NURS 3120 Lecture Notes - Lecture 6: Embolism, Liga Uruguaya De Basketball, Heart Sounds

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22 Feb 2017
School
Department
Course
Cardiac Assessment
Health History/Present
Chronic illnesses like DM, renal disease, COPD, HTN
Medications prescribed, over the counter, or homeopathic
Aspirin (heart attack) or other blood thinners (fib) for dysrhythmias
Family history of any comorbidities
Parents
Grandparents
Aunts and Uncles
Personal and Psychosocial
“esitie Questios – the peissio uestios…
Cocaine or other street drugs?
How often?
Exercise? Yes/No and/or how often?
Describe personality type
Type A
Type B
How does the patient deal with stress
Relaxation techniques how do they relax?
Present Nutritional Assessment
Eating habits
Special diets cultural considerations
Red meat, salt intake
Processed foods, canned foods
Whole grains, dietary supplements
Cholesterol levels?
Drink alcohol? How often?
Drink coffee or other caffeinated beverages?
Chocolate?
Ever smoke, how long? How many?
Presently smoke? Desire to quit?
Problem Based Conditions Chest Pain
Does the patient experience any chest pain?
Where? Have them show you does it adiate…
Point to area
Intermittent or constant
First noticed it? Triggers..
Aggressive exercise
Subside with rest
Nitroglycerin? How many pills needed for relief?
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Do you have other symptoms with the chest pain?
Sweats
SOB
Pale
Palpitations
Light headed
Anxious
Problem Based Conditions Shortness of Breath
How long has it been occurring
Are they SOB during the present visit?
How often?
Duration?
Exacerbations?
With ADL’s?
Do breathing exercises help?
Relaxation techniques
Do episodes occur at night? Disturb sleep patterns?
How many pillows do they use for sleep?
Do they sleep in a bed?
Recliner?
Pulmonary or respiratory etiology
Any swelling of hands, face or feet?
Problem Based Conditions Cough
When did you first notice it?
How often? Productive or dry cough?
Productive: may not be viral or bacterial etiology, can lead to pulmonary edema
Does it wake you?
Triggers noticed?
What makes the cough worse?
Does anything help?
Suppressants?
Decongestants?
Problem Based Conditions Nocturnal Urination
How often does the patient/client get up to urinate?
Frequency versus urgency?
Any incontinence?
Night time use of disposable under garments?
Do ot use od diapes
Diuretic use?
For hypertension, if using at night could be problem
Type?
How often is it taken?
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What is the fluid intake of the patient/client?
Problem Based Condition Fatigue
First notice of fatigue?
Onset sudden or gradual?
Better or worse in day time versus night time?
Can you patiipate i ADL’s ithout feelig tied?
Any mental health conditions?
Interfere with work and/or hobbies?
Social gatherings?
Anemic?
Notie a othe sptos like…
Racing heart
Headache
Tingling in hands/feet
Circulation problem
Problem Based Condition Fainting
What do you remember doing right before you fainted?
Are you dizzy?
Loss of consciousness?
Was someone there with you during the episode
How often has it happened?
Did you eat today?
Othe sptos otied…
Feel nauseous
Light headed
Headache
Palpitations
Room spinning or darkening?
Problem Based Conditions Edema
Arms/legs
Both extremities or just one sided
What helps the swelling? Worse in morning or night?
SOB
New onset of weight gain
Can they get rings on?
Socks too tight?
Edema: press, fingers of depression stay there
May take 2 weeks to go away
Sodium decrease, diuretics, elevation will help
What kind of motion?
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Document Summary

Have them show you does it (cid:396)adiate : point to area. How many pills needed for relief: do you have other symptoms with the chest pain, sweats, sob, pale, palpitations. Loss of consciousness: was someone there with you during the episode, how often has it happened, did you eat today, othe(cid:396) s(cid:455)(cid:373)pto(cid:373)s (cid:374)oti(cid:272)ed . Varicose and spider veins would not be painful. Clot or deep vein thrombosis could be painful. Ue & le look the same: respirations easy/effortless, vital signs recorded, palpation of brachial & radial pulses, rate & rhythm, amplitude & contour, palpate temporal/carotid pulses for amplitude. I(cid:374)spe(cid:272)t & palpate the lo(cid:449)e(cid:396) e(cid:454)t(cid:396)e(cid:373)ities fo(cid:396) : symmetry, integrity, color/warm or cold, capillary refill time, hair distribution, color/angle of nail beds, clubbing, color. Palpate pulses fo(cid:396) a(cid:373)plitude : femoral, popliteal, posterior tibial, dorsalis pedis. Erb"s point: 3rd left intercostal space (left sternal border) this is your s1s2 sounds. Tricuspid: 4th left intercostal space (left lower sternal border)

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