Health Assessment PDF

Health Assessment Basic Cardiac, Peripheral Vascular, Abdomen Lab SLO 2 Anne Jones-Sutton Wake Tech MMSSON 2024-2025 Basic Cardiac Assessment Location of Cardiac Listening Areas Mitral Area - PMI - Apex of Heart  Normal Heart Sounds...

Health Assessment Basic Cardiac, Peripheral Vascular, Abdomen Lab SLO 2 Anne Jones-Sutton Wake Tech MMSSON 2024-2025 Basic Cardiac Assessment Location of Cardiac Listening Areas Mitral Area - PMI - Apex of Heart  Normal Heart Sounds S1: “Lub”, Heard best at “PMI” or apex of heart. Mitral & Tricuspid Valves close; Ventricles contract; Systole S S 2: “Dub”, Heard best at 2nd ICS or base of heart. Aortic & Pulmonic Valves Close; Ventricles relax & fill; Diastole  Cardiac Auscultation Listen for “lub” - “dub” at each listening area “Lub” is louder at the Point of Maximal Impulse (PMI), apex of heart Dub is louder at 2nd intercostal spaces (aortic & pulmonic areas), base  Auscultation, cont. Listen for rate & rhythm Is the rate in the expected range? Listen to the intervals between lub & dub, (systole) then between dub & lub (diastole) Do you hear any extra beats or flow murmurs? Is the rhythm regular, irregular or regularly irregular? (Not a trick question!)  Vascular Assessment Assess pulses, cap refill, general edema vs. local swelling, discoloration, warmth, sensation, discomfort, ulcers, atrophy, hair growth pattern, toenail growth. Note presence of petechiae. Immediately notify RN if calf muscle noted to be warm, red, tender, swollen (risk for blood clot – DVT: Deep Vein Thrombosis). Can also occur in upper extremities! See Neurovascular Assessment Supplement on BB Petechiae Red, pinpoint hemorrhagic lesions that do not blanche when palpated. Can be caused by low platelets or toxins in the system.  Peripheral Pulses Assess upper extremities & lower: at least radial & pedal Compare side to side Carotids: one at a time only! Use Doppler ultrasound device prn difficulty feeling pulse. Practice in lab. Grade pulses on a 0 to 4 + scale 0 = absent 1 = Diminished, barely palpable 2 = Expected, normal 3 = Full pulse, increased 4 = Bounding  Assessing & Grading Edema Correlate with other signs/symptoms as well as activity level. Laying in bed with feet up or has the person been on their feet all day? Any pulmonary edema – crackles & rhonchi? Any peritoneal fluid notable? Abdominal Assessment - Four Quadrants Key Points for Abdominal Assessment Dorsal Recumbant or supine with knees bent & arms at side best I - A - P – P “Look, Listen & Feel” Palpate abdomen after inspecting and auscultating. Touch tender areas last! Difficult to assess with tense belly muscles Abdominal Assessment: Inspection & Auscultation Observe for guarding, contour, scars, bowel motility, any obvious distention Auscultate bowel sounds all 4 quadrants. Evaluate as Normal, Hypoactive, Hyperactive or Absent. Think-Pair-Share: What types of patients may have altered bowel sounds? Abdominal Palpation Note: No poking with fingertips!  Deep Palpation of Abdomen Note: Can use to palpate for stool if history indicates; no digging for masses! ajs 9/2024