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What techniques are used when assessing the cardiovascular system?
- Interview
- Inspection
- Auscultation
- Palpation
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When assessing the heart, what general appearance is being assessed?
- Skin color and moisture
- Mentation - Awake, Alert & Oriented
- Posture
- Respiratory Pattern
- Precordium - Heaves, Lifts or Pulsations (aortic pulse)
- Neck Veins - JVD (right side heart failure)
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What risk factors should be identified during the interview of a cardiovascular assessment?
- Medications
- Cardiac Hx - murmurs, rheumatic fever, heart Sx
- Family history of HTN, CAD, DM or Hyperlipidemia - Cannot change your genes/opprotunity to educate patient on modifying risk factors within their control.
- Hx of smoking or alcohol abuse
- Diet and exercise habits
- Hx of blood clots, leg pain or sores on legs that do not heal - signs of poor circulation
- Signs and Symptoms - Why are they at the hospital or being seen?
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What should be inspected when assessing the peripheral vascular system?
- Skin color, moisture and integrity
- Edema
- Hair quantity and distribution
- Varicosities
- Nail color & integrity
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What should be palpated when assessing the peripheral vascular system?
- Skin temp and moisture
- Capillary refill time - delayed when < 2-3 seconds
- Peripheral Pulses - rate, rhythm & quality
- Edema - Pitting or non pitting
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What would be some age related (pediatric) variations when performing a cardiovascular & peripheral vascular system assessment?
- Visible pulsation r/t thin chest wall
- Sinus dysrhythmia - HR increases w/ inspiration and decreased w/ expiration
- S3 present in 1/3 of all children
- More rapid HR up to ~ age 8
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What would be some age related (geriatric) variations when performing a
cardiovascular & peripheral vascular system assessment?
- Apical & Distal pulses can be more difficult to palpate
- Dilated proximal arteries
- Varicosities more common
- Increased BP
- Widened pulse pressure
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What tests would be used to measure blood flow?
- Angiogram
- Doppler Flow Studies
- Cardiac Catheterization
- Red Blood Cell Count
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What tests would be used to visualize structures of the circulatory system?
- CXR
- Echocardiogram - ultrasound
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What test would be used to identify abnormal cells or infections?
CBC
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What labs are commonly used when assessing the cardiovascular system?
- Cardiac Markers
- Hematology, chem & coag panels
- Cholesterol & lipids
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Nursing Diagnoses
- Altered tissue perfusion, cardiac, r/t decreased arterial blood flow
- Altered tissue perfusion, peripheral, r/t decreased arterial blood flow
- Pain r/t imbalace between oxygen supply and demand
- Activity intolerance r/t insufficient oxygen to meet physiological needs
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