John Gordon Assessment & Reasoning Cardiac System 2021 | NUR 213 Cardiac System _ COMPLETE

John Gordon Assessment & Reasoning Cardiac System 2021 | NUR 213 Cardiac System _ COMPLETE Assessment & Reasoning Cardiac System John Gordon, 65 years old Suggested Cardiac Nursing Assessment Skills to Be Demonstrated: Anterior: Inspection • Chest pulsations, heaves, lifts, color of skin; symmetry of movement; anatomical defects, retractions Palpation • Apical impulse (4th to 5th ICS, Left MCL) Auscultation • HR & rhythm (60-100 bpm) • Identify S1 & S2 – 2nd ICS, Right sternal border (aortic); 2nd ICS, Left sternal border (pulmonic); 3rd ICS, Left sternal border (Erbs); 4th ICS, Left sternal border (tricuspid); 5th ICS, Left MCL (pulmonic). S1 is louder at Apex, S2 louder at the base. This is the traditional method and a systematic method of learning. • Diaphragm and bell to be used. Do not allow the patient to hold breath. Auscultate for S3 and S4 heart sounds and murmurs. May be done in lying and sitting position, lying on left side and on back with head elevated 30 degrees Peripheral Arms: • Inspection –for symmetry, skin characteristics, hair distributions size (edema), venous pattern, color • Palpation – temperature using back of the hand, cap. refill Pulses • Palpation of radial/ulnar pulses, if suspecting arterial insufficiency, palpate brachial artery Legs: • Inspection – for symmetry, skin characteristics, hair distributions, size(edema), venous pattern, color, varicosities, thrombophlebitis • Palpation – edema, temperature, inguinal lymph nodes, • Pulses - femoral, popliteal, pedal Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group. • Review the case study as an application exercise in small groups or together as a class. • Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead, use it to promote learning by having students identify what they do not yet know and provide guidance on where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge! - - -