CV Nsg Assess

Report
Cardiovascular Nursing
Assessment
Health History
– Identify present and potential health problems
– Identify possible familial and lifestyle risk factors
– Involve the client in planning long-term health
care
Health History
Patient Health History should be obtained:
– High Blood Pressure
– Congestive Heart Failure
– Previous Heart Attack
– Previous Heart Surgery or procedures (Stent,
Valvuloplasty)
– Atrial Fibrillation, Atrial Flutter or other
dysrhythmias
– Palpitations
– Dizziness, lightheadedness (presyncope), or
passing out (syncope)
– Full list of medications
– Family hx.
Cardiovascular Assessment
• Requires a full head to toe assessment
– Every body function is dependant on the
cardiovascular system
• Subjective vs. Objective data
– Subjective data- verbal statements provided by
the patient
– Objective data- observable and measurable data
Signs & Symptoms of Cardiovascular
Deficits
•
•
•
•
Chest Pain
Palpitations
Cyanosis
Dyspnea
Assessment
Subjective Data
• Pain is whatever the patient says it is.
• Pain (chest, back, jaw, abdomen or
extremities)
Assessment- Subjective Data
• Extremities
– 3 of the 5 “P’s of Peripheral Artery Disease”
– Pain
– Parasthesia
• Alteration in sensation
– Numbness, tingling, pins and needles
– Paralysis
Assessment
Subjective Data
• Dyspnea
– At rest
– Exertional- with activity
– Orthopnea- short of breath while lying down
– Paroxysmal Nocturnal Dyspnea- awakening
suddenly short of breath and sweating
Assessment
Subjective Data
• Ask pt. to: Describe Chest Pain (CP)
or Shortness of Breath (SOB) in as
much detail as possible.
Assessment
Subjective Data
• Is patient c/o:
– Fainting (Syncope)
– Palpitations
– Fatigue
Assessment - Objective Data
• Head to Toe Assessment
–Skin
• Cyanosis
• Turgor
• Temperature
• Diaphoresis
• Integrity
–Skin breakdown
Jugular Vein Distention
JVD
JVD
ABNORMAL
NORMAL
Cardiac Assessment
Heart Sounds (listen with both the bell and
diaphragm of your stethoscope)
• Right upper sternal border, Left upper sternal
border, Left lower sternal border
Assessment- Objective Data
• Are there any abnormal heart sounds?
– Murmurs
– Rubs
• Are there any additional heart sounds?
– Gallops
Is the heartbeat regular, regularly irregular, or
irregularly irregular?
Assessment - Objective Data
Assessment
Objective Data
• Respiratory
–
–
–
–
–
Rate and ease of breathing
Appearance of dyspnea
Coughing
Frothy Sputum
Abnormal breath sounds
• Diminished
• Crackles/Rales
• Wheezing
Assessment - Objective Data
Post tibial Pulses
Dorsalis pedis Pulses
Popliteal pulses
Femoral pulses
Ulnar pulses
Radial pulses
Brachial pulses
Carotid pulses
Assessment
Objective Data
Check Pulses:
Carotid Right/ Left
Brachial R/L
Radial R/L
Ulnar R/L
Point of Maximum Impulse (PMI)
Femoral R/L (groin crease or slightly
above crease)
Popliteal (behind the knee)
Post Tibial (medial ankle)
Dorsalis Pedis (top of foot)
Pulse Strength
0 Absent pulse
1+Thready pulse
2+Weak pulse
3+Normal pulse
4+Bounding pulse
OR
0 Absent Pulse
1+ Weak Pulse
2+ Normal Pulse
Assessment
Objective Data
• Edema
• 1+ trace edema-barely
perceptible (2mm)
• 2+mild edema-deeper pit
that rebounds in 10-15
seconds (4mm)
• 3+moderate edema-deep
pit that lasts 30-60
seconds before it
rebounds (6mm)
• 4+severe edema-an even
deeper pit lasting as long
as 2-5 minutes before
rebounding (8 mm)
Assessment
Objective Data
Check for Homan’s sign Pain=Positive
Homan’s Sign
If Positive: Notify RN or Practitioner
and do not check Homan’s Sign
Again!
Capillary Refill of finger tips and toes
(actually any area)
Normal: < 3 seconds
Slow: 3-5 seconds
Abnormal: >5 seconds
Assessment
Objective Data
• Allen’s Test
– Tests the ability of the ulnar artery to supply the hand with
adequate blood supply
Assessment
Objective Data
• Vital Signs
– Heart Rate (full minute) Normal 60-100 bpm
• Apical Pulse
• Radial Pulse
• Pulse deficit is the difference between the above two
– Blood Pressure Normal 90-139/60-89 mmHg
• Mean Arterial Pressure (MAP)
(2 * DBP) + SBP
3
Blood Pressure
No sound
BP cuff inflated to 160 mmHg
First
sound
120 mmHg
No
sound
50
mmHg
• Korotkoff sounds: heard during blood pressure
determination using a stethoscope and sphygmomanometer.
– Originates within from the blood passing through the
vessel or
– Produced by a vibrating motion of the arterial wall
Orthostatic Hypotension
aka Postural Hypotension
• Have the client in supine position for 3-5 minutes,
then measure the HR and BP
• Then, have the client in the sitting position for 3-5
minutes and then measure the HR and BP. Monitor
for dizziness.
• Then, have the client stand for 3-5 minutes. If the
client is having severe dizziness, STOP! (if they have a
syncopal episode, they are at risk for injury).
Otherwise, measure the HR and BP after 3-5
minutes.
Orthostatic Hypotension
• A client is considered to have orthostatic
hypotension if:
– HR increases by 10-20% from baseline
– SBP decreases by 10-15 mmHg from baseline
– DBP decreases by 10 mmHg from baseline

similar documents