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med surg finalchpt 25 assess cardio function
Terms in this set (30)
if the client is experiencing chest pains a history of its location frequency duration is necessary a description of pain is needed included rather it radiates to a particular area precipitate its onset what brings relief the nurse weighs the client and measures vital signs blood pressure in both arms and compare finding assess apical and Radial pulse no team great quality and rhythm check peripheral pulses in lower extremities
establishing accurate Baseline data. 25
assess the adequacy of peripheral circulation
Peripheral arteriography is used to diagnose occlusive arterial disease and smaller arteries the nurse observes the client for bleeding and cardiac dysrhythmias and assesses the adequacy of peripheral circulation by frequently checking the peripheral pulses
hemodynamic monitoring is used to assess the volume and pressure of blood in the heart and vascular system
during auscultation of the lungs what would a nurse note when assessing a client with left-sided heart failure
if the left side of the heart fails to pump efficiently blood backs up into the pulmonary veins and long tissue. for abnormal and normal breath sounds the nurse listen to the lungs
with left-sided congestive heart failure ausculation reveals a crackling sound wheezes and gurgles
wet lung sounds are accompanied by dispigna and an effort to sit up to breathe with left-sided congestive heart failure listening to the long does not reveal a high-pitch sound
what is revealed by atrial gallop
auscultation of the heart an extra sound just before S1 is an S4 heart sound or a trell gallop and S4 sound is often associated with hypertensive heart disease a sound that follow if one is too it's called an S3 heart sound or ventricular gallop. an S3 heart sound is often an indication of heart failure in an adult. in addition to heart sounds auscultation May reveal other abnormal sound such as murmurs and clicks caused by turbulent blood flow through the disease heart valve
term describes the ability of the heart to initiate an electrical impulse
automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse. contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contrast in response to an electrical impulse. Conductivity refers to the ability of the specialized electronical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse
auscultation of of the apex beat at which anatomical location
the left ventricle is responsible for the apex beat or the point of Maximum impulse which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. the right ventricle lies anteriorly just beneath the sternum. use of inches to identify the location of the apex beat is inappropriate based upon variation in human anatomy. auscultation below and to the left of the xiphoid process will detects GI sounds but not the apex beat of the heart
stroke volume is detected by preload afterload and contractility of the heart. Cardiac output is the amount of blood pumped by each ventricle during a given. And is computed by multiplying the stroke volume of the Heart by the heart rate
ejection fraction is the percentage of the end-diastolic volume that is ejected with each stroke measured at 42% to 50% in The Normal Heart. afterload is defined as the pressure that The ventricular myocardium must overcome to eject blood during systole and is one of the determinants of stroke volume
central venous pressure is measured in which heart chamber
right atrium is used to assess right ventricular function and venous blood return to the heart. The left atrium receives oxygenated blood from the pulmonary circulation. The left ventricle receives oxygenated blood from the left atrium the right ventricle is not the central collecting chamber of Venous circulation
when the balloon is inflated the tip of the catheter floats into smaller branches of the pulmonary artery until it can no longer be passed. The pressure is recorded reflecting left arterial pressure and left ventricular end diastolic pressure. Central venous pressure is measured in the right atrium. Pulmonary artery pressure is measured when the balloon tip is not inflated. Cardiac output is determined through the thermal dilution which involves injection of fluid into the pulmonary artery catheter
when the balloon on a distal tip of a pulmonary artery catheter is inflated in the pressure is measured the measure our pain is referred to as the
sinoatrial node is the primary pacemaker of the heart
the AV node coordinates the incoming electrical impulses from the Atria and, after a slight delay, relays the impulse to the ventricles. The Purkinje fibers rapidly conduct the impulses through the thick walls of the ventricles
contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse. Depolarization is the electrical activation of a cell caused by a influx of the sodium into the cell while potassium exit the cell
repolarization is the return of the cell to the resting state caused by re-entry of potassium into the cell while sodium Exit the cell. diastole is the Of ventricular relaxation returning in ventricular filling
AGE-RELATED changes associated with the cardiac system includes endocardial fibrosis increase size of the left atrium a decreasing number of SA node cells and myocardial thickening
fatigue is an EARLY WARNING symptom of acute coronary syndrome ACS, heart failure, valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of Consciousness, and weight gain
decrease pulse pressure reflects reduce stroke volume and ejection velocity for obstruction to blood flow during systole. Increase pulse pressure would indicate reduce distensibility of the arteries, along with bradycardia.
Erb point is located at the third intercostal space to the left of the sternum. aortic area is located at the second intercostal space to the right of the sternum. the epigastric area is located below the xiphoid process
during pericarditis a harsh grating sound that can be heard in both systole and diastole is called a friction rub
a murmur is created by the turbulent flow of blood. A cause of the turbulence maybe critically narrowed valve. an opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. an ejection click is caused by very high pressure within the ventricle displacing a rigid and classified in your attic valve
the left ventricle is responsible for the apical impulse or the point of Maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at V and psicosis face.
the right ventricle lies and anteriorly, just beneath the sternum. use of inches to identify the location of the PMI is inappropriate based on variation in human anatomy. Auscultation below and to the left of the xiphoid process will detect GI sound
decreased pulse pressure reflects reduce stroke volume and ejection velocity or obstruction to blood flow during systole.
increase pulse pressure would indicate reduce distensibility of the arteries, along with bradicardia
during the stress test the following are monitored two or more ECG leads for heart rate, Rhythm, ischemic changes, blood pressure, skin temperature, physical appearance, perceived exertion, and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue.
the test is terminated when the target heart rate is a cheese or the client experiences size of myocardial ischemia. FURTHER diagnostic testing such as cardiac catheterization may be warranted if the client develops chest pain, extreme fatigue, a decrease in blood pressure or pulse rate, serious dysrhythmias or ST SEGMENT CHANGES on the ECG DURING the STRESS test. (SO STOP TEST ASSESS IF OCCUR DURINGTEST)
central venous pressure catheter the client CVP is 8 mmhg
the normal CVP is 2 to 6 mm HG. CVP greater than 6 mm HG indicates an elevated right ventricular preload. Many problems can cause an elevated CVP, but the most common is hypervolemia- excessive fluid circulate in the body or right sided heart failure. And contrast a low PVP less than 2 mm HG indicates reduced right ventricular preload which is most often from hypovolemia
radiopaque contrast agents are used to visualize the coronary arteries. Some contract agents contain iodine and the client is assess before the procedure for previous reaction to contrast agent or allergies to iodine containing substances such a seafood.
if the client has a suspected or no allergy to the substance antihistamines or methylprednisolone may be administered before the procedure.
accessing client postural blood pressure changes
1. position the client the pine for 10 minutes before taking the initial BP and HR measurement
2. reposition the client to a sitting position with the legs in the dependent position, and wait 2 minutes to reassess both BP and HR measurement
3. if the client is symptom free or has no significant decreases in systolic or diastolic BP, assist the client into a standing position, obtain measurements immediately and recheck in 2 minutes.
4. continue measurement every two minutes for a total of 10 minutes to rule out postural hypotension
RETURN the client supine position if postural hypotension is detected or if the client become systemic.
Document HR and BP measured in each position examples to suPine sitting standing and any signs or symptoms that accompany postural changes
magnetic resonance angiogram MRA
a client may have a mouse a date up if they are claustrophobic the client is position supine on a table Place into an enclosed immature or two remove any metal item ECG lead in jewelry the client we're here intermittent cranking or thumping
remove the client's transderm nitro patch jewelry and offer the client a headset to listen to music during the procedure remove nyko Derm Androderm transderm Nitro transderm scope catapres TTS patches remove them to prevent burning of the client's skin
when applying cardiac electrolyte
clip do not shave hair from around the electric site
if the client is is sweaty diaphoretic apply a small amount of benzoin to the skin
debride the skin surface of dead cells with soap and water and dry well
change the electrodes every 24 to 48 hours or as recommended 5 examine the skin for irritation and apply the electroids to different location
a BNP greater than 100 p g / ml is suggestive of heart failure. Because the sternum Laboratory test can be quickly obtain BNP level are you supposed to prom heart failure NCLEX setting at the emergency
elevations and BNP can occur for a number of positions or region such as pulmonary embolus myocardial infraction Mi and ventricular hypertrophy. There for the healthcare provider correlates BNP levels with abnormal physical assessment findings and other diagnosis test before making a definitive diagnosis of heart failure
clubbing of the fingers and toes indicate chronic hemoglobin desaturation decreased oxygen supply and is associated with congenital heart disease
the nurse should assess the client's O2 saturation level and intervene as directed when caring for a client with clubbing of the fingers and toes
postural orthostatic hypotension is sustained decrease of at least 20 mmhg and systolic BP 410 mmhg and diastolic BP within 3 minutes of moving from a lying or sitting position to a standing position.
example the supine BP 120 over 70, heart rate 70 BPM, sitting bp100 over 55 mmhg heart rate 90 BPM, standing BP 98 over 52 mmhg heart rate 94 BPM.
normal responses are a heart rate increase of 5 to 20 BPM above the resting rate, 2 an unchanged systolic pressure or a slight decrease if up to 10 mm mg, 3 slight increase of 5 mmhg in diastolic pressure
the nurse should instruct the client to follow these guidelines when they receive the left groin cardiac catheterization
the next 24 hours do not be in at the waist rain or lift heavy objects if the arteries of the groin what shoes contact the primary provider is swelling, new bruising or pain from the procedure puncture site, or a temperature of 101 Fahrenheit or more occur. If bleeding occurs lie down growing approach and apply firm pressure to the puncture site for 10 minutes. Notify the primary provider as soon as possible and follow instructions. If there is a large amount of bleeding call 911
the INR reported with the PT, provides a standard method for reporting PT levels and eliminating the variations of PC results from different Laboratories. The INR rather than the PT alone is used to monitor the effectiveness of Warfarin.
the therapeutic range for INR is 2 to 3.5
client is prescribed Warfarin orally PT is evaluated what other laboratory should the nurse evaluate
assessment findings associated with reduced cardiac output include reduced post pressure hypotension tachycardia reduced urine output lethargy or disorientation
decreased cardiac output
complications from use of hemodynamic monitoring systems are uncommon and can include pneumothorax , infection, air embolism.
pneumothorax may occur during the insertion of catheters using a central venous approach CVP and pulmonary artery catheter. Air emboli can be introduced into the vascular system if the stopcock attached to the pressure transducer are mishandled during blood drawing, administration of medication, or other procedures that require opening the system to air
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