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UNIT 4 - CARDIOVASCULAR ASSESSMENT - Coggle Diagram
UNIT 4 - CARDIOVASCULAR ASSESSMENT
validates the pts complaints related to health
assists in formulating nursing diagnoses and interventions
monitors current health problems
obtains baseline information for future assessments
RISK FACTORS
NON MODIFIABLE
Positive family history
Increasing age
Gender
Race
MODIFIABLE
Hyperlipidemia
Hypertension
Cigarette smoking
Elevated blood glucose level
Obesity
Physical inactivity
Type A personality
Use of oral contraceptives
INSPECTION
General appearance
› Anxiety, emotional factors
› Level of consciousness
› Level of distress
Inspection of skin
› Pallor
› Peripheral cyanosis
› Central cyanosis
› Xanthelasma
› ↓ skin turgor
› Temperature
› Ecchymosis
› Wounds, scars
Inspection of skin
› Pallor
› Peripheral cyanosis
› Central cyanosis
› Xanthelasma
› ↓ skin turgor
› Temperature
› Ecchymosis
› Wounds, scars
PALPATION
Temperature
Texture
Moisture
Organ size and location
Rigidity or spasticity
Crepitation, Vibration
Position
Presence of lumps or masses
Tenderness, or pain
Blood pressure
BP measurement
arterial pulse
jugular venous pulsations and pressure
PERCUSSION
Assess underlying structures for location, size, density of underlying organs
Indirect lung percussion
Direct: SInus tenderness
Blunt percussion: Organ tenderness
Percussion Sounds:
Flatness: Bone or muscle
Dullness: Heart, liver, spleen
Resonance: Air filled lungs (Holllow)
Hyperresonance: emphysematous lung (hyperinflated)
Tympany: air filled stomach (drumlike)
JUGULAR VEIN PRESSURE
reflects increased filling volume and pressure on the right side of the heart
PULSE DEFICIT: the difference between apical HR and peripheral pulse-associated with Afib, and heart blocks
PULSE PRESSURE: the difference between systolic and diastolic pressure
HORMANS SIGN: discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight