valve (begin of systole)
S2- closure of semilunar valve (end of systole)
When does S3 occur
When does S4 occur
after S2
before S1
normal
Where do you auscultate heart sounds?
aortic, pulmonic, erb's point, tricuspid, mitral valve area
Where are S1 and S2 best heard?
S1 - loudest at apex
S2 - loudest at base
Where are S3 and S4 best heard?
at the apex (mitral area)
What is the pulse amplitude scale
0 = absent
1= weak
2 = normal
3= increased/bounding
How do you palpate the carotid arteries?
one at a time
Where should you listen for S1 and S2
at all 5 auscultation sites
When is it "normal" to hear S3? S4?
S3- can be normal in children and pregnant women
S4 - older adults
What is a pulse deficit?
difference between apical and radial pulse - indicates issue with arterial blood flow
how to assess for a carotid bruit
have pt extend neck, hold breath, and auscultate over carotid - bruit will sound like whooshing
how to assess for a pulse deficit and who should be assessed for one
one nurse takes apical pulse while another nurse takes radial pulse - both for the same minute
- should assess for pulse deficit in pts with irregular HR
What's an important question to ask during your health history?
any chest pain, heart palpitations, past cardiac events.....
What tool may be needed when a peripheral pulse cannot be palpated?
a doppler