Cardiac and Peripheral Vascular Lab Guide PDF

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CARDIOVASCULAR SYSTEM - REGIONAL WRITE-UP Directions: Gather your equipment. Wash your hands. Clean your stethoscope with an alcohol wipe. Record your findings on pages 1 and 2 using Jarvis as a guide. Then close Jarvis as you complete Page 3 as a narrative summary/ documentation of your findings. Date Examiner Patient Reason for visit I.

Age

Health History

NO

Gender

YES, EXPLAIN

Any chest pain or tightness? Any shortness of breath? Use more than one pillow to sleep? Do you have a cough? Do you seem to tire easily? Facial skin ever turn blue or ashen? Any swelling of feet or legs? Awaken at night to urinate? Any past history of heart disease? Any family history of heart disease? Any change in usual daily activities? Current medications? Do you use tobacco? How many/ how much per day? 14. Alcohol use? Number of drinks per day? 15. Assess cardiac risk factors: diabetes, hypertension, smoking, high cholesterol, obesity, sedentary lifestyle, age 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

16. Teaching Needs ______________________________________________________________ II.

Physical Examination A. Carotid arteries Palpate R L (absent, weak, moderate, bounding) B. Inspect the Jugular venous system External (or internal) jugular veins (circle one): (a) collapsed supine/ not visible (b) meniscus visible at bed elevated C. Precordium – inspect and palpate. 1. Skin color and condition 2. Chest wall pulsations 3. Heave/lift noted______

4. Apical impulse in the

at

5. Thrill_____________________________________________________________________ 6. Lymph nodes (see top of Page 397, Jarvis for 4 locations)___________________________ D. Auscultation 1. Identify anatomic areas where you will listen. 2. Rate and rhythm 3. Identify S1 and S2 4. Listen in systole and diastole: Extra heart sounds Systolic murmur Diastolic murmur

CHAPTER 20: PERIPHERAL VASCULAR SYSTEM - REGIONAL WRITE-UP III.

Health History 17. 18. 19. 20. 21. 22. 23.

IV.

NO

Any leg pain (cramps)? Where? Any skin changes in arms or legs? Any sores or lesions in arms or legs? Any swelling in the legs? Any swollen glands? Where? What medications are you taking? Teaching Needs________________________

Physical Examination C. Arms, Inspect: Color of skin and nail bed Symmetry Lesions Edema

Clubbing

Palpate Temperature Capillary refill

YES, EXPLAIN

Locate and grade pulses (record below) Check epitrochlear lymph nodes

D. Legs, Inspect: Color

Hair Distribution

Venous pattern, varicosities Swelling/ edema If so, measure calf circumference in centimeters: R Skin lesions or ulcers

L

Palpate Temperature Calf tenderness Inguinal lymph nodes Locate and grade pulses (record below) Capillary refill_________________________________________________________ Check pretibial edema (grade if present)

Brachial

Radial

Femoral

Popliteal

R L 0 = absent, 1+ = weak, 2+ = normal, 3+ = full, bounding

Subjective (health history)

Objective (physical examination findings)

Dorsalis pedis

P. tibial...