Steps of Assessment
What is the first step of the cardiac assessment in the head to toe?
Assessing
What is included in the assessing step of the cardiac assessment?
A history, physical examination, a review of relevant diagnostic data
What is the first cardiac landmark a nurse auscultates, and where is it located?
Aortic, it is found at the second intercostal space just right of the sternum
What is the normal range for heart rate?
60-100 beats per minute
What do you need the client to describe regarding the cardiac assessment?
If they have any pain in their chest/breasts
What is the second step of the cardiac assessment in the head to toe?
Nursing History
What is included in the nursing history phase?
Current or past cardiac problems, family history of cardiac problems, exercise/activity level, diet, presence of any symptoms, medications, and lifestyle
What is the second cardiac landmark to be auscultated?
Pulmonic, left of the sternum at the second intercostal space
When documenting, what do you need to include for heart rate?
The number of beats per minute, and if it was regular or irregular
What are some symptoms that you should ask the client to expand upon during the assessment?
Dizziness, shortness of breath, and fatigue
What is third step of the cardiac assessment in the head to toe?
Physical Examination
What is included in the physical assessment phase?
Heart rate, auscultating 5 cardiac landmarks, checking for bruits, and capillary refill
What is the third cardiac landmark to be auscultated?
Erb's Point, just left of the sternum at the third intercostal space
While auscultating, what must be noted?
S1 and S2 sounds must be noted
What lifestyle habits should you inquire about while assessing the cardiac area?
medications, tobacco use, alcohol consumption, caffeine consumption, dietary pattern, and activity level
Where do you assess for bruits?
Carotid, iliac, renal, and aortic
What is the fourth cardiac landmark and where is it located?
Tricuspid, just left of the sternum at the fourth intercostal space
What sounds should you not hear?
S3 and S4
How quickly should color come back, when testing capillary refill?
What is fifth cardiac landmark and where is it located?
Mitral, left midclavicular line at the fifth intercostal space
After assessing the five cardiac landmarks, how should you document a healthy heart?
Regular rate/rhythm noted, no adventitious sounds