HEART ASSESSMENT

Anatomy OverviewHeat and Great Vessels

-The heart is a hallow, muscular, four-chambered organ located in the middle of the thoracic cavity between the lungs in the space called the mediasturium. It is about the size of a clenched fist and weighs a proximately 225g (9 oz) in women and 310 g (10. 9 oz) in men. The language reins and arteries leading in directly to and away from the heart are referred to as the great vessels. The heart consists of four chambers or cavities: two upper chambers, the night and left atria and two lower chambers, the right and left ventricles. The entrance and exit of each ventricle are protected by one way valve that direct the flow of blood through the heart. The atrioventricular and the triacuspid and bicuspid valve.

Production of Heart Sound:-Heart are produced by valve closure.-Normal heart sounds characterized as “lubb dubb” (s, and S2)

- The first heart sound is (S) result of closure of the AV- The second heart sound if (S2) result from the semilunar valves

Equipment Needed Ruler with centimeter Marking Pen Stethoscope with bell and diaphragm Alcohol swab to clean ear an d end piecesSubjective Data: Focus Question- Chest pain-location? Radiation? Quality? Rating on scale of 1to 10 (10 being the worst?)

Duration? What bring it on? What relieves it? And it is usual being said by the patient/client.Objective Data: Assessment Tecniques-Heart Chamber, valves, and direction of circulatory flow.Inspection:

Procedure Normal Findings Deviations from Normal

•Intercostal space 9ICS: locate by finding the sternal angle w/c is felt as nidge in the sternumn approximately 2 inch below the sternal notch

•Small apical impulse (S, 2.5 cm) at or medical to left midxclavcular line at fourth of fifth ICS. May not be visible in client with large chest.

•Impulses lateral to midclavicular line, pulsations (heaves or lifts) other than the apical pulsation are considered abnormal & may be seen w. an enlarged left

Procedure Normal Findings Deviations from Normal

•Midsternal line: Imaginary line extending down the chest.• Anterior Axillary line: (ALL): Imaginary line extending along the lateral wall of the anterior chest & even with the anterior axillary fold.

ventricle due to work overload , apical impulse on right side of chest.• Prominent impulse at right sternal border in pulmonic or aortic area.

Palpation

Procedure Normal Findings Deviations from Normal

• Aortic area: Palpate second ICS at the night sternal border• Pulmonic area: Palpate second ICS at left sternal border• Triaspid area: Palpate fifth ICS at lowertleft sternal border

• No vibrations of pulsation are palpated in aortic , pulmonic or triaspid area.

• Thrill w/c feels similar to a purring cate or pulsation in any of these areas except the mitral area is usually associated w/ a grade 4 or higher muumuu.

Percussion- May be done to define cardiac border by identifying areas of dullness, but it is

generally unreliable, size of heart can be more accurately determined by chest x-ray.Auscultation- Systemic fashion beginning with the aortic area. More across and then down the

chest. Auscultate each area w/ the stethoscope diaphragm applied firmly to the chest auscultate in supine position. Then have the client lean forward & exhale while you listen over the aortic area with the diaphragm.

Geriatric Variations- Thickening of heart walls- Decreased elasticity of heart & arteries, reduced pumping ability of heart- Decreased cardiac output and cardiac reserve- Apical impulse be difficult palpate owing to increase in anteroposterior diameter of

chest.Possible Collaborative Problems

Decreased cardiac output Congenital Heart DiseaseCongestinal heart failure endocarditisMyo cardial lischemia AnginaCardiogenic shock dysrhythmia

Peripheral Vascular AssessmentAnatomy OverviewArteries• Blood vessels that carry oxygenated, nutrient-rich blood from the heart to the capillaries. The femoral artery is

the major supplier of blood to the legs. This artery travels down the front of the thigh and then crosses to the back of the thigh, where it is termed the popliteal artery.

Veins• Carry deoxygenated , nutrient-depleted, waste-laden blood from the tissues back to the heart. There are three

types of viens deep veins, super ficial veins, and perforator veins. The two veins in the leg are the femoral vein in the popliteal vein located behind the knee.

Equipment Needed:• Stethoscope• Sphygnomamometer• Doppler• Tape measure• Cotton• Paper clip• Tuning forkSubjective Data Focus Questions

• Any changes in skin color, texture, or temperature? Pain in claves, feet, buttocks or legs?Risk Factors:• Risk for arterial peripheral vascular disease related to tobacco smoking, age over 50 year, family history of

peripheral vascular disease, hypertension coronary or peripheral vascular disease or male sexAdjective Data:Assessment TechniquesInspection, Palpation and Auscultation or circulation to arms & neck.- Performed together to assess blood and circulation to the upper extremities neck while the client is in sitting

position . A special maneuver is used to detect arterial insufficiency of the hand.

Possible Collaborative Problem

HypertensionThromphlebitisArterial insufficiencyPeripheral neurophatyThrombosis/emboli

EdemaVasospasmsClaudicationStatis ulcers

Abdominal AssessmentAbdominal Overview- The abdomen into four quadrants for purpose of physical exam. These

are the right quadrant (RUQ), Right Lower Quadrant (RLQ), left lower quadrant (LLQ) left Upper Quadrant (LUQ).

Hallow Vicera- The stomach is a distensible, flesh like organ located in the LUQ, just

below the diaphragm and in between the liver and spleen. The gallbladder a muscular sac approximately 10 cm long is not normally palpated because it is difficult to distinguish between the gallbladder and the liver. The small intestine is actually the longest portion of the digestive tract. The colon is composed of the three major sections ascending, transverse, and descending

The urinary bladder is a distensible muscular sac located behind the public bone in the midline of the abdomen.

Equipment Needed:• Stethoscope• Small meter• Marking pencil• Small fillowsSubjective Data: Focus QuestionsObjective Data: Assessment TechniquesMechanism & Sources of Abdominal PainTypes of Pain- Viscernal Pain-Poorly defined or localized

- and intermittently timed- Parietal Pain-This pain tends to localize more to the source and as more severe

and steady pain.- Referred pain-The accompanying illustrations shows clinical patterns and

referents of pain.

Inspection

• skin•Color•Venous pattern• integrity

Normal findings•Normally paler w;/ white striae•Tene viens observable•Norashes or lesions

Deviations from normal• Dark bluish utria seen in cushing syndrome.•Engorged, prominent veins•Rashes, lesions

Umbilicus:• position• color•Abdomen• contour• symmetry

• Sunken, centrally located• symmetrical

• generalized distention seen w/ air or fluid accumulation.• asymmetrical w/ organ enlargement, large masses, hemia, diastosis recti, or bowel obstruction.

Auscultation• Using the diaphragm of a warm stethoscope, apply light pressure to auscultate for bowel sounds for up to 5 minutes in each quadrant. Use the bell to aus•cultate for vascular sounds.

Percussion• Notes will vary from dull to tymphanic, w/ tymphany dominating the hallow organs.

The hallow include the stomach, intestines, bladder, aorta, & gallbladder.Palpation• Light palpation precedes deep palpation to detect tenderness and superficial masses.

Deep palpation to detect masses and size or organs.Possible Collaborative Problems• Bowel Strangulation• Asates• Metabolic Acidosis/Alkalosis• GL Bleeding• Gastric UlcerTeaching tips for selected diagnosisAdult ClientNursing diagnosis: Imbalance Nutrition: More or less than body requirements nursing

diagnosis: Risk constipationPediatric Client:Nursing Diagnosis: Readiness for enhanced nutritional-metabolic pattern of childNursing Diagnosis: Fluid volume deficit related to vomiting or diarrheaNursing Diagnosis: Risk for aspiration related to improper feeding and small size of

stomach in newborns.

GENITOURINARY ASSESSMENTAssessment for female Genitalia

Equipment Needed:Gown and drapeFillowMovable light sourceGloves lubricantPrivate locationVaginal speculum

Vaginal swabsPittpaperCotton-tipped applicatorsMirror

Subjective Data: Focus QuestionsObjective Data: Diaphragm for the external female genetaliaInspection:Have a client empty bladder and lie her back with head slightly elevated on a pillow. Knees should be bent and separated with feet resting on the bed. Light should be adjusted to provide good visualization of the genetalia.

Palpation• Don gloves left thumb and index or third finger, gently separate labia and

hold a part. Lubricate right index and insert into vaginal opening. Push up on anterior wall and milk toward opening. Push down on posterior wall and grasp tissue between thumb and index finger , palpate tissue along entire lower half of vaginal onifice.

Bimanual Examination• Tell client you’re going to perform a manual examination. Apply water

soluble lubricate to gloved and index fingers of your dominant hand. Standard and place non dominant hand on client’s lower abdomen. Next insert index middle fingers into the vagina.

Assessment of Male GenitaliaEquipment:• Gloves• Private locationSubjective Data: Focus QuestionsObjective Data: Assessment Technique

Inspection:- To make genitalia should be inspected with the client in a standing position

privacy should be ensured.Palpation• With client standing, gently palpate shaft of penis gloved thumb and fingers.

If foreskin is present, retract from tip of penis, then replace. Grasp each testicle between thumb and fingers. Gently roll testicles all surface are palpated.

• Palpate inguinal area. Then have client strain down as you palpate inguinal area. Then have client down as you palpate inguinal area and scrotum.

Assessment of RectumEquipment Needed• Examiantion gloves• Drape• PillowSubjective Data: Focus QuestionsObjective Data: Assessment Technique

Inspection:- Have client lie on left side w/ right flexed at hip and knee. Support leg on

pillow if necessary. Provide a pillow for under the head. With one hand, gently separate buttocks so rectum is exposed.

Pediatric VariationsSubjective Data: Assessment TechniquesInspection & Palpation of external male & female genitalia constitute the

total genitourinary assessment until puberty. Assessment of the level of sexual development of girls and boys usually begins at approximately age 11 years.

Cultural Variations• Male and Female genitalia are mutilated in pubertal rites in some cultures,Example: circumference, removal of clitoris, or surgical incision along penile

shaft and into its base for passage of urine and semen. Female pubic hair shaved or plucked on some cultures.

Geniatric Variations• Bladder capacity decreases to 250 ml owing to periurethral atrophy• One Collaborative Problems

Possible Collaborative Problems

Bladder perforationUrinary tract infectionPelvic inflamatory diseaseGenitalia ulcers or lesions

Obstruction urethraHemorrhage Hormonal imbalancesRenal failure

Renal calculiHyperrheaplymenorrhea

Musculoskeletal Assessment

Overview of anatomy-The body bones, muscles, & joints compose the muscukeletal system. 206 bones make up the axial skeleton (head and trunk) and the appendicular skeleton (stremeties, shoulders, and hips.

Three Types of Muscles:• Skeletal• Smooth• CardiacMuscular system is made up of 650 skeletal ( voluntary muscles. The joint or articulation is the place where two or more bones meet. Synovial joints are enclosed by a fibrous made or connective tissue and connected to the peiorsteum of the bone.

Equipment needed:• Tape measure• Geniometer (measure angles of joints)• Marking penSubjective data: Focus questionsObjective data: Assessment Techniques• Inspections & palpation are performed while client is standing, sitting, and

sufine, ROM can be measured by degrees, using approximation or a goniometer.

Inspection: Observe for ROM, deformity, atrophy, condition of sorrounding tissues and pain.

Palpation: Palpate for heat, strength, tone, edema, crepitus, and nodules

Inspection of Stance and Gait- Observe stance and gait as client enters and walks around the room.Inspection of the spine, shoulder, and posterior iliac crest- With client standing, observe in the erect position and as the client bends

forward to touch toes, stabilize client at the waist, and evaluate ROM of the upper trunk.

Palpation of the Spine, shoulder, & posterior iliac crest- With client in standing or sitting position, palpate the paravertebral

muscles using both moderate pressure & gentle motion. Ask to shrug shoulders against resistance.

Inspection of the head, thorax, and neck- With client sitting position facing you, inspect body parts. Ask client to open

and close mouth to assess temporo mandibular joint (TMJ) functionPalpation of the head, thorax , and neck- While inspecting the TMJ, palpate it bilaterally anterior to the tragus of

the ear as client opens mouth and clenches teeth. Ask client to tum head laterally against.

Palpation of the Upper Extremeties- As the musculoskeletal structure of the upper extremity is going through

active or passive ROM, palpate bones, muscles, tendons, and joints. Assess muscles strength & tone.

Inspection of the Lower Extremeties- Position the client in standing position to inspect the hips, and in sitting

position with legs hanging freely to inspect the knees, feet, & toes.

Palpation of the Lower Extremities- As the musculoskeletal structure of the lower extremely is going through active or

passive ROM, palpate bones; bony landmarks, muscles, and joints. Assess muscles strength and tone.

Teaching Tips for selected Nursing DiagnosisAdult ClientNursing Diagnosis: Readiness for enhanced mobilityNursing Diagnosis: Chronic Pain (Muscles & joints)Nursing Diagnosis: Risk for injury to exercise/improper body mechanicsPediatric Client:Nursing Diagnosis: Risk for injury (child) related to parent’s knowledge deficit of

correlating musculoskeletal development & home safety.Geniatric Client:Nursing Diagnosis: Risk for injury related decalcification of bones secondary to lifestyle

and postmenopausal stateNursing Diagnosis: Risk injury related to unstable gart secondary to aging processNursing Diagnosis: Impaired Physical Mobility related to decreased activity secondary

to aging process.Nursing Diagnosis: Self-Care defiat (specify) related decreased mobility and or

weakness.