Anterior:
Inspection
• Chest pulsations, heaves, lifts, color of skin; symmetry of movement; anatomical defects, retractions Palpation
• Apical
... [Show More] impulse (4th to 5th ICS, Left MCL) Auscultation
• HR & rhythm (60-100 bpm)
• Identify S1 & S2 – 2nd ICS, Right sternal border (aortic); 2nd ICS, Left sternal border (pulmonic); 3rd ICS, Left sternal border (Erbs); 4th ICS, Left sternal border (tricuspid); 5th ICS, Left MCL (pulmonic). S1 is louder at Apex, S2 louder at the base. This is the traditional method and a systematic method of learning.
• Diaphragm and bell to be used. Do not allow the patient to hold breath. Auscultate for S3 and S4 heart sounds and murmurs. May be done in lying and sitting position, lying on left side and on back with head elevated 30 degrees
Peripheral
Arms:
• Inspection –for symmetry, skin characteristics, hair distributions size (edema), venous pattern, color
• Palpation – temperature using back of the hand, cap. refill Pulses
• Palpation of radial/ulnar pulses, if suspecting arterial insufficiency, palpate brachial artery Legs:
• Inspection – for symmetry, skin characteristics, hair distributions, size(edema), venous pattern, color, varicosities, thrombophlebitis
• Palpation – edema, temperature, inguinal lymph nodes,
• Pulses - femoral, popliteal, pedal
Make Learning Active!
• Role play or go through the interview/body assessment process – student to student or as a group.
• Review the case study as an application exercise in small groups or together as a class.
• Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead, use it to promote learning by having students identify what they do not yet know and provide guidance on where they can find the information in the
textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!
Present Problem:
John Gordon is a 65-year-old male who has a history of myocardial infarction (MI) two years ago and heart failure with a current ejection fraction (EF) of 30%. He presents to the emergency department (ED) for increasing shortness of breath (SOB) for the past three days. He is more fatigued than usual and becomes short of breath with minimal activity. The last two nights he had to sleep upright in a recliner so he could breathe easier and fall asleep. He has noted increased swelling in his lower legs and has gained six pounds the last two days.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
- History of MI & HF, SOB, lg edema, weight gain - Patient is suffering from SOB due to MI & HF
- Swelling in the leg and weight gain indicates fluids overload.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Myocardial infarction
Ischemic cardiomyopathy w/ejection fraction 30% Aspirin 81 mg PO daily Lisinopril 20 mg PO daily
Carvedilol 25 mg PO BID NSAID
ACE inhibitor Beta blockers Prevents or treats blood clots Decrease BP, treats HF
Treats HF, decrease BP & HR [Show Less]