Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system PowerPoint PPT Presentation


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Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

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1. Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

2. Great vessels of the neck Jugular veins Carotid arteries

3. Top line – level of the higest visible point of distention Bottom line – level of the sternal angle Measure: the vertical distance between the sternal angle and the highest level of jugular distentionTop line – level of the higest visible point of distention Bottom line – level of the sternal angle Measure: the vertical distance between the sternal angle and the highest level of jugular distention

4. JVD

5. Anatomy of the Heart Note av valves and semilunar valvesNote av valves and semilunar valves

6. Assessment Position client supine Then head elevated at 45 degrees INSPECTION: Lifts, heaves PMI (assess location)

7. Palpation

8. Physical Landmarks Suprasternal notch Sternum Manubriosternal angle – Angle of Louis Intercostal Spaces

9. Auscultation: Auscultatory Sites

10. Auscultatory Sites: Cont.

11. Heart Sounds – S1…(Lub)… S1: Closure of AV valves (mitral and tricuspid valves: M1 before T1) Correlates with the carotid pulse Can be split but not often

12. Heart Sounds – S2…(Dub)… S2: Closure of Semilunar valves (aortic & pulmonic) May have a split sound (A2 before P2)

13. Heart Sounds – Cont. Base (R/L 2nd ICS) S2 louder than S1 Apex S1 louder than S2 Normal physiologic S2 Split Best heard at pulmonic area during inspiration Fixed split (no variation with inspiration)

14. Extra Heart Sounds S3… Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky) S4… Due to slow ventricular contraction: atrial gallop S4-S1 — S2 (Ten-nes—see)

15. Murmurs Grade I :barely audible Gr II : audible but quiet and soft Gr III : moderated loud, without thrust or thrill Gr IV : loud, with thrill Gr V : louder with thrill, steth on chest wall Gr VI : loud enough to be heard before steth on chest turbulent blood flow within the heart Listen for murmurs in the same auscultatory sites APETM

16. Peripheral Vascular Assessment Skin temp Color Pulses Cap refill edema

17. Peripheral Pulses

18. Documentation of Pulses

19. Capillary Refill Should test fingers and toes Press down on nail to compress capillaries Color goes white, then release Color should return briskly; < 3 seconds Document “sluggish” if > 3 seconds Should test fingers and toes Press down on nail to compress capillaries Color goes white, then release Color should return briskly; < 3 seconds Document “sluggish” if > 3 seconds

20. Edema

21. Pitting edema

22. Assessing for Edema Depress pretibial area & medial malleolus for 5 seconds Grade pitting edema 1+ to 4+ Depress pretibial for 5 seconds Depress pretibial for 5 seconds

23. Deep Vein Thrombosis (DVT)

24. Assessment Guide: Gas Transportation Blood Pressure: 128/64, 132/72 Apical Heart Rate: 80, 74 Peripheral Pulse: Radial rate: 78, 74 Rhythm: regular, irregular Strength: strong, weak, thready, bounding,0-+4 Rt. Pedal pulse: 2+ Lt. Pedal pulse: 2+ Edema: present, none Degree: 1+, 2+ Location: LLE, RUE Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc. Blood Pressure: 128/64, 132/72 Apical Heart Rate: 80, 74 Peripheral Pulse: Radial rate: 78, 74 Rhythm: regular, irregular Strength: strong, weak, thready, bounding,0-+4 Rt. Pedal pulse: 2+ Lt. Pedal pulse: 2+ Edema: present, none Degree: 1+, 2+ Location: LLE, RUE Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc.

25. Cap refill Upper extremities: 2 sec Lower extremities: 2 sec Skin/Mucous Membranes: Other (bleeding, infection) Skin /mucous membranes pink note vascular lesions (purpura, ecchymoses, petechiae) redness and inflammation Interventions in use Venodyne/leg compression machine; elevated LEs on pillow; thigh high tedhose in use Med List: Digoxin, Atenolol, Zestril, etc.

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