N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide agencies, there may be diagrams for documenting areas of the breast abnormalities. 2.11 Cardiac/Cardiovascular The cardiovascular assessment is typically performed from the patient's right side with the patient in a supine or semi-reclined position. Equipment needed for the cardiovascular exam includes a stethoscope and a ruler. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled, and upon completion of the exam. • Provide a quiet, well-lit, and private place for the exam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Family history of heart disease, hypertension, stroke, diabetes, high cholesterol, obesity, rheumatic fever, heart murmur, heart attack, congestive heart failure, etc. o Signs and symptoms of cardiovascular disease (cough, chest pain, palpitations, wheezing, bloody sputum, edema, syncope, orthopnea, etc.) o Smoking o Eating and exercise • Assess the anterior chest for pulsations. o Normal: No pulsations, lifts, or heaves o Deviations from normal: Pulsations, lifts, or heaves • Palpate the apical area of the heart. o Normal: Pulsations palpable at PMI (point of maximal impulse at the fifth intercostal space at midclavicular line); pulsations may also be visible at this point o Deviations from normal: PMI deviated down or laterally • Assess the epigastric area for pulsations. o Normal: Aortic pulsation may be visible o Deviations from normal: Bounding or excessive abdominal pulsation; if noted, do not palpate area but report finding; palpation of an aortic aneurysm may cause rupture and death

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