NSB103 Lecture Notes - Lecture 5: Capillary Refill, Heart Sounds, Edema
Week 5: Cardiovascular Assessment
Cardiovascular System
High Fowler = 90 degrees
Semi-Fowler = 45 degrees
Supine = flat
Cardiovascular Assessment
• General Observation (General Survey)
• Primary Survey (ABCDE)
• Vital Signs
• Auscultation (Heart sounds)
• Inspection (colour, peripheral vessels, oedema)
• Palpation (neurovascular observation- identify any changes)
• Electrocardiogram (ECG)
• Observe and record urine output and other fluid losses
Focused Cardiovascular Assessment
• Reie patiet’s baselie assessent data
• Perform hand hygiene; Ensure comfort and privacy; Explain procedure and clarify any concerns
• Approach from the right-hand side; Patient positioned at 45 degrees supine
• General observation of skin colour, temperature and mental status
• Inspect and palpate upper limbs for colour, warmth, movement and sensation
• Check peripheral and central capillary refill time
• Palpate radial pulse for rate, rhythm and strength
• Measure manual blood pressure
• Observe neck veins (patient at 45-degree angle)
• Auscultate apical heart sounds (noting rate and rhythm); determine normal heart sounds;
listen for acute changes (i.e. added sounds or murmurs)
• Inspect and palpate lower limbs for colour, warmth, movement and sensation. Palpate pedal
pulses, check for pitting oedema (ankles)
• Inspect and palpate calves for redness, warmth, tenderness
• Observe urine output and any losses in drains etc
• Observe ECG for abnormal changes
General Survey
• Physical presents - observe colour of skin
• Psychological presence - mental status
• Presence of pain or distress
Subjective Data:
• What the person tells you:
o Past medical history
o Feelings/perceptions
Objective Data:
• What the nurse observes
o Physical assessment
o Diagnostic tests
o Specialist investigations
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