Page 108 - Critical Care Nursing Demystified

Chapter 3 CARE OF THE PATIENT WITH CRITICAL CARDIAC AND VASCULAR NEEDS 93

refill, temperature of the skin, and the presence and amount of edema (using the
scale of 0 to +4). Pulse strength and volume is usually graded on a scale of
0 to +3) and includes the bilateral assessment of the following arteries: carotid,
brachial, radial, ulnar, popliteal, dorsalis pedis, posterior tibial, and femoral.

NURSING ALERT

An abnormal tremor or vibration felt on palpation in the lower left abdominal area is
known as a thrill and can indicate a cardiac murmur or abdominal aortic aneurysm.

NURSING ALERT

Use the pads of the fingers to assess pulse function. Never assess the carotid pulses
simultaneously because doing so will obstruct oxygenated blood flow to the brain,

especially if these arteries are compromised by arteriosclerosis or plaque.

Use a systematic approach when palpating areas of the patient’s body. It is rec-
ommended that the nurse first locate the PMI, which represents where the apical
pulse is most readily felt and is very reliable in determining the size and functioning
of the left ventricle, which corresponds with the actual apex of the heart. 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.
Applying pressure to the nail beds of the upper and lower extremities deter-
mines the status of capillary refill. Signs of pitting and nonpitting edema can be
can be seen and felt not only in the feet and ankles, but also in the shins, sacrum,
and abdomen.

NURSING ALERT

A patient with cardiac failure can gain as much as 10 or more pounds of excess body

fluid before pitting edema becomes recognizable.

Percussion

Generally, and with good reason, this assessment technique is omitted when
caring for the cardiovascular patient. If assessment is needed a chest x-ray
provides the necessary data for cardiac enlargement (cardiomegaly).

Auscultation
Normal and abnormal heart sounds, bruits, and murmurs can be detected using
the assessment skill of auscultation. Normal heart sounds are referred to as S1
and S2.