Page 180 - Critical Care Nursing Demystified

Chapter 4 CARE OF THE PATIENT WITH CRITICAL CARDIAC RHY THM DISTURBANCE NEEDS 165

TABLE 4–1 Symptoms of Decreased Cardiac Output
Body System Method Symptoms
Neurological Inspection Change in the level of consciousness or Glasgow
Coma Scale; dizziness, anxiety, distress,
confusion; sense of impending doom;
dilated pupils
Cardiovascular Inspection Pale or bluish coloration
Pulsations in the pericardial area lateral and
inferior to the point of maximum impulse (PMI)
Cool, clammy skin
Diaphoresis
Jugular venous distention (JVD)
Peripheral edema
Syncope (fainting)
Palpation Thrills/bruits
Weak, thready pulses; full and pounding
pulses
Percussion Not generally done as x-rays are readily available
Auscultation Orthostatic hypotension; hypotension, 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.
hypertension
Bradycardia, tachycardia
Pulse deficits; skipped beats
S3, S4
Muffled heart sounds; pericardial friction rubs
Pulmonary Inspection Productive cough; pink or blood-tinged sputum
Use of accessory muscles of respiration
(intercostals, abdominals); nasal flaring
Auscultation Diminished breath sounds
Crackles (rales), gurgles (rhonchi), wheezes
GU Inspection Oliguria; concentrated amber urine
GI ∗ Auscultation Decreased or absent bowel sounds
Inspection Nausea, vomiting; anorexia

NURSING ALERT
* Remember your basic assessments; the order of physical assessment is changed
here so that palpation/percussion will not alter auscultated bowel sounds.