Cardio and PV Assessment PDF

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CARDIOVASCULAR AND PERIPHERAL VASCULAR ASSESSMENT 1. Wash Hands 2. Gather your supplies and put them on top of the tray  Tray  Gloves  Alcohol Wipes (3)  Stethoscope 3. Knock at the door 4. Introduce yourself and explain the type of assessment you’re going to performing  “Good morning, my name is Alicia Saenz, I am a nursing student at Miami Dade College and today I’m going to be performing your Cardiovascular and Peripheral Vascular examination on you.”

5. Ask for Patient’s name and DOB and verify identity. (Use two ways to identify the patients)  “Could you tell me your name and DOB?”  Patient says name and DOB  “Can I verify your name band?”  Patient rise their arm and allows you to see their name band.  “Thank you!” 6. Put tray down 7. Move everything that is out of your way  “I’m going to move everything out of my way.” 8. Provide privacy  “I’m going to close the curtain to provide privacy for my patient.” 9. Provide safety  “I’m going to rise up the rails on one side and down on the other side. Put the bed level toward my waist and workable height of 30-45-degree semi-fowler.”  Always have your supplies at your side (never between or close to your patient) 10. Put on gloves INSPECTION OF THE NECK 1. “I’m going to start by inspecting the skin of your neck” 2. Look at the patient’s neck on both side  “Skin color is even and consistent with genetic background”  “No lesions, no masses or no pigmentation”  “No moisture, no visible edema”  “Also, there’s no cyanosis, no pallor, no erythema”  “No bruises”  Go look at neck on both sides to see the jugular vein  “No pulsation, no jugular vein distention (JVD) noted”  “Trachea is midline” (anterior)

PALPATION OF CARTOID ARTERY 1. “I’m going to palpate the carotid artery located between the sternomastoid muscle and the trachea, THE RULE IS: ONE AT A TIME” 2. Palpate unilaterally – DO NOT CROSS OVER 3. Count patient’s pulse rate for 30 seconds and measure for rhythm, intensity, and symmetry.  “Patient’s carotid pulse is _____. Normal range is 60-100 bpm. Pulse has a bounding intensity, and it’s symmetrical” AUSCULTATION OF CAROTID ARTERY 1. “I will now auscultate the carotid artery for bruit using bell and lightly pressing to form a seal” 2. Clean the stethoscope (top, middle, and bottom) 3. Explain on how to put on the stethoscope  “The earpiece tubes should be facing forward toward the bridge of your nose and tap on the diaphragm to make sure the bell is on” 4. Patient’s need to keep neck in neutral position and apply stethoscope at the angle of jaw, midcervical area, and base of neck. Remember do it both side.  “(Angle of Jaw), Take a deep breath in and out and hold and breathe, (Mid-Cervical0, Take a deep breath in and out and hold and breathe, (Base of neck), Take a deep breath in and out and hold and breathe.  “No bruit is noted” (you will normally hear a blowing, swishing sound indicating blood flow turbulence)

INSPECTION OF ANTERIOR CHEST 1. “Inspecting of the Anterior Chest”  Color of skin is even and consistent with genetic background  No lesions, no masses  No moisture, no visible edema  No cyanosis, no pallor, no erythema  No bruises  No surgical scars  No lifts, no heaves, no visible pulsations PALPATION OF PRECORDIUM 1. To palpate the 5-precordium point, place one hand on patient’s left scapula on the back, stand on the left side of the patient, locate the clavicle. Start with Aortic.  “I’m going to palpate the 5 precordium points”  “Aortic pulse located at the right side 2nd intercostal space, sternal border.” i. Palpate using pads of your fingers in a circular motion and ask patient, “Do you feel any pain or tenderness?”  “Pulmonic pulse located at left side 2nd intercostal space, sternal border

i. Palpate using pads of your fingers in a circular motion and ask patient, “Do you feel any pain or tenderness?”  “ERB’s point located at the left side 3rd intercostal space, sternal border. i. Palpate using pads of your fingers in a circular motion and ask patient, “Do you feel any pain or tenderness?”  “Tricuspid point located at the left side 4th intercostal space sternal border.” i. Palpate using pads of your fingers in a circular motion and ask patient, “Do you feel any pain or tenderness?”  “Mitral point located at the left side 4th to 5th intercostal space, mid-clavicular line.” i. Palpate using pads of your fingers in a circular motion and ask patient, “Do you feel any pain or tenderness?”  “No thrills or brills noted throughout precordial points  PMI (Point of Maximum Impulse) i. Ask patient to lead ii. “PMI located on the left side 5th intercostal space at the mid clavicular line” iii. Palpate the apical impulse iv. “PMI is present” AUSCULTATION HEART SOUND 1. 2. 3. 4.

“I will now auscultate for heart sound using the diaphragm in a Z pattern Get stethoscope from the tray Make sure it’s clean and make sure you’re using the diaphragm and test it before using it. “I’m going to listen to your heart. I may be listening to every part of your heart for a little bit. I want to make sure that I hear all the sounds, but it doesn’t mean that I found that is abnormal.” 5. Auscultate the 5 precordial points using the diaphragm 6. Note for rate, rhythm, and intensity 7. Listen to extra sounds and describe characteristics. 8. Switch the diaphragm to the bell and start auscultating the mitral 9. Listen to murmurs 10. “Normal heart sounds noted, bounding, and no murmurs (blood doesn’t move forward)” 11. “Normal S1 and S2 heart sound (LUB-DUP) 12. “No S3 and S4 sound ” PERIPHERAL VASCULAR ASSESSMENT INSPECTION OF THE NAIL (UPPER EXTREMITY) 1. Color: Look at nailbed color  “Nailbed even and pink, no cyanosis, no pallor” 2. Consistency: Look at nailbed for brittle and Splitting  “Smooth and regular”

3. Grooming and Hygiene: Look for clean and well-groomed nails  “Nail looks clean and well-groomed, and hair is evening distributed bilaterally” 4. Shape and contour: Place hand at profile sign position and look for slightly curved or flat  “Nails slightly curved 160 degrees smooth and round, no nail clubbing” PALPATION OF NAILS 1. Capillary refill: Press and release nailbed and note the time for color to return.  “Good capillary refill within 1-2 seconds” INSPECTION OF THE ARMS 1. Skin color: Look for color to be even and consistent  “Color is even and consistent with genetic background” 2. Skin Integrity: Look for lesion and masses  “No lesion or masses” 3. Hygiene: Look for skin to be well groomed and clean  “Skin is clean and well groomed”  “Hair distribution is even” 4. Moisture: Look at skin for signs of moisture  “No moisture noted” 5. Edema: Look for signs of swelling, skin indentations  “No visible signs of swelling, no edema”  “No bruises”  “No surgical scars” PALPATION OF THE ARMS Temperature: Use dorsa part of hand and palpate at hand, forearm, and upper arm. Should be warm and equal bilaterally “Temperature is warm and equal bilaterally” Texture/ Masses and Tenderness: Use pads of finders to palpate, look for skin to be smooth and even bilaterally. Also, use pads of fingers in circular motion, ask patient if they feel any pain or tenderness.  “Do you feel any pain or tenderness?”  “Skin is smooth and even bilaterally Also, no masses no crepitus, no bumps” 2. Edema: With two fingers at hands, wrist, forearm, and upper arm  “No indentation, no edema” 3. Turgor/ Mobility/Thickness: Pinch skin at the hand, forearm, upper arm, see if the skin rises and returns to place and skin is uniformly thin  “Skin rises and falls easily, good turgor and mobility, skin is uniformly thin” 4. Radial Pulse: Look for radial pulse with pads of index and middle fingers, check both bilaterally.  “Pulse rate at ___ bpm, normal rate 60-100bpm, regular rhythm, bounding intensity, and symmetrical radial pulse” 

INSPECTION OF THE LEGS: LOWER EXTREMITY  1.

2.

3. 4. 5.

The patient needs to stretch the legs and also I need lift the legs using the calf and under thigh Color: Look for even and consistent skin color  “Skin color is even and consistent with genetic background. No pallor, No cyanosis, no erythema” Hair Distribution: Look for hair that covers legs (if not then dorsa on toes)  “Hair is distributed evenly bilaterally”  “skin is clean and well groomed” Moisture: Look at skin for signs of moisture  “No moisture” Skin Integrity: Look for lesions and masses  “No lesions and no masses” Edema: Look for swelling on legs:  “No signs of swelling, no visible edema”  “No bruises”

INSPECTION OF NAILS IN TOES 1. Color: look for pink nailbed  “Nailbed is pink and even, no cyanosis or pallor” 2. Consistency: look for smooth and regular nailbed. No brittle or splitting  Nailbed smooth and regular 3. Shape and Contour: Look at toenails  “Smooth and round, no clubbing” 4. Grooming and hygiene: Look for clean and well-groomed nails  “Nails clean and well groomed” PALPATION OF TOENAILS 1. Capillary Refill: Press and release the toenail great toe and note for healthy color return in 1-2 seconds  “Good capillary refill within 1-2 seconds” PALPATION OF LEGS 1. Temperature: Place dorsa of hand in feet, legs, and upper legs for warm temperature and equal bilaterally  “Temperature is warm and equal bilaterally” 2. Tenderness, Masses, and Texture: Palpate using pads of fingers, feet, leg, upper legs, ask patient if there is any pain or tenderness, flex knee and gently compress the calf muscle  “Do you feel any pain or tenderness?”  “No pain or No tenderness or masses noted, no moisture, texture is smooth and even bilaterally”

3. Turgor, mobility, thickness: pinch skin at feet, legs, and upper legs, check for elasticity and hydration.  “Skin rises and falls easily, good turgor and mobility, uniform thickness” 4. Edema: Palpate using two fingers pressing on feet, ankles, legs, and upper legs  “No indentation, no edema noted” 5. Dorsalis Pulse: Use pads of two fingers to palpate top of feet (at groove between great toe and second toe), check both bilaterally.  “Dorsalis pedis is located at the groove between the great and second toe”  “Dorsalis pedis Pulse rate at ______bpm, normal rate 60-100bpm, normal rhythm, bounding intensity, and symmetrical” NAME LANDMARKS:             

2nd rib Suprasternal notch Sternum Angle of Louis Manubrium Intercostal spaces C7 Midsternal line Midclavicular line Midaxillary Line Anterior Axillary Line Posterior Axillary Line Midscapular Line...