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Cardiovascular Assessment

Terms in this set (22)

Step 1
Perform hand hygiene
Step 2
Gather equipment: Stethoscope
Step 3
Introduce your self:

Hello, my name is ________, I am your student nurse today.
Step 4
Identify patient using 2 identifiers:
Can you telling me your name and date of birth.
Step 5
Explain the procedure to the patient.
Step 6
Provide for privacy
Step 7
Ask the patient if they are experiencing any chest pain or having any shortness of breath.
Step 8
Use inspection and palpation to examine the neck

1) Have the patient positioned with the head of the bed at 45 degrees.
2) Remove their pillow and have patient turn their head in each direction, observing the lateral side of the neck for distention and pulsation.
Step 9
Locate the carotid artery by placing your fingers lateral to the trachea.
- Palpate each carotid artery, one at a time.
- Note strength, rhythm, and regularity of pulse.
Step 10
Position patient supine if tolerated
Remove clothing
Step 11
Using the diaphragm of the stethoscope auscultate the 4 heart valves:
1) 2nd intercostal space ( ICS), AORTIC VALVE, found at the right of the sternum.
2) 2nd intercostal space (ICS), PULMONIC VALVE, found at the left of the sternum.
3) 4th intercostal space( ICS), TRICUSPID VALVE, found left of the sternum
4) 5th intercostal space ( ICS) , MITRAL VALVE or APICAL PULSE, found left of the sternum, midclavicular.
ausculate
Listening to the internal sounds of the body, usually using a stethoscope.
Auscultation is performed for the purposes of examining the circulatory and respiratory systems (heart and breath sounds), as well as the gastrointestinal system (bowel sounds).
Step 12
Assess capillary refill bilaterally
Normal less than 3 seconds
Depress 2 or 3 fingertips on each hand and observe how fast the color comes back.
*** Check fingers on each hand
Bilaterally
Pertaining to the right and left sides of a structure
Step 13
Locate the following pulses for strength and equality.
1) Radial pulse- Wrist
2) Dorsalis pedis- Top of the foot, close to the ankle.
3) Posterior tibial- Side of the ankle.
Step 14
Assess for edema ( Anterior tibia, ankle, dorsum of foot)
Edema
Serous fluid into the interstices of cells in tissue spaces or into body cavities.
Effusion
An escape of fluid into a body cavity
Step 15
Position patient into a comfortable position
Step 16
Put call light within reach and make sure bed is at lowest position
Step 17
Perform hand hygiene
Step 18
Document findings
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