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Hand hygiene
clean stethoscope diaphram w/ alcohol
Introduce yourself by name & student nurse
Explain procedure:
Cardiac
Peripheral Vascular and
Musculoskeltal ASSESSMENT
how patient can help, and get permission.
Provide for privacy.
ID Patient:
Full name & Birthday (courtesy really)
Confirm allegies
Because you are comparing ID versus chart for:
Name
Birthdate
MRN
Allergies
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We are going to begin with some questions before the physical assessment.
Do you have any chest pain?
If so,
Location
Radiation
Quality
Rating on a scale 1-10
Duration
What elicits pain
What relieves pain
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IF CHEST PAIN, then: Any associated symptoms?
Nausea
Vomiting
Diaphoresis (excessive sweating commonly associated with shock and other medical emergency conditions)
Palpitations
Irregular heart beat
Syncope/Presyncope (fainting or dizziness)
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Does your heart pound or beat too fast?
Does your heart skip beats or jump?
Do you experience dizziness?
Do you have swollen ankles?
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Any history of heart defect?
Any history of Murmurs?
Any history of Heart surgery?
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Do you smoke? How much? How long?
Any family history of heart disease?
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With regard to activities of daily living:
Type of diet?
Recommended Diet:
Grain 6-7 oz / day
Dark Green Veg 3 cups / wk
Orange Veg 2 cups / wk
Legumes 3 cups / wk
Well-known legumes:
peas
beans
lentils
lupins
mesquite
carob
soy
peanuts
Starchy Veg 3 cups / wk
Fruit 1.5-2 cups / day
Meat & Beans 5-6 oz / day
Dairy 3 cups / day
Any alcohol consumption?
Normal exercise pattern?
Daily stressors?
Forms of relaxation?
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Now since we're not taking your vital signs, which would include resting heart rate and BP, we are going to assess you range of motion.
Lead patient through 1 or 2 ROM for each joint:
Neck
Shoulder
Elbow
Evaluate strength of elbow flexion
Evaluate strength of hand squeeze
Wrist
Hand & Fingers
Thumb
Hip
Knee
Ankle
Foot
Trunk
Have patient sit on bed for the musculoskeletal interview.
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Do you experience PAIN in your:
Joints
Muscles
Bone
If so WHEN:
At rest
With activity
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IF PAIN: then What aggravates pain?
Walking
Sitting for long periods
Standing for long periods
Has PAIN ever awaken you from sleep?
If so What relieves pain?
Elevating legs
Rest
Lying down
IF PAIN: Do you experience any associated symptoms with pain?
Coldness
Cyanosis
Edema
Varicosities
Parasthesia
Tingling
Have you noticed any changes in shape or size of extremity?
Have you experienced any changes in ability to perform ADL�s, sports and/or work?
Do you experience any changes in sensations?
If so, where and describe:
Decreased
Altered
Absent
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Do you have any history of:
Bone problems
Fractures
Surgery
Arthritis
Osteoporosis
is a disease of bones that leads to an increased risk of fracture.[1] In osteoporosis the bone mineral density (BMD) is reduced,
Gout
usually characterized by recurrent attacks of acute inflammatory arthritis � a red, tender, hot, swollen joint. The metatarsal-phalangeal joint at the base of the big toe is the most commonly affected (approximately 50% of cases).
Osteomyelitiis
simply means an infection of the bone or bone marrow
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Have patient lie down in 45 degree Fowler's
Demonstrate inspection of Jugular veins at 45 degrees.
Distention would be an indicator of CHF.
Demonstrate inspection and palpation of right & left carotid artery.
Auscultate right & left carotid artery.
Evaluate
rhythm (Regular/irregular)
strength (0 -none, +1 - weak, +2 - typical, +3 - full)
symetry (e/g/ even bilateral)
of carotid arteries
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Lower bed to SUPINE
Verbalize inspection of midsternal line landmark.
Verbalize inspection of midclavicular line landmark, left being most relevant.
Verbalize inspection of anterior axillary line landmark.
Inspect chest for visibility of the PMI and any abnormal pulsations
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Palpate and auscultate the aortic area (2nd IC R)
Palpate and auscultate the pulmonic area (2nd IC L)
Palpate and auscultate Erbs point (3rd IC L)
Palpate and auscultate the tricuspid area (5th IC L)
Palpate and auscultate the mitral area (5th IC L mid-clavicular)
Count rate for a full minute. Evaluate rhythym.
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Have you noticed any changes in skin?
Color
Texture
Temperature
Demonstrate inspection and palpation of right & left brachial artery.
Evaluate
rhythm (Regular/irregular)
strength (0 -none, +1 - weak, +2 - typical, +3 - full)
symetry (e/g/ even bilateral)
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Demonstrate inspection and palpation of right & left radial artery.
Evaluate
rhythm (Regular/irregular)
strength (0 -none, +1 - weak, +2 - typical, +3 - full)
symetry (e/g/ even bilateral)
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Evaluate color, temperature, edema and sensation of upper extremities.
Evaluate capillary refill of the upper extremities.
Inspect upper extremities for joint swelling, deformities, and pain.
Palpate upper extremities for tenderness, visible abnormalities and warmth.
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Evaluate capillary refill of the lower extremities.
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Demonstrate inspection and palpation of right & left posterior tibial artery.
Evaluate
rhythm (Regular/irregular)
strength (0 -none, +1 - weak, +2 - typical, +3 - full)
symetry (e/g/ even bilateral)
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Demonstrate inspection and palpation of right & left pedal artery.
Evaluate
rhythm (Regular/irregular)
strength (0 -none, +1 - weak, +2 - typical, +3 - full)
symetry (e/g/ even bilateral)
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Evaluate
color
temperature
edema
+1 slight, no perceptable swelling
+2 indentation subsides rapidly
+3 indentation remains short time, swelling visible
+4 indent remains long time, grossly swollen
sensation
of lower extremities.
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Inspect lower extremities for joint swelling, deformities, and pain.
Palpate lower extremities for tenderness, visible abnormalities, warmth and
strength - have patient push (plantar flexion) equally against both of your palms.
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If patient is not at suspect for a leg clot
Look for Homans Signs - pain in the popliteal or calf area when leg is extended and the examiner abruptly dorsiflexes the foot
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Do you have any leg veins that are ropelike, bulging or contorted?
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Do you have any leg sores? If so,
Location
Size
appearance
Length of time
Any family history of...
Diabetes
Hypertension
Coronary Artery Disease
High cholesterol or triglycerides
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Any client history of heart or blood vessel surgery?
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With regard to self care activities,
Does client have well fitting shoes?
Does client wear restrictive garments or hose?
Does client cross legs frequently?
What is normal exercise routine?
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Ask if there is anything that you can do for them before you leave.
Hand Hygiene
Leav to document assessment
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Document findings of cardiac assessment.
Document 3 abnormal findings of auscultation of cardiac assessment.
Document 3 normal geriatric variations of cardiac assessment.
Document 3 potential nursing diagnoses related to cardiac assessment.
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Document findings of peripheral vascular assessment.
Document 3 abnormal findings of peripheral vascular assessment.
Document 3 normal geriatric variations of peripheral vascular assessment.
Document 3 potential nursing diagnoses related to peripheral vascular assessment.
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Document findings of musculosketal assessment.
Document 3 abnormal findings of musculoskeletal assessment.
Document 3 normal geriatric variations of musculoskeletal assessment.
Document 3 potential nursing diagnoses related to musculoskeletal assessment.
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