Exam (elaborations)
CARDIOVASCULAR ASSESSMENT/NRSG 358HA Practical HEAD TO TOE
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CARDIOVASCULAR ASSESSMENT/NRSG 358HA Practical HEAD TO TOE
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NRSG 358HA Practical HEAD TO TOECARDIOVASCULAR ASSESSMENT
SUBJECTIVE DATA
1) Any chest pain or tightness?
2) Any shortness of breath?
3) Any family hx of hypertension, obesity, diabetes, coronary artery disease?
4) Any skin changes in arms or legs?
OBJECTIVE DATA
1- Inspect neck for pulsations
• Position person supine from 30- to 45-degree angle
• Turn person’s head away from examiner
• Shine light tangentially onto the neck “highlights pulsations and shadows”
➢ Internal jugular pulsation present when supine
2- Auscultate each for carotid bruit
• Ask person to take deep breath, exhale, and hold briefly (make sure to hold breath as well so you know when
person out of breath)
• Lightly apply bell of the stethoscope over the carotid artery at 1) the angle of the jaw, 2) the mid-cervical area, 3) the
base of the neck
No carotid bruit present bilaterally
3- Palpate each carotid artery for amplitude of pulse
• Palpate each carotid artery medial to the sternomastoid muscle in the neck
➢ Carotid artery 2+ bilaterally
,NRSG 358HA Practical HEAD TO TOE
4- Inspect precordium for visible pulsations, lifts, heaves, color, consistency
• Arrange tangential lighting to accentuate any flicker of movement
• **May or may not see apical impulse**
➢ No lifts, heaves, or visible pulsations present; color is consistent w/ ethnicity, no lesions, or cyanosis present
5- Palpate for aortic, pulmonic, erb’s point, tricuspid, and mitral areas for thrills
• Use palmar aspects of four fingers
• Gently palpate at: 2nd Right interspace—aortic; 2nd Left interspace—pulmonic; 3rd Left interspace—Erb’s point; 5th
Left interspace @ left sternal border—tricuspid; 5th interspace @ midclavicular line—mitral
No thrills in aortic, pulmonic, Erb’s point, tricuspid, and mitral valve areas
6- Palpate apical impulse for location, size, strength, and duration of pulsations
,NRSG 358HA Practical HEAD TO TOE
• Position person supine
• Ask person to take deep breath, exhale, and hold briefly
• Using one finger pad localize pulsation;**may need to roll person to the left—displaces apical impulse farther to
the left**
➢ Apical impulse short, gentle tap; located at the 5th ICS @ left mid-clavicular line; 1cm X 2cm
➢
7- Auscultate heart sounds in all areas, using diaphragm
➢ Rate 60-100 beats per minute, rhythm regular
8- Auscultate heart sounds in all areas, using the bell
➢ No S3, no S4, or other extra heart sounds, no murmurs
9- Identify S1 and S2
• S1 at 5th intercostal space (towards the left); listen as simultaneously palpate carotid artery
• S2 at the 2nd intercostal space (towards the right)
a. S1-S2 normal not diminished or accentuated.
b. S1 is louder at apex, and S2 is louder at base
10- Inspect arms for size and palpate for presence of edema
➢ Arms are equal size bilaterally, no presence of edema
11- Inspect fingers for clubbing
• View fingers from the side (profile sign)
➢ No presence of clubbing in fingers; nail bed angle >160
, NRSG 358HA Practical HEAD TO TOE
12- Inspect skin color of arms/hands
➢ Skin color consistent w/ ethnicity, no cyanosis
13- Palpate fingers, hands, arms for temperature
➢ Fingers, hands, and arms warm to touch
14- Determine capillary refill
➢ Capillary refill <3 seconds bilaterally
15- Palpate radial pulses, bilaterally
➢ Radial pulses 2+ bilaterally
16- Inspect legs for skin color, hair distribution, lesions
➢ Skin color consistent w/ ethnicity; hair is evenly distributed; no lesions present
17- Palpate legs for temperature; determine presence of edema
• Touch legs bilaterally w/ back of hands
➢ Legs are warm to touch; no presence of edema in legs
18- Inspect nails and palpate for capillary refill (toes)
• Depress nail beds and release—note return of color
➢ Capillary refill <3 seconds bilaterally
19- Palpate dorsalis pedis pulses
• Palpate by the big toe
•
➢ Dorsalis pedis pulses 2+ bilaterally
20- Palpate posterior tibial pulses
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