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Health Assessment
Cardiovascular Function
28
Nursing
Undergraduate 3
11/13/2012

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Cards

Term
Subjective Data Question: 1
Definition
Do you tire easily or experience fatigue?
Term
Subjective Data Question: 1 - rational
Definition
Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses.
Term
Subjective Data Question: 2
Definition
Have you ever had heart surgery or cardiac balloon interventions?
Term
Subjective Data Question: 2 - rational
Definition
Heart surgery may change the heart sounds and indicate prior cardiac compromise.
Term
Subjective Data Question: 3
Definition
Have you ever had a lipid profile blood test? If so, do you know what your cholesterol levels were?
Term
Subjective Data Question: 3 - rational
Definition
Dyslipidemia presents the greatest risk for developing coronary artery disease and elevated cholesterol levels have been linked to the development of atherosclerosis.
Term
Subjective Data Question: 4
Definition
Do you take medications or use other treatments for heart disease? How often and why do you take them?
Term
Subjective Data Question: 5
Definition
Do you monitor your own hear rate or blood pressure?
Term
Cardiovascular Function Assessment:
Definition
Term
1
Definition
Assist client to supine or semi-Flower's position (30-45 degrees), keeping the head and the torso on the same plane.
Term
2
Definition
Expose chest while providing privacy.
Term
3
Definition
Inspect skin color: "It is within normal limits for race."
Term
4
Definition
Inspect for symmetry: "The chest is symmetrical on both sides."
Term
5
Definition
Inspect for pulsations: "The jugular veins are not fully distended."
Inspect descending aorta for AAA (abdominal aortic aneurysm).
Term
6
Definition
Inspect extremities for edema, reduced hair growth, changes in pigmentation, and thick nail growth.
Term
7
Definition
Identify and palpate PMI (point of maximal impulse), aka apical impulse. If you cannot palpate the apical impulse, have the pt lean forward because it moves the heart forward.
Term
8 - The apical impulse is located...
Definition
...at the 5th intercostal space (ICS), slightly lateral to the midclavicular line (MCL).
Term
9 - The apical impulse is a result of...
Definition
...the left ventricle moving outward during systole.
Term
10
Definition
Auscultate the apical pulse for one minute.
Term
11
Definition
Auscultate the heart by placing stethoscope at all four locations and identifying the sounds heard.
Term
12 - S1 corresponds with...
Definition
...each carotid pulsation.
Term
13 - S1 is the loudest at...
Definition
...the apex of the heart.
Term
14 - S2 is the loudest at...
Definition
...the base of the heart.
Term
15
Definition
"Lateral to the sternum on the right, at the 2nd ICS, I'm listening to the aortic valve and it sounds normal (no murmurs or irregular rhythms)."
Term
16
Definition
"Lateral to the sternum on the left, at the 2nd ICS, I'm listening to the pulmonary valve."
Term
17
Definition
"Below that at the 3rd ICS is Erb's point, which is not a valve location, but just a point where we can also hear heart sounds."
Term
18
Definition
"At the 4th ICS, left MCL, I'm listening to the tricuspid valve."
Term
19
Definition
"At the 5th ICS, slightly lateral to the MCL, I'm listening to the PMI (aka apical impulse) and the mitral valve."
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