Practical - Heart Peripheral Pulses and Extremities Physical Assessment Cues PDF

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Cue sheets for physical assessment for body system...

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PYHSICAL ASSESSMENT CUES

CRITERIA FOR HEART, PERIPHERAL PULSES AND EXTREMITIES PREPARATION

EVIDENCE

Equipment, self (washes hands), environment and client (include correct position) Stethoscope with a bell and diaphragm Watch with a second hand Quiet room Gloves Client lying supine with upper body at 30 -45 degrees. Assess from the right side of the client. Therapeutic interactions with client Explain procedure and gain informed consent Keep hands warm Rapport Modesty Obtains appropriate nursing history COLDSPA if it were a presenting cardiac problem Past health history including questions about previous heart defects, rheumatic fever, heart surgery, ECG, lipid profiles, medications for heart disease, self monitor BP or HR. Family history of: HTN, MI, CHD, high cholesterol, Diabetes M. in family Lifestyle and health practices: smoke, stress, diet, alcohol, exercise, number of pillows to sleep

HEART

INSPECT

Skin characteristics (see integument) Colour: N-evenly coloured skin tones without unusual or prominent discolouration A-pallor: pale-ashen, cyanosis-blue tinged or mottled, jaundice-yellow pale-pumpkin. Colour variation: N-freckles, moles, suntanned areas A-rashes-red or dark, albinism-general loss of pigmentation Integrity: N-skin intact and no reddened areas A-skin breakdown evident –reddened area-pressure ulcer Lesions: N-smooth without lesions, scattered moles and freckles, birthmarks A-primary, secondary or vascular lesions, note distribution: diffuse or localised and configuration: discrete,grouped,confluent,linear,annular,zosteriform. Texture: N-sin is smooth and even A-skin is rough,flaky,dry Moisture: N-skin moist to dry A-diaphoresis in fever, clammy, reduced moisture or dry in dehydration Temp: N-warm temp A-cold-shock, cool-reduced circulation, very warm-fever Mobility and Turgor: N-skin pinches easily and returns to original position immediately A-decreased turgor in dehydration or decreased mobility seen in oedema Precordium for contours, pulsations: With head of bed elevated to 45degrees, stand on client’s right side and look for apical pulse and any abnormal pulsations. Contours should be symmetrical. Apical pulse may or may not be visible. If visible it would be in mitral area(LT MCL 4th or 5th ICS)The apical pulse is a result of the LT ventricle moving outward during systole.

PALPATE IDENTIFY AUSCULTATE

Pulsations or heaves/lifts are abnormal. They may occur as result of an enlarged ventricle from an overload of work.(see page 377 of text) No pulsations visible in the areas of the apex, sternal border or base. Precordial landmarks (Aortic, Pulmonic, Erb, Tricuspid, Mitral ) (See pg 359 of text) Identify and palpate first aortic area then pulmonic area, Erbs point, tricuspid area and then mitral area. Heart sounds at precordial landmarks (APETM) Use diaphragm then bell and compare S1 & S2.

PHYSICAL ASSESSMENT CUES 2012

Identify differences in locations of S1 & S2 Position self on RT side of patient, use the diaphragm focus on one sound at a time as you auscultate each area of the precordium. Start by listening to HR and rhythm, then id the first and second heart sounds, concentrate on each sound individually, listen for extra heart sounds, listen for murmurs and finally listen in different positions if applicable. S1 starts systole and S2 starts diastole. The space or pause between S1 and S2 is short(thus S1 and S2 are very close together) whereas the space between S2and S1 is of longer duration. S1-a distinct sound is heard in each area but loudest in apex. May become softer with inspiration. Accentuated, diminished, varying or split S1 are all abnormal findings. S2-a distinct sound is heard in each area but is loudest at the base. A split S2(into 2 distinct sounds of its components A2 and P2) is normal and is usually heard late in inspiration. Auscultate apical and palpate radial for PULSE DEFICIT This is done if you detect an irregular rhythm. Palpate the radial pulse while you auscultate the apical pulse. Count for a full minute. A pulse deficit (difference between apicalradial pulses)may indicate arrhythmia.

PERIPHERAL PULSES AND EXTREMITIES INSPECT AND Skin colour, temperature, capillary refill, Inspect colour of hands and arms. Colour should be the same bilaterally or abnormal may indicate PALPATE rapid changes of colour (pallor, cynanosis and redness) noted. Palpate the fingers, hands and arms and note temperature. Skin is warm to touch bilaterally from fingertips to upper arms. Abnormal-cool extremity, cold fingers. Palpate to assess capillary refill-Compress the nailbed until it blanches. Release the pressure and calculate the time it takes for colour to return. This test indicates peripheral perfusion and reflects cardiac output. N-capillary beds refill in 2 secs or less. Peripheral pulses: radial, dorsalis pedis, posterior tibialis, popliteal (include grade) Palpate the radial pulse-gently press the radial artery against the radius. Note elasticity and strength. N-radial pulses have equal strength bilaterally. Artery walls have a resilient quality(bounce). A-diminished, absent, increased pulse. Palpate the dorsalis pedis pulse- dorsiflex the client’s foot and apply light pressure to and along side the extensor tendon of the big toe. Assess amplitude bilaterally. In an oedematous foot a Doppler ultrasound may be useful. Dosalis pedis bilaterally strong. The pulse is congenitally absent in 5-10% of population. Palpate the posterior tibialis- palpate behind and just below the medial malleolus. Assess amplitude bilaterally. Posterior tibialis should be strong bilaterally. It is absent in 15% of healthy clients. Palpate the popliteal- ask patient to partially bend knee and useuse fingers deep in bend of knee. Located lateral to medial tendon. Assess amplitude bilaterally. May be difficult or impossible to detect and yet for circulation to be normal. A Doppler ultrasound may be useful in an oedematous foot (see pg 403 of text). Movement and sensation (See Motor and Sensory Assessment Document on Bb)

BLOOD PRESSURE AND PULSE TO BE TAKEN

PHYSICAL ASSESSMENT CUES 2012...