Question

Continue your Nursing Health Assessment. Please include rational for assessment techniques. (why do you assess a certain way and what findings are you looking for).

Please answer questions as if you are a nurse providing assessment to the a patient.

Cardiovascular Assessment:

Inspect and Palpate for Pulsations on Chest and at PMI (state what and where the PMI is located), describe.

Auscultate heart sounds in correct ausculatory areas.

First, use diaphragm of stethoscope. The, use the bell of the stethoscope. What do you hear and why? Correctly name ausculatory sites and state where S1 and S2 are heard the loudest.

Auscultate the rhythm and rate at the apex. Where is the apex? Compare with palpated radial pulse. Why is this important?

Palpate all pulse sites bilaterally. Where are they located? (2).Describe pulse in terms of rhythm & strength or grade(1).Assess carotid artery appropriately (1).

Palpate temperature of extremities and describe.

Inspect and palpate extremities for edema and capillary refill, compare both sides.

Answer 1

As a nurse, before get ino the cardiovascular assesment explain procedure and its benefits to the client,
after introducing about the examination , the nurse may start to examine the client,

1) Inspect the client chest superficially, check for any scars on the anterior or posterior part of the chest.
look for any surgical invasion the chest region.

after inspection, palpate the patient chest with the palm of the hand, palpate on the four heart chambers and
chest walls, it may feels kind of vibration on the hand.

PMI stands for the location in which the maximum pulsation can be feelable...the location for the PMI is
the fifth intercostal space of the midclavicular line,
the nurse may need to palpate on the sternal edges in this assessment.

2) Nurse needs to auscultate in the following region, with the use of diaphragm such as,

• aortic region
• right upper sternal border
• left upper sternal border
• pulmonic region

3) By using the diaphragm of the stethoscope we can hear high frequency sound because the pressure is given more on this side
and it is very firm.

But, the bell of the stethoscope we can only hear the low frequency sound because the pressure applied in this area is
very low.

4) S1 sound is heared best at the apex region of the heart and it can be heared on the begning of the systole,
S1 sound is low frequency sound,,

S2 sound is heared best at the base region,

so S1 and S2 represent the lub dub sound. S1 is louder in apex and S2 is louder in base.

5) Apex is the lowest end point of the region of the heart, exactly it is located on the left ventricles of the heart and it is the inferior
part of the heart. By means of auscultation nurse may find out the rate it may range on 60-100 beats per minute and check the
rythm whether it is regular or irregular.