Skill
|
Document: assessment,
interventions, outcomes
|
Inspect
|
Overall
condition and appearance. Inspect skin,
nailbeds,
and extremities for flushing, pallor,
cyanosis,
bruising, and edema. Observe chest for
scars,
symmetry, movement, and deformity. Inspect neck
for JVD and inspect the PMI (point of maximal impulse)
for any remarkable pulsations. Analyze ECG recording
if available.
|
Palpate
|
Skin
temperature and moisture. Palpate PMI for any lifts, heaves,
thrills, or vibrations. Palpate and grade radial, dorsalis
pedis, and posterior tibial pulses, noting rate and
rhythm. Palpate and grade edema if present.
|
Percuss
|
Starting
at the midaxillary line, percuss toward the left cardiac
border along the 5th ICS. Sound should change
from resonance to dullness at the
midclavicular
line.
|
Auscultate
|
Use a
stethoscope and auscultate the apical pulse and compare
it with the radial pulse. Auscultate heart valves
for normal S1 (lub) and S2 (dub) heart sounds. Abnormal
sounds include extra beats (S3 and S4), bruits,
valvular murmurs, paricarditic rubs, and artificial
valve clicks.
|
1/2/14
Assess of Cardiovascular System
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