How to document circulation assessment
- 0Feb 5, '08 by natrgrrlWhat do I include in a client assessment for circulation?
So far I have color, temperature, edema, pedal pulse.
When assessing pedal pulse do I use a number like +3 or do I use words like weak or strong?
- 1Feb 5, '08 by DaytoniteAssessment of the circulation includes observation and documentation of/for the following:
- symmetry of extremities
- chest pain
- skin and appendages (also note the nail beds and conjunctiva)
- capillary refill
- color changes (pallor, cyanosis, redness, brownishness)
- shiny skin
- presence of any ulcers
- condition of the nails
- presence or loss of hair
- (dependent) edema (nonpitting or pitting)
- blood pressure (lying, sitting and standing)
- by palpation
- by auscultation
- rate and rhythm
- pulsus alternans - alternating pattern of a weak and a strong pulse that occurs at regular intervals
- pulsus bigeminus - same as pulsus alternans but occurs at irregular intervals
- pulsus paradoxus - increased and decreased amplitude in pulse associated with respirations
- thrills - vibrations you can feel over turbulence
- heart sounds
- S3 ventricular gallop
- S4 atrial gallop
- friction rub
4+ = boundingYou should also check the links on this sticky thread:
3+ = increased
2+ = normal
1+ = weak, diminished
0 = absent
- http://allnurses.com/forums/f205/hea...ms-145091.html and http://connection.lww.com/Products/b.../PDFs/ch08.pdf - assessment of the cardiovascular system which is on post #14 of that thread.