Heart and Neck Vessels Case Study – Flashcards
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Determine if the client is currently experiencing any angina.
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Auscultate the apical pulse for 1 minute.
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Encourage the client to describe his chest discomfort.
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"At what time of day do you feel most fatigued"
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How the client's spiritual beliefs impact his health care expectations.
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-Dietary need. -Herbs or purgatives used.
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Help the client to a supine position on the bed with his chest exposed.
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-Left midclavicular line. -5th intercostal space.
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-Right sternal border. -2nd intercostal space.
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Roll half-way to his left side.
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Chest x-ray, Echocardiogram.
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Inch the stethoscope across and down in a "z" pattern.
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S1 and S2 heart sounds.
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Palpate the carotid artery pulse.
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Document this normal finding on the initial assessment record.
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Systolic murmur.
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Note how easily the murmur is heard by gradually lifting the stethoscope.
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Repeat auscultation across the chest using the bell of the stethoscope.
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Use the bell of the stethoscope to continue listening at the apical site.
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Check for jugular vein distention.
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-Remove the client's pillow and turn his head away slightly. -Place the Client in a Semi-Fowler's position.
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Document the level at which the pulsation is observed.
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Palpate one artery and then palpate the artery on the opposite side.
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Move the bell of the stethoscope up the right side of the neck to the mid-clavicular area.
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-Onset of an S3 heart sound. -Observed jugular vein distention. -Client's subjective report of dyspnea.
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-Assessment -Recommendation -Situation
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