Cardiovascular Assessment
This vital sign is one of the first assessments performed when evaluating a client for cardiovascular distress.
What is blood pressure?
The first step of the nursing process involves collecting subjective and objective information about the client.
What is assessment?
This condition occurs when the heart cannot pump enough blood to meet the body's metabolic needs.
What is heart failure?
A low hemoglobin level decreases the blood's ability to transport this essential substance to tissues.
What is oxygen?
Before starting a blood transfusion, the nurse must verify the client's identity and compare the blood product with this information.
What is the blood type/compatibility and transfusion order?
A client with left-sided heart failure develops crackles and increasing shortness of breath. These findings suggest fluid accumulation in this organ.
What are the lungs?
A client with heart failure has a 3-kg weight gain over several days and increasing bilateral leg edema. The nurse should prioritize this problem.
What is excess fluid volume?
A client with shock has hypotension, tachycardia, cool clammy skin, and altered mental status. These findings indicate inadequate delivery of this to the tissues.
What is oxygen/perfusion?
A client with severe anemia may experience fatigue, weakness, dyspnea, and this cardiovascular response as the body attempts to compensate.
What is tachycardia?
During a transfusion, the client develops fever, chills, back pain, and anxiety. The nurse's first action is to stop this.
What is the blood transfusion?
This assessment finding may indicate decreased peripheral perfusion when the extremity is cool, pale, and has a weak or absent pulse.
What is impaired peripheral circulation?
For a client with chronic heart failure, this assessment is especially useful for identifying fluid retention early.
What is daily weight?
In a client experiencing acute circulatory compromise, the nurse's initial priority is to assess and support these three basic functions: airway, breathing, and this.
What is circulation?
A client with thrombocytopenia is at increased risk for this complication because platelets are essential for normal clot formation.
What is bleeding/hemorrhage?
After stopping a suspected transfusion reaction, the nurse should maintain IV access using this solution according to institutional policy.
What is normal saline (0.9% sodium chloride)?
A client reports new chest pressure accompanied by diaphoresis, nausea, and shortness of breath. The nurse should recognize these findings as possible signs of this cardiovascular emergency.
What is acute coronary syndrome/myocardial infarction?
A client with peripheral arterial disease reports severe leg pain with activity that improves with rest. The nurse should prioritize interventions aimed at improving this problem.
What is impaired peripheral tissue perfusion?
A client suddenly develops unilateral leg swelling, warmth, and pain. The nurse should suspect this vascular disorder and assess for complications.
What is deep vein thrombosis (DVT)?
A client receiving anticoagulant therapy develops bleeding, hypotension, and a decreasing hemoglobin level. The nurse's priority is to recognize this potentially life-threatening complication.
What is hemorrhage?
Fever, chills, flushing, dyspnea, hypotension, and hemoglobinuria during or shortly after a transfusion may indicate this serious type of reaction.
What is an acute hemolytic transfusion reaction?
A client suddenly develops severe dyspnea, hypotension, distended neck veins, and muffled heart sounds. The nurse should suspect this life-threatening condition involving compression of the heart.
What is cardiac tamponade?
When evaluating whether a cardiovascular nursing intervention has been effective, the nurse should compare the client's current findings with these established targets.
What are the expected outcomes/goals of the care plan?
A client with a suspected DVT suddenly develops chest pain, dyspnea, tachycardia, and hypoxemia. The nurse should recognize this potentially fatal complication.
What is a pulmonary embolism (PE)?
A client develops sudden neurologic changes, chest pain, or shortness of breath associated with abnormal clot formation. The nurse must recognize this as a possible consequence of this hematologic problem.
What is thromboembolism?
A client receiving multiple blood products develops dyspnea, pulmonary edema, and hypertension. The nurse should suspect this transfusion-associated complication caused by circulatory volume overload.
What is transfusion-associated circulatory overload (TACO)?