Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

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Physical examination involves clinical practices such as inspection, auscultation, palpation, and percussion. This is aligned with exclusive documentation of the findings to influence clinical reasoning and decision-making. Besides, the documented results allow for critical thinking as well as determining the need for patient follow-up. This paper documents normal and abnormal findings of cardiovascular and lymphatic examination.

Cardiovascular System

Patient inspection in cardiovascular examination describes the skin color, the precordium, and extremities and determines evidence of jugular vein distention. According to Bickley et al. (2021), concise and short phrases can be used instead of long sentences. On inspection, the skin color should be bilaterally uniform and appropriate for the patient’s race (Open Resources for Nursing, 2023). Palpation assesses peripheral pulses, edema, and capillary refill and gives an insight into the local temperatures and skin moisture. Auscultation is mainly done on five main sections, that is, aortic, pulmonic, Erb’s point, Tricuspid, and mitral regions, to elicit valvular sounds (Open Resources for Nursing, 2023). Close attention is paid to the rate, rhythm, murmurs, and third and fourth sounds (Dains et al., 2023). Valvular defects in blood can be noted from the auscultation of the heart sounds during blood movement. Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

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Documenting Normal Cardiac and Peripheral Vascular Findings

The patient denies shortness of breath, chest tightness, and chest pain radiating to the neck or ear. The vital signs are within range. On inspection, the skin color is pink, warm, and dry. Jugular vein distention is absent, and the precordium is scar-free; no deformities or pulsations are seen. The color, sensation, and movement of the extremities with hair are evenly distributed on the lower extremities. On palpation, maximum impulse is felt at mid-clavicular, fifth intercostal space. There are equal, bilateral peripheral pulses felt (+2) with no thrills, heaves, or lifts felt. Capillary refill takes less than 2 seconds, and there is no peripheral edema noted. S1 and S2 are heard and carotid bruits are absent.

Documenting Abnormal Cardiac and Peripheral Vascular Findings

The patient reports difficulty in breathing and chest tightness. The patient’s skin is pink, warm, and dry. There is no jugular vein distention. There have been notable bilateral swelling of the lower extremities for the past two days. The bilateral peripheral pulse is diminished (+1), and there is pitting edema (+2) in the lower extremities on palpation. There is an extra heart sound (S3), and there are notable crackles in the posterior bases of the lungs on auscultation. No heart murmurs, clicks, pleural rubs, or carotid bruits heard. Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

Documenting Normal and Abnormal Findings on Lymphatic System Examination

The lymphatic system is examined to assess the body’s immune system. The examination involves inspection and palpation of the head, neck, upper arm, axillary region, and groin area. Lymph node examination is conducted from proximal to distal from the head, neck, axillary, to groin lymph nodes (Open Resources for Nursing, 2023). Besides, the tonsils and the spleen are also examined under the lymphatic system.

Normal Findings

There are no visible or palpable swellings and erythema on the skin around. The axillary and groin lymph nodes are unpalpable, with the patient denying any pain or tenderness reported. Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

Abnormal Findings

The preauricular and cervical lymph nodes are symmetrical and visible. Tonsils are inflamed, touching each other, and covered by a white exudate. On palpation, the nodes are 3cm large, soft, and matted, with no increase in the local temperature. The patient denies any pain or tenderness on palpation of the nodes. The upper arm, axillary, and groin area lymph nodes are not felt on palpation. There is no palpable spleen felt.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates’ Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer.

Dains, J. E., Scheibel, P., & Baumann, L. C. (2023). Advanced Health Assessment & Clinical Diagnosis in Primary Care (7th ed.). ELSEVIER – HEALTH SCIENCE.

Open Resources for Nursing (Open RN). (2023). 9.3 cardiovascular assessment. Nursing Skills 2e. https://wtcs.pressbooks.pub/nursingskills/chapter/9-3-cardiovascular-assessment/

Assignment Overview

Documenting an accurate history and physical examination is important to make an accurate diagnosis and deliver safer and more effective patient care. This assignment focuses on documenting normal and abnormal findings of the cardiovascular and lymphatic systems. Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper

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Guidelines

Submit written documentation of normal and abnormal physical findings for cardiovascular and lymphatic systems. Do not forget that your exam has to be done systematically. Think Inspection, Palpation, Percussion, and Auscultation – (if indicated) when submitting this assignment. That means your exam should start with an Inspection before palpation, percussion, and auscultation.

Books for class:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates’ Guide to Physical Examination and history taking (13th ed.). Wolters Kluwer.
Dains, J. E., Scheibel, P., & Baumann, L. C. (2023). Advanced Health Assessment & Clinical Diagnosis in Primary Care (7th ed.). ELSEVIER – HEALTH SCIENCE. Documenting Normal Cardiac and Peripheral Vascular Findings Discussion Paper