Midterm

• What is a murmur?

  - dysfunctional valves = defect of papillary muscle or tendinae not allowing valves to open/shut properly

  - Stenosis: Valve doesn't open properly

  - Regurggitation: Valve doesn't close properly

  - some are intermitted
• What is Nursing?


  Nursing is promoting health, protecting, and caring for patients. It is prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
• What is a Scratch Test (GI) and how do you perform it?

  - Helps to locate lower edge of liver

  
  

  - Place stethoscope over RUQ above liver. With one finger of other hand, lightly scratch abdomen starting in RLQ moving up toward liver.

  
  

  - When scratching sound heard thru stethoscope becomes magnified, you have reached liver border.
• How do you percuss liver span?

  - Right midclavicular line

  - Below umbilicus, percuss upward (tympany to dullness)

  - Over lung, percuss downward (resonance to dullness)

  - Distance between two lines = liver span (2.5 inches/6-12 cm)
• How do you test for Fluid Wave?

  - Have the patient lying supine.

  - The pt or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the pt's mid abdomen, applying with slight pressure.

  - Place the fingertips of one hand along one flank, and with the other hand firmly give a sharp tap along the opposite flank.

  - Positive test: Nurse is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.
• How do you test for rebound tenderness (Blumberg's sign)?

  - Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

  
  

  - Suspect appendicitis, peritonitis, or diverticulitis
• How do you test for Murphy's sign and what does it detect?


  - Used to detect inflamed gallbladder

  - Stand at pt's right side, palpate at MCL at costal angle

  - Pt takes deep breath, moving gallbladder closer to examiner's hand, causing pain on inspiration

  
  

  - Presence of pain is positive Murphy's sign / Gall bladder disease
• Iliopsoas muscle test


  - Have pt lying supine

  - use hand to apply pressure to lower thigh while pt attempts to flex hip

  - Pain results from irritation of iliopsoas muscle

  
  

  - Associated with peritoneal irritation / appendicitis
• Obturator muscle test


  - pt lying supine, flexes right leg at hip and knee

  - Examiner places one hand just above pt's knee and other hand at ankle, rotate leg internally and externally

  - Pain results from irritation of obdurate muscle

  
  

  - suspect appendix / pelvic abscess
• Ballttement


  Palpation technique used to determine a floating mass
• McBurney's sign


  - press down on abdomen 2/3 from umbilical to iliac crest

  
  

  - if pt feels pain when you relieve pressure suspect appendicitis
• Abdominal distention may result from the 7 F's. What are the 7 F's?

  Fat (Obesity)

  Fetus (Pregnancy)

  Fluid (Ascites)

  Flatulence (Gas)

  Feces (Constipation)

  Fibroid Tumor

  Fatal Tumor
• Age-Related Variations for Older Adults

  - increased regurgitation

  - decreased gastric acids & digestive enzymes

  - decreased absorption of vitamin B12 & fats

  - reduced storage & protein synthesis in liver
• What is common to see in aging adults?

  Athersclerorsis, Arteriosclerosis

  Calf-Vein Enlargement- Increased risk of DVT and PE

  Skin and Hair changes- loss of hair on LE, thinner/shinier skin

  Atrophy of lymphatic tissue

  Loss of valvular competence
• What is a normal heart beat for an adult?

  60-100 beats per minute
• What are the great vessels?

  The pulmonary arteries and aorta
• Precordium


  The portion of the body over the heart and lower chest. Abnormal upon palpation (feel for vibration) if a valve doesn't open or close properly
• Mediastinum


  The ares in which the heart lies. The middle section of the chest cavity.
• Myocardium


  Thick muscular tissue that contracts to eject blood from the ventricles.
• What are the 4 heart valves?

  Atrioventricular

  - Tricuspid (right)

  - Mitral (left)

  
  

  Semilunar

  - Pulmonic

  - Aortic
• S1


  First heart sound (lub)

  Effect of respiration

  Closing of the mitral and tricuspid valves

  Low pitch

  Almost always synchronized with the carotid pulse

  Coincides with R wave on ECG
• S2


  2nd heart sound (dub)

  Closing of semilunar valves.

  High pitch
• Where is S1 heard the loudest?

  The apex / lower left ventricle
• Where is S2 the loudest?

  The base / upper part of the heart
• S3


  Third heart sound (abnormal)

  - common in ages 30-40

  - caused by increased fluid / increased atrial pressure

  
  

  - stretching due to increased flow from extra fluid (blood) (CHF = heart failure causes fluid overload)

  
  

  
  

  Ken-Tuck-y
• S4


  Results from stiffened L ventricle secondary to hypertension

  Ten-ness-ee
• When a nurse finds a murmur, how should he/she document?

  Posture

  Pitch

  Pattern

  Loudness

  Location

  Quality

  Radiation

  Timing
• Pulse points


  - temporal

  - carotid

  - apical

  - brachial

  - radial

  - femoral

  - popliteal

  - posterior tibial

  - dorsalis pedis
• What is the pulse amplitude rating scale? UE pulse objectives

  0+ Absent

  1+ Diminshed, barely palpable

  2+ Normal

  3+ Full volume / bounding

  4+ Full volume / increased

  Pulsus Bigeminus = irregular pulse

  
  

  Radial, ulnar, brachial, grade force
• Stenosis


  Valve does not open properly
• Regurgitation


  Valve does not close properly
• Thrill


  Palpable vibration over the precordium or artery:
• Lift


  A more sustained thrust than an expected apical pulse
• Heave


  More prominent thrust of the heart against the chest wall.
• Preload


  - Degree of myocardial fiber stretch at the end of diastole

  - Determined by left ventricular end-diastolic volume (LVED)

  - Starling's Law

  - Excessive filling= excessive LVED volume & pressure= decreased CO

  
  

  Increased preload due to fluid overload
• Afterload


  - Pressure ventricles must overcome to eject blood into the peripheral blood vessels

  - Amount of resistance is directly related to arterial B/P and the diameter of the blood vessels.

  - Impedance: the pressure the heart must overcome to open the aortic valve; amount depends on compliance and total systemic vascular resistance.

  If after load is up = hypertension

  Lower afterload = hypertension meds
• Starling's Law


  The more the heart is filled during diastole the more forcefully it contracts
• Preload decreases/increases with?


  - decreases with Diuretics

  
  

  - increases with fluids
• Sympathetic Nervous System


  - Releases Norepinephrine

  - Increases HR, AV conduction, Contractility

  Vasoconstriction

  - Due to stress/anxiety
• Parasympathetic System


  - Release Acetylcholine

  - Decreases Contractility, Conductivity, SA firing, and HR

  - stimulates vagus nerve (by rectum or rubbing carotid artery)