NURSING ASSESSMENT PART 4
Name: Adina Perlow
Date: April 18, 2018
Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for).
Cardiovascular Assessment:
• Inspect and Palpate for Pulsations on Chest and at PMI (state what and where the PMI is located), describe.
Rationale:
o The point of maximal impulse, is the location at which the cardiac impulse can be best palpated on the chest wall. o It is located at the fifth intercostal space at the midclavicular line. o Abnormalities that are being examined includes some arrhythmias, such as premature ventricular contraction or atrial fibrillation.
Assessment:
o K.O laid on his left side
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Assessment: o K.O. Rate and rhythm was 80 beats per min, which was consistent with his radial pulse. o No abnormal dysrhythmia o Apical pulse was normal and expected with a grade of 3.
• Palpate all pulse sites bilaterally. Where are they located? (2). Describe pulse in terms of rhythm & strength or grade(1).Assess carotid artery appropriately (1).
Rationale: o Assessing the pulse is direct indicator that the circulatory system has a continuous flow of blood. o Feeling the pulse indicates means we are feeling successive contractions of the heart.
Assessment:
Pulse Location Rhythm Strength
Carotid artery
(One at a time) located along the medical edge of the sternocleidomastoid muscle in the neck. No dysrhythmia 4
Brachial pulse groove between biceps and triceps at antecubital fossa No dysrhythmia 3
Radial thumb side of forearm at wrist No dysrhythmia 4
Femoral below the inguinal ligament, midways between symphysis pubis and anterior superior iliac spin No dysrhythmia 3
Popliteal behind the knee No dysrhythmia
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No dysrhythmia 3
• Palpate temperature of extremities and describe.
Rationale: o We palpate the skin for temperature, moisture, texture turgor, tenderness, distention or masses.
Assessment
o Arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally. o No observed lesions or cuts o Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers, warm bilaterally. o No observed lesions or cuts
• Inspect and palpate extremities for edema and capillary refill, compare both sides.
Rationale:
o We look for capillary refill to monitor dehydration and amount of blood flow to the tissue. o For a normal capillary refill, a pink color should return 3 seconds after pressure is removed. o We look for edema by examining areas of the skin that is swollen or edematous from a buildup of fluid in the tissues.
Assessment:
o Finger capillary refill time less than 2 seconds, bilaterally o No edema present in bilateral arms o Toe capillary refill time less than 2 seconds, bilaterally o Slight edema present on right ankle
Non- pitting edema
Tender
Pain 2/10, pain has been on and off for 2
There are several different heart problems that show up as an abnormal EKG reading. For example, a heart block can occur when there is a delay in the signals coming from the SA node, AV node, or the Purkinje fibers. However, clinically the term heart block is used to refer to an AV block. This delays or completely stops communication between the atria and the ventricles. AV block is shown on the EKG as a delayed or prolonged PR interval. The P wave represents the activity in the atria, and the QRS complex represents ventricular activity. This is why the PR interval shows the signal delay from the AV node. There are three degrees of severity, and if the delay is greater than .2 seconds it is classified as first degree. Second degree is classified by several regularly spaced P waves before each QRS complex. Third degree can be shown by P waves that have no spacing relationship to the QRS complex. Another type of blockage is bundle branch block. This is caused by a blockage in the bundle of His, creating a delay in the electrical signals traveling down the bundle branches to reach the ventricles. This results in a slowed heart beat, or brachycardia. On an EKG reading this is shown as a prolonged QRS complex. A normal QRS is about .8-.12 seconds, and anything longer is considered bundle branch block. Another type of abnormal EKG reading is atrial fibrillation, when the atria contracts very quickly. On the EKG this is shown by no clear P waves, only many small fibrillating waves, and no PR interval to measure. This results in a rapid and irregular heartbeat. On the other hand, ventricular fibrillation is much more serious and can cause sudden death if not treated by electrical defibrillation.
Arch Dermatol. 2007;143(1):124–125. Puchenkova, S. G. (1996). "
Cardiac dysrhythmias come in different degrees of severity. There are heart conditions that you are able to live with and manage on a daily basis and those that require immediate attention. Atrial Fibrillation is one of the more frequently seen types of dysrhythmias (NIH, 2011). The best way to diagnosis a heart condition is by reading a cardiac strip (Ignatavicius &Workman, 2013). Cardiac strips play an chief part in the nursing world allowing the nurse and other trained medical professionals to interpret what the heart is doing. In a normal strip, one can clearly identify a P wave before every QRS complex, which is then followed by a T wave; in Atrial Fibrillation, the Sinoatrial node fires irregularly causing there to be no clear P wave and an irregular QRS complex (Ignatavicius & Workman, 2013). Basically, it means that the atria, the upper chambers of the heart, are contracting too quickly and no clear P wave is identified because of this ‘fibrillation’ (Ignatavicius & Workman, 2013).
to the upper body and arms. These symptoms occur after four weeks and start by
Heather is a 26yo, G3 P1011, who is currently 24 weeks 2 days as dated by ultrasound. She is relatively healthy. She has one prior full-term delivery without complications. She was referred today to evaluate her lower extremities. Her issue started on Black Friday, when she came home from shopping, she noticed red areas all over her legs. It started as 4-5 but quickly developed into several on her bilateral shins. After a day or two they became nodules and then turned to discolorations such as bruises. During this time, she was evaluated in your office and there was concern for varicosities and possible phlebitis. She was started on Lovenox and an aspirin. She was seen by vascular surgery and there was no evidence of DVT’s. She was
Examination revealed an oxygen saturation of 96% and chest auscultation was clear. The was no cervical lymphadenopathy or obvious hepatosplenomegaly. On the left leg there was a circular mildly??? erythematous area that was non-blanching.
The heart is a pump with four chambers made of their own special muscle called cardiac muscle. Its interwoven muscle fibers enable the heart to contract or squeeze together automatically (Colombo 7). It’s about the same size of a fist and weighs some where around two hundred fifty to three hundred fifty grams (Marieb 432). The size of the heart depends on a person’s height and size. The heart wall is enclosed in three layers: superficial epicardium, middle epicardium, and deep epicardium. It is then enclosed in a double-walled sac called the Pericardium. The terms Systole and Diastole refer respectively and literally to the contraction and relaxation periods of heart activity (Marieb 432). While the doctor is taking a patient’s blood pressure, he listens for the contractions and relaxations of the heart. He also listens for them to make sure that they are going in a single rhythm, to make sure that there are no arrhythmias or complications. The heart muscle does not depend on the nervous system. If the nervous s...
Pulse rates can vary from 60 up wards to about a 180 (this is the
O:Right arm, wrist, and hand: no edema, discoloration noted, full ROM , tenderness with palpation
Physical examination is unremarkable with no evidence of leg edema, lung crepitations, heart S3 sound, or ascites. Skin turgor is normal. Laboratory studies show a normal urinalysis and CBC, with comprehensive chemistry
-Skin on affected limb may appear to change in texture, look shinier, or look thinner
Predictable and caused due to reduced flow of blood to the heart causing a lack of oxygen to heart muscles.
in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning
fluid for you. You can check the count on a hemacytometer if you want, but no one does