N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide • Assess the heart sounds: Eliminate all noise in the room if possible. Have the patient in a semi- reclining position. Use both the bell and diaphragm of the stethoscope to auscultate all areas of the heart. Listen for S1, the silent interval of systole, S2, and the silent interval of diastole at all areas of theheart. o Normal: S1 is usually loudest at apex; S2 usually loudest at base; systole and diastole as silent intervals between S1 and S2; heart rate 60-90 beats per minute; S3 may be present in children; S4 may be present in older adults o Deviations from normal: Increased or decreased intensity of any of the heart sounds; any sharp sounding clicks; S3 in older adults; S4 until determined to be a variation of normal in older adult • Assess carotid arteries: When palpating the carotid artery, palpate only one side at a time and use extreme caution since this may cause bradycardia or diminished blood flow to the brain. o Normal: Symmetrical pulse volumes; no changes in intensity or quality when patient breathes or turns head; elastic walls; no sound heard on auscultation o Deviations from normal: Asymmetrical pulse volumes; changes in intensity or quality when patient breathes or turns head; decreased pulsations; rigid walls; bruit heard on auscultation • Assess jugular veins. o Normal: Veins not visible in semi-recumbent position o Deviations from normal: Veins visibly distended Evaluation It is important to compare all findings with the previous findings to determine if there are changes to any abnormal cardiovascular findings. Record and report any significant deviations from the normal. 2.12 Abdomen Have the patient empty his bladder before beginning the abdominal exam. This will allow the patient to be more comfortable during the assessment. Equipment needed for the abdominal exam includes a tape measure and a stethoscope. 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. Achieve Test Prep Page 44 of 135 ©2017