{"id":3708,"date":"2018-11-12T20:05:29","date_gmt":"2018-11-13T01:05:29","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&#038;p=3708"},"modified":"2019-09-30T12:59:49","modified_gmt":"2019-09-30T16:59:49","slug":"2-8-head-to-toe-assessment-cardiovascular-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-8-head-to-toe-assessment-cardiovascular-assessment\/","title":{"raw":"2.8 Head-to-Toe Assessment: Cardiovascular Assessment","rendered":"2.8 Head-to-Toe Assessment: Cardiovascular Assessment"},"content":{"raw":"Checklist 18 provides a guide for subjective and objective data collection in a cardiovascular assessment.\r\n<table style=\"border: 1px solid #000000;width: 100%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\">\r\n<h3 align=\"center\" style=\"text-align: center\"><span style=\"color: #000000\">Checklist 18:<\/span>\u00a0Cardiovascular (CV) Assessment<\/h3>\r\n[caption id=\"attachment_3683\" align=\"aligncenter\" width=\"300\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System.png\" rel=\"noopener\" target=\"_blank\"><img width=\"300\" height=\"169\" class=\"wp-image-3683 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System-300x169.png\" \/><\/a> Figure 2.11 Cardiovascular system[\/caption]\r\n<h5 style=\"text-align: center\" align=\"center\"><em>Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.<\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 100%\">\r\n<h5><span style=\"color: #000000\">Safety considerations:<\/span><\/h5>\r\n<ul>\r\n \t<li><span style=\"color: #333333\">Perform hand hygiene.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Introduce yourself to patient.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Explain process to patient.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Be organized and systematic in your assessment.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Use appropriate listening and questioning skills.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Listen and attend to patient cues.<\/span><\/li>\r\n \t<li><span style=\"color: #333333\">Ensure patient's privacy and dignity.<\/span><\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border: 1px solid #000000;width: 100%\" border=\"1\">\r\n<tbody>\r\n<tr style=\"height: 118px\">\r\n<td style=\"width: 99.92%;height: 118px\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Objective Data<\/h3>\r\n<h5 style=\"text-align: center\">Consider the following observations.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000\">\r\n<h4 style=\"text-align: center\">Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Colour<\/strong> of Skin &amp; Mucous Membranes<\/td>\r\n<td style=\"border: 1px solid #000000\">Cyanosis (a bluish tinge) may suggest inadequate oxygenation and CV compromise<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Temperature<\/strong> of Extremities<\/td>\r\n<td style=\"border: 1px solid #000000\">Hot skin may suggest fever and should be followed up with full vital signs, report to the primary prescriber, and investigation of any suspected sources of infection.\r\n\r\nCold skin may suggest existing or new circulatory related issues.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Blood Pressure,\u00a0Heart Rate,\u00a0SpO<sub>2<\/sub><\/strong><\/td>\r\n<td style=\"border: 1px solid #000000\">Baseline vital signs are important in any assessment. Vital signs should be compared to the patient\u2019s normal values. Patterns and trends outside of the normal range should be reported to the appropriate person.\r\n\r\nSee <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-4-vital-signs\/\">Chapter 2.4 Vital Signs<\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Capillary Refill<\/strong>\r\n\r\n<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" class=\" wp-image-331 aligncenter\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-300x199.jpg\" \/><\/a><\/td>\r\n<td style=\"width: 50%;height: 266px\">Press on the nail beds of toes and\/or fingers until there is blanching (whiteness). Release the pressure and count how many seconds until the patient\u2019s full colour returns.\r\n<ul>\r\n \t<li><strong>Brisk capillary refill<\/strong>: &lt; (less than) 3 seconds<\/li>\r\n \t<li><strong>Delayed capillary refill<\/strong>: &gt; (greater than) 3 seconds<\/li>\r\n<\/ul>\r\nDelayed cap refill may suggest cardiovascular or respiratory dysfunction and should be followed-up with a focused assessment.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Edema<\/strong>\r\n\r\n[caption id=\"attachment_4157\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" class=\"wp-image-4157\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema-300x234.jpg\" \/><\/a> Figure 2.12 Hand edema[\/caption]\r\n\r\n[caption id=\"attachment_4158\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" class=\"wp-image-4158 size-full\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema.jpg\" \/><\/a> Figure 2.13 Foot and ankle edema[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000\">Edema can be the result of many things, including:\r\n<ul>\r\n \t<li>Inflammatory response from things like bee stings, sprains, or injury<\/li>\r\n \t<li>Altered venous return<\/li>\r\n \t<li>Diseases of the lymphatics<\/li>\r\n \t<li>Fluid shifts<\/li>\r\n \t<li>Side effects of some medications<\/li>\r\n \t<li>Circulatory overload<\/li>\r\n \t<li>Heart failure<\/li>\r\n<\/ul>\r\nIt is important to ask the patient if is this normal for them.\r\n\r\nObserve limbs simultaneously in order to compare.\u00a0Unilateral edema of the leg may suggest deep vein thrombosis (DVT).\r\n\r\nEdematous tissue has a high risk of skin breakdown. Implement strategies to maintain skin integrity.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\">Palpate Extremities to Quickly Assess Colour, Warmth, Movement, and Sensation (CWMS), Capillary Refill of Hands and Feet\r\n\r\n<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2279-1.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" height=\"199\" class=\"aligncenter size-medium wp-image-328\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2279-1-300x199.jpg\" \/><\/a><\/td>\r\n<td style=\"width: 50%;height: 348px\"><strong>Colour<\/strong> and <strong>warmth<\/strong> provide information about perfusion.\r\n\r\n<strong>Movement<\/strong> provides a brief overview about musculoskeletal function of extremities, which is affected by circulation.\r\n\r\n<strong>Sensation<\/strong>: by asking if the client has numbness and\/or tingling in extremities the nurse gets a brief overview of client baseline. Altered sensation may be the result of impaired neurological function or impaired perfusion.\r\n\r\nPalpate pulses for symmetry in quality, rate, and rhythm. This provides information about perfusion.\r\n\r\nAsymmetry in relation to assessment findings may indicate a number of things including cardiovascular conditions, history of injury, or post surgical complications.\r\n\r\nReport concerns to the appropriate healthcare professional.\r\n\r\n&nbsp;<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\">Auscultate: Apical Heart Rate for Rate and Rhythm\r\n\r\n<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" class=\"aligncenter size-medium wp-image-314\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-300x199.jpg\" \/><\/a><\/td>\r\n<td style=\"width: 50%;height: 266px\">Apical pulses are assessed using a stethoscope placed over the 4th\u20135th intercostal space of the midclavicular line on the left side on adults.\u00a0For accuracy, an apical heart rate should be taken for a full minute. Identify S1 and S2 and follow up on any unusual findings.\r\n\r\nSee <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&amp;p=112&amp;preview=true\">Chapter 2.3 Vital Signs<\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000\">\r\n<td style=\"border: 1px solid #000000\"><strong>Clubbing of Nails<\/strong>\r\n\r\n[caption id=\"attachment_3682\" align=\"aligncenter\" width=\"250\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"250\" class=\"wp-image-3682 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails-300x225.jpg\" \/><\/a> Figure 2.14 Clubbing of finger nails[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000\">Clubbing of nails may suggest underlying cardio pulmonary disease<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border: 1px solid #000000;width: 100%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 50%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Subjective Data<\/h3>\r\n<h5 style=\"text-align: center\">Ask about chest discomfort, pain, or pressure. All of these may be indicative of a larger cardiovascular issue. Reports of these must be followed up with a more detailed assessment and notification to the appropriate healthcare provider.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 50%\" colspan=\"2\">\r\n<h4 style=\"text-align: left\">A focused cardiovascular assessment may also include:<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Rating of\u00a0Edema\u00a0Using an Objective Scale\r\n\r\n[caption id=\"attachment_3691\" align=\"aligncenter\" width=\"244\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"244\" height=\"240\" class=\"wp-image-3691 size-full\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema.jpg\" \/><\/a> Figure 2.15 Pitting edema[\/caption]<\/td>\r\n<td style=\"width: 50%\">\r\n<table style=\"border-collapse: collapse;width: 99.8498%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\" colspan=\"4\">Rating of Edema<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">Grade<\/td>\r\n<td style=\"border: 1px solid #000000;width: 52.5526%;text-align: center\">Description<\/td>\r\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">Depth of Indent<\/td>\r\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">Time to Return to Normal<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+1<\/td>\r\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Slight pitting, no visible change in the shape of the extremity;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">0\u20131\/4 inch\r\n(&lt; 6 mm)<\/td>\r\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">Rapidly<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+2<\/td>\r\n<td style=\"border: 1px solid #000000;width: 52.5526%\">No marked change in the shape of the\r\n\r\nextremity<\/td>\r\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">1\/4\u20131\/2\u201d\r\n(6\u201312 mm)<\/td>\r\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">10\u201315 seconds<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+3<\/td>\r\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Noticeably deep pitting, swollen extremity<\/td>\r\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">1\/2\u20131\u201d\r\n(1\u20132.5 cm)<\/td>\r\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">1\u20132 minutes<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+4<\/td>\r\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Very swollen, distorted extremity<\/td>\r\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">&gt; 1\u201d\r\n(&gt;2.5 cm)<\/td>\r\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">2\u20135 minutes<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: left\" colspan=\"4\">Adapted from Brodovicz et al., 2009<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 50%\">\r\n<p style=\"margin-left: 18.0pt\">Jugular Vein Distension (JVD)<\/p>\r\n\r\n\r\n[caption id=\"attachment_3684\" align=\"aligncenter\" width=\"163\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"163\" height=\"163\" class=\"wp-image-3684 \" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD.jpg\" \/><\/a> Figure 2.16 Jugular vein distension (JVD)[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Jugular vein distension of more than 3 cm above the sternal angle while the patient is sitting at\r\n45 degrees may indicate heart failure.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Rating of Peripheral Pulses\u00a0Using an Objective Scale\r\n\r\n[caption id=\"attachment_3690\" align=\"aligncenter\" width=\"191\"]<a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg.jpg\" rel=\"noopener\" target=\"_blank\"><img width=\"191\" height=\"300\" class=\"wp-image-3690 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg-191x300.jpg\" \/><\/a> Figure 2.17 Pulse Sites[\/caption]<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Pulse quality may be important to assess following surgery when the patient is at risk for arterial compromise (i.e., graft occlusion). A deterioration in pulse quality might suggest arterial occlusion.\r\n<table style=\"border-collapse: collapse;width: 99.8498%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\" colspan=\"2\">\u00a0Peripheral Pulse Rating Scale<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">Rating<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%;text-align: center\">Description<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">0<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%\">No pulse<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+1<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Faint but detectable<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+2<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Slightly diminished compared to normal<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+3<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Normal<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+4<\/td>\r\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Bounding<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: left\" colspan=\"2\">Adapted from Hill &amp; Smith, 1990<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Auscultation of Heart Sounds<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%\">Depending on the context, nurses may need to have the skill to be able to assess specific heart sounds.\r\n\r\nAdditional resources:\r\n<ul>\r\n \t<li><span style=\"font-size: 18.9px\">Last Second Medicine. (2017, June 12).\u00a0<\/span><em>Complete heart sounds in 7 minutes - with heart sounds audio<\/em> [Video file]. Retrieved from\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=6StYVx6BVLo\">https:\/\/www.youtube.com\/watch?v=6StYVx6BVLo<\/a>.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 50%\" colspan=\"2\">Potential cardiovascular related nursing diagnoses:\r\n<ul>\r\n \t<li>Activity intolerance related to diminished cardiac function.<\/li>\r\n \t<li>Acute chest pain due to increased cardiac workload.<\/li>\r\n \t<li>Ineffective cardiac or peripheral tissue perfusion secondary to heart failure.<\/li>\r\n \t<li>Learning need in relation to risk factors associated with cardiovascular disease.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 50%\" colspan=\"2\">Data sources: Assessment Skill Checklist, 2014; BCCNP, 2018; Brodovicz et al., 2009; Hill &amp; Smith, 1990; Jarvis, Browne, MacDonald-Jenkins, &amp; Luctkar-Flude, 2014; Perry, Potter, &amp; Ostendorf, 2018; Potter et al., 2019; Stephen, Skillen, Day, &amp; Jensen, 2012; Wilson &amp; Giddens, 2013<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>A client has +4 edema to bilateral feet and ankles. Identify two strategies to assist in maintaining skin integrity.<\/li>\r\n \t<li>A client has just had a femoral popliteal bypass. Which peripheral pulses should be included in the assessment specific to determining arterial perfusion of the affected leg?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<h2>Attributions:<\/h2>\r\nFigure 2.11\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Human_Heart_and_Circulatory_System.png\">3D Human Heart and Circulatory System Illustration<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:WhatIfWeCould&amp;action=edit&amp;redlink=1\">Bryan Brandenburg<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.\r\n\r\nFigure 2.12\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:2707_Edema_of_Right_Hand_Due_to_Allergic_Reaction.jpg\">Edema of Right Hand Due to Allergic Reaction<\/a> by CNX Openstax is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> Attribution 4.0 International license.\r\n\r\n<span style=\"text-indent: 1em;font-size: 14pt\">Figure 2.13\u00a0<\/span><a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Catastrophic_Edema_of_the_legs_harefield_hospital_10.jpg\" style=\"text-indent: 1em;font-size: 14pt\">Post Heart Transplant 21 October 2018 Harefield Hospital<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> by <\/span><a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Ryaninuk&amp;action=edit&amp;redlink=1\" style=\"text-indent: 1em;font-size: 14pt\">Ryaninuk<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> is used under a <\/span><a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" style=\"text-indent: 1em;font-size: 14pt\">Creative Commons<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> <\/span><a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/deed.en\" style=\"text-indent: 1em;font-size: 14pt\">Attribution 4.0 International.<\/a>\r\n\r\nFigure 2.14\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Acopaquia.jpg\">Clubbing Fingers<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Desherinka\">Desherinka<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">Attribution-Share Alike 4.0 International license<\/a>.\r\n\r\nFigure 2.15\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Combinpedal_Right_to_Left.jpg\">Pitting Edema<\/a> by James Heilman is used under a\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.\r\n\r\nFigure 2.16\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Jugular_Venous_Distention_(JVD).JPG\">JVD<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Ferencga&amp;action=edit&amp;redlink=1\">Ferencga<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.\r\n\r\nFigure 2.17\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Pulse_sites-en.svg\">Pulse Sites<\/a> by \u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:CFCF\">CFCF<\/a> \u00a0is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.","rendered":"<p>Checklist 18 provides a guide for subjective and objective data collection in a cardiovascular assessment.<\/p>\n<table style=\"border: 1px solid #000000;width: 100%\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000\">\n<h3 style=\"text-align: center; text-align: center;\"><span style=\"color: #000000\">Checklist 18:<\/span>\u00a0Cardiovascular (CV) Assessment<\/h3>\n<figure id=\"attachment_3683\" aria-describedby=\"caption-attachment-3683\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System.png\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"169\" class=\"wp-image-3683 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System-300x169.png\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System-300x169.png 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System-65x37.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System-225x127.png 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Human_Heart_and_Circulatory_System.png 320w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-3683\" class=\"wp-caption-text\">Figure 2.11 Cardiovascular system<\/figcaption><\/figure>\n<h5 style=\"text-align: center; text-align: center;\"><em>Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.<\/em><\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 100%\">\n<h5><span style=\"color: #000000\">Safety considerations:<\/span><\/h5>\n<ul>\n<li><span style=\"color: #333333\">Perform hand hygiene.<\/span><\/li>\n<li><span style=\"color: #333333\">Introduce yourself to patient.<\/span><\/li>\n<li><span style=\"color: #333333\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\n<li><span style=\"color: #333333\">Explain process to patient.<\/span><\/li>\n<li><span style=\"color: #333333\">Be organized and systematic in your assessment.<\/span><\/li>\n<li><span style=\"color: #333333\">Use appropriate listening and questioning skills.<\/span><\/li>\n<li><span style=\"color: #333333\">Listen and attend to patient cues.<\/span><\/li>\n<li><span style=\"color: #333333\">Ensure patient&#8217;s privacy and dignity.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border: 1px solid #000000;width: 100%\">\n<tbody>\n<tr style=\"height: 118px\">\n<td style=\"width: 99.92%;height: 118px\" colspan=\"2\">\n<h3 style=\"text-align: center\">Objective Data<\/h3>\n<h5 style=\"text-align: center\">Consider the following observations.<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000\">\n<h4 style=\"text-align: center\">Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Colour<\/strong> of Skin &amp; Mucous Membranes<\/td>\n<td style=\"border: 1px solid #000000\">Cyanosis (a bluish tinge) may suggest inadequate oxygenation and CV compromise<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Temperature<\/strong> of Extremities<\/td>\n<td style=\"border: 1px solid #000000\">Hot skin may suggest fever and should be followed up with full vital signs, report to the primary prescriber, and investigation of any suspected sources of infection.<\/p>\n<p>Cold skin may suggest existing or new circulatory related issues.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Blood Pressure,\u00a0Heart Rate,\u00a0SpO<sub>2<\/sub><\/strong><\/td>\n<td style=\"border: 1px solid #000000\">Baseline vital signs are important in any assessment. Vital signs should be compared to the patient\u2019s normal values. Patterns and trends outside of the normal range should be reported to the appropriate person.<\/p>\n<p>See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-4-vital-signs\/\">Chapter 2.4 Vital Signs<\/a><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Capillary Refill<\/strong><\/p>\n<p><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1.jpg\" rel=\"noopener\" target=\"_blank\"><img decoding=\"async\" width=\"250\" class=\"wp-image-331 aligncenter\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-300x199.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2311-1-350x232.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/td>\n<td style=\"width: 50%;height: 266px\">Press on the nail beds of toes and\/or fingers until there is blanching (whiteness). Release the pressure and count how many seconds until the patient\u2019s full colour returns.<\/p>\n<ul>\n<li><strong>Brisk capillary refill<\/strong>: &lt; (less than) 3 seconds<\/li>\n<li><strong>Delayed capillary refill<\/strong>: &gt; (greater than) 3 seconds<\/li>\n<\/ul>\n<p>Delayed cap refill may suggest cardiovascular or respiratory dysfunction and should be followed-up with a focused assessment.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Edema<\/strong><\/p>\n<figure id=\"attachment_4157\" aria-describedby=\"caption-attachment-4157\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema.jpg\" rel=\"noopener\" target=\"_blank\"><img decoding=\"async\" width=\"250\" class=\"wp-image-4157\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema-300x234.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema-300x234.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema-65x51.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema-225x176.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/Hand-edema.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-4157\" class=\"wp-caption-text\">Figure 2.12 Hand edema<\/figcaption><\/figure>\n<figure id=\"attachment_4158\" aria-describedby=\"caption-attachment-4158\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema.jpg\" rel=\"noopener\" target=\"_blank\"><img decoding=\"async\" width=\"250\" class=\"wp-image-4158 size-full\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema.jpg 259w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2019\/03\/foot-and-ankle-edema-225x169.jpg 225w\" sizes=\"(max-width: 259px) 100vw, 259px\" \/><\/a><figcaption id=\"caption-attachment-4158\" class=\"wp-caption-text\">Figure 2.13 Foot and ankle edema<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000\">Edema can be the result of many things, including:<\/p>\n<ul>\n<li>Inflammatory response from things like bee stings, sprains, or injury<\/li>\n<li>Altered venous return<\/li>\n<li>Diseases of the lymphatics<\/li>\n<li>Fluid shifts<\/li>\n<li>Side effects of some medications<\/li>\n<li>Circulatory overload<\/li>\n<li>Heart failure<\/li>\n<\/ul>\n<p>It is important to ask the patient if is this normal for them.<\/p>\n<p>Observe limbs simultaneously in order to compare.\u00a0Unilateral edema of the leg may suggest deep vein thrombosis (DVT).<\/p>\n<p>Edematous tissue has a high risk of skin breakdown. Implement strategies to maintain skin integrity.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\">Palpate Extremities to Quickly Assess Colour, Warmth, Movement, and Sensation (CWMS), Capillary Refill of Hands and Feet<\/p>\n<p><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2279-1.jpg\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"250\" height=\"199\" class=\"aligncenter size-medium wp-image-328\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2279-1-300x199.jpg\" \/><\/a><\/td>\n<td style=\"width: 50%;height: 348px\"><strong>Colour<\/strong> and <strong>warmth<\/strong> provide information about perfusion.<\/p>\n<p><strong>Movement<\/strong> provides a brief overview about musculoskeletal function of extremities, which is affected by circulation.<\/p>\n<p><strong>Sensation<\/strong>: by asking if the client has numbness and\/or tingling in extremities the nurse gets a brief overview of client baseline. Altered sensation may be the result of impaired neurological function or impaired perfusion.<\/p>\n<p>Palpate pulses for symmetry in quality, rate, and rhythm. This provides information about perfusion.<\/p>\n<p>Asymmetry in relation to assessment findings may indicate a number of things including cardiovascular conditions, history of injury, or post surgical complications.<\/p>\n<p>Report concerns to the appropriate healthcare professional.<\/p>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\">Auscultate: Apical Heart Rate for Rate and Rhythm<\/p>\n<p><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1.jpg\" rel=\"noopener\" target=\"_blank\"><img decoding=\"async\" width=\"250\" class=\"aligncenter size-medium wp-image-314\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-300x199.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/06\/DSC_2321-1-350x232.jpg 350w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/td>\n<td style=\"width: 50%;height: 266px\">Apical pulses are assessed using a stethoscope placed over the 4th\u20135th intercostal space of the midclavicular line on the left side on adults.\u00a0For accuracy, an apical heart rate should be taken for a full minute. Identify S1 and S2 and follow up on any unusual findings.<\/p>\n<p>See <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/?post_type=chapter&amp;p=112&amp;preview=true\">Chapter 2.3 Vital Signs<\/a><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000\">\n<td style=\"border: 1px solid #000000\"><strong>Clubbing of Nails<\/strong><\/p>\n<figure id=\"attachment_3682\" aria-describedby=\"caption-attachment-3682\" style=\"width: 250px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails.jpg\" rel=\"noopener\" target=\"_blank\"><img decoding=\"async\" width=\"250\" class=\"wp-image-3682 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails-300x225.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails-300x225.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails-225x169.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/clubbing-of-nails.jpg 320w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-3682\" class=\"wp-caption-text\">Figure 2.14 Clubbing of finger nails<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000\">Clubbing of nails may suggest underlying cardio pulmonary disease<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border: 1px solid #000000;width: 100%\">\n<tbody>\n<tr>\n<td style=\"width: 50%\" colspan=\"2\">\n<h3 style=\"text-align: center\">Subjective Data<\/h3>\n<h5 style=\"text-align: center\">Ask about chest discomfort, pain, or pressure. All of these may be indicative of a larger cardiovascular issue. Reports of these must be followed up with a more detailed assessment and notification to the appropriate healthcare provider.<\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 50%\" colspan=\"2\">\n<h4 style=\"text-align: left\">A focused cardiovascular assessment may also include:<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 50%\">Rating of\u00a0Edema\u00a0Using an Objective Scale<\/p>\n<figure id=\"attachment_3691\" aria-describedby=\"caption-attachment-3691\" style=\"width: 244px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema.jpg\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"244\" height=\"240\" class=\"wp-image-3691 size-full\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema.jpg 244w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema-65x64.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pitting_Edema-225x221.jpg 225w\" sizes=\"auto, (max-width: 244px) 100vw, 244px\" \/><\/a><figcaption id=\"caption-attachment-3691\" class=\"wp-caption-text\">Figure 2.15 Pitting edema<\/figcaption><\/figure>\n<\/td>\n<td style=\"width: 50%\">\n<table style=\"border-collapse: collapse;width: 99.8498%\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\" colspan=\"4\">Rating of Edema<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">Grade<\/td>\n<td style=\"border: 1px solid #000000;width: 52.5526%;text-align: center\">Description<\/td>\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">Depth of Indent<\/td>\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">Time to Return to Normal<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+1<\/td>\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Slight pitting, no visible change in the shape of the extremity;<\/td>\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">0\u20131\/4 inch<br \/>\n(&lt; 6 mm)<\/td>\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">Rapidly<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+2<\/td>\n<td style=\"border: 1px solid #000000;width: 52.5526%\">No marked change in the shape of the<\/p>\n<p>extremity<\/td>\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">1\/4\u20131\/2\u201d<br \/>\n(6\u201312 mm)<\/td>\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">10\u201315 seconds<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+3<\/td>\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Noticeably deep pitting, swollen extremity<\/td>\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">1\/2\u20131\u201d<br \/>\n(1\u20132.5 cm)<\/td>\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">1\u20132 minutes<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: center\">+4<\/td>\n<td style=\"border: 1px solid #000000;width: 52.5526%\">Very swollen, distorted extremity<\/td>\n<td style=\"border: 1px solid #000000;width: 17.4174%;text-align: center\">&gt; 1\u201d<br \/>\n(&gt;2.5 cm)<\/td>\n<td style=\"border: 1px solid #000000;width: 22.0721%;text-align: center\">2\u20135 minutes<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 7.80781%;text-align: left\" colspan=\"4\">Adapted from Brodovicz et al., 2009<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 50%\">\n<p style=\"margin-left: 18.0pt\">Jugular Vein Distension (JVD)<\/p>\n<figure id=\"attachment_3684\" aria-describedby=\"caption-attachment-3684\" style=\"width: 163px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD.jpg\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"163\" height=\"163\" class=\"wp-image-3684\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD.jpg 240w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD-150x150.jpg 150w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD-65x65.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Jugular_Venous_Distention_JVD-225x225.jpg 225w\" sizes=\"auto, (max-width: 163px) 100vw, 163px\" \/><\/a><figcaption id=\"caption-attachment-3684\" class=\"wp-caption-text\">Figure 2.16 Jugular vein distension (JVD)<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%\">Jugular vein distension of more than 3 cm above the sternal angle while the patient is sitting at<br \/>\n45 degrees may indicate heart failure.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 50%\">Rating of Peripheral Pulses\u00a0Using an Objective Scale<\/p>\n<figure id=\"attachment_3690\" aria-describedby=\"caption-attachment-3690\" style=\"width: 191px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg.jpg\" rel=\"noopener\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" width=\"191\" height=\"300\" class=\"wp-image-3690 size-medium\" alt=\"\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg-191x300.jpg\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg-191x300.jpg 191w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg-65x102.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/11\/Pulse_sites-en_svg.jpg 223w\" sizes=\"auto, (max-width: 191px) 100vw, 191px\" \/><\/a><figcaption id=\"caption-attachment-3690\" class=\"wp-caption-text\">Figure 2.17 Pulse Sites<\/figcaption><\/figure>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%\">Pulse quality may be important to assess following surgery when the patient is at risk for arterial compromise (i.e., graft occlusion). A deterioration in pulse quality might suggest arterial occlusion.<\/p>\n<table style=\"border-collapse: collapse;width: 99.8498%\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\" colspan=\"2\">\u00a0Peripheral Pulse Rating Scale<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">Rating<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%;text-align: center\">Description<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">0<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%\">No pulse<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+1<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Faint but detectable<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+2<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Slightly diminished compared to normal<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+3<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Normal<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: center\">+4<\/td>\n<td style=\"border: 1px solid #000000;width: 82.5826%\">Bounding<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 17.2673%;text-align: left\" colspan=\"2\">Adapted from Hill &amp; Smith, 1990<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 50%\">Auscultation of Heart Sounds<\/td>\n<td style=\"border: 1px solid #000000;width: 50%\">Depending on the context, nurses may need to have the skill to be able to assess specific heart sounds.<\/p>\n<p>Additional resources:<\/p>\n<ul>\n<li><span style=\"font-size: 18.9px\">Last Second Medicine. (2017, June 12).\u00a0<\/span><em>Complete heart sounds in 7 minutes &#8211; with heart sounds audio<\/em> [Video file]. Retrieved from\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=6StYVx6BVLo\">https:\/\/www.youtube.com\/watch?v=6StYVx6BVLo<\/a>.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%\" colspan=\"2\">Potential cardiovascular related nursing diagnoses:<\/p>\n<ul>\n<li>Activity intolerance related to diminished cardiac function.<\/li>\n<li>Acute chest pain due to increased cardiac workload.<\/li>\n<li>Ineffective cardiac or peripheral tissue perfusion secondary to heart failure.<\/li>\n<li>Learning need in relation to risk factors associated with cardiovascular disease.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%\" colspan=\"2\">Data sources: Assessment Skill Checklist, 2014; BCCNP, 2018; Brodovicz et al., 2009; Hill &amp; Smith, 1990; Jarvis, Browne, MacDonald-Jenkins, &amp; Luctkar-Flude, 2014; Perry, Potter, &amp; Ostendorf, 2018; Potter et al., 2019; Stephen, Skillen, Day, &amp; Jensen, 2012; Wilson &amp; Giddens, 2013<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>A client has +4 edema to bilateral feet and ankles. Identify two strategies to assist in maintaining skin integrity.<\/li>\n<li>A client has just had a femoral popliteal bypass. Which peripheral pulses should be included in the assessment specific to determining arterial perfusion of the affected leg?<\/li>\n<\/ol>\n<\/div>\n<h2>Attributions:<\/h2>\n<p>Figure 2.11\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Human_Heart_and_Circulatory_System.png\">3D Human Heart and Circulatory System Illustration<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:WhatIfWeCould&amp;action=edit&amp;redlink=1\">Bryan Brandenburg<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.<\/p>\n<p>Figure 2.12\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:2707_Edema_of_Right_Hand_Due_to_Allergic_Reaction.jpg\">Edema of Right Hand Due to Allergic Reaction<\/a> by CNX Openstax is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> Attribution 4.0 International license.<\/p>\n<p><span style=\"text-indent: 1em;font-size: 14pt\">Figure 2.13\u00a0<\/span><a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Catastrophic_Edema_of_the_legs_harefield_hospital_10.jpg\" style=\"text-indent: 1em;font-size: 14pt\">Post Heart Transplant 21 October 2018 Harefield Hospital<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> by <\/span><a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Ryaninuk&amp;action=edit&amp;redlink=1\" style=\"text-indent: 1em;font-size: 14pt\">Ryaninuk<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> is used under a <\/span><a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" style=\"text-indent: 1em;font-size: 14pt\">Creative Commons<\/a><span style=\"text-indent: 1em;font-size: 14pt\"> <\/span><a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/deed.en\" style=\"text-indent: 1em;font-size: 14pt\">Attribution 4.0 International.<\/a><\/p>\n<p>Figure 2.14\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Acopaquia.jpg\">Clubbing Fingers<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Desherinka\">Desherinka<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">Attribution-Share Alike 4.0 International license<\/a>.<\/p>\n<p>Figure 2.15\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Combinpedal_Right_to_Left.jpg\">Pitting Edema<\/a> by James Heilman is used under a\u00a0<a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.<\/p>\n<p>Figure 2.16\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Jugular_Venous_Distention_(JVD).JPG\">JVD<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Ferencga&amp;action=edit&amp;redlink=1\">Ferencga<\/a> is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.<\/p>\n<p>Figure 2.17\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Pulse_sites-en.svg\">Pulse Sites<\/a> by \u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:CFCF\">CFCF<\/a> \u00a0is used under a <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\">Attribution-Share Alike 3.0 Unported<\/a> license.<\/p>\n","protected":false},"author":397,"menu_order":8,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3708","chapter","type-chapter","status-publish","hentry"],"part":102,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3708","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":27,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3708\/revisions"}],"predecessor-version":[{"id":5114,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3708\/revisions\/5114"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/102"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/3708\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=3708"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=3708"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=3708"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=3708"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}