Nursing 245 Exam 3 Review Notes: Heart and Neck Vessels, Exams of Nursing

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Nursing 245 Exam 3 Review Notes

Health Assessment and Promotion

(Massachusetts College of Pharmacy and

Health Sciences)

• Heart has four chambers: 2 atria and 2 ventricles
• Great vessels lie bunched above base of heart
  • VENOUS GREAT VESSELS:
    • Jugular veins
    • Superior vena cava & Inferior vena cava:
      • Return deoxygenated blood to right heart
    • Pulmonary artery carries venous blood from right heart to lungs where blood picks up 02 & releases C02 (gas exchange).
  • ARTERIAL GREAT VESSELS:
    • Pulmonary veins : oxygenated blood from lungs to lefi atrium
    • Aorta: blood to the body
• There are two circulations: pulmonary and systemic Direction of Blood Flow
• Veins: blood vessels containing DEOXYGENATED blood flowing TO the heart
• Arteries: blood vessels containing OXYGENATED blood flowing FROM the heart

1. Deoxygenated blood enters right atrium through Superior and Inferior Vena Cava
2. Blood enters right ventricle through tricuspid valve
3. Blood exits right ventricle through pulmonary valve and enters pulmonary artery
4. Lefi and right pulmonary arteries send blood to lungs, where gas exchange occurs
5. Oxygenated blood returns to heart via the pulmonary veins enters lefi atrium
6. Blood enters lefi ventricle through mitral valve
7. Blood exits lefi ventricle through aortic semilunar valve to enter aorta
8. Aorta distributes blood to body

• SUPERIOR VENA CAVA (FROM UPPER BODY) /INFERIOR VENA CAVA (FROM LOWER BODY) → RA → TRICUSPID VALVE → RV → PULMONARY VALVE → PULMONARY ARTERY → L/R PULMONARY ARTERY → LUNGS → PULMONARY VEINS→ LEFT ATRIUM → MITRAL/BICUSPID VALVE → LEFT VENTRICLE → AORTIC SEMILUNAR VALVE → AORTIC ARCH RIGHT SIDE LEFT SIDE

1. SUPERIOR (FROM UPPER BODY)/INFERIOR (FROM LOWER BODY) VENA CAVA

7. PULMONARY VEINS

2. RIGHT ATRIUM 8. LEFT ATRIUM

3. TRICUSPID VALVE 9. MITRAL/BICUSPID VALVE

4. RIGHT VENTRICLE 10. LEFT VENTRICLE

5. PULMONIC VALVE 11. AORTIC VALVE

6. PULMONARY ARTERY 12. AORTA

• Unoxygenated red blood drains into vena cava, follows route of venous blood
  • From liver to right atrium (RA) through inferior vena cava
    • Superior vena cava drains venous blood from the head and upper extremities
    • From RA, venous blood travels through tricuspid valve to right ventricle (RV)
  • From RV, venous blood flows through pulmonic valve to pulmonary artery
    • Pulmonary artery delivers deoxygenated blood to lungs Cardiac Cycle : continuous movement of blood through contraction & relaxation of heart
• Rhythmic flow of blood through heart is cardiac cycle
• Has two phases, diastole and systole
• Diastole: ventricles relax and fill with blood; this takes up two thirds of cardiac cycle
• Systole: heart’s contraction, blood pumped from ventricles fills pulmonary and systemic arteries; this is one third of cardiac cycle
• First heart sound (S1): beginning of ventricular systole; “lub”, denotes closure of AV valves, coincides with R wave (upstroke of QRS), loudest at apex

• Cardiac output (CO) : CO = heart rate × stroke volume
• Preload: volume of venous return which builds in diastole
• Contractility : ability of heart muscle to increase force of contraction via capacity to shorten muscle fibers, thereby contraction during systole
• Afterload : amount of pressure heart works against with each heartbeat/stroke, i.e., stroke volume Heart Rate: controlled by sympathetic (SNS) + parasympathetic nervous systems (PNS)
• SNS
• “Fight versus flight” reactions
• Indirect function
• Baroreceptors; chemoreceptors
• PNS: causes a decrease heart rate via vagus nerve
• “Rest and digest” reaction
• Vagus nerve also decreases conduction via AV junction Objective Data: Physical Assessment
• When performing a regional cardiovascular assessment, use this order:
• Pulse and blood pressure
• Extremities
• Neck vessels
• Precordium
• Logic of this order is that you begin observations peripherally and move in toward heart
• When palpating carotid arteries, palpate only one at a time to avoid compromising arterial blood to the brain
• For patients middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of bruit Infant and Children
• Infants
• Assess cardiovascular system for the first 24 hours and then again in 2-3 days
• Extra cardiac signs of heart status: pink to pinkish brown, watch for cyanosis
• Liver- should not be enlarged
• Respiratory- should not be labored
• Children
• Extra cardiac signs: poor weight gain, developmental delay, persistent tachycardia, tachypnea, DOE, cyanosis, clubbing
• Venous hum: turbulent flow in JV system
• Innocent murmur 30+% Electrocardiograph (ECG)
• P: depolarization of atria
• P-R interval: from beginning of P wave to beginning of
• QRS complex (time necessary for atrial depolarization plus time for impulse to travel through AV nodes to ventricles)
• QRS complex: depolarization of ventricles

• T wave: repolarization of ventricles Lifespan Considerations
• Pregnant woman: blood volume increases by 30-50% during pregnancy, increased cardiac output, arterial BP decreases because of peripheral vasodilation (lowest in the 2nd trimester, increases afier)
• Infants and children: fetal heart starts to beat afier 3 weeks gestation, inflation and aeration of lungs at birth causes circulatory changes
• Aging adult: it is difficult to isolate because it is so closely interrelated with lifestyle, habits, and diseases
• Risk factors
• Modifiable: lifestyle, HTN, smoking, serum cholesterol, physical inactivity, obesity, diabetes, alcohol/drugs, nutrition/diet, stress
• Non-modifiable: age, gender, ethnic background, family history of heart disease
• Cardiac changes once thought to be due to aging are partially due to sedentary lifestyle accompanying aging
• Isolated systolic HTN: increase in systolic BP due to thickening and stiffening of arteries
• LV wall is thicker and stiffer, causes decrease in strength of pump
• Increased risk of developing arrhythmias
• LA size increases, MV closes more slowly
• Less able to respond with HR or CO to stress/exercise
• Stress hormone receptors become less sensitive
• Ability of heart to augment CO with exercise is decreased
• Elder adult:
• SBP gradually rises, DBP remains constant
• Yield, widening pulse pressure
• Orthostatic hypotension may occur in elders
• Palpate and auscultate carotid artery gently, one at a time- avoids reflex slowing of heart rate
• More likely to have arrhythmias Smoking and Heart Disease
• Nicotine increases risk of myocardial infarction (MI) and stroke by causing
• Increase in oxygen demand with a concomitant decrease in oxygen supply
• Activation of platelets, activation of fibrinogen; and an adverse change in lipid profile Culture and Genetics
• Coronary heart disease is leading cause of death among Hispanics, African Americans
• Hypertension prevalence in African Americans are highest, develop it earlier in life than Caucasians- increase risk of CVA, death from CAD, end stage kidney disease Health Promotion
• ABCs of Heart Health
• A spirin (low dose) controversial in primary prevention
• B lood pressure: New guidelines, education
• C holesterol: annual screening
• D iabetes management
• Smoking

beginning of pubertal development; precedes menarche by 2 years

• Menarche: first day a girl receives her period
• Colostrum: produced by the breasts a few days afier delivery in pregnant women; rich in antibodies that protect newborns against infections
• Afier menopause the ovaries decrease secretion of estrogen/progesterone > cause breast glandular tissue to atrophy

Chapter 21: Peripheral Vascular System and Lymphatic System

Vascular system and lymphatics:

• Consists of arteries/veins
• Diseases affect delivery of O2/nutrients to the tissues or elimination of waste
• Lymphatic vessels : transport fluid from interstitial space back to the blood
• Related organs: spleen, tonsils (located at entrance to resp./GI tracts and respond to local inflammation), thymus (located in superior mediastinum behind the sternum and in front of aorta)
• FOUR FUNCTIONS OF THE LYMPHATIC SYSTEM:
  1. Destroy old red blood cells 2. Produce antibodies 3. Store red blood cells 4. Filter microorganisms from the blood Aging Adults
• Early mobilization and low-dose anticoagulants reduce the risk of pulmonary embolisms when caring for myocardial infarctions
• Loss of lymphatic tissue = fewer lymph nodes; decreased size of remaining lymph nodes ARTeriosclerosis is the stiffening or hardening of the artery walls.
• Peripheral blood vessels grow more rigid with age vs. ATHerosclerosis is the narrowing of the artery because of plaque build-up. Atherosclerosis is a specific type of arteriosclerosis. Assessing Subjective and Objective Data

1. Subjective Data KNOW THE 6 P’s TO ASSESSMENT:

• ** Arterial disease causes symptoms of oxygen deficit
• ** Venous disease causes symptoms of metabolic waste build up

2. Objective Data

• Inspect, palpate, and auscultate arms and legs

- ARMS

• Normal nail bed angle: 160 degrees
• Look for signs of early clubbing
• Capillary refill should be 1-2 seconds: gives index of peripheral perfusion and cardiac output
• Radial pulses: note the amplitude on a three point scale (0, 1+, 2+, 3+)
• Abnormal findings: Raynaud phenomenon (decreased blood flow to the fingers) and Lymphedema (swelling due to damaged lymph nodes); aneurysms; occlusions
• LEGS
• Check for pretibial edema: firmly depress skin over tibia or medial malleolus for 5 seconds, then release; your finger shouldn't leave an indent How to grade pitting edema (mild > very deep): 1+, 2+, 3+, 4+
• Ankle-brachial index (ABI): check how well your blood is flowing; used to check for peripheral artery disease (PAD). Patients with PAD have blocked arteries in the arms and legs.
• The Trendelenburg test: place the pt. Head down and elevate the feet; The Trendelenburg test determines the integrity of hip abductor muscle function
• Abnormal findings: Arterial-ischemic ulcer; venous (stasis) ulcer; superficial varicose veins; DVT; aneurysms; occlusions *Powerpoint Question: The nurse is assessing a patient’s risk for developing a deep vein thrombosis (DVT). The patient considered at the highest risk is a 60 y/o patient who: a) Has been on bed rest for 3 days. (WHY? Bed rest and inactivity increase a patient’s risk of DVT) b) Has been receiving PT for left knee replacement (this is considered a risk factor, but not the highest) c) Has calf and thigh measurements less than an inch of variation on both legs (this is normal) d) Admitted to the hospital with asthma exacerbation (would not put pt at high risk for DVT) **URGENT ASSESSMENTS:

1. Complete arterial occlusions: limb-threatening (look for pain, numbness, coolness, and color change)
2. Deep vein thrombosis (DVT): immediate anticoagulant therapy (look for pain, edema, extremity warmth)
3. Pulmonary embolism: life-threatening (look for acute dyspnea, chest pain, tachycardia,

Developmental Competence: Adolescence

• Period of rapid physical growth, endocrine, & hormonal changes
• Increase in caloric & protein requirements to meet these demands
• Usually requires > 3 meals/day. Supplement with healthy foods & drinks.
• Boys < body fat than girls (replaced by muscle mass) decrease to 12%
  • Double their weight 10-17 years
• Females body fat increases to 25%
  • Double their weight 8-14 years.
• Childhood most active period in life span, decreasing progressively as age Developmental Competence: Aging Adults
• Adequate vitamin D
• Adequate calcium intake
• Physical activity continues to slow to a stop at times
• Poor habits: smoke, alcohol, over eating, increase stress obesity all risk factors for disease
• Metabolic syndrome more prevalent: increases cardiac risk (dx≥ 3 factors)
• Elevated BP, glucose, triglycerides, LDL, weight circumference & low HDL Dietary Practices
• Knowing person’s religious practices related to food
• Enables you to suggest improvements or modifications that do not conflict with dietary laws
• Other issues are fasting and other religious observations that may limit a person’s food or liquid intake during specified times Nutrition Screening Methods
• Various methods for collecting current dietary intake information are available
• 24-hour recall
• Food frequency questionnaire
• Food diary
• During hospitalization, documentation of nutritional intake can best be achieved through calorie counts of nutrients consumed or infused

Chapter 22: Abdomen

Key Terms

• Anorexia : lack or loss of appetite for food
• Dysphagia : difficulty swallowing
• Hematemesis : vomiting blood
• Pica : psychological disorder characterized by an appetite for substances that are largely non-nutritive
• Hepatomegaly : enlarged liver
• Obesity : excess caloric intake
• Flatus/flatulence : gas in or from the stomach or intestines, produced by swallowing air or by bacterial fermentation
• Digestion : breaking down food by mechanical and enzymatic action in the alimentary canal into substances that can be used by the body
• Melena : dark, tarry stool Structure and Function
• Structure:
• Anatomical landmarks: xiphoid to the superior margin of pubic bone
• Reference lines: quadrant method; nine regions
• Organs: GI and GU organs
• Contains blood vessels, peritoneum, muscles
• Function: ingestion, digestion of food (mechanical and chemical), nutrient absorption, solid waste elimination Elimination : the excretion of waste products via skin, kidneys, lungs, intestines; stool reaches

rectum, pressure causes urge to defecate via int. muscle

• Bowel elimination : the passage of stool via the intestinal tract and expelling stool by the intestinal smooth muscle contraction
• Bowel incontinence : unable to purposely control fecal elimination
• GI system:
  • Breakdown and absorption of nutrients from foods ingested, elimination of waste from this process
  • Extends from esophagus to anus
• Waste formation occurs in the colon
  • Smooth muscle stimulates peristalsis (moves waste aka stool)
  • Large intestine is 5-6 fi long, 2 in in diameter: cecum and appendix, colon, rectum, anus - Function: absorb water and electrolytes as fecal matter moves via walls, intestinal mucous helps lubricate walls and assists with expulsion - Excess peristalsis: stool moves quickly, less water absorbed=loose stool - Decreased peristalsis: stool moves slowly, more water absorbed=harder stool Internal Anatomy
• Viscera: all internal organs inside the abdominal cavity
• Solid viscera: maintain characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus)
• Hollow viscera: stomach, gallbladder, small intestine, colon, bladder
• Lower edge of liver and right kidney may normally be palpable
• Spleen : sofi mass of lymphatic tissue on posterolateral wall of abdominal cavity, immediately under diaphragm
• Aorta : just to the lefi of midline in upper part of the abdomen
• Pancreas : sofi, lobulated gland located behind the stomach
• Kidney: bean shaped, retroperitoneal (posterior to abdominal contents), right kidney rests 1- 2 cm lower than lefi kidney due to placement of liver
• Peritoneum lines abdominal wall (parietal) and covers surface (visceral) of most organs
• Divided into four quadrants (small intestine is located in all four)
• Midline organs: aorta, uterus (if enlarged), bladder (if distended) Small Intestine
• Duodenum : begins at the opening from the stomach, shorter section
• Jejunum : continuous with the third portion
• Ileum : distal part of the small intestine, joins with the cecum *Powerpoint Question - Emily, a 22 year old woman, comes into the clinic complaining of severe right lower quadrant pain. The nurse suspects that Emily is experiencing pain to her A. Liver (RUQ) B. Spleen (LUQ) C. Appendix (RLQ)

tympany and dullness

• Move clockwise; tympany should predominate because air in intestines rises to surface when person is supine
• Costovertebral Angle Tenderness: positive tenderness indicates inflamed kidney
• To assess the kidney, place one hand over 12th rib at costovertebral angle on back. Palpation of the abdomen
• Perform light palpation to judge size, location, and consistency of certain organs and screen for obvious abnormal mass or tenderness
• Light palpation: objective is not to search for organs but to form an overall impression of skin surface and superficial musculature
• Deep palpation is not part of the nursing assessment
• Normally palpable structures: lower pole of right kidney, normal liver edge, xiphoid process, pulsatile aorta, lateral borders of rectus muscles, sigmoid colon, sacral promontory, full bladder, gravid uterus, cecum/ascending colon
• Rebound tenderness (Blumberg’s sign): pain on release of pressure
• Inspiratory arrest (Murphy’s sign): e licited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive
• Iliopsoas muscle test Enlargement of liver and spleen
• Enlarged liver: mononucleosis, cirrhosis, hepatitis, portal hypertension, cancers, fatty liver diseases
• Enlarged spleen: mononucleosis, leukemia, lymphomas, portal hypertension, HIV Abnormal findings:
• Abdominal distention: obesity, air/gas, ascites, ovarian cyst, pregnancy, feces, tumor
• Abnormal bowel sounds: hypoactive, hyperactive Developmental Competence: Aging Adult
• Aging alters appearance of abdominal wall
• Changes of the GI system occur with aging, but most do not significantly affect function as long as no disease is present
• Salivation decreases, leading to a dry mouth and decreased sense of taste
• Esophageal emptying and gastric acid secretion are delayed
• Incidence of gallstones increases with age
• Although liver size decreases, most liver functions remain normal; however, drug metabolism is impaired
• Aging adults frequently report constipation
• On inspection, you may note increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities
• Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may note peristalsis
• Because of thinner, sofier abdominal wall, organs may be easier to palpate, in the absence of obesity
• Liver is easier to palpate; normally you will feel liver edge at or just below costal margin
• With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin with inhalation
• Kidneys are easier to palpate Developmental Considerations
• Infants and children:
• Babies: umbilical cord shows right on the abdomen, 2 arteries, 1 vein
• Liver takes up more space in the abdomen, lower edge may be palpated
• Bladder is higher in abdomen than adult
• Abdominal wall is less muscular making it easier to palpate organs

• Pregnant women:
  • Enlarged uterus causes organs to be moved up against intestines, bowel sounds are diminished, appendix may be displaced up and to the right
  • Skin changes on abdomen (striae and linea nigra)
  • Esophageal reflux causes nausea, vomiting (morning sickness), heartburn, pyrosis
  • GI mobility decreases which causes fluid to be reabsorbed in colon which leads to constipation Culture and Genetics
• Lactose intolerance
• Celiac disease: autoimmune disorder, gluten intolerance Risk Reduction and Health Promotion
• Colorectal cancer screening
• Reduce new cases of ESRD
• Reduce cirrhosis deaths
• Screenings, patient teachings
• Foodborne illnesses are worse among the very young, elderly, immunocompromised
• Food allergies appear to be on the rise
• Severity can vary
• Symptoms typically developed within a few minutes- 2 hours
• Hepatitis
• A, B and C are viruses
• Hepatitis A & B have vaccinations
• Hepatitis A transmitted from oral fecal road
• Hepatitis B & C transmitted via blood & body fluid exposure
• Chronic hepatitis C: >3/4 infected develop
• Liver fibrosis, cirrhosis, & liver cancer