HEART  ASSESSMENT<br />Anatomy Overview<br />Heat and Great Vessels<br />-The heart is a hallow, muscular, four-chambered ...
Normal heart sounds characterized as “lubbdubb” (s, and S2)</li></li></ul><li><ul><li>The first heart sound is (S) result ...
The second heart sound if (S2)  result from the semilunar valves</li></ul>Equipment Needed<br /><ul><li> Ruler with centim...
Marking Pen
Stethoscope  with bell and diaphragm
Alcohol swab to clean ear an d end pieces</li></ul>Subjective Data:  Focus Question<br /><ul><li>Chest pain-location? Radi...
Percussion<br /><ul><li>May be done to define cardiac border by  identifying  areas of dullness, but it is generally unrel...
Decreased elasticity of heart  & arteries, reduced pumping ability  of heart
Decreased cardiac output and cardiac reserve
Apical impulse be difficult palpate  owing to increase in anteroposterior diameter of chest.</li></ul>Possible Collaborati...
Peripheral Vascular Assessment<br />Anatomy Overview<br />Arteries<br /><ul><li>Blood vessels  that carry  oxygenated, nut...
Sphygnomamometer
Doppler
Tape measure
Cotton
Paper clip
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Heart

  1. 1. HEART ASSESSMENT<br />Anatomy Overview<br />Heat and Great Vessels<br />-The heart is a hallow, muscular, four-chambered organ located in the middle of the thoracic cavity between the lungs in the space called the mediasturium. It is about the size of a clenched fist and weighs a proximately 225g (9 oz) in women and 310 g (10. 9 oz) in men. The language reins and arteries leading in directly to and away from the heart are referred to as the great vessels. The heart consists of four chambers or cavities: two upper chambers, the night and left atria and two lower chambers, the right and left ventricles. The entrance and exit of each ventricle are protected by one way valve that direct the flow of blood through the heart. The atrioventricular and the triacuspid and bicuspid valve.<br />Production of Heart Sound:<br /><ul><li>Heart are produced by valve closure.
  2. 2. Normal heart sounds characterized as “lubbdubb” (s, and S2)</li></li></ul><li><ul><li>The first heart sound is (S) result of closure of the AV
  3. 3. The second heart sound if (S2) result from the semilunar valves</li></ul>Equipment Needed<br /><ul><li> Ruler with centimeter
  4. 4. Marking Pen
  5. 5. Stethoscope with bell and diaphragm
  6. 6. Alcohol swab to clean ear an d end pieces</li></ul>Subjective Data: Focus Question<br /><ul><li>Chest pain-location? Radiation? Quality? Rating on scale of 1to 10 (10 being the worst?) Duration? What bring it on? What relieves it? And it is usual being said by the patient/client.</li></ul>Objective Data: Assessment Tecniques<br />-Heart Chamber, valves, and direction of circulatory flow.<br />Inspection:<br />
  7. 7.
  8. 8. Percussion<br /><ul><li>May be done to define cardiac border by identifying areas of dullness, but it is generally unreliable, size of heart can be more accurately determined by chest x-ray.</li></ul>Auscultation<br /><ul><li>Systemic fashion beginning with the aortic area. More across and then down the chest. Auscultate each area w/ the stethoscope diaphragm applied firmly to the chest auscultate in supine position. Then have the client lean forward & exhale while you listen over the aortic area with the diaphragm.</li></ul>Geriatric Variations<br /><ul><li>Thickening of heart walls
  9. 9. Decreased elasticity of heart & arteries, reduced pumping ability of heart
  10. 10. Decreased cardiac output and cardiac reserve
  11. 11. Apical impulse be difficult palpate owing to increase in anteroposterior diameter of chest.</li></ul>Possible Collaborative Problems<br />Decreased cardiac output Congenital Heart Disease<br />Congestinal heart failure endocarditis<br />Myocardiallischemia Angina<br />Cardiogenic shock dysrhythmia<br />
  12. 12. Peripheral Vascular Assessment<br />Anatomy Overview<br />Arteries<br /><ul><li>Blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries. The femoral artery is the major supplier of blood to the legs. This artery travels down the front of the thigh and then crosses to the back of the thigh, where it is termed the popliteal artery.</li></ul>Veins<br /><ul><li>Carry deoxygenated , nutrient-depleted, waste-laden blood from the tissues back to the heart. There are three types of viens deep veins, super ficial veins, and perforator veins. The two veins in the leg are the femoral vein in the popliteal vein located behind the knee.</li></ul>Equipment Needed:<br /><ul><li>Stethoscope
  13. 13. Sphygnomamometer
  14. 14. Doppler
  15. 15. Tape measure
  16. 16. Cotton
  17. 17. Paper clip
  18. 18. Tuning fork</li></ul>Subjective Data Focus Questions<br /><ul><li>Any changes in skin color, texture, or temperature? Pain in claves, feet, buttocks or legs?</li></ul>Risk Factors:<br /><ul><li>Risk for arterial peripheral vascular disease related to tobacco smoking, age over 50 year, family history of peripheral vascular disease, hypertension coronary or peripheral vascular disease or male sex</li></ul>Adjective Data:Assessment Techniques<br />Inspection, Palpation and Auscultation or circulation to arms & neck.<br />- Performed together to assess blood and circulation to the upper extremities neck while the client is in sitting position . A special maneuver is used to detect arterial insufficiency of the hand.<br />
  19. 19. Abdominal Assessment<br />Abdominal Overview<br /><ul><li>The abdomen into four quadrants for purpose of physical exam. These are the right quadrant (RUQ), Right Lower Quadrant (RLQ), left lower quadrant (LLQ) left Upper Quadrant (LUQ).</li></ul>Hallow Vicera<br /><ul><li>The stomach is a distensible, flesh like organ located in the LUQ, just below the diaphragm and in between the liver and spleen. The gallbladder a muscular sac approximately 10 cm long is not normally palpated because it is difficult to distinguish between the gallbladder and the liver. The small intestine is actually the longest portion of the digestive tract. The colon is composed of the three major sections ascending, transverse, and descending</li></li></ul><li>The urinary bladder is a distensible muscular sac located behind the public bone in the midline of the abdomen.<br />Equipment Needed:<br /><ul><li>Stethoscope
  20. 20. Small meter
  21. 21. Marking pencil
  22. 22. Small fillows</li></ul>Subjective Data: Focus Questions<br />Objective Data: Assessment Techniques<br />Mechanism & Sources of Abdominal Pain<br />Types of Pain<br /><ul><li>Viscernal Pain-Poorly defined or localized
  23. 23. and intermittently timed</li></ul>- Parietal Pain-This pain tends to localize more to the source and as more severe and steady pain.<br /><ul><li>Referred pain-The accompanying illustrations shows clinical patterns and referents of pain.</li></li></ul><li>Auscultation<br /><ul><li> Using the diaphragm of a warm stethoscope, apply light pressure to auscultate for bowel sounds for up to 5 minutes in each quadrant. Use the bell to aus
  24. 24. cultate for vascular sounds.</li></li></ul><li>Percussion<br /><ul><li>Notes will vary from dull to tymphanic, w/ tymphany dominating the hallow organs. The hallow include the stomach, intestines, bladder, aorta, & gallbladder.</li></ul>Palpation<br /><ul><li>Light palpation precedes deep palpation to detect tenderness and superficial masses. Deep palpation to detect masses and size or organs.</li></ul>Possible Collaborative Problems<br /><ul><li>Bowel Strangulation
  25. 25. Asates
  26. 26. Metabolic Acidosis/Alkalosis
  27. 27. GL Bleeding
  28. 28. Gastric Ulcer</li></ul>Teaching tips for selected diagnosis<br />Adult Client<br />Nursing diagnosis: Imbalance Nutrition: More or less than body requirements nursing diagnosis: Risk constipation<br />Pediatric Client:<br />Nursing Diagnosis: Readiness for enhanced nutritional-metabolic pattern of child<br />Nursing Diagnosis: Fluid volume deficit related to vomiting or diarrhea<br />Nursing Diagnosis: Risk for aspiration related to improper feeding and small size of stomach in newborns.<br />
  29. 29.
  30. 30. Palpation<br /><ul><li>Don gloves left thumb and index or third finger, gently separate labia and hold a part. Lubricate right index and insert into vaginal opening. Push up on anterior wall and milk toward opening. Push down on posterior wall and grasp tissue between thumb and index finger , palpate tissue along entire lower half of vaginal onifice.</li></ul>Bimanual Examination<br /><ul><li>Tell client you’re going to perform a manual examination. Apply water soluble lubricate to gloved and index fingers of your dominant hand. Standard and place non dominant hand on client’s lower abdomen. Next insert index middle fingers into the vagina.</li></ul>Assessment of Male Genitalia<br />Equipment:<br /><ul><li>Gloves
  31. 31. Private location</li></ul>Subjective Data: Focus Questions<br />Objective Data: Assessment Technique<br />
  32. 32. Inspection:<br /><ul><li>To make genitalia should be inspected with the client in a standing position privacy should be ensured.</li></ul>Palpation<br /><ul><li>With client standing, gently palpate shaft of penis gloved thumb and fingers. If foreskin is present, retract from tip of penis, then replace. Grasp each testicle between thumb and fingers. Gently roll testicles all surface are palpated.
  33. 33. Palpate inguinal area. Then have client strain down as you palpate inguinal area. Then have client down as you palpate inguinal area and scrotum.</li></ul>Assessment of Rectum<br />Equipment Needed<br /><ul><li>Examiantion gloves
  34. 34. Drape
  35. 35. Pillow</li></ul>Subjective Data: Focus Questions<br />Objective Data: Assessment Technique<br />
  36. 36. Inspection:<br /><ul><li>Have client lie on left side w/ right flexed at hip and knee. Support leg on pillow if necessary. Provide a pillow for under the head. With one hand, gently separate buttocks so rectum is exposed.</li></ul>Pediatric Variations<br />Subjective Data: Assessment Techniques<br />Inspection & Palpation of external male & female genitalia constitute the total genitourinary assessment until puberty. Assessment of the level of sexual development of girls and boys usually begins at approximately age 11 years.<br />CulturalVariations<br /><ul><li>Male and Female genitalia are mutilated in pubertal rites in some cultures,</li></ul>Example: circumference, removal of clitoris, or surgical incision along penile shaft and into its base for passage of urine and semen. Female pubic hair shaved or plucked on some cultures.<br />Geniatric Variations<br /><ul><li>Bladder capacity decreases to 250 ml owing to periurethral atrophy
  37. 37. One Collaborative Problems</li></li></ul><li>
  38. 38. Equipment needed:<br /><ul><li>Tape measure
  39. 39. Geniometer (measure angles of joints)
  40. 40. Marking pen</li></ul>Subjective data: Focus questions<br />Objective data: Assessment Techniques<br /><ul><li>Inspections & palpation are performed while client is standing, sitting, and sufine, ROM can be measured by degrees, using approximation or a goniometer.</li></ul>Inspection: Observe for ROM, deformity, atrophy, condition of sorrounding tissues and pain.<br />Palpation: Palpate for heat, strength, tone, edema, crepitus, and nodules<br />Inspection of Stance and Gait<br /><ul><li>Observe stance and gait as client enters and walks around the room.</li></ul>Inspection of the spine, shoulder, and posterior iliac crest<br /><ul><li>With client standing, observe in the erect position and as the client bends forward to touch toes, stabilize client at the waist, and evaluate ROM of the upper trunk.</li></li></ul><li>Palpation of the Spine, shoulder, & posterior iliac crest<br /><ul><li>With client in standing or sitting position, palpate the paravertebral muscles using both moderate pressure & gentle motion. Ask to shrug shoulders against resistance.</li></ul>Inspection of the head, thorax, and neck<br /><ul><li>With client sitting position facing you, inspect body parts. Ask client to open and close mouth to assess temporomandibular joint (TMJ) function</li></ul>Palpation of the head, thorax , and neck<br /><ul><li>While inspecting the TMJ, palpate it bilaterally anterior to the tragus of the ear as client opens mouth and clenches teeth. Ask client to tum head laterally against.</li></ul>Palpation of the Upper Extremeties<br /><ul><li>As the musculoskeletal structure of the upper extremity is going through active or passive ROM, palpate bones, muscles, tendons, and joints. Assess muscles strength & tone.</li></ul>Inspection of the Lower Extremeties<br />- Position the client in standing position to inspect the hips, and in sitting position with legs hanging freely to inspect the knees, feet, & toes.<br />
  41. 41. Palpation of the Lower Extremities<br /><ul><li>As the musculoskeletal structure of the lower extremely is going through active or passive ROM, palpate bones; bony landmarks, muscles, and joints. Assess muscles strength and tone.</li></ul>Teaching Tips for selected Nursing Diagnosis<br />Adult Client<br />Nursing Diagnosis: Readiness for enhanced mobility<br />Nursing Diagnosis: Chronic Pain (Muscles & joints)<br />Nursing Diagnosis: Risk for injury to exercise/improper body mechanics<br />Pediatric Client:<br />Nursing Diagnosis: Risk for injury (child) related to parent’s knowledge deficit of correlating musculoskeletal development & home safety.<br />Geniatric Client:<br />Nursing Diagnosis: Risk for injury related decalcification of bones secondary to lifestyle and postmenopausal state<br />Nursing Diagnosis: Risk injury related to unstable gart secondary to aging process<br />Nursing Diagnosis: Impaired Physical Mobility related to decreased activity secondary to aging process.<br />Nursing Diagnosis: Self-Care defiat (specify) related decreased mobility and or weakness.<br />

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