Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal breast findings. Record and report any significant deviations from the normal. In many 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 theexam. • 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

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