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!
© 2019 Keith Rischer/www.KeithRN.com
Present Problem:
John Gordon is a 65-year-old male who has a history of myocardial infarction (MI) two years ago and heart failure with a
current ejection fraction (EF) of 30%. He presents to the emergency department (ED) for increasing shortness of breath
(SOB) for the past three days. He is more fatigued than usual and becomes short of breath with minimal activity. The last
two nights he had to sleep upright in a recliner so he could breathe easier and fall asleep. He has noted increased swelling
in his lower legs and has gained six pounds the last two days.

What data from the present problem are RELEVANT and must be interpreted as clinically significant by the
nurse? (Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:

65 yr old male, history of MI and heart Preexisting heart condition will influence assessment and some
failure increasing swelling lower leg and finding short of breath and orthopnea weight gain swelling are sign
weight gain and symptoms are sign of heart failure

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current
meds? (Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):

Myocardial infarction Aspirin 81 mg PO daily Nsaid Decrease the platelet aggregation

Ischemic Lisinopril 20 mg PO Ace inhibitor dilate the blood vessels to improve

cardiomyopathy
w/ejection fraction 30%
your blood flow
daily Carvedilol 25 mg
Beta blocker
PO BID beta-blocker effects in heart failure
are cardiac protection from beta1-
adrenoceptor overstimulation,
antiarrhythmic effects, reduction in
heart rate and positive energetic
effects

You place John on a cardiac monitor, continuous oximetry

and quickly collect the following assessment data:

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 98.6 F/37.0 C (oral) Provoking/Palliative:
P: 92 (reg) Quality: Denies Pain

R: 26 (reg) Region/Radiation:
 BP: 162/84 MAP: 110 Severity:
O2 sat: 91% room air Timing:

What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:

Resp 26 Expiring tachypnea respiratory distress due to ishme

BP 162/84 Past medical history taking lisinopril it interfere with hypternsive

O2 91% Heart failure can lead to low oxygen saturation hypoxia and decreased cardiac output

© 2019 Keith Rischer/www.KeithRN.com

Current Assessment:

GENERAL Appears anxious, restless

APPEARANCE:

RESP: Breath sounds have coarse crackles on inspiration and expiration scattered throughout
both lung fields ant/post, labored respiratory effort, patient sitting upright

CARDIAC: Forehead diaphoretic, cool to the touch, radial, pedal and post-tibial pulses regular 3+, has
3+ pitting edema bilateral lower extremities in feet, ankles, 2+ up to knees bilat, S3 gallop
most prominent over apex, no jugular venous distention (JVD) noted sitting up at 45
degrees

NEURO: Alert and oriented to person, place, time, and situation (x4)

GI: Abdomen pale soft/nontender, symmetrical, bowel sounds audible per auscultation in all
four quadrants

GU: Voiding without difficulty, urine clear/yellow

IINTEGUMENTARY: Pale, skin integrity intact, skin turgor elastic, no tenting present, cap. Refill brisk <1 second

What assessment findings are abnormal? What is the reason (pathophysiology) for these
findings? (Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:

Appears anxious, restless Anxiety can due conditions heart failure also effect of dypea

Breath sounds have coarse crackles
on inspiration
post-tibial pulses regular 3+, has 3+
pitting edema bilateral lower
Crackles could lead to left sided heart faikre pt upright to help
breathing
Poor circulation can lead to diaphoresis and cool extremities
 extremities in feet, ankles, 2+ up

Put it All Together and Think Like a Nurse!

1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most
thoroughly based on the primary/priority concern?
What’s the What’s causing the problem? PRIORITY
problem? (explain pathophysiology in OWN words) Body System
to Assess:

pulmonary When the left side of the heart is failing, it can't handle the Cardiac system
peripheral blood it is getting from the lungs. Pressure then builds up
congestive heart
in the veins of the lungs, causing fluid to leak into the lung
failure and Lv
tissues. This may be referred to as congestive heart
failure
failure.

2. Which specific nursing assessments for this body system are most important? Validate successful completion of
each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY Nursing Assessments: Rationale: Validate
Student
Performance:

Assess heart rate, rhythm apical pulse Listen to dysrhythm

Heart sounds associated with HF
Lungs sounds Pulmonary congestion
Daily weight for crackles in lungs
Monitor intake and output
Assess Fluid intake
Monitor BP for lower extremities

© 2019 Keith Rischer/www.KeithRN.com

3. If this patient begins to complain of chest pain, what specific questions would you ask to thoroughly
assess this patient, document in the medical record and communicate to the primary care provider?

4. What is the current nursing priority and plan of care?

Nursing PRIORITY: Excess fluid volume

PRIORITY Nursing Interventions: Rationale: Expected

Outcome:
Determine the amount of fluid Fluid overload due to fluid shift and changes in Stabilizes fluid
intake from all source intake of electrotye imbalance volume as
sodium postassoum and protein evidence by
balance intake
and output

5. State the rationale and expected outcomes for the medical plan of care.
Medical Management: Rationale: Expected Outcome:

Titrate oxygen to keep Allow avaluty of oxygen for gas exchange and incase Relieve symptoms of hypoxia
O2 sat >92% oxygen saturation of shortness of breath

Furosemide 40 mg IV push
Nitroglycerin 0.4 mg
transdermal patch daily
Strict I&O
Loop diuretics blocks chloride and reabsorption Improve pateintn hearth status
of current heart failure
Vasodilators are highly considered when treating Heart Increase cardiac output
failure and they reduce circulating volume and decrease
SVR by reducing ventricular workoard

Fluid restriction of 2000

mL PO daily

Low sodium diet

Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray

Results: Clinical Significance:

Bilateral diffuse pulmonary Pulmonary vascular congestion due to heart failure a significant cause of patient
infiltrates consistent with impaired gas exchange and hypoxia
pulmonary edema

© 2019 Keith Rischer/www.KeithRN.com

Lab Results:
Basic Metabolic Panel (BMP)

Na K Gluc. Creat.
 Current: 133 4.9 105 1.9

RELEVANT Lab(s): Clinical Significance:

Na 133 Fluid retention that increase myocardial workload

K 4.9 Elevate fluid and electrolyte balance to monitor

Creat 1.9 Very high and indicates heart failure problem with cardiac output related excess
fluid volume

Cardiac

Trop. BNP Mg

Current: 0.01 985 1.8

What lab results are RELEVANT and must be recognized as clinically significant by the
nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance:

Troponin 0.01 Increased amount are released in the bloodstream when infarction can cause
myocardium

BNP 985 BNP levels may be caused by intrinsic cardiac dysfunction or may be
secondary to other causes such as pulmonary or renal diseases

Evaluation: 60 minutes later…

Students construct the remainder of this case study by determining what they would
notice if client condition improves or deteriorates (faculty decides!)

Evaluate the response of your patient to nursing and medical interventions during your shift.
All physician orders have been implemented that are listed under client management.
Current VS: Most Recent: Current PQRST:

T: T: 98.6 F/37.0 C (oral) Provoking/Palliative:

P: P: 92 (reg) Quality:
 R: R: 26 (reg) Region/Radiation:

BP: BP: 162/84 MAP: 110 Severity:

O2 sat: O2 sat: 91% room air Timing:

© 2019 Keith Rischer/www.KeithRN.com

Current Assessment:

GENERAL
APPEARANCE:

RESP:

CARDIAC:

NEURO:

GI:

GU:

INTEGUMENTARY:

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable:
R 22 Cardiac output vitals signs are within in Improved
BP 138/ normal range
O94CAR

RELEVANT Clinical Significance: TREND: Improve/Worsening/Stable:

Assessment Data:

2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be
modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
Improved due to intervention a Patient been taken care and monitor improve heart
complication

3. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and
weaknesses this case study identified. What is your plan to make any weakness a future strength?
What Did You Learn? What did you do well in this case study?

Cardiac system specifically heart failure I think the intervention with position upright

What could have been done better? What is your plan to make any weakness a future strength?

Critical thinking Weakness is nursing judgement future strength is making

connection through assessment

© 2019 Keith Rischer/www.KeithRN.com