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1. What is a normal heart rate for an infant, child, adolescent & adult
- infant? 120-160
- Child? 75-100
- Adolescent? 60-90
- Adult? 60-100
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2. What is a normal blood pressure for an infant, chld, adolescent & adult
- infant? 85/54
- Child? 105/65
- Adolescent? 119/75
- Adult? 120/80
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3. What is the point of maximal impulse (PMI) and where can it be located on an adult?
- The apex touches the anterior chest was at approximately the 4th to 5th intercostal space just medial to the left midclavicular line-this is the place the apical impulse or PMI is the strongest.
- Child? Located at 3rd or 4th intercostal space just to the left of midclavicular line.
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4. At what age would the PMI for a child be in the same location as an adult?
7
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5. What occurs in the heart during systole?
- Ventricles contract & eject blood from left ventricle into aorta and from right ventricle into pulmonary artery.
- Diastole? Ventricles relax and atria contract so ventricles and coronary arteries can fill up
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6. What causes the first heart sound (S1)?pulmonary
- Mitral & tricuspid valves closing-Lub: Remember 1 looks like L=Lub=Loud
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7. What causes the second heard sound (S2)?
- Aortic & pulmonary valves closes-Dub: Remember 2 is circular like a in aortic, d in dub, p in pulmonary
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8. What would cause a third (S3) or fourth (S4) heart sound?
If the heart tries to fill an already distended ventricle; tis happens in heart failure. This is an abnormal heart sound in adults over 30 but can be normal in children and young adults and women in late pregnancy.
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9. What would the nurse inspect and palpate for during cardiac assessment and how would this be performed?
- Visible pulsations and exaggerated lifts, the apical pulse and any vibrations (thrills).
- Cardiovascular
- Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
- Inspection: Examine circulatory status and hydration status of upper and lower extremities:
- --Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed , clubbing
- --Capillary Refill Time (CRT): brisk (< 2 sec) or sluggish
- -- Presence of edema (central and/or peripheral)
- -- Hydration status: Skin turgor, oral mucosa, and anterior fontanels in infants
- Palpation: --Palpate central and peripheral pulses for rate, rhythm and volume
- --Skin condition temperature, turgor and diaphoresis
- Auscultation:
- --Auscultate the apical pulse
- --Compare peripheral pulse and apical pulse for consistency (the rate and rhythm should be similar).
- --Auscultate the chest for heart sounds and murmurs
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10. How would the nurse use auscultation to evaluate heart sounds?
- Follow a systemic pattern beginning at aortic area and inching stethoscope across each anatomical site. Listen for complete cycle (lub-dub) clearly at each location. Repeat using bell of stethoscope.
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11. Where would the nurse hear S1 sounds the loudest? S2 the loudest? S1 & S2 equally?
- S1 is Loudest Lower (at apex) lots of lines in letters
- S2 loudest Higher (aorta)-curvy letters again. S & S2 are heard equally midway at 2nd pulmonic/Erbs point.
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How would the nurse rate the strength of a pulse?
- From 0 to 4+:
- 0 no pulse detected
- 1+ thready, weak pulse; obliterated with pressure; pulse may come and go
- 2+ pulse difficult to palpate; may be obliterated with pressure
- 3+ normal pulse
- 4+ bounding, hyperactive pulse; easily palpated and cannot be obliterated
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What are the pulse sites used to evaluate the vascular system?
Be able to demonstrate
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What would the nurse do if a pulse is difficult to palpate?
Use an ultrasound (Doppler) stethoscope to amplify sound
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How would the nurse evaluate tissue perfusion?
- Nurse examines the face and upper extremities, looking at the skin, mucosa and nail bed.
- Cyanosis= poor arterial oxygenation; blue lips, mouth & conjunctiva. Blue lips, earlobes and nail beds =peripheral cyanosis.
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What is clubbing and what causes it to develop?
- Bulging of tissues in nail bed; caused by insufficient oxygenation at periphery from condition like chronic emphysema and congestive heart disease.
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How would the nurse evaluate the status of peripheral veins?
By asking patient to assume sitting and standing positions; inspect & palpate for varicosities, peripheral edema and phlebitis.
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What is phlebitis and what assessment findings would confirm this?
- Inflammation of the vein that occurs commonly after trauma to vessel wall, infection immobilization and prolonged insertion of IV catheters.
- To assess in legs: inspect calves for localized redness, tenderness and swelling over vein sites. Gentle palpation of calf muscles reveals warmth, tenderness and firmness of the muscle. Unilateral edema of the affected leg is one of the most reliable findings of phlebitis. If dorsiflexion of the foot (Homans sign) causes pain in calf it could be an indicator but is not fool proof.
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