Assessing Lower Extremities and Peripheral Pulses Quiz

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69 Questions

What should the nursing history include when assessing cardiovascular and peripheral vascular systems?

Subjective and objective data

Which of the following is NOT part of the nursing history related to cardiovascular and peripheral vascular systems?

Vision problems

Why is it important to ask about the duration of symptoms when assessing the cardiovascular system?

To determine if the patient needs immediate medical attention

Which data collection method is NOT mentioned as being utilized for assessing cardiovascular and peripheral vascular systems?

Percussion

What is the most common cause of death in the United States according to the text?

Cardiovascular diseases

Which characteristic is specifically associated with the cardiovascular system according to the text?

Chest pain/discomfort

'How much does it bother you?' is a question that aims to assess:

Severity of symptoms

What is the recommended order of assessment for physical examination?

Head to toe

What does a sustained decrease of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP indicate?

Orthostatic hypotension

What is assessed by auscultating for a bruit and palpating for a thrill?

Carotid Arteries

Where is the apical impulse usually palpable?

5th left ICS & L MCL

What do the sounds 'lub' and 'dub' correspond to in the cardiac cycle?

Closure of mitral and tricuspid valves

What does the presence of an S3 heart sound indicate?

Indicates heart failure or regurgitation

In which phase of the cardiac cycle does the S4 heart sound occur?

Late diastole

What may cause sudden arrhythmias and heart failure according to the text?

Emotional and physical stress

Which pulse intensity/strength grade indicates a full/bounding pulse?

3+

What does it indicate if peripheral perfusion shows marked edema and cyanosis?

Venous insufficiency

Which group is identified to have a higher incidence of hypertension compared to Caucasians?

African Americans

In the capillary refill test, what does it indicate if the nail does not return to normal color within 3 seconds?

Peripheral insufficiency

How is deep pitting edema graded based on the depth of indentation?

3+ (6mm)

What does pallor followed by a dusky red color when limb position changes indicate?

Arterial insufficiency

What might asymmetrical pulses suggest during palpation?

Arterial insufficiency

How can you describe the characteristics associated with the skin abnormalities: tense glistening skin, purple striae, and distention?

Tense glistening skin, Purple striae, Distention

What is a sign of liver disease that can be observed visually during a physical examination?

Visible venous patterns

Which group has a high incidence of lactose intolerance according to the text?

African Americans

What does a rounded abdomen indicate according to the text?

Increased adipose tissue

What is a symptom of hypersensitivity and muscle guarding during palpation?

Tenderness near xiphoid process

Which factor contributes to slower peristalsis and less frequent bowel movements?

Decreased muscle tone

What is the effect of high fiber diets according to the text?

Facilitation of bowel elimination

What does a distended and palpable tense mass indicate during a physical examination?

Urine retention

What is a primary characteristic of high lactose intolerance among specific ethnic groups?

Muscle wasting and loss of fibroconnective tissue

What does a prolonged capillary refill time indicate during a physical examination?

Peripheral insufficiency

Which pulse intensity/strength grade indicates a weak/thready pulse?

1+ (weak/thready)

What does the presence of cyanosis and marked edema signify in terms of peripheral perfusion?

Venous insufficiency

During palpation, what may asymmetrical pulses suggest?

Peripheral vascular issues

What is indicated by a nonpitting edema over the tibia or medial malleolus?

Arterial insufficiency

What is a characteristic feature of deep pitting edema graded as 4+?

(8mm) Very deep pitting with long-lasting indentation and severe swelling

What does it signify if a nail does not return to its normal color within 3 seconds during the capillary refill test?

Peripheral insufficiency

Which data collection method is mentioned as being utilized for assessing cardiovascular and peripheral vascular systems?

Observation, auscultation, and palpation

What is the primary cause of death in the United States according to the text?

Cardiovascular diseases

What should be included in the nursing history when assessing cardiovascular and peripheral vascular systems?

Past medical history, current health status, and family history

Why is it important to inquire about the duration of symptoms when assessing the cardiovascular system?

To identify possible triggers of the symptom

What factor contributes to slower peristalsis and less frequent bowel movements?

Low-fiber diet

What does a sustained decrease of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP indicate?

Orthostatic hypotension

What is assessed by auscultating for a bruit and palpating for a thrill during a physical examination?

Peripheral pulses

What characteristic skin change should be considered when assessing cardiovascular and peripheral vascular systems?

Purplish striae

What is the purpose of assessing the carotid arteries during a physical examination?

To auscultate for a bruit and palpate for a thrill

What is a potential implication of a sustained decrease in blood pressure during orthostatic measurements?

May be a sign of dehydration

When assessing a patient's heart sounds, what could the presence of extra sounds like murmurs and friction rubs indicate?

Abnormalities in heart valves or structures

What does the displacement of the Point of Maximal Impulse (PMI) suggest during a cardiac assessment?

Cardiac hypertrophy or enlargement

In which phase of the cardiac cycle does the S3 heart sound typically occur?

Mid-diastole

Why should auscultation of the jugular veins be performed with the head of the bed elevated?

To enhance visualization of pulsations and distension

What might be a reason for palpable pulsations on chest examination?

Normal finding in young patients with thin chest walls

What is the significance of Latinos in the U.S. having three times the risk of developing diabetes than non-Hispanic Caucasians?

Their blood vessels lengthen and become more tortuous and prominent

How can nursing history be utilized to assess potential gastrointestinal issues?

By assessing past abdominal history and food intolerance

When inspecting the oral mucosa during an assessment, what signs should be observed to detect abnormalities?

Pallor, swelling, and ulcers

Why is it essential to subdivide the abdomen into four quadrants during an examination?

To help with locating organs and documentation

What does the presence of unblemished skin, uniform color, and silver-white striae indicate during an abdominal assessment?

Normal skin findings

Why should clients be advised to void before an abdominal assessment?

To promote comfort during assessment

What do flat, rounded, and symmetric contours indicate during an abdominal assessment?

Normal liver and spleen size

In an abdominal examination, what does peristalsis not being visible suggest?

"WNL" bowel sounds

What does high lactose intolerance among certain ethnic groups result in?

Decreased medication absorption

What is a primary characteristic of a rounded abdomen as described in the text?

Tenderness on deep palpation

Which group has a high incidence of colon cancer based on the text?

African Americans

What is the effect of slower peristalsis and less frequent bowel movements?

Increased risk of constipation

What do higher pain thresholds in individuals lead to?

Underestimation of symptoms severity

How do high fiber diets contribute to bowel elimination according to the text?

Facilitation through gastrocolic reflexes

What is the significance of a distended and palpable tense mass during a physical examination?

Indication of urine retention

What characteristic is associated with liver enlargement during a physical examination?

Hypersensitivity and muscle guarding

Study Notes

Cardiovascular and Peripheral Vascular Systems

  • Assessment Methods:
    • Observation
    • Auscultation
    • Palpation
    • Patient, family, and medical history
  • Cardiovascular Diseases:
    • Most common cause of death in the United States
    • High-risk factors:
      • High blood pressure
      • Smoking
      • High cholesterol levels
      • Obesity
      • Diabetes

Nursing History

  • Subjective and Objective Data:
    • Past medical history/current health status
    • Family history
    • Chest pain/discomfort
    • Shortness of breath (SOB)
    • Dyspnea
    • Palpitations
    • Fainting/syncope
    • Fatigue
    • Peripheral skin changes (e.g. edema)
  • Assessment Questions:
    • How long have you had this symptom(s)?
    • How much does it bother you?
    • Does any particular incident or episode trigger the symptom?
    • How does it affect your lifestyle?
    • What activities or interventions alleviate the symptoms?
    • What do you think is causing the problem?
    • How far can you walk?
    • What muscle groups hurt and what measures relieve the pain?

Vital Signs and Inspection

  • Blood Pressure:
    • Variance expected in different extremities
    • Postural (Orthostatic) hypotension:
      • Lying down, sitting, and standing
      • Include HR
      • Sustained decrease of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP
  • Inspection:
    • Lips, ear lobes, and buccal mucosa
    • Note any deviations: cyanosis (bluish tinge)
    • Examine neck veins (Internal and External Jugular):
      • Head of bed elevated
      • Assess for pulsation and distension
      • Bilateral jugular vein distension (JVD)

Auscultation

  • Auscultatory Areas:
    • Right ICS - Aortic valve
    • 2nd left ICS - Pulmonic valve
    • 3rd left ICS - Erb's point
    • 4th and 5th left ICS - Tricuspid valve
    • 5th left ICS, MCL - Apical/Mitral valve
  • Heart Sounds:
    • S1: Closure of mitral and tricuspid (AV valves)
      • "Lub" heard best at the apex
      • Systole phase, ventricles contract, 1/3 of cardiac cycle
    • S2: Closure of aortic and pulmonic (SL valves)
      • Heard best at the base
      • Diastole phase, ventricles relax and fill with blood, 2/3 of cardiac cycle

Peripheral Vascular System

  • Pulses:
    • Grading of intensity/strength:
      • 0 = absent
      • 1+ = weak/thready
      • 2+ = Normal
      • 3+ = Full/bounding pulse
    • Asymmetrical pulses
    • Diminished/weak/thready pulse
    • Bounding pulse
  • Peripheral Veins:
    • Tenderness on palpation
    • Swelling of one calf or leg
  • Peripheral Perfusion:
    • Cyanosis, marked edema, indicates venous insufficiency
    • Pallor while limb is elevated, then dusky red color when limb is lowered, indicates arterial insufficiency
    • Skin thin, shiny, or thick, waxy, shiny, fragile, reduced hair, and ulceration may indicate both venous or arterial insufficiency
    • Nonpitting edema feels hard to touch and no indentation when firm pressure is applied on skin over the tibia or the medial malleolus for 5 seconds

Cultural Variations

  • African Americans, Puerto Ricans, Cubans, and Latinos:
    • Higher incidence of hypertension
    • Higher risk of developing diabetes
  • High-Risk Factors:
    • Smoking
    • High cholesterol levels
    • Obesity
    • Diabetes

Health Promotion and Client Teaching

  • Balanced Diet:

  • Exercise:

  • Annual Check-Ups:

  • Compliance with Medication/Health and Wellness Regimes:

  • Community Support Groups for Health Resources:

  • Strategic Community Education and Interventions:### Abdominal Assessment

  • Visible peristalsis and visible venous patterns associated with liver disease may be present

  • Auscultate all 4 quadrants, listening for:

    • Loud bruit
    • Hyperactive bowel sounds (>35 per minute)
    • Hypoactive bowel sounds (1-2 sounds in 2 minutes)
    • Absent bowel sounds (no sounds in 3-5 minutes)

Palpation Findings

  • Normal: no tenderness, relaxed abdomen with smooth, consistent tension
  • Abnormal:
    • Tenderness near xiphoid process, over cecum, or over sigmoid colon
    • Liver may not be palpable, with smooth borders
    • Bladder not palpable

Abnormal Findings

  • Tenderness and hypersensitivity
  • Muscle guarding
  • Generalized or localized tenderness
  • Mobile or fixed masses
  • Enlarged liver with smooth, tender, or nodular, hard texture
  • Distended and palpable tense mass indicating urine retention

Cultural Considerations

  • High lactose intolerance (70-90%) in African Americans, Native Americans, Asians, and Mediterranean groups

Age-Related Changes

  • Rounded abdomen due to increased adipose tissue and decreased muscle tone
  • Muscle wasting and loss of fibroconnective tissue
  • Higher pain threshold
  • Slower peristalsis and less frequent bowel movements

Health Implications

  • High incidence of colon cancer
  • Decreased medication absorption
  • Decreased salivation
  • Decreased gastric acid secretion

Healthy Habits

  • Maintain a high fiber diet with a balanced intake of raw, fresh foods
  • Educate patients about the effects of the gastrocolic and duodenocolic reflexes on bowel elimination
  • Encourage annual health exams, regular exercise, and staying up-to-date with research

Test your knowledge on assessing lower extremities and peripheral pulses in clients. Questions cover inspecting lower extremities, palpating, checking skin temperature, assessing range of motion and muscle strength, and grading the intensity of pulses.

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