N113 Cardiovascular, Peripheral Vascular & GI Assessment PDF

1       Identify questions when assessing cardiovascular and peripheral vascular systems. Discuss methods utilized for the assessment of cardiovascular and peripheral systems Describe characteristics associated with CV and PV systems Identify cultural variations related to CV and PV systems Di...

1       Identify questions when assessing cardiovascular and peripheral vascular systems. Discuss methods utilized for the assessment of cardiovascular and peripheral systems Describe characteristics associated with CV and PV systems Identify cultural variations related to CV and PV systems Discuss CV and PV systems variations in the older adult Identify health promotion and client teaching for the CV and PV systems 2  Cardiovascular diseases remain the most common cause of death in the United States.  Incorporates data obtained from: observation, auscultation, and palpation – also include patient, family, and medical history 3 1  Nursing history should include both subjective and objective data: › › › › › › › › › Past medical history/ Current health status Family History Chest pain/discomfort Shortness of breath (SOB) Dyspnea Palpitations Fainting/syncope Fatigue Peripheral skin changes example: edema 4  How long have you had this symptom(s)?  How much does it bother you?  Does any particular incident or episode trigger the symptom?  How does it affect your lifestyle? 5  What activities or interventions alleviate the symptoms?  What do you think is causing the problem?  How far can you walk?  What muscle groups hurt and what measures relieve the pain? 6 2  Include the following: › Childhood and infectious diseases › Major illness & hospitalizations › Medications: Prescription & OTC › Lifestyle & Social history 7  Obtain objective data by: › Inspection, palpation, and auscultation  Recommended order of assessment is cephalocaudal (head to toe). 8  Assessment will include: › Level of Consciousness (LOC) › Behavior 9 3  Vital signs  Blood pressure: some variance is expected in different extremities  Postural (Orthostatic) hypotension: › Lying down, Sitting, and Standing – include HR › Sustained decrease of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP 10  Assess: › Lips, ear lobes and buccal mucosa › Note any deviations: cyanosis – bluish tinge  Examine neck veins (Internal and External Jugular): › Head of bed elevated › Assess for pulsation and distension › Bilateral jugular vein distension (JVD) 11  Assess Carotid Arteries: › Auscultate for a bruit › Palpate for a thrill 12 4  Have pt assume a supine position for:  Assess › Size, shape, symmetry of movement and any pulsations  Pulsations usually are absent except for the apical impulse › Commonly seen in young patients & adults with thin chest walls › If present, should be confirmed with palpation 13 14  Examine pt in a warm and quiet place 30-45 degrees  Start from the Base of the heart ( 2nd right ICS) to the Apex (5th ICS & L MCL): › (Mnemonic: APE To Men) (aortic, pulmonic, Erb’s, tricuspid, mitral (apical)  Elevate HOB 15 5  Auscultate: › Rate › Intensity (soft or loud)  Rhythm (regular or irregular) › Presence of extra sounds (murmurs, friction rubs) 16 17 18 6  Auscultatory Areas › right ICS – Aortic valve › 2nd left ICS – Pulmonic valve › 3rd left ICS - Erb’s point  both S1 & S2 heard well › 4th & 5th left ICS – Tricuspid valve › 5th left ICS , MCL – Apical/Mitral valve 2nd 19 20 21 7 Pulmonic Aortic Mitral Tricuspid 22 23  University of Washington Department of Medicine Advanced Physical Diagnosis https://depts.washington.edu/physdx/heart/demo.html  Easy Auscultation http://www.easyauscultation.com/heart-sounds 24 8 25 26 27 9 28  1st sound heard (S1):  Closure of the mitral and tricuspid (AV valves) › “Lub” heard best at the apex (use diaphragm of the stethoscope) › Systole phase, ventricles contract, 1/3 of cardiac cycle  2nd sound heard (S2): › Closure of the aortic & pulmonic (SL valves), heard best at the base with diaphragm of the stethoscope “dub” › Diastole phase, ventricles relax & fill with blood, 2/3 of the cardiac cycle 29 30 10  S3 › Occurs when left ventricle overly compliant to filling in early diastole › Normal finding in children and younger adults but pathological in those over 30yrs (may indicate left ventricular failure or mitral valve regurgitation)  S4 › Occurs in later diastole immediately before S1 › The left ventricle is noncompliant or resistant to filling (may indicate CAD, LVH, or aortic stenosis) 31  Pulsations  Displaced Point of Maximal Impulse (PMI)  Bounding Abdominal Pulse 32  Abnormally high pressure in the right side of the heart:  Abnormally high pressure in the left side of the heart: 33 11  With no disease, heart size remains same throughout life  Decreased cardiac output and contraction strength leading to reduced activity tolerance  Heart rate returns to resting rate much slower after activity  Sudden emotional & physical stress may result to arrhythmias and heart failure 34  Possible age- related downward displacement of the heart (PMI auscultation @ 6th ICS)  Arteries may be palpated more easily due to loss of supportive tissues  Systolic and diastolic BP increase  Peripheral edema insufficiency r/t venous 35 36 12  When did you first notice any changes?  Do you wear any prosthesis, and do they fit properly with no pressure points?  Clients with venous insufficiency 37  Inspect lower extremities  Palpate  Check skin temperature for calf tenderness  Check peripheral pulses by palpating and compare pulse on both sides 38 Assess ROM and muscle strength Note the: › rate, rhythm, intensity, symmetry of pulse volumes 39 13  Grading of the intensity/ strength of pulses 0 - No pulse (Please see instructor) 40  Grading of the intensity/ strength of pulses continued 0 = absent 1+ = weak/thready 2+ = Normal 3+ = Full/bounding pulse 41  Peripheral Pulses › Pulses asymmetrical › Diminished/weak/thready pulse › Bounding pulse 42 14  Peripheral Veins › Tenderness on palpation › Swelling of one calf or leg 43  Peripheral Perfusion › Cyanosis, marked edema, indicates venous insufficiency › Pallor while limb is elevated then dusky red color when limb is lowered indicates arterial insufficiency › Skin thin, shiny or thick, waxy shiny fragile, reduced hair and ulceration may indicate both venous or arterial insufficiency 44  Peripheral Perfusion › Nonpitting edema feels hard to touch & no indentation when firm pressure is applied on skin over the tibia or the medial malleolus for 5 seconds. 45 15  If Pitting edema is present, it is graded as:  1+ (2mm) mild pitting, slight indentation  2+ (4mm) moderate pitting, indentation resolves rapidly  3+ (6mm) Deep pitting , indentation remains for a short time and leg appears swollen  4+ (8mm) Very deep pitting, indentation lasts a long time, leg very swollen. 46 47  Capillary Refill Test › If fingernail or toenail squeezed to cause blanching: if it does not return to normal color in 3 seconds or less then, peripheral insufficiency indicated. 48 16  Major high-risk factors for heart disease and stroke include: › high blood pressure › smoking › high cholesterol levels › obesity › diabetes 49  African American, Puerto Ricans, Cubans & Latinos have a higher incidence of hypertension than Caucasians.  Latinos in the U.S. have three times the risk of developing diabetes than non-Hispanic Caucasians. 50  Decreased effectiveness of blood vessels  Proximal arteries thinner and dilate  Peripheral arteries are thicker & dilate less effectively  Blood vessels lengthen and more tortuous & prominent. 51 17  Balanced diet  Exercise  Annual Check ups  Compliance with medication/ health and wellness regimes  Community support groups for health resources  Strategic Community Education and Interventions 52 53  Nursing History › Changes in appetite, weight › Difficulties swallowing (dysphagia) › Any food intolerance › Abdominal pain › Any nausea and vomiting › Bowel habits 54 18  Nursing History cont. › Past abdominal history › Medications/ alcohol/smoking › Nutritional assessment 55  Inspect oral mucosa: redness, pallor, swelling, ulcer  Lips  Gums  Teeth  Tongue  Pharynx 56  Subdivide the abdomen into 4 quadrants: › RLQ, RUQ, LUQ, LLQ › Helps with location of organs & documentation  Advise client to void before assessment  Promotes comfort during assessment  Abdomen is assessed by:  inspection, auscultation, palpation and percussion 57 19  Skin:  Unblemished skin, uniform color, silver white striae  Contour and symmetry:  Flat, rounded, WNL liver & spleen size, symmetric contour 58  Abdominal movements:  Peristalsis not visible  Vascular pattern: not visible  Audible bowel sounds:  (normal), no arterial bruits, no friction rub 59  Presence of rash/lesions on the skin  Tense glistening skin  Purple striae  Distention  Liver or spleen enlargement 60 20  Asymmetric contour:  Hernia or tumor?  Visible peristalsis  Visible venous patterns associated with liver disease 61 62  Auscultate all 4 quadrants: auscultate each quadrant for up to 5 minutes.  Loud bruit  Hyperactive BS - >35 per minute  Hypoactive BS – 1-2 sounds in 2 minutes  Absent BS – no sounds in 3-5 minutes 63 21  No tenderness, relaxed abdomen with smooth, consistent tension  On deep palpation tenderness near xiphoid process, over cecum, over sigmoid colon  Liver may not be palpable, borders feel smooth  Bladder not palpable 64 Tenderness and hypersensitivity, muscle guarding  Generalized or localized tenderness, mobile or fixed masses  Liver enlargement, smooth but tendernodular hard  Distended and palpable tense mass indicate urine retention  65  High lactose intolerance 70-90% among African Americans, Native Americans, Asians, and Mediterranean groups 66 22  Increased adipose tissue and decreased muscle tone resulting to rounded abdomen  Muscle wasting and loss of fibroconnective tissue  Higher pain threshold  Slower peristalsis, less frequent BM 67  High incidence of colon cancer  Decreased medication absorption  Decreased salivation  Gastric acid secretion decreases 68  High fiber diets with high quantity of raw fresh foods/balanced diet  Teach effects of the gastrocolic & duodenocolic reflexes facilitation with bowel elimination - initiated by food (more active with 1st meal) entrance to stomach and duodenum. 69 23  Annual Health Exams/ Screening  Exercise  Education  Remain up to date with research 70 24