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3 Abnormal Findings of Cardiac Auscultation:
1. Upon auscultation of the carotid artery, a bruit indicates turbulence due to local vascular cause, e.g. atherosclerotic narrowing.
2. Premature beat: an isolated beat is early or a pattern occurs in which every third or fourth beat sounds early.
3. Both heart sounds are diminished with increased air or tissue between the heart and your stethoscope, such as emphysema, obesity and pericardial fluid.
3 Normal Geriatric Variations of Cardiac Assessment:
1. A gradual rise in the systolic blood pressure is common while the diastolic stays fairly constant with a resulting widening of the pulse pressure.
2. Some older adults experience orthostatic hypertension, which is a sudden drop in blood pressure when rising to sit or stand.
3. Occasional ectopic beats are common and do not necessarily indicate underlying heart disease.
3 Potential Nursing Diagnoses Related to Cardiac Assessment:
1. Decreased cardiac output related to myocardial contractility associated with ischemia of the myocardium.
2. Home maintenance, impaired - related to inadequate financial resources.
3. Ineffective Tissue Perfusion: Cardiopulmonary related to decreased hemoglobin concentration secondary to CHF.
3 Abnormal Findings of peripheral vascular assessment:
1. Capillary refillmore than 1 or 2 seconds signifies vasoconstriction or decreased cardiac output. The hands are cold, clammy and pale.
2. A unilateral cool foot occurs with arterial deficit.
3. Enlarged lymph nodes, tender or fixed.
3 Normal Geriatric Variations of peripheral vascular assessment:
1. Dorsalis pedis pulse not palpable.
2. Thin, shiny skin resulting from arterial insufficiency.
3. Loss of hair on lower legs probably resulting from arterial insufficiency.
3 Potential Nursing Diagnoses Related to peripheral vascular assessment:
1. Activity intolerance related to imbalance between oxygen supply with demand - COPD.
2. Impaired tissue integrity related to chronic arterial insufficiency associated with ulcers of the lower leg.
3. Disturbed body image related to varocosities of the saphenous veins.
3 Abnormal Findings of musculoskeletal assessment:
1. Swelling of the right knee.
2. Mass, 2 cm on diameter, firm but not hard, moveable, dorsal forearm near elbow.
3. Crepitation of the left knee. Abnormal grinding sound due to uneven surfaces of the joint contact bone usually related to arthritis.
3 Normal Geriatric Variations of musculoskeletal assessment:
1. Kyphosis: an exagerated posterior curvature of the thorasic spine. Compensation may include hyperextension of the head to maintain level vision.
2. Decrease in fat on the body periphery as well as over the abdomen and hips.
3. Gait with shuffling pattern; swaying arms out to aid balance; and watching feet.
3 Potential Nursing Diagnoses Related to musculoskeletal assessment:
1. Diversional Activity Deficit related to musculoskeletal impairments as evidenced by observed statement of boredom/depression from inactivity.
2. Self-care deficit related to compound fracture of right forearm.
3. Delayed growth and development related to weakness of shoulder muscles as evidenced a test of muscle strength under the baby's axillae.