Assessment & Reasoning
Cardiac System
John Gordon, 65 years old
Suggested Cardiac Nursing Assessment Skills to Be Demonstrated:
Anterior:
Inspection
• Chest pulsations, heaves, lifts, color of skin; symmetry of mov
...
Assessment & Reasoning
Cardiac System
John Gordon, 65 years old
Suggested Cardiac Nursing Assessment Skills to Be Demonstrated:
Anterior:
Inspection
• Chest pulsations, heaves, lifts, color of skin; symmetry of movement; anatomical defects, retractions
Palpation
• Apical impulse (4th to 5th ICS, Left MCL)
Auscultation
• HR & rhythm (60-100 bpm)
• Identify S1 & S2 – 2nd ICS, Right sternal border (aortic); 2nd ICS, Left sternal border (pulmonic); 3rd ICS, Left
sternal border (Erbs); 4th ICS, Left sternal border (tricuspid); 5th ICS, Left MCL (pulmonic). S1 is louder at
Apex, S2 louder at the base. This is the traditional method and a systematic method of learning.
• Diaphragm and bell to be used. Do not allow the patient to hold breath. Auscultate for S3 and S4 heart sounds
and murmurs. May be done in lying and sitting position, lying on left side and on back with head elevated 30
degrees
Peripheral
Arms:
• Inspection –for symmetry, skin characteristics, hair distributions size (edema), venous pattern, color
• Palpation – temperature using back of the hand, cap. refill
Pulses
• Palpation of radial/ulnar pulses, if suspecting arterial insufficiency, palpate brachial artery
Legs:
• Inspection – for symmetry, skin characteristics, hair distributions, size(edema), venous pattern, color,
varicosities, thrombophlebitis
• Palpation – edema, temperature, inguinal lymph nodes,
• Pulses - femoral, popliteal, pedal
Make Learning Active!
• Role play or go through the interview/body assessment process – student to student or as a group.
• Review the case study as an application exercise in small groups or together as a class.
• Depending on your program some of this content in the case study may not have been taught. Do not let
that prevent you from utilizing this case study! Instead, use it to promote learning by having students
identify what they do not yet know and provide guidance on where they can find the information in the
textbook or on the internet to address knowledge gaps. This is educational best practice and another way
to scaffold knowledge!
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https://www.coursehero.com/file/71174337/STUDENT-KEITH-RN-CARDIAC-Assessment-and-Reasoningpdf/
© 2019 Keith Rischer/www.KeithRN.com
Present Problem:
John Gordon is a 65-year-old male who has a history of myocardial infarction (MI) two years ago and heart failure with a
current ejection fraction (EF) of 30%. He presents to the emergency department (ED) for increasing shortness of breath
(SOB) for the past three days. He is more fatigued than usual and becomes short of breath with minimal activity. The last
two nights he had to sleep upright in a recliner so he could breathe easier and fall asleep. He has noted increased swelling
in his lower legs and has gained six pounds the last two days.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Myocardial infarction
Ischemic cardiomyopathy
w/ejection fraction 30%
Aspirin 81 mg PO daily
Lisinopril 20 mg PO daily
Carvedilol 25 mg PO BID
Patient Care Begins:
What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 98.6 F/37.0 C (oral) Provoking/Palliative:
P: 92 (reg) Quality: Denies Pain
R: 26 (reg) Region/Radiation:
BP: 162/84 MAP: 110 Severity:
O2 sat: 91% room air Timing:
You place John on a cardiac monitor, continuous oximetry
and quickly collect the following assessment data:
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© 2019 Keith Rischer/www.KeithRN.com
What assessment findings are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
Put it All Together and Think Like a Nurse!
1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most
thoroughly based on the primary/priority concern?
What’s the
problem?
What’s causing the problem?
(explain pathophysiology in OWN words)
PRIORITY Body
System to Assess:
2. Which specific nursing assessments for this body system are most important? Validate successful completion of
each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY Nursing Assessments: Rationale: Validate Student
Performance:
Current Assessment:
GENERAL
APPEARANCE:
Appears anxious, restless
RESP: Breath sounds have coarse crackles on inspiration and expiration scattered throughout both
lung fields ant/post, labored respiratory effort, patient sitting upright
CARDIAC: Forehead diaphoretic, cool to the touch, radial, pedal and post-tibial pulses regular 3+, has 3+
pitting edema bilateral lower extremities in feet, ankles, 2+ up to knees bilat, S3 gallop most
prominent over apex, no jugular venous distention (JVD) noted sitting up at 45 degrees
NEURO: Alert and oriented to person, place, time, and situation (x4)
GI: Abdomen pale soft/nontender, symmetrical, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
IINTEGUMENTARY: Pale, skin integrity intact, skin turgor elastic, no tenting present, cap. Refill brisk <1 second
This study source was downloaded by 100000831988016 from CourseHero.com on 12-19-2021 05:27:02 GMT -06:00
https://www.coursehero.com/file/71174337/STUDENT-KEITH-RN-CARDIAC-Assessment-and-Reasoningpdf/
© 2019 Keith Rischer/www.KeithRN.com
3. If this patient begins to complain of chest pain, what specific questions woul
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