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NUR 1060C Health Assessment Exam 2 with complete solution Updated
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NUR 1060C Health Assessment Exam 2 with complete solution Updated
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NUR 1060C Health Assessment Exam 2with complete solution Updated
What are some landmarks to take note of in regards to the heart? - "the heart is an upside
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down triangle"
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apex of the heart is at the "bottom" of the heart
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base of the heart is at the "top"
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Great vessels and the right and left borders (always refers to the pt's right and left)
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II IIWhat is the pericardium? - double-walled sac that encloses the heart
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What are the great vessels? - - Superior and Inferior vena cava - drain blood into the R.
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atria
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- Aorta - ejects/sends/delivers blood to the body from the l. ventricle via the pulmonary
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vein passed the aortic valve
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- Pulmonary Arteries and Veins - PA sends blood to the lungs to be oxygenated via the
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pulmonic valve, PV - takes oxygenated blood to the L. atria
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What is the pulmonary artery and how is it different from the pulmonary vein? - PA
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carries *deoxygenated* blood from the RV via the pulmonic valve to the lungs whereas
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the PV takes *oxygenated* blood to the LA and then the blood in the LA passes through
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mitral valve and moves to the LV to the aorta via the aortic valve
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What is the atrium? ventricle? - Atrium and Ventricles (the right AND left sides) make up
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the 4 chambers of the heart. The RA recieves blood from the body via the IVC and SVC,
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The LA recieves blood from the lungs via the pulmonary vein, The LV receives blood from
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the LA via the mitral valve (atrioventricular valve), RV receives blood from the RA via the
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tricuspid valve (atrioventricular valve)
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Atrium = blood reservoir II II II II
Ventricle = muscular pump II II II
What are the AV valves? - tricuspid and mitral = "ATM" = valves between the atria and
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ventricles, contribute to the S1 first heart sound (lub) when they close, the AV valves
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close becasue the the ventriculars are contracting
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What is diastole? systole? - Diastole + systole = cardiac cycle
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*Diastole* = relaxation of the ventricles, ventricular filling, takes longer than systole,
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second heart sound, S2 = semilunar valve closure, aortic and pulmonic (SAP) = closed,
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"dub" = base= loudest point
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*Systole* = ventricular/heart contraction = arterial filling, tricuspid and mitral valves (ATM)
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is closed, loudest at apex, S1 = AV valve closure
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, What are the semilunar valves? - Aortic and Pulmonic valves = "SAP" = valves between
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the ventricles and arteries , contribute to S2 heart sound (dub) when they close
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What is the direction or pathway of blood flow through the heart? - - head and upper
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extremities drain blood into the R.atria via the SVC and the liver drains blood into the R.
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atria via the IVC
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- blood from the R.atria goes to the R.Ventricle via the tricuspid valve
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- since blood on the right side is deoxygenated it needs to get to the lungs via the
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pulmonary arteries through the pulmonic valve
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- once the blood is in the lungs it is then oxygenated
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- it then comes back to the l. atria of the heart via the pulmonary vein
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- then the blood moves to the l. ventricles passed the mitral valve
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- the blood in the L. ventricle needs to get to the aorta via the aortic valve and then the
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aorta sends the oxygenated blood to the body
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What is the cardiac cycle? - Diastole + systole = ventricular filling/ventricular relaxation
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(SL valve closing) + atrial filling (AV valve closing) = S2 + S1 = lub + dub
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What are the S1 and S2 heart sounds? - S1 = lub = first heart sound = atrial filling = ATM
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closure = loudest at apex, ventricle contraction
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S2 = dub = second heart sound == ventricular filling = SAP closure = loudest at base,
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ventricle relaxation
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What is a murmur? - when the blood flow in the heart can be heard as turbulence or
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collision currents instead of silence/ no noise this is consider a murmur. murmurs are
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often described as blowing or swooshing sound. use the bell of the stethoscope for low
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pitched sounds usually heard with murmurs.
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there's a distinct muffling as opposed to clear tapping II II II II II II II II
What are some causes of murmurs? - Velocity of blood increase - e.g. exercise
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Viscosity of blood decrease - e.g. anemia II II II II II II II
Defective valves/ defective septum II II II
What are the four characteristics of heart sounds to take note of? - 1. frequency/pitch
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2. intensity
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3. duration - make note of silent periods
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4. timing - is it happening during diastole or systole?
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How does a nurse or HCP properly use the diaphragm and bell of a stethoscope to
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assess the heart and neck vessels? - diaphragm is for high pitched sounds e.g. normal
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heart sounds
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bell is for low pitched sounds e.g. murmurs, bruits, extra heart sounds
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, What are some accessible pulse points? - Carotid (neck), brachial (arm), radial (arm),
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femoral (upper thigh), popliteal (behind the knee), dorsalis pedis (foot), posterior tibial
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(back of foot/ankle)
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Carotid is the pulse you can feel the strongest II II II II II II II II II
Carotid is to be checked one at a time II II II II II II II II
What are some things we expect to find and don't expect to find across the lifespan
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during a cardiovascular exam? - The younger the pt the higher the HR
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Infants - 70 -90 BPM while asleep and 170 when crying II II II II II II II II II II II
Bradycardia - regular but slow HR is anything less 90 for newborns and anything less than II II II II II II II II II II II II II II II
60 for children
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Tachycardia - regular but fast HR is anything over 200 BPM for new borns and anything II II II II II II II II II II II II II II II
150 BPM for infants
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Eldery/ OAs - prone to hypotension = fainting, weakness, dizziness i.e. orthostatic
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hypotension, postural hypotension
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How does a nurse or HCP display respect for the pt while performing assessment
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techniques? - Asking perrmission to remove clothing, explaining the procedure to the pt,
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only uncover the part of the body you are assessing
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What is compliance? non-compliance? - the ability of tissue to stretch; heart or lung
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tissue that has lost some of it's stretching ability
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What are the neck vessels and where are they located? - Carotid artery and jugular
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veins; Carotid located between trachea and SCM (sternomastoid muscle)
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Jugular overlay the SCM and is associated with right sided heart problems because there
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are no valves between the SVC/ IVC and the Right Atria blood can back up and manifest
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as upright jugular vein dissention
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What are the effects of heart failure? - Heart enlarges to compensate for the decreased
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cardiac output, the heart muscles thicken, the decreased blood flow causes the kidney to
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decrease urine output which results in water retention which then manifests as edema or
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fluid back up in the legs, neck, and lungs
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What are some S/S of heart failure? - Cyanosis, low O2 sats, jugular vein distention
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(associated with right heart failure), crackles, wheezing
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What is the difference between arteries and veins? - *Arteries* have elastic fibers that
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allow them to stretch and relax during systole and diastole. Arteries are part of a high
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pressure system because of the pumping action from the heart. Every time the heart
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beats a pressure wave is created that you can feel through arteries as a pulse (can be felt
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at point on the body where the arteries are closer to the surface and over bone).
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Even though *veins* run parallel to arteries the direction of blood flow is opposite in veins.
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Veins are part of a low pressure system because it is carrying "bad blood" = CO2 and
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waste products back to the heart. The veins don't have the heart to generate blood flow so
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