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Cardiovascular Nursing

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Presentation on theme: "Cardiovascular Nursing"— Presentation transcript:

1 Cardiovascular Nursing

2 Health History Identify present and potential health problems
Identify possible familial and lifestyle risk factors Involve the client in planning long-term health care

3 Health History High Blood Pressure Congestive Heart Failure
Patient Health History should be obtained: High Blood Pressure Congestive Heart Failure Previous Heart Attack Previous Heart Surgery or procedures (Stent, Valvuloplasty) Atrial Fibrillation, Atrial Flutter or other dysrhythmias Palpitations Dizziness, lightheadedness (presyncope), or passing out (syncope) Full list of medications Family hx.

4 Cardiovascular Assessment
Requires a full head to toe assessment Every body function is dependant on the cardiovascular system Subjective vs. Objective data Subjective data- verbal statements provided by the patient Objective data- observable and measurable data

5 Signs & Symptoms of Cardiovascular Deficits
Chest Pain Palpitations Cyanosis Dyspnea

6 Assessment Subjective Data
Pain is whatever the patient says it is. Pain (chest, back, jaw, abdomen or extremities)

7 Assessment- Subjective Data
Extremities 3 of the 5 “P’s of Peripheral Artery Disease” Pain Parasthesia Alteration in sensation Numbness, tingling, pins and needles Paralysis

8 Assessment Subjective Data
Dyspnea At rest Exertional- with activity Orthopnea- short of breath while lying down Paroxysmal Nocturnal Dyspnea- awakening suddenly short of breath and sweating

9 Assessment Subjective Data
Ask pt. to: Describe Chest Pain (CP) or Shortness of Breath (SOB) in as much detail as possible.

10 Assessment Subjective Data
Is patient c/o: Fainting (Syncope) Palpitations Fatigue

11 Assessment - Objective Data
Head to Toe Assessment Skin Cyanosis Turgor Temperature Diaphoresis Integrity Skin breakdown

12 Jugular Vein Distention JVD


14 Cardiac Assessment Heart Sounds (listen with both the bell and diaphragm of your stethoscope) Right upper sternal border, Left upper sternal border, Left lower sternal border

15 Assessment- Objective Data
Are there any abnormal heart sounds? Murmurs Rubs Are there any additional heart sounds? Gallops Is the heartbeat regular, regularly irregular, or irregularly irregular?

16 Assessment - Objective Data

17 Assessment Objective Data
Respiratory Rate and ease of breathing Appearance of dyspnea Coughing Frothy Sputum Abnormal breath sounds Diminished Crackles/Rales Wheezing

18 Assessment - Objective Data
Post tibial Pulses Dorsalis pedis Pulses Popliteal pulses Femoral pulses Ulnar pulses Radial pulses Brachial pulses Carotid pulses

19 Assessment Objective Data
Check Pulses: Carotid Right/ Left Brachial R/L Radial R/L Ulnar R/L Point 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 Strength 0 Absent pulse 1+ Thready pulse 2+ Weak pulse 3+ Normal pulse 4+ Bounding pulse OR 0 Absent Pulse 1+ Weak Pulse 2+ Normal Pulse

20 Assessment Objective Data
Edema 1+ 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)

21 Assessment Objective Data
Check for Homan’s sign Pain=Positive Homan’s Sign If 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 seconds Slow: 3-5 seconds Abnormal: >5 seconds

22 Assessment Objective Data
Allen’s Test Tests the ability of the ulnar artery to supply the hand with adequate blood supply

23 Assessment Objective Data
Vital Signs Heart Rate (full minute) Normal bpm Apical Pulse Radial Pulse Pulse deficit is the difference between the above two Blood Pressure Normal /60-89 mmHg Mean Arterial Pressure (MAP) (2 * DBP) + SBP 3

24 Blood Pressure No sound BP cuff inflated to 160 mmHg 120 mmHg First sound 50 mmHg No sound Korotkoff sounds: heard during blood pressure determination using a stethoscope and sphygmomanometer. Originates within from the blood passing through the vessel or Produced by a vibrating motion of the arterial wall

25 Orthostatic Hypotension aka Postural Hypotension
Have the client in supine position for 3-5 minutes, then measure the HR and BP Then, 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.

26 Orthostatic Hypotension
A client is considered to have orthostatic hypotension if: HR increases by 10-20% from baseline SBP decreases by mmHg from baseline DBP decreases by 10 mmHg from baseline

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