Summary
Summary NSG 121 Exam 3 Study Guide
- Course
- NSG 121
- Institution
- Herzing University
This is a comprehensive and detailed study guide on Exam 3 for NSG 121. *Essential Study Material!!
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Health asssesment exam 3 study guideModule 8: Cardiovascular, peripheral vascular and lymphatic systems
● PAD: Peripheral arterial disease (PAD) in the legs or lower extremities is the
narrowing or blockage of the vessels that carry blood from the heart to the legs.
Risk factor modification
○ Smoking; high-fat diet; limited activity level
○ Hypertension; diabetes
○ 7 ps:
Pain
Pallor: pale skin color
Poikilothermia: inability to regulate core body temperature
Paresthesias: numbness, tingling
Pulselessness: lack of pulse via palpation, auscultation
Paralysis: complete loss of muscle function
Perfusion: capillary refill
Assess pulses- begin at distal site and work up the next extremity assessing next
proximal site
Use doppler if no pulse
Compression stocking
Patient complains of pain when walking, not when resting
● Lack of muscle tone or strength- adding
● DVT: Deep vein thrombosis occurs when a blood clot forms in a deep vein.
These clots usually develop in the lower leg, thigh, or pelvis, but they can also
occur in the arm.
Legs and Calf: want to touch edema, measure both side, pain
Notify provider
Use doppler if needed
Anticoagulant
Assess pulse, temp, color
, ● Lymphedema:swelling due to build-up of lymph fluid in the body.
Lymph obstructed, seen a lot on cancer patients
Know which side patient had masectomy, BP on opposite side
Lymphedema thick, edema, red, pus, 3-4 + edema
● With older adults when ambulating HR and BP will go up- high systolic- expected
finding
● The heart's natural pacemaker — the sinus node — produces electrical signals
that prompt your heart to beat
Landmarks
S3 sound (extra sound) is early diastolic ventricular filling- if ventricles are distended or
hypertrophic the filling can cause a vibration.
● Murmur: Turbulent blood flow through a diseased or damaged heart valve.“whooshing”
sound occurs when blood flows through diseased or damaged valves
Systolic murmurs fall between S1 and S2
diastolic murmurs will be heard after S2 before S1
● Peripheral edema- evaluate legs
● Assessing jugular vein- 30-45 angle see it? Fluid overload
● Jugular vein- flat- dehydration
● Normal heart sounds s1 and s2
● Mitral valve: can be heart in the 5th intercostal space a little more laterally, in the
midclavicular line
● Triscupid valve: fourth intercostal space to the left of the sternum.
● Venous system:
Blood return to the heart is regulated by a pressure gradient created by:
○ respirations, skeletal muscle contraction, and intraluminal valves.
● S/S of fluid overload:
SOB and fatigue with activity
Peripheral edema
Nocturia
Distended jugular veins (assess 30-45 degree angle)
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