NSB103 Health Assessment: Focused Cardiovascular Assessment PDF

11/02/2024...

11/02/2024 Learning This Week NSB103 Health Assessment Focused Cardiovascular Assessment Overview of the Cardiovascular System Paul Jarrett Common Cardiovascular problems – symptoms Assessment preparation Primary survey (C) Acknowledgements: Focused Cardiovascular Assessment ECG Pauline Gillan (UC) Clinical Reasoning Cycle Karen Wynne This weeks CPS en-la-computadora-portatil-grande_1253706.htm 1 2 Structure of the Cardiovascular Overview of the Cardiovascular System System Purpose: Anatomy and physiology: The primary function of the heart is to pump blood to all parts of the The heart is located in the thoracic body cavity between the lungs and above To deliver- oxygen, nutrients and other substances to the tissues the diaphragm (the area known as the mediastinum) To remove- waste products of cellular metabolism Circulatory system: consists of arterial pathways (distribution routes) and venous pathways (collection system returning blood to the heart) (Calleja et al., 2016, p. 442-446). https://oli.cmu.edu/jcourse/workbook/activity/ 3 4 Structure of Cardiovascular System con’t Cardiovascular Physiology Heart: has 4 chambers: Right side of the heart:  Right atrium Low O2 Receives deoxygenated blood from High CO2 body via Vena Cava Low pressure  Right ventricle Pumps deoxygenated blood into the lungs via Pulmonary artery Left side of the heart:  Left atrium High O2 Receives oxygenated blood from Low CO2 lungs via the Pulmonary vein High pressure  Left ventricle Pumps 4-5 litres of oxygenated blood to the body via the aorta per minute 5 6 1 1 1  11/02/2024 3/31/22 Cardiovascular Pathophysiology Cardiovascular Pathophysiology Conduction system  SA node Pacemaker in right atrium  AV node Impulses travel the internodal tract Slight delay Filling of ventricles  Bundle of HIS Interventricular septum  Purkinje fibres To myocardial cells Apex contracts first https://www-clinicalkey-com-au.ezp01.library.qut.edu.au/#!/content/book/3-s2.0- /https://antranik.org/conducting-system-of-the-heart B9781455750177000532?scrollTo=%23hl0000209 7 8 Circulatory System Pathophysiology Potential Cardiovascular Health Problems Colour change to lips, face and nail bed Blood vessels: Peripheral skin colour changes Closed system of tubes Chest discomfort, pressure, squeezing, pain Palpitations Sweating Blood volume: Light-headedness 64% in veins and venules Syncope 13% arterioles Shortness of breath 7% capillaries Oedema 9% pulmonary Pain and/or numbness/tingling in the extremities 7% heart Fatigue Feeling of doom Self care restrictions due to tiredness, pain, breathing difficulties 9 10 Preparing for a Physical Assessment Preparing for a Physical Assessment Introduce yourself; Explain what you plan to do and how long it will take Warm all equipment Invite and answer any questions from the patient; Explain why you If the patient complains of fatigue, continue the assessment later may be spending a long time performing one task Proceed using a systematic approach; e.g. the head-to-toe approach. Thank the patient when the exam is concluded Maintain privacy; ensure patient comfort throughout procedure Thoroughly document findings Ensure the patient is accessible from both sides of the bed or examination table; If a bed is used, raise the bed to an appropriate height 11 12 2 2 2  11/02/2024 3/31/22 Equipment for Cardiovascular Assessment Nursing Assessment Do you need some privacy? Do you need a quiet environment? https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUK https://www.staples.co.uk/gel-pens/cbs/297924951.html Do you need more lighting? Is the room warm enough? https://www.ebay.com/itm/ADC-Blood-Pressure-Monitor-Aneroid-Sphygmomanometer http://innovativeglass.net/health-care/green-emergency-room https://en.wikipedia.org/wiki/Tape_measure https://www.nurseoclock.com/silicone-nurses-fob-watch 13 14 Nursing Assessment Most of all…. Positioning of patient and access for assessment COMMUNICATION  Introduce yourself  Explain assessment  Inviteand answer any questions  Think about your non-verbal communication  Maintain privacy Semi Fowlers: 45°  Allow sufficient time High Fowlers: 90°  Thank the patient when exam is over DOCUMENT!!!!! https://en.wikipedia.org/wiki/Semi-Fowler%27s_position https://en.wikipedia.org/wiki/Supine_position https://www.cartoonstock.com/directory/p/patient_care.asp 15 16 General Survey Cardiovascular Assessment Objective data What the nurse observes: General observation (general survey)  During physical examination Primary survey (ABCDE)  Measured Vital signs- “obs”/”vitals” (manual blood pressure,  Observed radial pulse etc) Inspection - observing (skin colour, peripheral vessels,  Diagnostic tests (ultrasound/X-ray) oedema etc) http://richkosh.blogspot.com/2018/02/objective-vs-subjective.html  Specialist investigations Palpation – feeling (neurovascular obeservation- identify changes in sensation, circulation, presence of Subjective data pain) What the patient tells Auscultation – listening (heart sounds and apical heart beat) https://www.wkhs.com/heart/services/diagnostic-tests/echocardiogram-(cardiac-ultrasound) you: Electrocardiogram (ECG)  Past medical/health Observe and record urine output and other fluid losses history/family history/social history  Current health problem/s  Feelings/perceptions http://richkosh.blogspot.com/2018/02/objective-vs-subjective.html 17 18 3 3 3  11/02/2024 3/31/22 The Primary Survey C-Circulation The primary survey provides the nurse with a rapid visual assessment of the patient and their environment for important cues (Robeiro et al, 2017, Does the person have adequate circulation? p. 37). Observe skin colour (signs of cyanosis, palor) Purpose - is to identify: Feel for (radial) pulse (signs of abnormalities Any abnormalities or issues/concerns eg tachycardia, bradycardia, weak/bounding Any deterioration of patient pulse, regular/irregular) Any modifications to patient’s current care plan (Rebeiro et al, 2017, p. 37) A-Airway B-Breathing https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUK C-Circulation https://blog.kalixhealth.com/ D-Disability E-Exposure 19 20 4 Physical Assessment Techniques Focused Cardiovascular Assessment Cardiovascular Assessment IP(P)A Review patient’s baseline assessment data Perform hand hygiene; Ensure comfort and privacy; Explain procedure and clarify any concerns Approach from the right hand side; Patient positioned at 45 degrees supine General observation of skin colour, temperature and mental status Inspection (I) Inspect and palpate upper limbs for colour, warmth, movement and sensation Palpation (P) Check peripheral and central capiliary refill time Percussion (P) Palpate radial pulse for rate, rhythm and strength Auscultation (A) Measure manual blood pressure Observe neck veins (patient at 45 degree angle) Auscultate apical heart sounds (noting rate and rhythm); determine normal heart sounds; listen for acute changes (ie added sounds or murmurs) Inspect and palpate lower limbs for colour, warmth, movement and sensation. Palpate pedal pulses, check for pitting oedema (ankles) Inspect and palpate calves for redness, warmth, tenderness Observe urine output and any losses in drains etc https://slideplayer.com/slide/5716054/ Observe ECG for abnormal changes (Rebeiro et al, 2017, p. 49-50) 21 22 Inspection – Physical Appearance Palpation Always the first assessment technique used during assessment Remember: WARM HANDS and SHORT NAILS process Neck Skin Tracheal shifts Color Jugular vein distension cyanosis, flushed, pale, jaundice Communication Diaphoresis Extremities Flushed Clubbing, edema, skin tears LIGHT PALPATION Pallor Superficial, delicate, gentle Rash Discomfort Use finger pads Pain and anxiety Depress 1cm below surface Workof breathing Provides information on- Accessory muscles, nasal flaring, tachypnea, Size of patient shortness of breath Skin texture, moisture, masses, fluid, Malnourished, obese https://www.medicine.mcgill.ca/physio/vlab/cardio/palpa.htm tenderness, muscle guarding Chest Lethargic, alert, disoriented Shape and symmetry ASSESS for PAIN - If patient complains of tenderness, palpate this area last 23 24 4 4 4  11/02/2024 3/31/22 Inspection and Palpation Auscultation: Assessing Heart Sounds Peripheral limbs (arms & legs) Inspect and palpate for colour, warmth, movement and sensation. Radial pulse and pedal pulses for rate, rhythm and strength Palpate for pitting oedema Inspect and palpate calves for redness, warmth and tenderness. Check peripheral capillary refill time https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUK 25 26 Auscultation Heart sounds: 1st heart sound (S1- lub) Closure Mitral valve Tricuspid valve 2nd heart sound (S2- dub) Closure Aortic valve Pulmonary valve https://nurseslabs.com/ultimate-guide-to-head-to-toe-physical-assessment/ https://web.duke.edu/anatomy/Lab03/Lab4_preLab.html 27 28 Assessing Apical Heart Beat Documentation http://www.registerednursern.com/apical-pulse-assessment-and-location/ 29 30 5 5 5  11/02/2024 3/31/22 Assessing the Cardiac Conduction System Assessing the Cardiac Conduction System (ECG) Normal sinus rhythm Must always be a P wave P wave = rounded shape P wave = same shape P wave followed by a QRS P-R interval 3-5 small squares and constant Rhythm should be regular. https://ecgwaves.com/introduction-electrocardiography-ecg-book/retledningssystemet-7/ 31 32 Electrocardiogram (ECG) ECG Lead Placement https://www.cablesandsensors.com/pages/12-lead-ecg-placement-guide-with-illustrations https://www.primemedicaltraining.com/12-lead-ecg-placement/ 33 34 Sinus Rhythm: PQRST Sinus Rhythms 3 stages P wave Contraction of atria Atrial depolarisation Ventricular depolarisation QRS complex Atrial and ventricular repolarisation Contraction of ventricles Repolarisation of atria (hidden) T wave Repolarisation of ventricles https://www.newhealthadvisor.com/Conduction-System-of-the-Heart.html https://www.nottingham.ac.uk/nursing/practice/resources/cardiology/function/sinus_rythm.php 35 36 6 6 6  11/02/2024 3/31/22 Legal Considerations The Clinical Reasoning Cycle Establish a trusting and caring Assessment relationship. Gather Data While performing the physical Planning examination, inform the patient of: Process Information Identify problems/issues what to expect Establish goals where to expect it how it will feel. Implementation Take Action Address patients concerns prior to Evaluation continuing the examination. Evaluate & Reflect on outcomes Document the examination accurately. 37 38 Phase 1 Cardiovascular Assessment and Identifying Cardiovascular Phase 2 Phase 3 Health Problems Goal setting – realistic and person centred Colour change to lips, face and nail bed. Person states that they feel comfortable and pain free 1. Subjective Chest discomfort/palpitations or pain Person’s skin is dry Objective Data Sweating Light-headedness and syncope Person feels stable when walking & described Shortness of breath not feelings of light headedness Oedema 2. Compare the data Person has less peripheral oedema in their legs Pain and/or numbness/tingling in the extremities and feet against normal Fatigue parameters Feeling of doom Person feels positive about their health Self care restrictions due to tiredness, pain, breathing difficulties. Person is able to care for themselves independently 3. Start to Identify Health Problems 39 40 Some Cardiovascular Diseases This Week’s Classes Heart failure  returning blood not pumped fast enough CPS: Myocardial dysfunction Cardiovascular focussed assessment  Cardiomyopathy Taking Apical heart rate  Myocarditis Conducting a 12 lead ECG Listening to heart sounds Circulatory failure Neurovascular assessment  Hypovolemia (shock, haemorrhage, dehydration) ISBAR handover  Valvular dysfunction CRC en -la - co m p u ta d o r a - por tatil- gr ande_1253706. htm  Congenital defects Practice Vital signs Congestive heart failure  failing heart leads to fluid congestion In lungs – pulmonary oedema In body – oedema 41 42 7 7 7  11/02/2024 3/31/22 Reference List Calleja, P., Theobald, K., & Harvey, T. (2020). Health Assessment and Physical Examination. Australian and New Zealand (2nd Ed) Crisp, J., Taylor C., Douglas, C., Rebeiro, G., and Waters, D. (2021). Potter & Perry's Fundamentals of Nursing (5 t h Ed.) Sydney, Mosby Elsevier Duffy, J. (2013). Quality Caring in Nursing and Health Systems” Implications for Clinicians, Educators and Leaders. (2nd ED) Springer Publishing Company. Lewis, P., & Foley, D. (2011). Weber & Kelly’s Health Assessment in Nursing. First Australian and New Zealand Edition. Sydney AUS: Wolters Kluwer: Lippincott Williams & Wuikins. Lipworth, W., Little, M., Gordon, J., Markham, Pl and Kerridge, I (2013). Ch 4. The Place of Patient-Centred Care in Medical Professional Culture: A Qualitative Study in Keating, M., McDermott, A. and Montgomery, K. (Eds.). Patient- Centred Health Care. Achieving Co-ordination Communication and Innovation. Retrieved from http://qut.summon.serialssolutions.com Rebeiro, G., Wilson, C., Scully, N. & Jack, L. (2017). Fundamentals of Nursing Clinical Skills Workbook, 3 rd Ed. Sydney, Mosby Elsevier 43 43 8 8 8