NUR 216 Exam 3 Study Guide
Cardiac and peripheral vascular
• Cardiac cycle/”lub dub”
o “Lub” = S1
▪ Closing of mitral & tricuspid valves
▪ Heard during systole
▪ Best heard at the apex
o “Dub” = S2
▪ Closing of aortic & pulmonic valves
▪ Heard during diastole
▪ Best heard at the base
• Electrical conduction pathway
o SA node AV node bundle of His bundle branches Purkinje fibers
o SA node: “pacemaker of the heart” – impulse begins here
• Blood flow direction
o When blood (deoxygenated) returns to heart, first enters R atrium
o R atrium tricuspid valve R ventricle pulmonary valve pulmonary
artery lungs (now oxygenated) pulmonary vein L atrium mitral
valve L ventricle aortic valve aorta
• Health history
o Family history concerning for hypertension, heart attack, stroke, etc. is important
• General physical assessment
o Need both bell & diaphragm for assessment
▪ Bell used for murmurs and other low-pitched sounds
▪ Diaphragm used for rhythm/rate, high-pitched sounds
o Priority findings
▪ Chest pain and jaw pain (referred pain) – most common symptoms of
myocardial infarction/heart attack
• Check vitals & perform cardiac assessment if reported
▪ Cyanosis – sign of hypoxemia (low levels of oxygen in bloodstream)
o Heart rate: normal 60-100 BPM; < 50 BPM: bradycardia; >100 BPM: tachycardia
• Landmarks of the precordium
o Aortic: 2nd intercostal space, R sternal border
o Pulmonic: 2nd intercostal space, L sternal border
o Erb’s: 3rd intercostal space, L sternal border
o Tricuspid: 4th intercostal space, L sternal border
o Apical/Mitral/Point of Maximal Impulse: 5th intercostal space, L midclavicular line
• Inspection
o Jugular vein distention: assess in semi-fowler’s or sitting up at > 90 (NOT high
fowler’s, which is 60 )
o Note any heaves/lifts (visible outward thrust of precordium)
• Palpation
, o Pulses
▪ Normal findings: +2, regular rhythm, equal bilaterally
▪ Abnormal findings: 0 (absent), +1 (weak), +3 or +4 (bounding)
• Follow-up for any abnormal findings
▪ Carotid
• Normal findings: palpable, strong, steady, regular
• Abnormal findings: weak or thready, palpable thrill (vibration)
• Location: neck between sternocleidomastoid muscle & trachea
▪ If any pulse is irregular, assess for pulse deficit
• Palpate the peripheral pulse while auscultating apical pulse
• Note the difference in rate between the two pulses (pulse deficit)
▪ If a thrill is palpated auscultate for a murmur next
• Auscultation
o Use diaphragm to auscultate rhythm at point of maximal impulse (PMI)/apical
o Murmurs:
▪ May be hard to hear in obese patients follow up if you may hear one
• Murmurs are priority findings, so we don’t want to miss this
▪ Strategies to pick up on possible murmurs:
• Auscultate all 5 sites for several seconds with diaphragm
• Do not listen over patient’s gown
• Have patient sit forward and hold their breath
• Congestive heart failure
o Fatigue may be expected in both left-sided and right-sided
o Symptoms of possible exacerbation (follow up with provider if exhibiting):
▪ Excessive weight gain despite poor PO intake
▪ Increased fatigue or difficulty tolerating exercise (exertional dyspnea)
▪ Difficulty sleeping (paroxysmal nocturnal dyspnea)
o Left-sided heart failure: “lung”/pulmonary problems
▪ Productive cough & fatigue are expected
▪ Cyanosis/hypoxemia are priority findings
o Right-sided heart failure: peripheral edema, jugular vein distention, & GI distress
• Peripheral vascular assessment
o Discoloration: may indicate vascular insufficiency or peripheral arterial disease
o Capillary refill: normal is < 2 seconds
▪ Capillary refill > 2 seconds = decreased perfusion (may be priority finding)
▪ Monitor closely in patients with type 2 diabetes, as they are at increased
risk for arterial disease (priority assessment for neuropathy)
• Capillary refill is a priority assessment for peripheral neuropathy
o Peripheral neuropathy: loss of sensation in legs and feet
o Pitting edema: palpation leaves a depression/indentation after releasing finger
▪ 1+ = 2mm
▪ 2+ = 4mm
▪ 3+ = 6mm
Cardiac and peripheral vascular
• Cardiac cycle/”lub dub”
o “Lub” = S1
▪ Closing of mitral & tricuspid valves
▪ Heard during systole
▪ Best heard at the apex
o “Dub” = S2
▪ Closing of aortic & pulmonic valves
▪ Heard during diastole
▪ Best heard at the base
• Electrical conduction pathway
o SA node AV node bundle of His bundle branches Purkinje fibers
o SA node: “pacemaker of the heart” – impulse begins here
• Blood flow direction
o When blood (deoxygenated) returns to heart, first enters R atrium
o R atrium tricuspid valve R ventricle pulmonary valve pulmonary
artery lungs (now oxygenated) pulmonary vein L atrium mitral
valve L ventricle aortic valve aorta
• Health history
o Family history concerning for hypertension, heart attack, stroke, etc. is important
• General physical assessment
o Need both bell & diaphragm for assessment
▪ Bell used for murmurs and other low-pitched sounds
▪ Diaphragm used for rhythm/rate, high-pitched sounds
o Priority findings
▪ Chest pain and jaw pain (referred pain) – most common symptoms of
myocardial infarction/heart attack
• Check vitals & perform cardiac assessment if reported
▪ Cyanosis – sign of hypoxemia (low levels of oxygen in bloodstream)
o Heart rate: normal 60-100 BPM; < 50 BPM: bradycardia; >100 BPM: tachycardia
• Landmarks of the precordium
o Aortic: 2nd intercostal space, R sternal border
o Pulmonic: 2nd intercostal space, L sternal border
o Erb’s: 3rd intercostal space, L sternal border
o Tricuspid: 4th intercostal space, L sternal border
o Apical/Mitral/Point of Maximal Impulse: 5th intercostal space, L midclavicular line
• Inspection
o Jugular vein distention: assess in semi-fowler’s or sitting up at > 90 (NOT high
fowler’s, which is 60 )
o Note any heaves/lifts (visible outward thrust of precordium)
• Palpation
, o Pulses
▪ Normal findings: +2, regular rhythm, equal bilaterally
▪ Abnormal findings: 0 (absent), +1 (weak), +3 or +4 (bounding)
• Follow-up for any abnormal findings
▪ Carotid
• Normal findings: palpable, strong, steady, regular
• Abnormal findings: weak or thready, palpable thrill (vibration)
• Location: neck between sternocleidomastoid muscle & trachea
▪ If any pulse is irregular, assess for pulse deficit
• Palpate the peripheral pulse while auscultating apical pulse
• Note the difference in rate between the two pulses (pulse deficit)
▪ If a thrill is palpated auscultate for a murmur next
• Auscultation
o Use diaphragm to auscultate rhythm at point of maximal impulse (PMI)/apical
o Murmurs:
▪ May be hard to hear in obese patients follow up if you may hear one
• Murmurs are priority findings, so we don’t want to miss this
▪ Strategies to pick up on possible murmurs:
• Auscultate all 5 sites for several seconds with diaphragm
• Do not listen over patient’s gown
• Have patient sit forward and hold their breath
• Congestive heart failure
o Fatigue may be expected in both left-sided and right-sided
o Symptoms of possible exacerbation (follow up with provider if exhibiting):
▪ Excessive weight gain despite poor PO intake
▪ Increased fatigue or difficulty tolerating exercise (exertional dyspnea)
▪ Difficulty sleeping (paroxysmal nocturnal dyspnea)
o Left-sided heart failure: “lung”/pulmonary problems
▪ Productive cough & fatigue are expected
▪ Cyanosis/hypoxemia are priority findings
o Right-sided heart failure: peripheral edema, jugular vein distention, & GI distress
• Peripheral vascular assessment
o Discoloration: may indicate vascular insufficiency or peripheral arterial disease
o Capillary refill: normal is < 2 seconds
▪ Capillary refill > 2 seconds = decreased perfusion (may be priority finding)
▪ Monitor closely in patients with type 2 diabetes, as they are at increased
risk for arterial disease (priority assessment for neuropathy)
• Capillary refill is a priority assessment for peripheral neuropathy
o Peripheral neuropathy: loss of sensation in legs and feet
o Pitting edema: palpation leaves a depression/indentation after releasing finger
▪ 1+ = 2mm
▪ 2+ = 4mm
▪ 3+ = 6mm
