2Health History Identify present and potential health problems Identify possible familial and lifestyle risk factorsInvolve the client in planning long-term health care
3Health History High Blood Pressure Congestive Heart Failure Patient Health History should be obtained:High Blood PressureCongestive Heart FailurePrevious Heart AttackPrevious Heart Surgery or procedures (Stent, Valvuloplasty)Atrial Fibrillation, Atrial Flutter or other dysrhythmiasPalpitationsDizziness, lightheadedness (presyncope), or passing out (syncope)Full list of medicationsFamily hx.
4Cardiovascular Assessment Requires a full head to toe assessmentEvery body function is dependant on the cardiovascular systemSubjective vs. Objective dataSubjective data- verbal statements provided by the patientObjective data- observable and measurable data
5Signs & Symptoms of Cardiovascular Deficits Chest PainPalpitationsCyanosisDyspnea
6Assessment Subjective Data Pain is whatever the patient says it is.Pain (chest, back, jaw, abdomen or extremities)
7Assessment- Subjective Data Extremities3 of the 5 “P’s of Peripheral Artery Disease”PainParasthesiaAlteration in sensationNumbness, tingling, pins and needlesParalysis
8Assessment Subjective Data DyspneaAt restExertional- with activityOrthopnea- short of breath while lying downParoxysmal Nocturnal Dyspnea- awakening suddenly short of breath and sweating
9Assessment Subjective Data Ask pt. to: Describe Chest Pain (CP) or Shortness of Breath (SOB) in as much detail as possible.
10Assessment Subjective Data Is patient c/o:Fainting (Syncope)PalpitationsFatigue
11Assessment - Objective Data Head to Toe AssessmentSkinCyanosisTurgorTemperatureDiaphoresisIntegritySkin breakdown
17Assessment Objective Data RespiratoryRate and ease of breathingAppearance of dyspneaCoughingFrothy SputumAbnormal breath soundsDiminishedCrackles/RalesWheezing
18Assessment - Objective Data Post tibial PulsesDorsalis pedis PulsesPopliteal pulsesFemoral pulsesUlnar pulsesRadial pulsesBrachial pulsesCarotid pulses
19Assessment Objective Data Check Pulses:Carotid Right/ LeftBrachial R/LRadial R/LUlnar R/LPoint of Maximum Impulse (PMI)Femoral R/L (groin crease or slightly above crease)Popliteal (behind the knee)Post Tibial (medial ankle)Dorsalis Pedis (top of foot)Pulse Strength0 Absent pulse1+ Thready pulse2+ Weak pulse3+ Normal pulse4+ Bounding pulseOR0 Absent Pulse1+ Weak Pulse2+ Normal Pulse
20Assessment Objective Data Edema1+ trace edema-barely perceptible (2mm)2+mild edema-deeper pit that rebounds in seconds (4mm)3+moderate edema-deep pit that lasts seconds before it rebounds (6mm)4+severe edema-an even deeper pit lasting as long as 2-5 minutes before rebounding (8 mm)
21Assessment Objective Data Check for Homan’s sign Pain=Positive Homan’s SignIf Positive: Notify RN or Practitioner and do not check Homan’s Sign Again!Capillary Refill of finger tips and toes (actually any area)Normal: < 3 secondsSlow: 3-5 secondsAbnormal: >5 seconds
22Assessment Objective Data Allen’s TestTests the ability of the ulnar artery to supply the hand with adequate blood supply
23Assessment Objective Data Vital SignsHeart Rate (full minute) Normal bpmApical PulseRadial PulsePulse deficit is the difference between the above twoBlood Pressure Normal /60-89 mmHgMean Arterial Pressure (MAP)(2 * DBP) + SBP3
24Blood PressureNo soundBP cuff inflated to 160 mmHg120 mmHgFirst sound50 mmHgNo soundKorotkoff sounds: heard during blood pressure determination using a stethoscope and sphygmomanometer.Originates within from the blood passing through the vessel orProduced by a vibrating motion of the arterial wall
25Orthostatic Hypotension aka Postural Hypotension Have the client in supine position for 3-5 minutes, then measure the HR and BPThen, have the client in the sitting position for 3-5 minutes and then measure the HR and BP. Monitor for dizziness.Then, have the client stand for 3-5 minutes. If the client is having severe dizziness, STOP! (if they have a syncopal episode, they are at risk for injury). Otherwise, measure the HR and BP after 3-5 minutes.
26Orthostatic Hypotension A client is considered to have orthostatic hypotension if:HR increases by 10-20% from baselineSBP decreases by mmHg from baselineDBP decreases by 10 mmHg from baseline