Chapter 32 Common Assessment Abnormalities (objective #5)
Distended neck veins
distention greater than 3cm with pt sitting at a 30-45 degree angle.- Possible etiology is elevated right atrial pressure; right sided heart failure.
Bluish or purplish tinge to areas such as tongue, conjunctivae, inner surface of lips.- Inadequate O2 saturation of arterial blood due to pulmonary or cardiac disorders.
Bluish or purplish tinge in extremities, or in nose and ears.- Reduced blood flow because of heart failure, vasoconstriction, cold environment.
small red to black streaks under finger nails.- Infective endocarditis .
Clubbing of nail beds
obliteration of normal angle between base of nail and skin.-Endocarditis, congenital defects, prolonged O2 deficiency.
Color changes in extremities with postural change
Pallor, cyanosis, mottling of skin after limb elevation; dependent rubor (reddish-blue discoloration), glossy skin.- Chronic decreased arterial perfusion.
Venous- necrotic crater-like lesion usually found on lower leg. Characterized by slow wound healing. Arterial- pale ischemic base, well defined edges, usually found on toes, heels, lateral malleoli.
Visable dilated, discolored, tortuous vessels in lower extremities. - Incompetent valves in vein.
sharp, brisk, pounding pulse. - hyperkinetic states, anemia, hyperthyroidism.
Weak, slowly rising pulse; easily obliterated by pressure. - Blood loss, decreased CO, aortic valve disease, peripheral arterial disease.
regularly or irregularly; skipped beats. - Cardiac dysrhythmias.
Regular rhythm but strength of pulse varies with each beat.- Heart failure, cardiac tamponade.
lack of pulse. - atherosclerosis, trauma, embolus.
vibration of vessel or chest wall.- Aneurysm, aortic regurgitation, arteriovenous fistula.
Stiffness or inflexibility of vessel wall.- Atherosclerosis.
tachycardia.- Exercise, anxiety, shock, need for increased cardiac output, hyperthyroidism.
bradycardia. - Rest/sleeping, SA or AV node damage, athletic conditioning, side effect of drugs, hypothyroidism.
Displaced point of maximal impulse
palpated below the 5th intercostal space and left of the midline. -Left ventricluar dilation.
Unusually warm extremities
Hands or feet. - possible thyrotoxicosis.
Hands/feet cold to touch. -Intermittent claudication, peripheral arterial obstruction, low CO, severe anemia.
Pitting edema of lower extremities or sacral area
visable indentation after application of firm pressure; weight gain; tightening of clothing. - Interruption of venous return to heart, fluid in tissues.
Abnormal capillary refill
blanching of nail bed for >2sec after application of firm pressure is released.- Possible reduced arterial capillary perfusion, anemia.
Asymmetry in limb circumference
Measureable swelling in limb. -Venous thromboembolism, varicose veins, lymphedema.
Abnormal Cardiac Borders
left border of cardiac dullness extends past MCL in 5th ICS; border of cardiac dullness extends past sternal border. - Cardiac enlargement due to coronary heart disease, heart failure, cardiomyopathy.
apical HR exceeds the peripheral pulse rate.- Cardiac dysrhythmias; most commonly atrial fibrillation.
Turbulant flow sound in peripheral artery.- Arterial obstruction or aneurysm.
Third Heart Sound
Extra heart sound, low pitched, heard in early diastole, similar to the sound of a gallop. -Left ventricular failure; volume overload; mitral, tricuspid or aortic regurgitation; HTN.
Fourth Heart Sound
Extra heart sound, low pitched, heard in late diastole, similar to the sound of a gallop. -Forceful artrial contraction from resistance to ventricular filling.
Turbulent sounds occuring between normal heart sounds; characterized by loudness, pitch, shape, quality, duration and timing.- Cardiac valve disorder, abnormal blood flow patterens.
Pericardial friction rub
High-pitched, scratchy sound heard during S1 and/or S2 at the apex; heard best with pt sitting or leaning forward, at the end of expiration. -Pericarditis.
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