HEALTH ASSESSMENT Lecture 6 Denver School of Nursing Fall 2013
K.Hendrickson PhD, RN 1
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CHAPTER 12 Heart and Peripheral Vascular System
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Concept Overview: PERFUSION All tissues require perfusion of
oxygenated blood. Many physiologic concepts are related to
perfusion Oxygenation is foundational to all other processes Blood
flow supplies O 2 and nutrients to tissues 3 Perfusion Nutrition
Oxygenation Intracranial Regulation Elimination Pain Metabolism
Motion Tissue Integrity
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Anatomy and Physiology: The Heart and Great Vessels Heart is a
pump: Beats 60 to 100 times a minute without rest. Responds to both
external and internal demands. Each side has two chambers: Atrium
Ventricle Right side: Receives blood from superior and inferior
venae cavae. Pumps blood through pulmonary arteries to pulmonary
circulation. Left side: Receives blood from pulmonary veins. Pumps
blood through aorta into systemic circulation. Copyright 2013 by
Mosby, an imprint of Elsevier Inc. 4
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Anatomy and Physiology: Heart & Great Vessels Upper part of
heart is base. Lower left ventricle is apex. Heart lies behind
sternum and above diaphragm in mediastinum. Lies at an angle so
right ventricle makes up most of anterior surface and left
ventricle lies left and posteriorly. Pulmonary arteries and aorta
are termed the great vessels. Aorta curves upward out of left
ventricle and bends posteriorly and downward just above the sternal
angle. Pulmonary arteries emerge from superior aspect of right
ventricle near third intercostal space. 6
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 7
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Anatomy and Physiology: Pericardium and Cardiac Muscle Heart
wall layers: Pericardium, myocardium, & endocardium. Heart
encased in pericardium Fibrous pericardium, is fibrous sac of
elastic connective tissue shielding heart from trauma and
infection. Parietal layer lies next to fibrous pericardium &
visceral layer lies next to myocardium. 8
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 9
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A&P: Blood Flow through the Heart The Cardiac Cycle Four
valves govern blood flow through four chambers of heart:
Atrioventricular valves (AV) Tricuspid valve on right. Mitral valve
on left Semilunar valve Pulmonic valve opens from right ventricle
into pulmonary artery Aortic valve opens from left ventricle into
aorta. semilunar valves because of their half-moon shape. Copyright
2013 by Mosby, an imprint of Elsevier Inc. 10
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 11
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A&P: Blood Flow Through the Heart The Cardiac Cycle -
Diastole Diastole: Ventricles relax & fill with blood from left
& right atria. Movement of blood from atria to ventricles is
accomplished when pressure of blood in atria becomes higher than
pressure in ventricles. Higher atrial pressures passively open AV
valves, allowing blood to fill ventricles. About 80% of blood from
atria flows into relaxed ventricles. Contraction of atria forces
remaining 20% of blood into ventricles 12
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 13
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A&P: Blood Flow Through the Heart The Cardiac Cycle Systole
Systole: Ventricles contract creating pressure that closes AV
valves. Ventricular pressure also forces semilunar valves to open,
resulting in ejection of blood into aorta from left ventricle and
pulmonary arteries from right ventricle. As blood is ejected
ventricular pressure decreases, causing semilunar valves to close.
Ventricles relax to begin diastole. Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 14
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 15
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 16
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Anatomy and Physiology: Electric Conduction Heart stimulated by
electric impulse from SA node and travels in internodal tracts to
AV node. SA node usually discharges 60 to 100 impulses per minute.
Electric impulses stimulate contractions of both atria Impulses
then flow to AV node Impulses are then transmitted through the
Bundle of His and Purkinje fibers resulting in ventricular
contraction. Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Anatomy and Physiology: Electric Conduction Copyright 2013 by
Mosby, an imprint of Elsevier Inc. 18
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A&P: Electric Conduction Failures AV node usually prevents
excessive atrial impulses from reaching ventricles. If SA node
fails to discharge, AV node can generate ventricular contraction at
slower rate of 40 to 60 impulses per minute. If both SA and AV
nodes are ineffective, bundle branches may contract, but at very
slow rate of 20 to 40 impulses per minute. 19
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 20
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A&P: Peripheral Vascular System Arteries, Capillaries, and
Veins Maintain blood pressure by constricting or dilating in
response to stimuli and vascular resistance. Copyright 2013 by
Mosby, an imprint of Elsevier Inc. 21
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Anatomy and Physiology: Lymph System Works with the PV system
to remove fluid from interstitial spaces. During
Circulation/Perfusion: O 2 and nutrient-rich fluid is forced out at
arterial end of capillary into interstitial space, and then into
cells. Waste products from cells flow through interstitial spaces
to venous end of capillary. Excess fluid left in interstitial
spaces is absorbed by the lymphatic system and carried to lymph
nodes 23
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A&P: Lymphatic System Copyright 2013 by Mosby, an imprint
of Elsevier Inc. 24
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A&P: Lymph Node Copyright 2013 by Mosby, an imprint of
Elsevier Inc. 25
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A&P: Upper Body Lymph Nodes In the PV system, upper body
primary lymph node locations are axilla and arm Axillary nodes
drain lymph from the breasts Epitrochlear nodes on medial surface
of arm above elbow are palpable. These nodes receive fluid via
radial, ulnar, and median lymph vessels. Copyright 2013 by Mosby,
an imprint of Elsevier Inc. 26
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A&P: Lower Body Lymph Nodes In the PV system, lower body
primary lymph node locations are groin and led Inguinal lymph nodes
are superficial & receive most of lymph drainage from saphenous
lymphatic vessels in legs. In posterior surface of leg, behind
knee, are popliteal nodes, which receive lymph from medial portion
of lower leg. Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Cardiac Assessment 28
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General Health History: Present Health Status Do you have any
chronic illnesses such as diabetes mellitus, renal failure, chronic
hypoxia, or hypertension? Are you taking medications? What are you
taking, and when did you start? Have you experienced any side
effects? Do you take medications as prescribed? What
over-the-counter drugs do you take? Do you take an aspirin on a
regular basis to help thin your blood? Do you take herbal
medications? Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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General Health History: Past Medical History Hx of congenital
heart disease? During childhood did you have growing pains,
unexplained joint pains? Recurrent tonsillitis or strep throat
Rheumatic fever? Heart murmur? Have you been told you have high
levels of cholesterol or elevated triglycerides? Have you ever had
surgery on heart? On blood vessels? Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 30
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General Health History: Family Health Status Is there anyone in
your family with a history of diabetes mellitus, renal failure,
chronic hypoxia, or hypertension? If so, who? 31
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General Health History: Personal and Psychosocial History Do
you use cocaine? Other street drugs? How often do you use drugs? Do
you exercise? What kind of exercise? How often? How would you
describe your personality type? How do you deal with stress? How
often do you take time to relax? Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 32
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General Health History: Personal and Psychosocial History
Describe your usual eating habits: How often do you eat red meat?
Do you monitor your fat and salt intakes? Do you eat whole grains
each day? http://www.choosemyplate.gov/ Do you drink alcoholic
beverages? What type of alcohol do you drink? How much? How often?
Do you consume caffeine? Do you smoke, or have you been a smoker in
past? Are you interested in quitting smoking? Copyright 2013 by
Mosby, an imprint of Elsevier Inc. 33
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CV complaints & Problem-based Hx Chest pain SOB Cough
Nocturia Syncope Edema in extremities Leg pain Enlarged lymph nodes
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Problem-Based History: Chest Pain Where are you feeling the
chest pain? What does it feel like? Sharp, dull, ache? Does pain
radiate to any location? When did pain start? Is pain intermittent
or constant? What symptoms have you noticed with pain? Sweating?
Turning pale or gray? Heart skipping beats or racing? Shortness of
breath? Vomiting? Anxiety? What factors preceded pain? Exercise?
Rest? Highly emotional situations? Sexual intercourse? What makes
pain worse? What relieves pain? Rest? Nitroglycerin? How many
nitroglycerin tablets does it take to relieve chest pain? Copyright
2013 by Mosby, an imprint of Elsevier Inc. 35
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Problem-Based History: Shortness of Breath How long have you
had shortness of breath? Do you feel short of breath now? When does
shortness of breath happen? How often? How long does it last? Does
shortness of breath interfere with your daily activities? Do you
have other symptoms with shortness of breath (e.g., do your feet
swell during day)? What makes shortness of breath worse? Walking
upstairs? Lying down? How many pillows do you require when you lie
down to sleep? Do you sleep in recliner? When episodes of shortness
of breath occur, what do you do to breathe more easily? Copyright
2013 by Mosby, an imprint of Elsevier Inc. 37
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Problem-Based History: Cough When did your cough start? How
often do you cough? Do you cough up anything? ( What does it look
like? Is cough associated with position? More coughing when lying
down? With anxiety? Talking or activity? What makes it worse? What
actions do you take to relieve cough? Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 38
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Problem-Based History: Urinating During the Night For how long
have you been getting up during night to urinate? How many times a
night do you get up to urinate? What have you done to prevent this
from happening? How successful have your efforts been? Copyright
2013 by Mosby, an imprint of Elsevier Inc. 39
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Problem-Based History: Fatigue When do you notice fatigue? Was
onset sudden or gradual? Is it worse in morning or evening? Are you
too tired to take part in normal activities? Do you take iron
pills? Do you eat foods with iron, such as green leafy vegetables
and liver? For women: Do you have heavy menstrual flow? Have you
had any other symptoms associated with fatigue? Rapid heart rate?
Headache? Pale skin? Have you noticed any unusual feelings in your
feet and hands, muscle weakness, or trouble thinking? Copyright
2013 by Mosby, an imprint of Elsevier Inc. 40
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Problem-Based History: Fainting What were you doing just before
you fainted? Did you feel dizzy? Did you lose consciousness? Has
this happened to you before? Was fainting preceded by any other
symptoms? Nausea? Chest pain? Headache? Rapid heart rate?
Confusion? Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Problem-Based History: Swelling of Extremities Where is
swelling located? Arms or legs? Unilateral or bilateral? What makes
swelling go away? Does elevating your arms or feet reduce swelling?
Does swelling disappear after nights sleep? Are there any symptoms
associated with swelling? Shortness of breath? Weight gain?
Discoloration For women: Is swelling associated with your menstrual
period? Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Problem-Based History: Leg Cramps or Pain Describe pain and its
location. What makes pain worse? What relieves the pain? Have you
noticed any changes in skin of your legs? Coldness Pallor Hair loss
Sores Redness or warmth over the veins Visible veins Copyright 2013
by Mosby, an imprint of Elsevier Inc. 43
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PE: Cardiac Physical Examination Copyright 2013 by Mosby, an
imprint of Elsevier Inc.44
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Cardiac Physical Exam INSPECT General appearance, skin color,
breathing Anterior chest wall PALPATE The precordium The apical
pulse PERCUSS Heart Borders - probably not AUSCULTATE Heart Sounds
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Physical Exam: General Appearance Measure blood pressure.
Auscultate Inspect patient for general appearance, skin color, and
breathing effort. Palpate temporal and carotid pulses for
amplitude. Inspect jugular vein for pulsations. JVD Copyright 2013
by Mosby, an imprint of Elsevier Inc. 47
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Physical Exam: Upper Extremities Inspect and palpate upper
extremities for: Symmetry Skin integrity Color and temperature
Capillary refill Turgor/Edema Palpate brachial and radial pulses
for: Rate Rhythm Amplitude Copyright 2013 by Mosby, an imprint of
Elsevier Inc. 48
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Physical Exam: Lower Extremities Inspect and palpate lower
extremities for: Symmetry Skin integrity Color and temperature Hair
distribution Capillary refill, color and angle of nail beds
Tenderness Superficial veins. Palpate lower extremities for Pulses:
Femoral, Popliteal, Posterior tibial, and dorsalis pedis pulses.
Edema (grade) Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Locating Pulses 50
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Pitting Edema Scale 51
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Examination: Cardiac Assessment Inspect anterior chest wall
for: Contour Pulsations Lifts Heaves Retractions Palate PMI 5 th
ICS, MCL Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Auscultate Heart Sounds: S1 & S2 53
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Auscultate Heart Sounds: S1 & S2 Auscultate S 1 and S 2
heart sounds for: Rate Rhythm Pitch Splitting APE To Man Aortic
Pulmonic Erbs Point Tricuspid Mitral Copyright 2013 by Mosby, an
imprint of Elsevier Inc.54
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Landmarks Aortic: 2 nd ICS at left sternal border Pulmonic: 2
nd ICS at right sternal border Erbs Point: 2 nd ICS at right
sternal border Tricuspid: 4 th ICS at left sternal border Mitral: 5
th ICS and left MCL (apex) 55
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Abnormal Heart Sounds S 3 : just after S 2 in diastole.
Ken-tuck-y S 4 : just before S1 in diastole. Tenn-ess-ee Murmur
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Examination: Special Circumstances Peripheral vascular system:
Auscultate carotid artery for bruits. Estimate jugular venous
pressure for pulsations. Palpate epitrochlear lymph nodes for size,
consistency, mobility, borders, tenderness, and warmth. Palpate
inguinal lymph nodes for size, consistency, mobility, borders,
tenderness, and warmth. Copyright 2013 by Mosby, an imprint of
Elsevier Inc. 57
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Examination: Special Circumstances Cardiac assessment: Palpate
precordium for pulsations, thrills, lifts, and heaves. Copyright
2013 by Mosby, an imprint of Elsevier Inc. 58
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Age-Related Variations: Infants, Children, and Adolescents
There are several differences in assessment of cardiovascular
system for infants and young children: Equipment used to measure
blood pressure is smaller, sequence of exam may be different, and
findings may differ based on anatomic differences. Assessment of
older child and adolescent follows same procedures and reveals
similar expected findings. One exception in exam is
electrocardiography, which is not typically performed. Copyright
2013 by Mosby, an imprint of Elsevier Inc. 59
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Age-Related Variations: Older Adults Assessing cardiovascular
status of older adults usually follows same procedures as for all
adults. Expected variations may be found in heart rate and blood
pressure. Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Common Problems and Conditions: Cardiac Disorders Valvular
Heart Disease Valvular heart disease (VHD) is an acquired or
congenital disorder of heart valve characterized by: Stenotic
valve, which does not open completely. Incompetent valve, which
does not close completely. Rheumatic fever and endocarditis account
for most cases of acquired VHD. Copyright 2013 by Mosby, an imprint
of Elsevier Inc. 61
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Common Problems and Conditions: Cardiac Disorders Angina
Pectoris Angina pectoris is chest pain due to ischemia of
myocardium. Usually caused by atherosclerosis within coronary
arteries. Can occur during activity, stress, or exposure to intense
cold because of an increased demand on heart. Can also occur during
rest as result of spasms of coronary arteries. Clinical findings:
Patients describe pain as squeezing, suffocating, or constricting.
May be significant hypertension, but hypotension may also occur.
The duration of angina is important to determine: If precipitated
by exertion and patient rests promptly, may last less than 3
minutes. If it follows heavy meal or caused by anger, may last 15
to 20 minutes. Angina lasting more than 30 minutes is unusual, may
indicate developing myocardial infarction. Copyright 2013 by Mosby,
an imprint of Elsevier Inc. 62
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Common Problems and Conditions: Cardiac Disorders Myocardial
Infarction Myocardial infarction occurs when myocardial ischemia is
sustained, resulting in death of myocardial cells (necrosis). Left
ventricle more commonly affected, but right ventricle may also be
affected. Clinical findings: Patients describe pain as worst chest
pain ever experienced, pain lasts longer than 5 minutes. May
radiate to left shoulder, jaw, arm, or other areas of chest; it is
not relieved by rest or nitroglycerin. Dysrhythmias are common;
heart sounds may be distant with a thready pulse. Women report
different symptoms; they report pain or discomfort in center of
chest and shortness of breath, cold sweat, nausea, vomiting, or
lightheadedness Copyright 2013 by Mosby, an imprint of Elsevier
Inc. 63
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Common Problems and Conditions: Cardiac Disorders Heart Failure
Heart failure occurs when either ventricle fails to pump blood
efficiently into aorta or pulmonary arteries. Heart failure may
occur in left or right ventricle or both. Copyright 2013 by Mosby,
an imprint of Elsevier Inc. 64
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Common Problems and Conditions: Left Ventricular Failure Left
ventricular failure is caused by : Increased resistance that occurs
with aortic stenosis or hypertension, when ventricle can no longer
compensate for increased workload, or Weakening of left ventricular
contraction occurring after myocardial infarction when death of
myocardial cells may result in an ineffective contraction. Because
left ventricle cannot pump sufficient blood forward, some blood
backs up into left atrium and eventually into pulmonary
capillaries, causing pulmonary edema. Clinical findings: Fatigue
& SOB, including orthopnea, dyspnea on exertion, and paroxysmal
nocturnal dyspnea. Findings may reveal precordial movement,
displaced apical pulse, palpable thrill, S 3, and systolic murmur
at apex. In acute phase, patient usually has crackles bilaterally
from pulmonary edema. Copyright 2013 by Mosby, an imprint of
Elsevier Inc. 65
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Common Problems and Conditions: Right Ventricular Failure Right
ventricular failure caused by hypertrophy from pulmonary
hypertension or from necrosis from myocardial infarction. Failure
of right ventricle to pump blood into pulmonary arteries causes a
backflow of blood into inferior and superior venae cavae. Right
ventricular failure caused by pulmonary disease is termed cor
pulmonale. Clinical findings: Findings may include precordial
movement at xiphoid or left sternal border, elevated jugular venous
pressure, dependent peripheral edema, S 3 at lower left sternal
border, systolic murmur, and weight gain. Copyright 2013 by Mosby,
an imprint of Elsevier Inc. 67
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Common Problems and Conditions: Infective Endocarditis
Infective endocarditis is infection of endothelial layer of heart,
including cardiac valves: Develops when endocardial surface is
damaged by turbulent blood flow as result of valvular heart
disease, congenital lesions, or direct injury from intravenous
lines or injections, cardiac catheterization, or artificial valves.
Clinical findings: Heart sounds normal during early infection; in
late infection, murmur is heard if valve damage occurs. Copyright
2013 by Mosby, an imprint of Elsevier Inc. 69
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 70
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Common Problems and Conditions: Pericarditis Pericarditis is
inflammation of parietal and visceral layers of pericardium and
outer myocardium. May be idiopathic or the result of myocardial
infarction, uremia, cancer, trauma, infections, cardiac surgery, or
autoimmune reaction. Clinical findings: Two classic findings are
pericardial friction rub and chest pain. Pericardial friction rub
develops as inflamed layers of pericardium move against each other.
Friction rub is best heard with patient leaning forward so that
heart is closer to chest wall. Listen in second, third, or fourth
intercostal spaces at left sternal border or at apex; louder during
inspiration. Pain described as sharp pleuritic pain aggravated by
deep breathing, lying supine, or coughing. Copyright 2013 by Mosby,
an imprint of Elsevier Inc. 71
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 72
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Common Problems and Conditions: Hypertension Hypertension is
diagnosed on the basis of mean of two or more properly measured
seated blood pressure readings on each of two or more occasions
above 120/80 mm Hg in an adult over 18 years of age. Pressure in
arteries can become elevated due to constriction of blood vessels
or fluid volume overload or both. Clinical findings: Hypertension
Normal blood pressure values are less than 120 mm Hg systolic and
less than 80 mm Hg diastolic. Because there are no specific
symptoms of hypertension, periodic screening is important.
Copyright 2013 by Mosby, an imprint of Elsevier Inc. 73
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Common Problems and Conditions: Venous Thrombosis and
Thrombophlebitis Venous thrombosis occurs when a thrombus (clot)
develops within a vein. Triad of venous stasis, damage to inner
layer of veins, and hypercoagulability are usually responsible for
both. Either may occur in lower extremity, usually in deep veins.
Thrombophlebitis is inflammation of vein that may or may not be
accompanied by clot. Clinical findings: Thrombosis Sometimes
recognized by dilated superficial veins, edema and redness of
involved extremity, and increased circumference of involved leg. In
upper extremity, venous thrombosis and thrombophlebitis may occur
in superficial veins and are recognized by redness, warmth, and
tenderness over affected area. (can happen from IV therapy) Veins
may be visible and palpable. Copyright 2013 by Mosby, an imprint of
Elsevier Inc. 74
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Copyright 2013 by Mosby, an imprint of Elsevier Inc. 75
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Common Problems and Conditions: Thrombosis and Thrombophlebitis
(contd.) Copyright 2013 by Mosby, an imprint of Elsevier Inc.
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Common Problems & Conditions: Aneurysm Aneurysm is
localized dilation of artery caused by weakness in arterial wall.
Can occur anywhere along aorta and iliac vessels. Clinical
findings: Depend on location of aneurysm. Abdominal aortic
aneurysms are most common. Thoracic, usually asymptomatic with
deep, diffuse chest pain reported by some patients. Aorta and
aortic arch aneurysms can produce hoarseness from pressure on
laryngeal nerve or dysphagia from pressure on esophagus. A
pulsatile mass may be palpated in periumbilical area. A thrill or
bruit may be noted over aneurysm. Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 77
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Question 1 A patient has been admitted to the medical-surgical
unit for exacerbation of congestive heart failure. The nurse notes
bilateral +2 pitting edema and dry scaling skin. As the nurse
assesses the dorsalis pedis pulse, the nurse is unable to detect it
and notes that both feet are warm. What is the best action for the
nurse to take? A. Call the physician immediately. B. Assess skin
turgor over the clavicle. C. Use a Doppler and assess capillary
refill. D. Use a Doppler and assess for renal artery stenosis.
Copyright 2013 by Mosby, an imprint of Elsevier Inc. 78
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Question 2 In the cardiac unit, a patient awaits surgery for
mitral valve repair. As the nurse auscultates the patients heart,
the nurse will expect to hear a murmur that is: A. Most pronounced
at the base of the heart. B. Most pronounced over the carotid
arteries. C. Heard best at the left sternal border. D. Heard best
over the left midclavicular line. Copyright 2013 by Mosby, an
imprint of Elsevier Inc. 79