Professional Documents
Culture Documents
D. PALPITATION
Are rapid, forceful or irregular heartbeats felt by the patient
E. HEMOPTYSIS
Is coughing up of blood
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Small quantities of dark-clotted blood indicate mitral stenosis
A mixture of blood and pus indicates pulmonary suppuration
Pink, frothy sputum indicates acute pulmonary edema
Blood-streaked sputum indicates acute pulmonary congestion
Frank hemoptysis is due to lung pathology
F. FATIGUE
Syncope and fainting may be caused by anoxemia or reduced cardiac output, resulting in inadequate circulation
Other pertinent data:
Cyanosis is the bluish discoloration of the skin and the mucus membranes
Abdominal pain or discomfort
Clubbing of fingers: the angle of the nail is 180 due to chronic hypoxia
Jaundice is the yellowish discoloration of skin and sclera
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Percussion
Assess the size of cardiac area of dullness (CAD)
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AUSCULTATION
Check the rate and rhythm of apical pulse
Heart sounds
S1 1st heart sound closure of the AV valves, loudest at
the apex
S2 2nd heart sound, closure of semilunar valves, loudest
at the base
S3 ventricular gallop, 3rd heart sound, N in children,
abnormal in adult, caused by the oscillation of blood back
and forth between the walls of the ventricles initiated by
blood rushing in from the atria
S4 atrial gallop; 4th heart sound, N in children & YA, in adults associated with systemic or pulmonary
hypertension, MI or other cardiac disease; produced by the sound of blood being forced into a stiff or
hypertrophic ventricle
Murmurs sounds produced by vibrations within the heart and GV caused by turbulence of flow
Rubs sounds produced by interfacing of parietal and visceral surfaces of the pericardium
Heart rate
Normal = 60-100 bpm
Bradycardia= < 60 bpm
Tachycardia = > 100 bpm
Palpation
Edema: assess over bony prominence such as the medial malleolus, anterior tibia, sacrum
Press for 5 secs and measure for pitting
Pulse: carotid, dorsalis pedis, popliteal, posterior tibialis
Compare each side according to its rate, quality and symmetry of pulse
Temperature of lower extremities
Presence of varicosities
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Auscultation
N arteries do not produce sounds
Bruits are blowing sounds heard in conditions like AV fistula
Diagnostics
NON-INVASIVE: Electrocardiography (ECG)
A graphic recording of the electrical activity of the heart
Resting ECG presents a single recorded picture of the electrical activity of the heart
Preparation:
Secure electrodes to appropriate locations on the chest and extremities
Instruct the client to remain still during the test
Reassure the client that he or she will not receive any electrical shock or impulses
Remove all metallic materials in the clients body
Post-procedure:
none
Holter monitoring
Continuous ambulatory ECG monitoring over time (usual 24 hours) with a small, timed, portable ECG recording
devices
Preparation:
Secure electrodes to appropriate locations on the chest
Instruct the pt to continue normal activity and maintain a log of activities and record any symptoms
stress test
Continuous multi-lead ECG monitoring during controlled and supervised exercise, usually on a treadmill
Preparation:
Obtain a written consent
Instruct the client to eat a light meal 1-2 hours before the exam (no caffeine, alcohol or smoking)
Instruct the client to wear comfortable clothing and rubber-soled walking shoes
During the test:
Secure electrodes to appropriate locations on the chest
Obtain baseline BP and Ecg tracing
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Instruct client to exercise as instructed and report any pain, weakness, shortness of breath, or other symptoms
immediately
Monitor BP and ECG continuously, record at frequent intervals and with any symptoms or changes in vital signs,
ST segments or cardiac rhythm
Post-procedure nursing care:
Continue to monitor ECG and BP until the client returns completely to baseline and is symptom-free
Once stable, patients may resume their usual activity
Echocardiogram
Study performed to assist in the diagnosis of cardiovascular disorders.
It allows visualization of the internal cardiac structures for size, shape, position, and movement.
All four valves, both ventricles, and the left atrium, as well as the velocity of the blood flow, can be examined during
the movement of the transducer over the chest.
Client preparation:
Instruct the client to remain still during the test
Secure electrodes for simultaneous ECG tracing
Explain that there are no pain or electrical shocks.
Lubricant placed on the skin will feel cold
Post-procedure:
Cleanse the lubricant from the clients chest wall
Phonocardiography
A graphic recording of the heart sounds with simultaneous ECG
Client preparation:
Instruct the patient to remain quiet and still during the test
Secure electrodes for simultaneous tracing
Explain that there will be no pain or electrical shocks
Cardiac catheterization
invasive, but often definitive test for diagnosis of cardiac disease.
A catheter is inserted into the right or left side of the heart to obtain information.
a. Right-sided catheterization:
the catheter is inserted into an antecubital vein and advanced into the vena cava, right atrium, and right ventricle with
further insertion into the pulmonary artery.
b. Left-sided catheterization:
performed by inserting the catheter into a brachial or femoral artery;
the catheter is passed retrograde up the aorta and into the left ventricle
Purpose:
to measure intracardiac pressures and oxygen levels in various parts of the heart;
with injection of a dye, it allows visualization of the heart chambers, blood vessels, and course of blood flow
(angiography).
Nursing care: pretest
a. Confirm that informed consent has been signed.
b. Ask about allergies, particularly to iodine, if dye being used.
c. Keep client NPO for 12 hours prior to test.
Nursing care: pretest
d. Temporarily suspend metformin for dye and surgical procedures; do not restart until oral intake has resumed and renal
function is normal.
e. Record height and weight, take baseline vital signs, and monitor peripheral pulses.
f. Inform client that a feeling of warmth and fluttering sensation as catheter is passed is common.
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Nursing care: posttest
a. Assess circulation to the extremity used for catheter insertion.
b. Check peripheral pulses, color, sensation of affected extremity every 15 minutes for 4 hours.
c. If protocol requires, keep affected extremity straight for approximately 8 hours.
d. Observe catheter insertion site for swelling and bleeding; a sandbag or pressure dressing may be placed over insertion
site.
e. Assess vital signs and report significant changes from baseline.
Coronary Angiography/Arteriography
An invasive procedure during which the physician injects a dye intro the coronary arteries and immediately takes a
series of x-ray films to assess the structure of the arteries
Preparation
Obtain written consent and explain the procedure
Assess the client for history of allergies to dye or shellfish
Initiate IV site with fluids as ordered
Post-procedure:
Same as cardiac cath post-procedure care
Aortography
Injection of radiopaque contrast medium into the aorta to visualize the aorta, valve leaflets, and major vessels on a
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movie film.
Purpose:
to determine and diagnose aortic valve incompetence, aneurysms of the ascending aorta, abnormalities of
major branches of the aorta.
a safe, radioactive material called a tracer is injected through a vein into your bloodstream.
The tracer then travels to your heart.
The tracer releases energy, which special cameras outside of your body detect.
The cameras use the energy to create pictures of different parts of your heart