A cardiac nursing assessment consists of four primary steps: focused interview, visual inspection, palpation of the peripheral vasculature and auscultation of the heart, according to iStudentNurse. Abnormal findings should be noted, including extra heart sounds, edema, murmur, delayed capillary refill and deep vein thrombosis. It is also important to recognize if a nonpalpable peripheral pulse exists, as it can be indicative of deep vein thrombosis.
A focused interview focuses on the collection of data, specifically chest pain, leg pain, shortness of breath, tachypnea and a racing heart beat, states iStudentNurse. Palpitations or a heart that is skipping beats are other areas to note during a cardiac nursing assessment.
A visual inspection of a patient involves examining the chest and skin, determining vascular status, assessing skin color, and ascertaining if edema is present, explains iStudentNurse. It includes looking at oxygenation, compensation and cyanosis, in addition to determining where a patient belongs on the pulse intensity scale.
When examining palpitations, a nurse determines the palpitations of the heart, peripheral pauses and palpitations of peripheral arteries, and then notes whether any abnormalities exist, iStudentNurse states. A nurse should then take the apical pulse, listen to the heart sounds auscultation, find the site of maximum impulse, and point out any abnormalities. Using the diaphragm of the stethoscope, a patient is examined for bruits.