Assessment & Reasoning

Cardiac System

John Gordon, 65 years old

Suggested Cardiac Nursing Assessment Skills to Be Demonstrated:

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Anterior:

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Inspection

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• Chest pulsations, heaves, lifts, color of skin; symmetry of movement; anatomical defects, retractions
Palpation

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• Apical impulse (4th to 5th ICS, Left MCL)
Auscultation rs e
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• 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
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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
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and murmurs. May be done in lying and sitting position, lying on left side and on back with head elevated 30
degrees

Peripheral
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Arms:
• Inspection –for symmetry, skin characteristics, hair distributions size (edema), venous pattern, color
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• Palpation – temperature using back of the hand, cap. refill

Pulses
• Palpation of radial/ulnar pulses, if suspecting arterial insufficiency, palpate brachial artery
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Legs:
• Inspection – for symmetry, skin characteristics, hair distributions, size(edema), venous pattern, color,
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varicosities, thrombophlebitis
• Palpation – edema, temperature, inguinal lymph nodes,
• Pulses - femoral, popliteal, pedal
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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!

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 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:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)

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PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):

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Myocardial infarction Aspirin 81 mg PO daily

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Ischemic cardiomyopathy Lisinopril 20 mg PO daily

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w/ejection fraction 30%

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Carvedilol 25 mg PO BID
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You place John on a cardiac monitor, continuous oximetry
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and quickly collect the following assessment data:

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Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment (5th VS):
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T: 98.6 F/37.0 C (oral) Provoking/Palliative:

P: 92 (reg) Quality: Denies Pain
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R: 26 (reg) Region/Radiation:
BP: 162/84 MAP: 110 Severity:
O2 sat: 91% room air Timing:
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What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
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(Reduction of Risk Potential/Health Promotion and Maintenance)

Abnormal VS: Clinical Significance:
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© 2019 Keith Rischer/www.KeithRN.com

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 Current Assessment:
GENERAL Appears anxious, restless
APPEARANCE:
RESP: Breath sounds have coarse crackles on inspiration and expiration scattered throughout both
lung fields ant/post, labored respiratory effort, patient sitting upright
CARDIAC: Forehead diaphoretic, cool to the touch, radial, pedal and post-tibial pulses regular 3+, has 3+
pitting edema bilateral lower extremities in feet, ankles, 2+ up to knees bilat, S3 gallop most
prominent over apex, no jugular venous distention (JVD) noted sitting up at 45 degrees
NEURO: Alert and oriented to person, place, time, and situation (x4)
GI: Abdomen pale soft/nontender, symmetrical, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
IINTEGUMENTARY: Pale, skin integrity intact, skin turgor elastic, no tenting present, cap. Refill brisk <1 second

What assessment findings are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:

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Put it All Together and Think Like a Nurse!
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1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most
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thoroughly based on the primary/priority concern?

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What’s the What’s causing the problem? PRIORITY Body

problem? (explain pathophysiology in OWN words) System to Assess:
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2. Which specific nursing assessments for this body system are most important? Validate successful completion of
each nursing assessment on a manikin (if available) identified with peer or faculty initials.
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PRIORITY Nursing Assessments: Rationale: Validate Student

Performance:
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© 2019 Keith Rischer/www.KeithRN.com

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 3. If this patient begins to complain of chest pain, what specific questions would you ask to thoroughly
assess this patient, document in the medical record and communicate to the primary care provider?

4. What is the current nursing priority and plan of care?

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected

Outcome:

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5. State the rationale and expected outcomes for the medical plan of care.
Medical Management: Rationale:
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Titrate oxygen to keep O2
sat >92%
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Furosemide 40 mg IV push
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Nitroglycerin 0.4 mg
transdermal patch daily
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Strict I&O

Fluid restriction of 2000 mL

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PO daily
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Low sodium diet

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Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray
Results: Clinical Significance:
Bilateral diffuse pulmonary infiltrates
consistent with pulmonary edema
© 2019 Keith Rischer/www.KeithRN.com
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 Lab Results:
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 133 4.9 105 1.9

RELEVANT Lab(s): Clinical Significance:

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Cardiac

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Trop. BNP Mg

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Current: 0.01 985 1.8

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What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
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(Reduction of Risk Potential/Physiologic Adaptation)
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RELEVANT Lab(s): Clinical Significance:
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Evaluation: 60 minutes later…

Students construct the remainder of this case study by determining what they would
notice if client condition improves or deteriorates (faculty decides!)
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Evaluate the response of your patient to nursing and medical interventions during your shift.
All physician orders have been implemented that are listed under client management.
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Current VS: Most Recent: Current PQRST:

T: T: 98.6 F/37.0 C (oral) Provoking/Palliative:
P: P: 92 (reg) Quality:
R: R: 26 (reg) Region/Radiation:
BP: BP: 162/84 MAP: 110 Severity:
O2 sat: O2 sat: 91% room air Timing:

© 2019 Keith Rischer/www.KeithRN.com

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 Current Assessment:
GENERAL
APPEARANCE:
RESP:

CARDIAC:

NEURO:

GI:

GU:

INTEGUMENTARY:

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse?

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(Reduction of Risk Potential/Health Promotion and Maintenance)

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RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable:

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RELEVANT Assessment Clinical Significance: TREND: Improve/Worsening/Stable:
Data:
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2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be
modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
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Evaluation of Current Status: Modifications to Current Plan of Care:

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3. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and
weaknesses this case study identified. What is your plan to make any weakness a future strength?
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What Did You Learn? What did you do well in this case study?

What could have been done better? What is your plan to make any weakness a future strength?

© 2019 Keith Rischer/www.KeithRN.com

This study source was downloaded by 100000767905857 from CourseHero.com on 05-01-2021 09:48:48 GMT -05:00

https://www.coursehero.com/file/71174337/STUDENT-KEITH-RN-CARDIAC-Assessment-and-Reasoningpdf/
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