Page 106 - Critical Care Nursing Demystified

Chapter 3 CARE OF THE PATIENT WITH CRITICAL CARDIAC AND VASCULAR NEEDS 91

nurse should also ask about the patient’s diet, medication, alcohol, tobacco use,
and occupational history. Determine if the patient’s lifestyle is active or seden-
tary. A one-word response of “retired” needs further clarification by asking what
the person did and what do they do now.
The patient’s history, if accurately obtained, will provide substantial clues as
to the onset of debilitating cardiovascular problems. If patients are emotionally
distraught or in denial about recent changes in their health status, the nurse
should allow them some space and quiet time to compose themselves for a few
minutes prior to seeking and eliciting additional information, for example, a
family history of heart disease: “My father and both brothers all died of massive
heart attacks at the age of 69.”

Inspection

The critical care nurse can initially garner a wealth of information by simply
observing the patient’s attitude, body posture, facial expressions, weight, and
skin color. If the patient appears obese or overweight, this condition could sug-
gest a cardiac risk factor. Facial expressions alone can indicate apprehension or
pain, as well as lethargy, alertness, or confusion.
The skin should be assessed for color, temperature, and asymmetry. Skin Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
color such as pallor or cyanosis is an important indicator of poor cardiac perfu-
sion. Skin condition such as dry, scaly, cracked, shiny, tented turgor, and absence
of hair growth are indicative or poor peripheral circulation. Skin temperature
such as warm, cool, hot, or redness can indicate secondary complications like
poor circulation and infection. Look for signs of bruising, scars, and wounds
over the body. A bulge over the chest wall could signify a pacemaker or implant-
able cardiac defibrillator (ICD).
Systematically assess the patient for signs of edema, alterations in fluid and
nutritional status, and cyanosis of the lips, conjunctiva, mucous membranes, and
nail beds. Assess for “clubbing” of the nail beds, which was described in Chapter 2
as a sign of chronic hypoxia.
Body posture and position will give an indication of the effort the patient is
using to breathe easier or to relieve discomfort. Respiratory rate, pattern, and
effort should also be observed and recorded.
The only normal pulsation visualized on the chest wall is the apical impulse,
also referred to as the PMI or point of maximal impulse. It is a quick, localized,
outward movement located lateral to the left midclavicular line at the 5th
intercostal space (ICS). If this pulsation is visible, describe its location, size, and
character.