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 High Blood Pressure Congestive Heart Failure 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 120 mmHg First sound 50 mmHg No sound 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