lOMoAR cPSD| 28505380
lOMoAR cPSD| 28505380
NCLEX RN Assessment and
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!
, lOMoAR cPSD| 28505380
• 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!
Present Problem:
lOMoAR cPSD| 28505380
NCLEX RN Assessment and
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!
, lOMoAR cPSD| 28505380
• 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!
Present Problem:
