Inspect bilaterally for skin color

 Inspect bilaterally for skin color

 

Heart and Neck Vessels: Subjective data Name________________

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings
Current (or recent) Symptoms  
1. Chest pain (type, location, radiation, duration, frequency, intensity)?  
2. Palpitations?  
3. Dizziness?  
4. Ankle edema at any time of day?  
Past History  
1. Previous heart problems: heart defect, murmur, heart attack (MI)?  
2. Previous diagnosis of rheumatic fever, hypertension, elevated cholesterol, diabetes mellitus?  
3. Heart surgery or cardiac balloon intervention?  
Family History  
1. Hypertension?  
2. Myocardial infarction or heart disease?  
3. Elevated cholesterol?  
4. Diabetes mellitus?  
Lifestyle and Health Practices  
1. Cigarette smoking pattern?  
2. Life stress—type and amount?  
3. Usual exercise patterns?  
4. Sleep routine (use of extra pillows, up to urinate, feels rested)?  
5. Use of medications or treatments for heart disease?  
6. Self-monitoring of heart rate or blood pressure?  
7. How long ago was the last screening for blood pressure, cholesterol, ECG? Were there abnormal findings?  
   

 

Peripheral vascular system: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings
Current Symptoms  
1. Skin changes (color, temperature, or texture)?  
2. Leg pain, heaviness, or aching? Does it awaken you at night?  
3. Leg veins (rope-like, bulging, or contorted)?  
4. Leg sores or open wounds (location, pain)?  
5. Edema in legs or feet?  
6. Swollen glands or nodules (pain)?  
   
Past History  
1. Previous problems with circulation in arms or legs (blood clots, ulcers, coldness, hair loss, numbness, swelling, or poor healing)?  
2. Heart or blood vessel surgeries or treatments  
Family History  
1. Family history of varicose veins, diabetes, hypertension, coronary heart disease, or elevated cholesterol or triglyceride levels?  
Lifestyle and Health Practices  
1. Women: use of hormonal contraceptives or therapy?  
2. Peripheral vascular problems that interfere with ADLs?  
3. Use of support hose?  

 

Heart and Neck Vessels: Objective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings
Current Symptoms  
Neck Vessels  
1. Auscultate carotid arteries for bruits.  
2. Palpate each carotid artery for amplitude and contour of the pulse, elasticity of the vessel, and thrills.  
Heart (Precordium)  
1. Inspect for visible pulsations (note if apical or other).  
2. Palpate apical pulse for location, size, strength, and duration of pulsation.  
3. Palpate for abnormal pulsations or vibrations at apex, left sternal border, and base.  
4. Auscultate heart sounds for rate and rhythm (apical and radial pulses, beats/min, pulse rate deficit, S1 and S2).  
5. Auscultate S1 and S2 heart sounds for sound location and strength pattern (louder/softer at locations and with respiration, splitting of S2).

 

 
6. Auscultate the following areas for extra heart sounds–clicks, rubs, perhaps murmurs:

a. aortic

b. pulmonic

c. Erb’s point

d. tricuspid

e. mitral–note that this is level with the bottom of the sternum in the middle of the left side of the chest. Listen here for S3 or 4, esp. when pt is lying supine or on left side.

Auscultate with the client in the left lateral position and with the client sitting up, leaning forward, and exhaling.

 

 

Peripheral vascular system: Objective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings
Current Symptoms  
Assess Arms  
1. Inspect bilaterally for size, presence of edema, and venous patterning.  
2. Inspect bilaterally for skin color.  
3. Inspect fingertips for clubbing.  
4. Palpate fingers, hands, and arms for temperature, using dorsal surface of your fingers.  
5. Determine capillary refill time.  
6. Palpate radial, ulnar, and brachial pulses.  
7. Palpate epitrochlear lymph nodes behind the elbow in the groove between the biceps and triceps muscles.  
8. Perform Allen test by occluding the radial and ulnar arteries and observing for palm pallor. Then, release the ulnar artery and watch for color to return to hand. (Read about it thoroughly before beginning this exam.)
Assess Legs  
1. Inspect bilaterally for skin color (client in supine position).  
2. Inspect bilaterally for distribution of hair.  
3. Inspect for lesions or ulcers (note whether margins are smooth and even, location such as at pressure points, size, depth, drainage, odor).  
4. Inspect for edema, unilateral or bilateral (if calves are asymmetric, measure calf circumference).  
5. If client has edema, determine whether it is pitting or nonpitting. If client has pitting edema, rate on a 1+ to 4+ scale.  
6. Palpate skin temperature (cool, warm, hot). Use dorsal surface of hands.  
7. Palpate the superficial inguinal lymph nodes while keeping the genitals draped. If detected, note size, mobility, or tenderness.  
8. Palpate and auscultate femoral pulses over artery. Listen for bruits.  
9. Palpate popliteal, dorsalis pedis, and posterior tibial pulses.  
10. Inspect for varicosities and thrombophlebitis by asking client to stand.  
11.Perform the manual compression test by having client stand. Firmly compress the lower portion of the varicose vein with one hand. Place other hand 6 to 8 inches higher. Feel for pulsation in the upper hand.

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