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Common Problems/Assessment by Kimberly Napper

Unit III Objective 1
Describe the health assessment to be made in relation to clients experiencing cardiac/circulatory disorders across the
lifespan.
Unit IV Objective 1
Describe the health assessment to be made in relation to clients experiencing respiratory disorders across the lifespan.
Unit III Cardiac Health Assessment
A. Health History
B. Nursing Assessment
1) Areas to assess in relationship to cardiac/circulatory function
a. Pain
b. Pulses-apical and Peripheral
c. Capillary refill
d. Blood pressure
e. Heart sounds
f. Heart rate, rhythm
g. Skin-color, temperature, moisture, bruising, petechiae
h. Buccal, mucosa, gums
i. Edema
j. Muscle cramps
k. Skin changes of extremities
l. Sensory function-touch, pain, temperature
m. Jugular veins
Cardiac Assessment
 Health history
 Predisposition / Genetic (Brunner 13th ed p. 662)
 Lifestyle
 Medications
 Medical & Social History
 Client Perspectives
See Table 25-4 (Brunner 13th ed. p.676)
Physical examination
Monitor laboratory and diagnostic test results
The assessment priorities vary according to the needs of the patient.
Health History
Demographical data
Age: Elderly clients and those with diabetes may experience less pain
Gender: Women more likely to experience atypical symptoms of Coronary Artery Disease (CAD) than males
Ethnic origin: Caucasians more likely to have elevated cholesterol levels
African Americans more likely to have hypertension
African Americans more likely to develop symptoms of CAD at an earlier age
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Health History: Risk Factors p. 731 Brunner 13th edition

Modifiable
 Smoking
 Hyperlipidemia
 Hypertension
 Elevated blood glucose (diabetes)
 Obesity
 Physical inactivity
 Type A personality characteristics (particularly hostility)
 Use of oral contraceptives
Non-modifiable
 Family history for premature CAD
 Increasing age
 Gender
 Race

Cholesterol: An essential fat that provides support in the membranes of cells.

Some comes from diet and some is made by the liver.
Can't dissolve in blood, so transport proteins carry it where it needs to go.
These carriers are called lipoproteins
LDL (low-density lipoprotein)
HDL (high density lipoprotein)

Lipoproteins/Cholesterol
Goal: low LDL and high HDL values
LDL (low density lipid)
 harmful effect on coronary vasculature
 small LDL particles easily transported into the vessel lining
 leads to plaque growth and atherosclerosis
HDL (high density lipid)
 promotes use of total cholesterol by transporting LDL to the liver, where it is excreted
Triglyceride- another fatty substance made up of fatty acids
 Elevated levels a major risk factor for cardiovascular disease & insulin resistance (fasting glucose over 100).
 Goal less than 150 mg/dL & fasting glucose less than 100 mg/dL.
Soluble dietary fiber -found in fresh fruits, cereal grains, & vegetables
 Known to enhance excretion of metabolized cholesterol
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Areas to assess in relationship to cardiac/circulatory function

Pain
Intermittent claudication (p. 830 13th ed. Brunner)
Rest pain in lower extremities
Chest pain (p. 663 Table 25-2)
Joint pain
Pain Assessment p. 740 Chart 27-4 & p. 741 Chart 27- 5
P– position: “where is the pain?”
provocation: “What were you doing when the pain started?”
Q– quality: “How would you describe the pain?”
quantity: “Has the pain been constant?”
R– radiation: “Can you feel the pain anywhere else?”
relief: “Did anything make the pain better?”
S– severity: “How would you rate the pain (0-10 scale)?
symptoms: “Did you notice any other symptoms with the pain?”
T– timing: “How long ago did the pain start?”

Areas to assess in relationship to cardiac/circulatory function

Pulses- Apical and Peripheral
Capillary refill
Blood pressure p. 862 Brunner 13th ed.
Hypertension: “High Blood Pressure”, “The Silent Killer”
Systolic pressure greater than 140 mm Hg
Diastolic pressure greater than 90 mm Hg
(Based on the average of 2 or more accurate B/P measurements taken during 2 or more “check-ups”)
Pulse Pressure p. 667 Brunner 13th ed.
Complications of Hypertension (HTN)
Damage to blood vessels throughout the body
 Heart: Myocardial infarction, Congestive Heart Failure
 Kidneys: Renal Failure
 Brain: Stroke
 Eyes: Impaired Vision

Metabolic Syndrome (A group of risk factors that are known to lead to cardiovascular disease):
 Hypertension
 Dyslipidemia (↑ LDL, ↓ HDL cholesterol)
 Elevated Triglycerides
 Diabetes Mellitus
 Obesity (abdominal)
Management of Hypertension; Lifestyle Modifications (Brunner 13th ed p. 865 Table 31-2)
 implemented first
 to prevent complications
 Medications
 Monitor risk factors
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 Monitor blood pressure

Hypertension Management: Lifestyle Modification: Activity
 Regular aerobic activity at least 30 minutes/day
Hypertension Management: Lifestyle Modification: Diet
 Moderation of alcohol consumption
 2.4 gram sodium / 6 gram sodium chloride (per day restriction)
 DASH: “Dietary Approaches to Stop Hypertension”
 Fruits
 Vegetables
 Low-fat dairy products
 Reduced saturated & total fat
HTN Management Lifestyle Modification: Weight Reduction
 Maintain normal body weight
 Goal body mass index 18.5- 24.9 kg/m²
Hypertension Management: Medications
 Thiazides
 ACE inhibitors
 Angiotensin receptor blocker
 Beta blocker
 Calcium channel blocker
 Aldosterone antagonist
See also Brunner p. 867 Table 31-4

Hypotension (low blood pressure)

 any blood pressure that is below the normal expected for an individual in a given environment
 the opposite of hypertension

Neurologic Conditions leading to hypotension

 Postural changes Brunner 13th ed. p. 668
 Stroke
 Shock
 Parkinson's disease
 Neuropathy
 Fright

Hypotensive drugs leading to hypotension

Depression medications- amitriptyline (Elavil)
Alcohol - vodka (Grey Goose)
Diuretics- furosemide (Lasix)
Heart medications
 calcium antagonists- ex. nifedipine (Procardia)
 beta blockers- ex. Propranolol (Inderal)
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Nonneurologic Conditions leading to hypotension

 Infections
 Dehydration
 Heart disease
 Adrenal insufficiency
 Pregnancy
 Prolonged bed rest
 Poisoning
 Toxic shock syndrome
 Blood transfusion reactions

Hypotension Treatment
 Treat underlying cause!
 Positioning
 Have client “dangle” & rise gradually (to prevent orthostatic ↓B/P)
 Head down during hypotensive episode
 Support/replace fluid volume (including blood losses)
 Medications : stop or start, depending upon cause

Areas to assess in relationship to cardiac/circulatory function

Heart sounds
Heart rate, rhythm
YouTube Heart Sounds: http://www.youtube.com/watch?v=s_2jHlKHPO0
Gallops
S3 “Kentucky” = Heart failure, Fluid volume overload
S4 “Tennessee” = Hypertension, Left ventricular hypertrophy (LVH)
http://www.youtube.com/watch?v=dplpeUfy4qA

Murmurs: The sound of turbulent blood flow. (Leaky valves, etc.)

Areas to assess in relationship to cardiac/circulatory function

Skin-color, temperature, moisture, bruising, petechiae (Brunner 13th ed. p. 920)
Buccal, mucosa, gums
Skin changes of extremities
Sensory function-touch, pain, temperature

Cardiac Nursing Assessment: Skin Changes

Xanthelasma: Yellowish plaques along eyelids and nose (hypercholesterolemia)
Skin Turgor Abnormalities
Ecchymosis / Petechiae: Bruising/pink spots related to clotting factors / meds
Scars: Indicate previous surgeries
Brown discoloration, shiny skin, lack of hair
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Venous vs. Arterial

Venous :
 Cramping
 Aching or a feeling of heaviness
 Itching
 Varicose veins
 Changes in skin color- “brawny”
 Skin sores (ulcers)
 Swelling ankles Arterial:
 Intermittent claudication
 Numbness in legs
 Weakened pulse
 Change in color of legs
 Shiny skin
 Hair loss
 Sores on feet- Toes, heels
 Erectile dysfunction (men)
Circulatory Assessment: Changes of Extremities: Peripheral Arterial Disease (PAD) & Necrosis R/T

Areas to assess in relationship to cardiac/circulatory function

Edema
Muscle cramps
Jugular veins/ Jugular Vein Distension
Examine common problems of clients experiencing cardiac/circulatory disorders across the lifespan.
1) Shortness of breath
2) Chest pain
3) Palpitations
4) Ecchymosis, petechiae
5) Sore mouth, bleeding gums
6) Hemorrhage
7) Frothy sputum
8) Pain
9) Muscle cramps
10) Skin changes of extremities
11) Coolness and pallor
12) Edema
13) Irregular pulse
14) Irregular blood pressure
15) Faint or absent peripheral pulses
16) Positive Homan’s sign
17) Neck vein distribution
18) Weakness, fatigue, drowsiness
19) Cyanosis
20) Diaphoresis
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Examine common problems of clients experiencing cardiac/circulatory disorders across the lifespan.
21) Congestion in lungs
22) Productive cough and/or hemoptysis
23) Intermittent claudication
24) Rest pain in lower extremities
25) Restlessness, anxiety
26) Dyspnea
27) Fluid volume deficit/excess

Intake & Output

Great indicator of
 Cardiac output (“No pump, no pee”)
 Fluid volume status
Look at color of urine (water → tea)
Urine specific gravity (1.003 to 1.035)

Nursing Diagnosis of clients experiencing cardiac/circulatory disorders across the lifespan.

1) Nutrition, altered, less than or greater than body requirements
2) Activity intolerance
3) Tissue perfusion, altered
4) Cardiac output, decreased
5) Fluid volume deficit/excess
6) Risk for infection
7) Pain
8) Anxiety
9) Knowledge deficit

Unit IV Respiratory Health Assessment

A. Health History
B. Nursing Assessment
1) Areas to assess in relationship to respiratory function
a. Respirations
 Rate
 Pattern
 Depth
b. Breath sounds
c. Sputum
d. Pain
e. Skin- color, temperature, moisture, petechiae
f. Numbness and tingling
g. Thoracic cage
h. Mental status
i. Skin changes of extremities
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YouTube Breath Sounds

http://www.youtube.com/watch?v=gOB0nM0PRTc
http://www.youtube.com/watch?v=5JA6D1Mguh0&list=TLfojAd3aUCFA

Gas Exchange at the Alveolus

Examine common problems of clients experiencing respiratory disorders across the lifespan.
1) Shortness of breath
2) Barrel chest
3) Frothy sputum
4) Pain
5) Coolness and pallor
6) Weakness, fatigue
7) Congestion in lungs
8) Productive cough and/or hemoptysis
9) Abdominal breathing
10) Restlessness, anxiety
11) Dyspnea

Dyspnea R/T
1. Increased ventilatory demand
 exertion, febrile illness, hypoxic state, severe anemia, or metabolic acidosis
2. Decreased ventilatory capacity
 pleural effusion, pneumothorax, intrathoracic mass, rib injury, or muscle weakness
3. Increased airway resistance
 asthma or chronic obstructive pulmonary disease (COPD)
4. Decreased pulmonary compliance
 interstitial fibrosis or pulmonary edema

Examine common problems of clients experiencing respiratory disorders across the lifespan.
12) Respiratory
 Tachypnea
 Bradypnea
 Orthopnea
 Cheyne-Stokes
 Apnea
 Cyanosis
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Nursing Diagnosis of clients experiencing respiratory disorders across the lifespan.

1) Gas exchange, impaired
2) Airway clearance, ineffective
3) Breathing pattern, ineffective
4) Anxiety
5) Infection, risk for
6) Fatigue
7) Knowledge deficit

Nursing Assessment: Gordon’s Functional Health Patterns

a. Health-Perception Health Management
b. Nutritional –Metabolic
c. Activity-Exercise
d. Sleep-Rest
e. Role-Relationship
f. Elimination
g. Sexuality-Reproduction
h. Coping-Stress Tolerance
i. Value-Belief

Maslow’s Hierarchy of Needs:

Use this to prioritize your client’s needs.

When assessing a client, ask yourself, “Is the client Stable or Unstable?

Health Assessment:
 Lifespan Considerations
 Cultural Considerations