Cardiovascular assessment Flashcards
List the indications for a cardiovascular assessment.
It is done to asses the status of the cardiovascular system.
Establish a baseline for subsequent comparison.
A cardiovascular assessment may occur:
-During a routine admission physical assessment
-When monitoring patient status following trauma, treatment or a disease process
Give an example of therapeutic interaction.
Hi (insert patient’s name here), my name is (insert name here) and I am your nurse today. Is it ok if I come back and do a cardiovascular assessment on you? It will take approximately 20 minutes and will require you to wear a gown and I will look, listen and feel your chest. At sometime during the procedure I will be listening to your chest with a stethoscope and that will necessitate long periods of 1 - 2 minutes of listening to your heart.
What equipment would you gather?
A blanket - to maintain warmth, privacy and maintain dignity. Sphygmomanometer Stethoscope Some alcohol wipes Biro Documentation Maybe a doppler
When would you perform hand hygiene?
5 moments of hand hygiene.
You are doing this to remove micro organisms from the nurses hands and it is the most effective preventative measure for cross contamination.
How would you position your patient?
The supine position is well suited for assessing the anterior chest and is comfortable for most patients. The structures are easily accessible for inspection, palpation and auscultation.
Raising the bed as high as 45 degrees (fowlers) is acceptable if the patient has difficulty breathing however if the patient is obese it may be necessary to sit them upright or slightly forward.
The patient can also be positioned on their left side.
These positions bring the cardiac structures close to the chest wall and render their sounds easier to hear.
List some problem solving abilities that may occur.
Ensure the bed brakes are on!!
Providing privacy (closing curtain or door) is essential to the patients feelings of self worth and reduces embarrassment felt when clothing is removed from their torso.
Warmth is essential since removing clothing from half of the body exposes a large surface area.
Ask the patient to (assist them to) remove clothing from their torso, including brassiere, since some sound are masked or altered if the stethoscope is used over clothing.
Need to ensure that the environment is quiet (no tv, radio on) and you have sufficient lighting.
What questions would you be asking when asking them about their cardiac history and further history?
Family history of cardiac problems Information about chest pain Cholesterol levels (if known) Weight Chronic medical conditions Palpitations current medications smoking exercise tolerance diet and sleep difficulties (awakening at night with shortness of breath or need to pass urine) Fatigue Claudication Determine if the patient has a fever, or ingested alcohol, caffeine or nicotine recently
What is the first thing you would do when starting your objective data collection?
Hand hygiene!!!
Then take the patients pulse and B.P
What would you do when you observing the neck and blood vessels?
1st tell them that you are going to look at their neck.
2nd find the Carotid artery and check pule on each side (do this one at a time or they will black out)
Checking that they are bilaterally equal and strong.
3rd Inspect the Jugular venus pressure (ensure the bed is lowered and the pillow has been removed). See the pulsations by turning the head away from you and shining a torch if lighting is inadequate.
What do you do when inspecting the thoracic region?
1st tell them you will be opening and touching there chest area.
2. Inspect the thoracic cavity, looking at the movement of the chest, colour of the chest and feeling for warmth or sweatiness.
What do you do when assessing the apex of the heart?
Inspect the precordium. Locate the suprersternal notch and move down over the manubrium (5am) till you feel the ridge which joins it to the sternum and move left laterally till you feel the 2nd intercostal space. Star feeling your way down till you reach the 5th intercostal space, then move midclavicular. There is where you will locate,hear and see the apex of the heart. Listen for 1 minute for 1 minute with diaphragm for the S1 - Lub and S2- dub sounds ( needs to be equal and loud)
What are you doing when inspecting the peripheral pulses in the arms?
- Have the patient sit up.
- Inspect the arms - looking at the temp (should be warm), colour (no cyanosis)
- Assess the radial pulses together (should be equal)
- Assess the brachial pulses together
- Check hands for capillary refill (press fingertips and colour should come back within 2-3 seconds)
- Check for clubbing (nails are curved not straight)
Top area is finished assessing so cover your patient up for warmth and dignity purposes.
What are you doing when inspecting the peripheral pulses in the legs?
- Tell them you are now going to assess their legs.
- Inspect legs for shape, size, symmetry, warmth , fluid retention and colour.
- Palpate the each Popliteal artery (under knee) with gentle pressure. (a doppler can be used if having trouble feeling the pulse)
- Inspect and assess the dorsalis pedis checking they are both equal and strong.
- Inspect the posterior tibualis on both feet.
- Check capillary refill in toes
What do you do when finished assessing the patient?
- Tell them the assessment is finished and make them comfortable.
- Document all your findings
- Clean, dipose and return all equipment used
What questions would you ask a person over the age of 65?
Do you have any known heart or lung diseases? Hypertension, coronary artery disease or COPD
Do you take any medications for your illness?such as digitalis or beta blockers
Are you aware of side effects?
Have you recently stopped taking any meds? WHY?
Does your home have stairs?
How often do you climb them?
Does this effect on activities of daily living?
