Assessing the Heart, Lungs, and Peripheral Vascular System
Assessing the Heart, Lungs, and Peripheral Vascular System
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the video case studies in this week’s Learning Resources titled Advanced health assessment and diagnostic reasoning. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
To prepare:
With regard to the case study you were assigned:
· Review this week’s Learning Resources and consider the insights they provide.
· Consider what history would be necessary to collect from the patient.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 6”) with “Review of Case Study” identifying the number of the case study you were assigned.
Post a 1 page APA SOAP Note format
1. a description of the health history you would need to collect from the patient in the case study you were assigned (See attached case study below)
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Readings
· Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 13, “Chest and Lungs” (pp. 260-293)
This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.
o Chapter 14, “Heart” (pp. 294-331)
The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
o Chapter 15, “Blood Vessels” (pp. 332-349)
This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
· Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 8, “Chest Pain” (pp. 81–96)
This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.
o Chapter 11, “Cough” (pp. 118-147)
A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough through asking questions and performing a physical exam.
o Chapter 14, “Dyspnea” (pp. 159–173)
The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.
o Chapter 26, “Palpitations” (pp. 310-317)
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
o Chapter 33, “Syncope” (pp. 390-397)
This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.
· Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 6, “Outpatient Charting and Communications” (pp. 119–141)
Note: Download these Adult Examination Checklists and Physical Exam Summaries to use during your practice cardiac and respiratory examination.
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Blood vessels. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Blood Vessels Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for cardiovascular assessment. In Mosby’s guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Cardiovascular Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for chest and lung assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Chest and Lung Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Chest and lungs. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Chest and Lungs Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Heart. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Heart Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
· McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse,40(1), 35–41.
Retrieved from the Walden Library databases.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
· McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41.
Retrieved from the Walden Library databases.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.
· SkillStat Learning, Inc. (2014). The 6 second ECG. Retrieved from http://www.skillstat.com/tools/ecg-simulator#/-home
This interactive website allows you to explore common cardiac rhythms. It also offers the Six Second ECG game so you can practice identifying rhythms.
· University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on cardiac radiography and chest radiology.
Media
· Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning. Baltimore, MD: Author.
Exam Results: Scenario 2
Vital signs:
Temperature: 97.9 oral
Respiratory rate: 32, labored
Heart rate: 112, tachycardic
BP right arm: 148/88
Oxygen saturation: 90% on room air
Weight: 210 lbs, stable
Skin: Cool, diaphoretic
Thorax and lungs: Thorax symmetrical; diminished breath sounds right middle and lower lobes; no rales, rhonchi, or wheezes; breath sounds vesicular with no adventitious sounds left lung
Cardiovascular: Heart rate is irregular with good S1, S2; no S3 or S4; no murmur
Abdomen: Protuberant with normoactive bowel sounds auscultated x4 quadrants
Peripheral vascular: Right calf with 2+ edema, erythema; warmth and tenderness on palpation noted; left lower extremity without edema or erythema; 2+ dorsalis pedis pulses bilaterally
Neurologic: Anxious; awake, alert, and oriented to person, place, and time
