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CARDIOVASCULAR ASSESSMENT/NRSG 358HA Practical HEAD TO TOE
Typology: Exams
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4-Inspect precordium for visible pulsations, lifts, heaves, color, consistency Arrange tangential lighting to accentuate any flicker of movement May or may not see apical impulse No lifts, heaves, or visible pulsations present; color is consistent w/ ethnicity, no lesions, or cyanosis present
Use palmar aspects of four fingers Gently palpate at: 2nd^ Right interspace—aortic; 2nd^ Left interspace—pulmonic; 3rd^ Left interspace—Erb’s point; 5th^ Left interspace @ left sternal border—tricuspid; 5th^ interspace @ midclavicular line—mitral No thrills in aortic, pulmonic, Erb’s point, tricuspid, and mitral valve areas 6-Palpate apical impulse for location, size, strength, and duration of pulsations
12 -Inspect skin color of arms/hands Skin color consistent w/ ethnicity, no cyanosis 13-Palpate fingers, hands, arms for temperature Fingers, hands, and arms warm to touch 14-Determine capillary refill Capillary refill <3 seconds bilaterally 15-Palpate radial pulses, bilaterally Radial pulses 2+ bilaterally 16-Inspect legs for skin color, hair distribution, lesions Skin color consistent w/ ethnicity; hair is evenly distributed; no lesions present 17-Palpate legs for temperature; determine presence of edema Touch legs bilaterally w/ back of hands Legs are warm to touch; no presence of edema in legs 1 8-Inspect nails and palpate for capillary refill (toes) Depress nail beds and release—note return of color Capillary refill <3 seconds bilaterally 19-Palpate dorsalis pedis pulses Palpate by the big toe Dorsalis pedis pulses 2+ bilaterally 20-Palpate posterior tibial pulses
Curve fingers around medial malleolus Feel pulse on the inside of the ankle; right behind medial malleolus in the groove btwn malleolus and Achilles tendon Posterior tibial pulses 2+ bilaterally Auscultate 3 times, 2 times with bell, 1 time with diarghram Auscultate only to get the heart rate
Tactile fremitus present symmetrically upon saying 99; fremitus prominent between scapulae and around sternum 7-Percuss posterior lung fields Make side to side comparison Lung fields resonant upon percussion 8-Auscultate for breath sounds noting location of each Stand behind the client Use diaphragm endpiece !!; listen to at least one full respiration in each location Bronchial (Tracheal)—location: trachea, larynx Bronchovesicular—location: over major bronchi between scapulae esp. on right, posteriorly; around upper sternum in 1 st^ and 2nd^ intercostal spaces, anteriorly Vesicular—location: over peripheral lung fields Vesicular breath sounds clear over lung fields; no adventitious sounds 9-Auscultate for voice sounds (bronchophony, egophony, whispered pectoriloquy)
Listen w/ diaphragm!! Bronchophony —Ask client to say “99” or “blue moon” as you listen to voice sounds Egophony —Ask client to say “ee—ee—ee—ee” as you listen Whispered Pectoriloquy —Ask client to whisper phrase like “one-two-three” Locations same as those for tactile fremitus Bronchophony—99 is muffled; egophony—ee ee heard over lung fields; whispered pectoriloquy—whispered 1, 2, 3, is faint 10-Inspect anterior thorax for skin characteristics and configuration Anterior thorax symmetric; no redness or lesions; color consistent w/ ethnicity 11 - Inspect the slope of the ribs and costal margins Ribs slope downward; costal margins 90-degrees 12-Determine anterior/posterior to transverse diameter Make sure to look on side of person, then walk to front to get transverse
13-Inspect characteristics of respirations (rate, depth, rhythm) Respirations 12-20 breaths per minute; relaxed breathing is automatic and effortless, regular and even, and produces no noise; pattern of breathing is regular
2-Inspect skin surface of face Facial structures symmetric, color consistent w/ ethnicity, no lesions, no swelling, no involuntary movements 3-Inspect skull and hair Move hair around to take look at skull Skull is symmetric, hair is black, thick, equally distributed, no presence of dandruff or lice 4-Palpate head for consistency Head symmetric and smooth, no lumps or depressions present 5-Palpate hair and scalp Scalp is smooth, no lesions, hair is thick and equally distributed 6-Palpate temporal artery Above the cheek bone btwn the eye and top of ear Temporal artery 2+ bilaterally 7-Palpate temporomandibular joint Place finger tips near ear
Ask client to open and close mouth Smooth movement w/ no limitation; no tenderness noted 8-Palpate temporalis and masseter muscle—motor CN V Place fingertips on temporal and cheeks Ask client to open and close mouth Ask client to clench their teeth Try to separate jaws by pushing down on the chin Temporalis and masseter muscle equally strong bilaterally; no tenderness noted 9-Test soft touch over face—sensory CN V Ask client to close eyes Touch face at 6 different locations with cotton ball (forehead, cheeks, chin) Ask client to say “now” when they feel the cotton ball on their face Soft touch felt over face bilaterally 10-Test CN VII—Motor Function only Ask client to make facial expressions (smile, frown, close eyes tightly, lift eyebrows, show teeth, puff cheeks, press client’s puffed cheeks and note air escapes equally from both sides)
Wear gloves, use tongue depressor Ask client to open their mouth Lips—move top lip up to inspect; then the bottom Cheeks—hold open w/ tongue blade to inspect
16-Inspect Stenson’s and Wharton’s duct While inspecting buccal mucosa, look for any swelling on the ducts Stenson’s—near second molars Wharton’s—ask client to lift tongue and look for ducts
17-Inspect teeth and gums
Inspect gums and teeth
18-Inspect tongue and hard and soft palate Ask client to open mouth Shine light to roof of mouth Then ask client to lift up their tongue and touch roof of mouth
19-Inspect and grade tonsils
Tonsils are oval shaped bilaterally and have grade 1+ 20-Test CN IX and X—motor function only Have client stick out their tongue
Depress clients tongue w/ tongue blade at the center (trigger gag reflex) Have client swallow some water (test CN X) Gag reflex present; uvula rises upon phonation; patient able to swallow 21-Test CN XII Have client stick out their tongue Ask client to move their tongue
Tongue is midline, no tremors; lingual speech clear and distinct 22-Inspect neck for symmetry and pulsations
23-Palpate neck for lumps, tenderness No lumps, tenderness, pain noted on neck 24-Identify and palpate cervical lymph nodes
Place index finger on the trachea in the sternal notch Slip your finger off to each side to palpate for any tracheal shift Trachea is midline 28-Test CN XI Push down on clients shoulders with palms Have client try to shrug their shoulders
29-Palpate thyroid gland
Ask client to bend head slightly forward and to the right Use your left hand to push the trachea slightly to the right Curve your right fingers btwn the trachea and sternomastoid muscle Retracting it slightly, ask client to take sip of water and/or swallow Thyroid should move up under your fingers Reverse procedure for the left side
2-Inspect conjunctiva and sclera for color and clarity Ask client to look up Using thumbs, slide the lower lids down along the bony orbital rim Conjunctiva is clear and sclera is white 3-Inspect lacrimal apparatus and puncta for swelling, redness drainage Ask client to look down as you slide the outer part of the upper lid up along the bony orbit w/ your thumb Use your index finger to press against sac (just inside lower orbital rim, not side of nose) No swelling, redness, or excess drainage present 4-Inspect cornea and lens by shining light to determine transparency Shine a light from the side across the cornea, check for cloudiness and/or irregularities
5-Inspect color of iris and pupil for shape
Place 1 finger on the tragus & rapidly push it in and out Shield your lips as you whisper 2-syllable words Have client repeat words back Repeat in other ear Whispered words heard bilaterally 14-Perform Rinne test Place stem of vibrating tuning fork on client’s mastoid process Have client raise hand when sound goes away Then quickly place tuning fork near the ear canal Ask client to raise hand when sound no longer heard
15-Perform Weber test Place stem of vibrating tuning fork in the midline of client’s skull Ask client if they can hear the sound in both ears
16-Perform Romberg test to evaluate equilibrium
Wait for about 20 seconds Romberg test is negative
2-Inspect umbilicus
3-Inspect for any pulsations
Start at RLQ and move clockwise to LLQ Listen for bowel sounds for 1 minute in each quadrant
5-Percuss abdomen Begin in RLQ and move clockwise Percuss lightly Tympany predominates over abdomen 6-Perform light palpation