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Abnormal findings assessed during inspection of the patient's general appearance (skin color, and breathing effort)
- Dyspnea
- Cyanosis
- Pallor
- Use of accessory muscles to breathe
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ASSESS THE PERIPHERAL VASCULAR SYSTEM
Abnormal findings assessed while palpating temporal & carotid pulses for amplitude:
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Abnormal findings when palpating pulses:
- Rates >100 beats/min (tachycardia)
- Rates<60 beats/min (bradycardia)
- Irregular rhythms w/out any pattern
- Coupled beats (two beats that occur close together)
- Exaggerated or bounding upstroke
- pulses that are weak, small, thready
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Abnormal findings when inspecting the jugular vein for pulsations:
- fluttering or oscillating
- irregular rhythms
- unusually prominent waves (which may indicate right-sided heart failure)
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Abnormal findings found when measuring blood pressure:
- elevated systolic or diastolic pressures (hypertension)
- lowered systolic or diastolic pressures (hypotension)
- pulse pressure should not vary more than 5-10 mm Hg between the two arms
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Abnormal findings associated w/bp from the supine position to standing:
A decrease in systolic BP >20mm Hg & symptoms such as dizziness indicate orthostatic (postural hypotension) may be due to fluid volume deficit, drugs, prolonged bed rest)
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Abnormal findings when inspecting & palpating upper & lower extremities for skin turgor
- Tenting (when skin doesn't immediately fall back into place)....indication of fluid volume deficit
- Pitting edema (indention of fingers remains in skin.....indication of excess fluid
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Abnormal findings when inspecting & palpating upper extremities for symmetry
One arm is larger in circumference than the other.....lymphedema
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Abnormal finding when inspecting & palpating upper extremities for skin integrity, color and temperature:
- Thickening skin, skin tears, ulceration
- Arterial insufficiency may cause cold extremities in a warm environment
- Pallor or mottling when the extremity is elevated
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Abnormal findings when inspecting & palpating upper extremities for capillary refill, color and angle of nail beds
- capillary refill time >2 seconds....indicates poor perfusion
- Clubing of fingers (angle of nail disappears, becoming >160 degrees).....indicating chronic hypoxia
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Abnormal findings when inspecting & palpating lower extremities:
Use the 5 P's to remember abnormal findings: pulseless, pale, paresthesia, pain and poikilothermia (cold)
- Decrease in lack of hair peripherally, skin that appears thin, shiny & taunt.....indicates arterial insufficiency
- stocking anesthesia (where legs feel numb in a pattern resembling stockings
- distended veins in the anteromedial aspect of thig & lower leg or calf from knee to ankle
- edema....impaired venous blood flow
- >thigh circumference (immobile clients w/reduced sensation).....deep vein thrombosis
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Abnormal Findings when inspecting the anterior chest wall for contour, pulsations, lifts, heaves & retractions
- Sternal depression or asymmetry
- Retraction(when some of the tissue is pulled into the chest on the precordium).Marked retraction of apical space.....indicates pericardial disease or RV hypertrophy
- Apical pulsation observed after exertion....hyperthyroidism or LV hypertrophy
- Displaced pulsations.....cardiac anomalies or change in heart size
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Abnormal findings when palpating apical pulse for location
- PMI moved laterally....vetricular hypertrophy or myocardium enlarged
- Displaced PMI downward & to the right....chronic obstructive lung disease or overinflated lungs
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Abnormal findings when ausculating heart sounds for rate
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Abnormal findings when ausculating heart sounds for rhythm:
1st hear sound seems accented, diminished or muffled or when intensity varies w/different beats
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Abnormal findings when ausculating heart sounds for splitting:
- When the mitral & tricuspic valves do not close at the same time S1 sounds as if it were split into two sounds instead of one
- systolic & diastolic murmurs are also abnormal
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Abnormal findings when ausculating the carotid artery:
bruits......occlusion of the vessel
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Abnormal findings when estimating jugular venous pressure for pulsations:
Jugular venous pressure exceeds 1" above the level of the manubrium
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Abnormal findings when palpating epitrochlear lymph nodes for size, consistency, mobility, boarders, tenderness, and warmth
- enlarged, firm, warm, moveable & tender nodes......infection of the ulnar aspect of the forearm & 4th & 5th fingers
- One arm is larger in circumference than the other....lymphedema
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Abnormal findings when palpating inguinal lymph nodes for size, consistency, mobility, borders, tenderness and warmth
- Enlarged, tender, firm, warm, freely moveable nodes.....inflammatory process distal to these nodes such as in the leg, vulva, penis or scrotum
- Circumference of one leg is larger than other....lymphedema
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Abnormal findings when calculating the ankle brachial index to est. arterial occlusion
- An ABI <0.9.....indicates peripheral vascular disease
- An ABI <0.6.....associated w/ intermittent claudication
- ABI <0.2 reflects sever ischemia leading to gangrene
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Abnormal findings when performing Trendelenburg's test to evaluate competence of venous valves in client's w/varicose veins
veins fill rapidly, valves may be imcompetent & varicose veins may be present
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...Abnormal findings when palpating the precordium for pulsations, thrills, lifts & heaves
Chest seems to lift or heave w/heart beat....indicates LV enlargement
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Abnormal findings when palpating base of heart
- Pulsations....indicate aortic aneurysm
- Thrill....associated w/a murmur for a disorder of the aortic or pulmonic valve
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Abnormal findings when palpating left sternal boarder:
- Sustained lifts or palpatons....indicate RV hypertrophy
- Pulsations....indicate pulmonary hypertension
- Thrill....associated w/pulmonic valve stenosis
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Abnormal findings when palpating the apex of heart at the 5th ICS
- Forceful pulsation, displaced laterally or downward....associated w/increased cardiac output or LV hypertrophy
- Thrill.....indicates murmur
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Abnormal findings when palpating the epigastric area for pulsations
bounding pulsations....indicate abdomial aortic aneurysm or aortic valve regurgitation
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