Exam (elaborations) NURSING 113 Focused Exam Chest Pain Brian Foster 2

Exam (elaborations) NURSING 113 Focused Exam Chest Pain Brian Foster 2 FOCUSED EXAM: CHEST PAIN Patient: Brian Foster Grade: 100% Subjective Data Collection 23 out of 23 Objective Data Collection 21 out of 21 Time 183 minutes total spent in assignment Objective Data Collection: 21 of 21 (100%) Inspected face 1 of 1 point Appearance (1/1 point)  No visible abnormal findings  Rash or lesion  Cyanosis  Pallor  Redness or flushing  Evidence of trauma (scar, laceration, or bruising) Inspected for jugular venous distension 1 of 1 point Height Of Venous Pressure (1/1 point)  4 cm or less above the sternal angle  More than 4 cm above the sternal angle Inspected chest 1 of 1 point Symmetry (1/2 point)  Symmetric NURSING 113 Focused Exam Chest Pain Brian Foster 2018  Asymmetric Appearance (1/2 point)  No visible abnormal findings  Rash or lesion  AP diameter abnormal  Intercostal retraction while breathing  Excessive use of accessory muscles while breathing  Pectus excavatum  Skin growths (freckles or moles)  Evidence of skin trauma (scar, laceration, or bruising) Inspected hands and fingernails 1 of 1 point Right: Appearance (1/4 point)  No visible abnormal findings  Redness  Moles or skin tags  Masses (warts, cysts, or tumors)  Freckles, birthmark, or other discoloration  Excessive dry or flaking skin  Purpura  Scarring  Laceration, lesion, or wound  Bruising  Rash Left: Appearance (1/4 point)  No visible abnormal findings  Redness  Moles or skin tags  Masses (warts, cysts, or tumors)  Freckles, birthmark, or other discoloration  Excessive dry or flaking skin  Purpura  Scarring  Laceration, lesion, or wound  Bruising  Rash Right: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Left: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Inspected lower extremities and toenails 1 of 1 point Right: Appearance (1/4 point)  No visible abnormal findings  Visible distortion or swelling  Brownish pigmentation  Skin thickening  Ulceration  Varicose veins Right: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Left: Appearance (1/4 point)  No visible abnormal findings  Visible distortion or swelling  Brownish pigmentation  Skin thickening  Ulceration  Varicose veins Left: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Inspect lower extremities for edema 1 of 1 point Right: Edema (1/4 point)  No edema  Pitting  Non-pitting Right: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Left: Edema (1/4 point)  No edema  Pitting  Non-pitting Left: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Tested capillary refill time 1 of 1 point Fingers (1/2 point)  Less than 3 seconds  Greater than 3 seconds Toes (1/2 point)  Less than 3 seconds  Greater than 3 seconds Palpated carotid arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated PMI 1 of 1 point Location (1/3 point)  Present at midclavicular line and 5th intercostal space  Displaced laterally Diameter (1/3 point)  Less than 3 cm  Greater than 3 cm Amplitude (1/3 point)  Brisk and tapping  Increased amplitude (hyperkinetic) Palpated brachial arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated radial arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated femoral arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated popliteal arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated tibial arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Palpated dorsalis pedis arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Auscultated carotid arteries 1 of 1 point Right (1/2 point)  No bruit  Bruit Left (1/2 point)  No bruit  Bruit Auscultated heart sounds 1 of 1 point Heart Sounds (1/2 point)  S1 and S2 audible  S1, S2, and S3 audible  S1, S2, and S4 audible  S1, S2, S3, and S4 audible Extra Heart Sounds (1/2 point)  No extra sounds  Gallops  Murmur  Friction rub  Valve clicks Auscultated abdominal aorta 1 of 1 point Sounds (1/1 point)  No bruit  Bruit Auscultated abdominal and lower extremity arteries 1 of 1 point Right: Renal (1/6 point)  No bruit  Bruit Right: Iliac (1/6 point)  No bruit  Bruit Right: Femoral (1/6 point)  No bruit  Bruit Left: Renal (1/6 point)  No bruit  Bruit Left: Iliac (1/6 point)  No bruit  Bruit Left: Femoral (1/6 point)  No bruit  Bruit Auscultated breath sounds 1 of 1 point Breath Sounds (1/3 point)  Present in all areas  Diminished in some areas  Absent in some areas Adventitious Sounds (1/3 point)  No adventitious sounds  Wheezing  Fine crackles  Stridor  Rhonchi  Rales Location (1/3 point)  All areas clear  Adventitious sounds in anterior right upper lobe  Adventitious sounds in anterior right middle lobe  Adventitious sounds in anterior right lower lobe  Adventitious sounds in anterior left upper lobe  Adventitious sounds in anterior left lower lobe  Adventitious sounds in posterior right upper lobe  Adventitious sounds in posterior right lower lobe  Adventitious sounds in posterior left upper lobe  Adventitious sounds in posterior left lower lobe Performed EKG 1 of 1 point Sinus Rhythm (1/2 point)  Regular  Irregular St Changes (1/2 point)  No ST elevation  ST elevation present Subjective Data Collection: 23 of 23 (100.0%) A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Finding: Established chief complaint Finding: Reports chest pain (Found) Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source. Example Question: Do you have chest pain? History of Presenting Illness Finding: Asked about onset and duration of chest pain Finding: Reports chest pain started about five minutes ago (Found) Pro Tip: Establishing the onset of a patient's chest pain is essential in diagnosing its severity as well as the comfort of the patient. Example Question: When did the chest pain start? Finding: Reports chest pain has been constant since it began (Available) Pro Tip: Knowing the duration of a patient's pain gives you a more complete picture of its severity and potential impact on the patient's health. Example Question: How long does the chest pain last? Finding: Reports sitting in bed when pain began (Found) Pro Tip: A patient's position and posture when their pain began can inform you as to the nature of the pain, as pain upon exertion often has different causes than pain upon resting. Example Question: Were you sitting when the pain began? Finding: Asked to rate chest pain on a scale Finding: Reports current pain is 6/10 (Found) Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity. Example Question: On a scale of 0 to 10 how would you rate the chest pain? Finding: Asked about on characteristics of the pain Finding: Describes pain as tight and uncomfortable (Found) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Can you describe your pain? Finding: Denies crushing pain (Found) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain crushing? Finding: Denies gnawing or tearing pain (Found) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain gnawing? Finding: Denies burning pain (Found) Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning. Example Question: Is the pain burning? Finding: Asked about location of the pain Finding: Reports pain location is in middle of the chest (Found) Pro Tip: Identifying the location of a patient's pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat i