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Durham College *

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1211

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Medicine

Date

Oct 30, 2023

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Student Name:__________________________ Leads Based Worksheet Client information Client code: Rm no: Age: Date of admission: Reason for admission: Hx (hlt challenges): T P R BP baseline T P R BP Time: T P R BP Time: Neurological Assessment Nutrition: Diet: Amount of Meals consumed % B: L: S: ___________________________________ Intake & Output totals: ___________________________________ Intravenous Therapy/Saline lok: Rate: Solution: Cardiovascular Assessment Respiratory Assessment Musculoskeletal Assessment Gastrointestinal Assessment Chest pain/dyspnea/orthopnea/cough/fatigue/cyanosis or pallor/edema/nocturia/past cardiac hx/family cardiac hx/cardiac risk factors/leg pain/cramps/skin changes/lymph node enlargement/medications Neck vessels: Palpate carotid artery:  Located central to the heart  Palpate each carotid artery medial to the sternomastoid muscle in the neck  palpate only one carotid artery at a time .  Normally the contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is moderate. The findings should be the same bilaterally. Genitourinary Assessment Integumentary Assessment Elimination:

Student Name:__________________________ Leads Based Worksheet Auscultate carotid artery:  Auscultate each carotid artery for the presence of a bruit  This is a blowing, swishing sound indicating blood flow turbulence; normally none is present.  Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels: (1) the angle of the jaw, (2) the midcervical area, and (3) the base of the neck  Avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis  Ask the patient to take a breath, exhale, and hold still briefly without breathing while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruit.  Jugular vein Inspect jugular venous pulse  Position the patient supine at a 30- to a 45- degree angle, wherever you can best see the pulsations. In general, the higher the venous pressure is, the higher the position you need.  Remove the pillow to avoid flexing the neck; the head should be in the same plane as the trunk.  Turn the patient's head slightly away from the examined side, and direct a strong

Student Name:__________________________ Leads Based Worksheet light tangentially onto the neck to highlight pulsations and shadows. 1. Estimate jugular venous pressure  You can “read” the CVP at the highest level of pulsations. Use the angle of Louis (sternal angle) as an arbitrary reference point, and compare it with the highest level of venous pulsation.  Hold a vertical ruler on the sternal angle. Align a straight edge on the ruler like a T- square, and adjust the level of the horizontal straight edge to the level of pulsation  Read the level of intersection on the vertical ruler; normal jugular venous pulsation is 2 cm or less above the sternal angle.  Also state the patient's position: for example, “internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees.” Hepatojugular reflux  Position the patient comfortably supine and instruct the patient to breathe quietly through an open mouth.  Hold your right hand on the right upper quadrant of the patient's abdomen just below the rib cage. Watch the level of jugular pulsation as you push in with your hand.

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Student Name:__________________________ Leads Based Worksheet  Exert firm sustained pressure for 30 seconds. This empties venous blood out of the liver sinusoids and adds its volume to the venous system.  If the heart is able to pump this additional volume (i.e., if CVP is not elevated), the jugular veins will rise for a few seconds and then recede back to the previous level. Precordium Inspection: No visible pulsations, no heave or lift.  Anterior chest (lumps/bumps/lesions, skin colour/ condition : Arrange tangential lighting to accentuate any flicker of movement.  Inspect for apical impulse (landmark): You may or may not see the apical impulse , the pulsation created as the left ventricle rotates against the chest wall during systole. When visible, it appears at the level of the fourth or fifth intercostal space, at or inside the midclavicular line. It is easier to see in children and in patients with thin chest walls. Palpation (follow proper apetm sequence) apical impulse:  Locate the apical impulse precisely by using one finger pad  Asking the patient to “exhale and then hold it” aids the examiner in locating the pulsation.  You may need to roll the patient midway to the left to find it; note that this also displaces the apical impulse farther to the left palpate

Student Name:__________________________ Leads Based Worksheet  Note the following characteristics:  Location: The apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line  Size: Normally 1 × 2 cm  Amplitude: Normally a short, gentle tap  Duration: Short; normally occupies only first half of systole Precordium with palm for thrills, masses, pulsations:  Using the palmar aspects of your four fingers, gently palpate over the apex, the left sternal border, and the base, searching for any other pulsations.  Normally none are felt. If any are felt, note the timing.  Use the carotid artery pulsation as a guide, or auscultate as you palpate Percussion  not required to percuss cardiac borders Auscultation For each valve area identify landmarks, which heart sound is loudest & if you hear any murmurs Aortic area: Second right interspace Pulmonic area: Second left interspace Erb’s point:

Student Name:__________________________ Leads Based Worksheet Tricuspid area: Fifth intercostal space at lower left sternal border Mitral area: Fifth interspace at around left midclavicular line Heart Rate: 60-100BPM Rhythm: Regular BP: Ausculatate all valve areas again using bell of stethoscope to assess for murmurs If murmur heard, position patient on left to clarify which valve area Peripheral Vascular Inspection: Skin colour: Normally it is consistent with genetic background, no pallor/erythema/cyanosis/jaundice Nail beds:  The nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded.  Nail edges that are smooth, rounded, and clean suggest adequate self-care Hair distribution: Swelling: Ulcerations: Ulceration is the development or formation of an ulcer on a part of the body. Following ulceration, the affected area may bleed or produce unpleasant discharges. Ulceration on the skin can cause a painful sore that is prone to infection and the formation of pus. Palpation: Temperature: Moist/dry: Look for dehydration in the oral mucous membranes. Normally there is none, and

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Student Name:__________________________ Leads Based Worksheet the mucous membranes look smooth and moist. Be aware that dark skin may normally look dry and flaky, but this does not necessarily indicate systemic dehydration. Capillary refill (fingers & toes):  Peripheral pulses (temporal, carotid, brachial, radial, femoral, popiteal, tibial, dorsalis pedis) Edema:  Edema is fluid that accumulates in the intercellular spaces; it is not present normally.  To check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia.  Normally, the skin surface resumes its smoothness immediately.  f your pressure leaves a dent in the skin, “pitting” edema is present