CARDIAC ASSESSMENT.txt

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TomWruble
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135968
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CARDIAC ASSESSMENT.txt
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2012-02-17 07:02:26
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  1. 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
  2. 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
  3. 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)
  4. Does your heart pound or beat too fast?

    Does your heart skip beats or jump?

    Do you experience dizziness?

    Do you have swollen ankles?
  5. Any history of heart defect?

    Any history of Murmurs?

    Any history of Heart surgery?
  6. Do you smoke? How much? How long?

    Any family history of heart disease?
  7. 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?
  8. 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.
  9. Do you experience PAIN in your:

    Joints
    Muscles
    Bone

    If so WHEN:

    At rest
    With activity
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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.
  15. 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)
  16. 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)
  17. 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.
  18. Evaluate capillary refill of the lower extremities.
  19. 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)
  20. 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)
  21. 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.
  22. 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.
  23. 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
  24. Do you have any leg veins that are ropelike, bulging or contorted?
  25. 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
  26. Any client history of heart or blood vessel surgery?
  27. 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?
  28. Ask if there is anything that you can do for them before you leave.

    Hand Hygiene

    Leav to document assessment
  29. 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.
  30. 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.
  31. 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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