Foundations Exam 2 review, Study Guides, Projects, Research of Nursing

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Cardiovascular System Layers of the Heart Wall (From superficial to deep)

o Epicardium

o Myocardium

o Endocardium

● Pericardium: Protective layer of the heart, on top of epicardium

Chambers and Valves of the heart

● Atrium: low pressure area

o Right atrium: receives deoxygenated blood from the rest of the body

▪ Blood from lower body (legs and abdomen) enters through inferior vena

cava

▪ Blood from upper body (head and neck) enters through superior vena

cava

● Ventricles: low pressure area

o Left ventricle has the thickest wall because it pumps oxygenated blood to the

rest of the body

● Valves (REMEMBER APT M)

o Tricuspid: 5th^ intercostal space, left sternal border (5 th^ ICS LSB)

▪ Between right atrium and right ventricle

▪ 3 “leaves”

o Mitral: 5th^ intercostal space midclavicular line (5 th^ ICS MCL)

▪ Between left atrium and left ventricle

o Aortic: 2nd^ intercostal space right sternal border (2 nd^ ICS RSB)

▪ Between left ventricle and aorta

o Pulmonic: 2nd^ intercostal space left sternal border (2 nd^ ICS LSB)

● Pulmonary artery: receives deoxygenated blood from right ventricle and brings it to

lungs

● Pulmonary Veins: carries oxygenated blood from the lungs to the left atrium

Cardiac Cycle

● Rhythmic movement of blood through the heart

● Diastole

o Ventricles relaxed

o AV valves are open

o Pressure in atria is higher than in ventricles

o Blood pours rapidly intro ventricles

● Systole

o Ventricle pressure is higher than atria

o Mitral and tricuspid valves swing shut

● Diastole again

Heart sounds

● S1: When tricuspid and mitral valves close (“lub”)

o REMEMBER: “TeaM 1”

● S2: When aortic and pulmonic valves close (“dub”)

● Murmur: “whooshing sound” in between lub and dub

o Valve isn’t closing fully, and blood can regurgitate back into the atrium from the

ventricle

o Grades

▪ 1= minimal

▪ 2 = slightly louder

▪ 3= can hear immediately with stethoscope

▪ 4= very loud

▪ 5= can hear without stethoscope (needs valve transplant to fix)

● Normal heart sounds: S1 and S

● Extra heart sounds: S3 and S

o S3: 3 looks like 2 ‘C’s’ so remember 3HF= CONGESTIVE HEART FAILURE

o Auscultate carotid artery

o Inspect jugular venous pulse

● Precordium

o Inspect anterior chest for:

▪ Heave or lift (at point of maximal impulse)

▪ Palpate apical pulse

▪ Palpate across precordium

o Thrill: vibrating when they aren’t doing anything

o Auscultation of precordium

▪ Rate and rhythm

▪ Identify S1 and S

▪ Timing: regular or irregular

▪ Listen for extra heart sounds

▪ Loudness

▪ Pitch

▪ Pattern: can have irregularly irregular (ex. Afib)

▪ Quality: strong, weak, or thready

▪ Location

▪ Radiation

▪ Posture

● Altered cardiovascular function

o Changes in vital signs (BP, HR, respiration)

o Changes in skin (ex. Blue= cyanosis)

o Ischemia: decreased blood flow to a specific area

o Thrombus: clot

o Embolism: clot that breaks off and travels to another part of the body

o Angina: chest pain, occurs due to ischemia of heart

▪ Give 3 nitroglycerin’s, if no improvement call 911

o Altered blood flow: shock

● Physical assessment

o Inspection

▪ Cognition: peripheral blood flow (capillary refill, looks at tips of fingers,

toes, and legs) LOC (level of consciousness): carotid artery blockage can cause this from lack of oxygen to brain

▪ Skin color: lips (blue/purple), paleness

▪ Edema: pooling of fluid caused by poor blood flow

▪ Shiny skin= swollen

▪ Ulcerations

▪ Varicose veins

o Palpation

▪ Skin temp, pulses

▪ Capillary refill: normal= <3 seconds

▪ Edema

▪ Homan’s sign: “point toes to nose”

● Pt should feel a stretch while doing this, if they feel pain, it is a (+)

Homan’s sign

● Checks for DVT

o Auscultate

▪ BP

▪ Apical Pulse

▪ Abnormal heart sounds

● Clicks: metal valve closing (lub, click, dub)

o In patients with valve transplants

From Lecture

● Left side of the heart pumps oxygenated blood to the body

● Right side of the heart received oxygenated blood

● Right atrium: collects deoxygenated blood from the rest of the body

● Blood components

o Plasma: 50% of blood

o Buffy coat (platelets and leukocytes): 1% of blood

o Red Blood Cells (erythrocytes)

▪ Biconcave shape

▪ Flexible

▪ Able to fit through small spaces

● Platelets: promote clotting

● If a vessel is damaged/injured: platelets go to stop and fibrinogen travels there and

forms a clot

o Can possibly break off and cause damage

o Can cause DVT in leg (ischemia to area will cause pain)

o Can go through heart and lead to MI (heart attack)

o Can go to veins and travel to lungs and cause pulmonary embolism

o Can go to brain and cause stroke

● Static blood and cause clots

o If you’re in bed for more than 2 days, a clot can start to form

Respiratory System

● Right lung: has 3 lobes

o RML: right middle lobe

o RUL: right upper lobe

o RLL: right lower lobe

o Horizontal fissure: separates RUL from RML

o Oblique fissure: separates RML from RLL

● Left lung: has 2 lobes

o LUL: left uppjjer lobe

o LLL: left lower lobe

o Oblique fissure separates LUL from LLL

● Apex of the lung is at the top

● Base is the bottom of the lung

● Esophagus is posterior to trachea

● Mediastinum: where the heart is located

● Pleurae

o Parietal: lies against ribs (outside layer)

o Visceral: encapsulates lungs

● We breathe 21% oxygen

● Trachea: bifurcates into right main bronchus and left main bronchus

Bronchi->segmental bronchus-> tertiary bronchus->bronchiole->terminal bronchiole-->alveoli

● Posterior landmarks

o Vertebra Prominens

o Spinous Processes

o Inferior Border of the Scapula

o Twelfth Rib

Reference lines (TEST QUESTION!)

● Anterior Chest

● Posterior chest

● Factors that affect breathing

o Body position: elderly people with kyphosis cannot breathe fully

o Environment

▪ Air pollution

▪ Pollens and allergies

o Lifestyle

▪ Smoking

▪ Drugs and alcohol

▪ Nutrition

o Increased work of breathing

▪ Restricted lung movement (ex. Braces for scoliosis)

▪ Airway obstruction

● Levels of dyspnea

o Level 1: client can walk 1 mile at own pace before experiencing SOB

o Level 2: client becomes short of breath after walking 100 yards on level ground

of climbing a flight of stairs

o Level 3: client becomes short of breath while talking or performing ADLs

o Level 4: client is short of breath during periods of no activity

o Orthopnea: client is short of breath lying down

▪ Needs 2 or more pillows

Physical Assessment

● Inspection

o AP diameter vs transverse diameter: should be 2:1 ratio

▪ 2:2 indicates barrel chest (COPD)

o Chest all should be symmetrical

● Palpation

o Tactile fremitus: “99” or “blue moon”

▪ Want equal vibration on anterior and posterior chest

o Crepitus: air leaking from lungs (subcutaneous air)

▪ Can feel popping while palpating

● Percussion

o Resonance: want to hear hollow sounds on lungs

RESPIRATORY=RESONANCE

● Auscultation

o Egophony: “E” to “A” change

▪ Indicates area of consolidation (ex. Pneumonia, tumor, or growth)

▪ E sound is normal

▪ A is abnormal

o Whispered pectoriloquy: Pt will whisper 1,2,3,

▪ Sound will be louder if there is an obstruction in lungs

o Bronchophony: Have patient say “99” or “blue moon”

▪ (+) bronchophony: sounds will be louder in certain spots; indicates

consolidation of lung tissue in certain spots

▪ Cheyne-stokes: cyclical breathing (stop and go)

● Indicates brain damage, impending death and increased

intracranial pressure

▪ Biot: sequence of several breaths that alternate with apnea

● Indicates brain damage

o Pleural friction rub: caused by inflammation of pleural structures

▪ Grating sound

▪ Heard during inspiration or expiration

Respiratory Diseases/Illnesses/ Treatments

● Aspiration pneumonia is common in the elderly

o Head of the bead should be 30-45° when feeding patients

● Hypoxia symptoms

o Early signs

▪ Agitation, anxiety, irritability

▪ Changes in level of consciousness

▪ Disorientation

▪ Tachypnea

o Late stage

▪ Bradycardia

▪ Cardiac arrythmias

▪ Cyanosis

▪ Bradypnea

▪ Substernal retractions

● Atelectasis: collapse of part of all of a lung

● Venturi mask: PRECISE way of providing oxygen

o Order is given in percentage NOT liters

o For COPD patients

Gastrointestinal System Nursing responsibilities

● Assess bowel function

● Promote normal bowel health

o Fiber from fruits and vegetables are necessary for healthy bowel movements

● Manage alterations in bowel function

o Coffee: if you drink it already, don’t stop. If you don’t drink it don’t start

o Caffeine can affect the heart

o Coffee can reduce colon cancer

▪ The number one way to prevent colon cancer is to have at least one

bowel movement a day

▪ Constipation causes constant friction, breaks down the cells, which can

become abnormal, and cancer can form

▪ Cells will thicken first (lichen patterns)

Structure of the GI tract

● Esophagus-> Small Intestine-> Large intestine (ESL)

● Esophagus-> stomach->DJI (duodenum, Jejunum, ileum: parts of small intestine)

● Ileum->ileocecal valve

● Ascending color (on right side next to appendix)-> transverse colon (poop becomes

thicker here)

o Appendix collects poop

o Appendicitis can occur if something gets caught inside the appendix and the

bacteria reproduces, infection can occur