[ANSWERED 2023] Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

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 DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.

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?

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 14, “Chest and Lungs”
    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.
  • Chapter 15, “Heart”
    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.
  • Chapter 16, “Blood Vessels”
    This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
• Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
  • Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)
• Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
• Download “X-Ray Interpretation: Chest (pp. 480–487)
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
• Chapter 8, “Chest Pain”
• Download Chapter 8, “Chest Pain”
  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.
• Chapter 11, “Cough”
• Download Chapter 11, “Cough”
  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 by asking questions and performing a physical exam.
• Chapter 14, “Dyspnea”
• Download Chapter 14, “Dyspnea”
  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.
• Chapter 26, “Palpitations”
• Download Chapter 26, “Palpitations”
  This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.
• Chapter 33, “Syncope”

• Download Chapter 33, “Syncope”
  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.

• Links to an external site. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help desk.
• Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students

Download Walden University quick start guide: NURS 6512 NP students.

• Links to an external site. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
• Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)

Download DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.

Expert Answer and Explanation

Focused SOAP Note

SUBJECTIVE DATA:

Chief Complaint: “I have chest pain that has lasted about a month.”

History of Present Illness (HPI): Brian Foster is a 58-year-old male of Caucasian origin who presents to the clinic complaining of chest pain that has lasted about a month. The patient says that the pains make his chest feel tight, non-radiating, and uncomfortable. On a scale of 1-10, the patient rates the pain as five out of ten.

The says that his last episode of chest pain and tightness started three days ago. The first episode occurred when he was at work, the send while down the stairs to bed, and the third while having dinner with his wife. The says that the pain is aggravated when he moves and relieved when he is resting. The pain has never been worse and has not thought of it as an emergency. However, he was concerned when the pain occurred thrice in one month and that is why he came for a heart check-up. Other associated symptoms include pain in the jaws, fatigue, shortness of breath when episodes occur, and dizziness.

Medications: Atorvastatin (Lipitor) 20 mg PO Daily at bedtime, last dose 10 pm yesterday, Metoprolol (Lopressor) 100mg PO daily, Omega-3 Fish Oil 1200 mg PO BID last dose 8 am (OTC supplement), Lisinopril (Prinivil) 20mg PO daily, OTC Ibuprofen for pain management, OTC Tylenol for pain.

Allergies: He is allergic to Codeine. He experiences vomiting and nausea after taking Codeine.

Past Medical History (PMH): He was diagnosed with Hyperlipidemia and Hypertension- Stage II one year ago.

Past Surgical History (PSH): NO history of surgery.

Sexual/Reproductive History: Not Applicable.

Personal/Social History: Drinks 2 -3 beers on Sundays. Denies smoking or use of illicit drugs. He has two children aged 19 and 26. Exercised last two years ago but is conscious about his diet.

Immunization History: Received Influenza vaccine this season and Tdap on 2014 October.

Significant Family History: Father had obesity, HBP, and hyperlipidemia. He died at age 75 of colon cancer. The mother and sister have hypertension and type two diabetes. His maternal grandfather died at age 54 from a heart attack. His Maternal grandmother died at age 65 from breast cancer. His Paternal grandmother died at age 78 from pneumonia and his paternal grandfather died at age 85 of old age. His daughter is asthmatic at age 19.

Review of Systems 

• General: No weight loss, fever. Reports weakness.
• Cardiovascular/Peripheral Vascular:Denies previous heat problems.
• Respiratory: Denies previous respiratory issues. No cough.
• Gastrointestinal:No adnominal pain.
• Musculoskeletal:No joint or muscle pain.
• Psychiatric:No mental health diseases. Denies depression or anxiety.

OBJECTIVE DATA:

Physical Exam:

• Vital signs:P 104, BP 146/90, RR 19, Temp 36.4, SPO2: 98% in room air, Wt. 197lbs, Ht. 5’ 11.
• General: The patient is alert and oriented to place, time, and people. He is well-dressed and answers questions appropriately. His speech is clear. He sits comfortably with no acute distress. He walks without crutches and his gait is normal. His mood is normal and his affect is consistent with his mood. His concertation is normal.
• Cardiovascular/Peripheral Vascular: S1 and S2 without rubs or murmurs. No fluid retention or swelling of the chest. S3 is present in the mitral region. LJP is present 3 cm above the sternal angle. No JVD present. Right carotid pulse with thrill, 3+. Tight side carotid with bruit. Left carotid with no bruit. Capillary refill is <3 seconds in all 4 extremities.
• Respiratory: Fine crackles present in posterior bases of L/R lungs. Breathing in unlabored and quiet. No wheezes or gallops.
• Gastrointestinal:Normal bowel movements in all four quadrants. The abdomen is non-tender and soft. No abdominal pain. No tenderness to deep or light palpation. Tympanic throughout. No abdominal bruits.
• Musculoskeletal:No joint or muscle pain or swelling.
• Neurological:Moves all extremities. He is oriented and alert.
• Skin:No rash or burning.

Diagnostic Test/Labs: 

• Electrocardiogram: EKG is needed to check the patient’s heart rate.
• Chest-X-ray: A chest x-ray will show the condition of the lungs and chest. The test can help determine the cause of the symptoms presented by the patient.
• Blood tests: Blood tests can show if heart enzymes have entered the bloodstream.

ASSESSMENT:

Differential Diagnosis

1. Angina Pectoris
2. Congestive heart failure
3. Carotid artery disease

The primary diagnosis for this case is angina pectoris. According to Gallone et al. (2021), angina pectoris causes chest tightness and pain. The authors also note that the disease causes shortness of breath and fatigue. All these symptoms are present in the patient. The patient also has hypertension which is a risk factor for the disease (Webb & Collins, 2021).

Chest pain in angina is increased during activity and relieved on rest as experienced by the patient. The second diagnosis is congestive heart failure. The disease is part of the diagnosis because it causes shortness of breath, fatigue and chest pain (Seah et al., 2019). The presence of S3 in the mitral region is a vital sign of congestive heart failure.

However, it is a secondary diagnosis because there is no presence of severe narrowing of blood vessels (Porumb et al., 2020). The last diagnosis is carotid artery disease. The disease causes chest pain and that is why it has been included in the diagnosis (Kashyap et al., 2020). However, it is a secondary diagnosis because it causes trouble speaking and numbness and tingling of limbs which are not present in this case.

References

Gallone, G., Baldetti, L., Angelini, F., Saglietto, A., Bellettini, M., Beneduce, A., & De Ferrari, G. M. (2021). The placebo effect on symptoms, quality of life, and functional outcomes in patients with angina pectoris: A meta-analysis of randomized placebo-controlled trials. Canadian Journal of Cardiology. https://www.sciencedirect.com/science/article/pii/S0828282X21002415

Kashyap, V. S., Schneider, P. A., Foteh, M., Motaganahalli, R., Shah, R., Eckstein, H. H., & ROADSTER 2 Investigators*. (2020). Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease. Stroke, 51(9), 2620-2629. https://doi.org/10.1161/STROKEAHA.120.030550

Porumb, M., Iadanza, E., Massaro, S., & Pecchia, L. (2020). A convolutional neural network approach to detect congestive heart failure. Biomedical Signal Processing and Control, 55, 101597. https://doi.org/10.1016/j.bspc.2019.101597

Seah, J. C., Tang, J. S., Kitchen, A., Gaillard, F., & Dixon, A. F. (2019). Chest radiographs in congestive heart failure: Visualizing neural network learning. Radiology, 290(2), 514-522. https://doi.org/10.1148/radiol.2018180887

Webb, C. M., & Collins, P. (2021). Medical management of anginal symptoms in women with stable angina pectoris: A systematic review of randomised controlled trials. International Journal of Cardiology, 341, 1-8. https://doi.org/10.1016/j.ijcard.2021.07.018

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FAQs

Venous filling test

The venous filling test is a medical procedure used to assess the efficiency of blood circulation in the veins. It is often employed in the context of vascular studies and can provide valuable information about the vascular system’s function.

During a venous filling test, a healthcare professional typically evaluates how quickly veins refill with blood after they have been emptied. This can be done by applying pressure to a specific area of the body, often a vein in the arm or leg, to temporarily block blood flow. Once the pressure is released, the healthcare provider observes how quickly the blood returns to the area, which helps in assessing the venous return and the overall vascular health.

The test is commonly used to diagnose conditions such as venous insufficiency, where the veins have difficulty returning blood to the heart. It can also provide insights into the presence of blood clots, varicose veins, or other vascular issues.

It’s important to note that the venous filling test is just one of many diagnostic tools available to healthcare professionals, and its interpretation is often combined with other clinical information and test results to form a comprehensive assessment of a patient’s vascular health.

How do you check for venous fillings?

The venous filling test involves a series of steps to assess how quickly blood refills in the veins. Here’s a general overview of the procedure:

1. Patient Preparation:
   • The patient is typically in a seated or lying position, depending on the area being tested.
   • The healthcare professional may ask the patient to expose the area where the test will be performed, such as an arm or a leg.
2. Selection of Vein:
   • The healthcare provider selects a suitable vein for the test. Common sites include the forearm or the back of the hand.
3. Application of Pressure:
   • A tourniquet or similar device is applied proximal (closer to the body) to the chosen site to temporarily block venous blood flow. This is done to empty the veins of blood.
4. Observation:
   • The healthcare provider observes the area for changes in color. As the veins empty, the skin may appear pale.
5. Release of Pressure:
   • The pressure is released, allowing blood to flow back into the emptied veins.
6. Observation of Refill Time:
   • The healthcare provider watches for the speed at which blood refills the veins. The normal refill time is typically within a few seconds.
7. Interpretation:
   • A faster-than-normal refill time may suggest good venous function, while a slower refill time may indicate issues such as venous insufficiency.

What is the normal time for venous filling?

The normal time for venous filling, also known as refill time, typically ranges from 5 to 15 seconds. This refers to the time it takes for blood to return and refill the veins after they have been emptied by applying pressure or a tourniquet. During a venous filling test, a healthcare professional observes the skin color and the speed at which the veins refill.

A faster-than-normal refill time may indicate good venous function, while a slower refill time may suggest potential issues with venous return or circulation, such as venous insufficiency. It’s important to note that specific protocols and reference ranges may vary among healthcare providers and laboratories, so the interpretation of test results should be done in consultation with a qualified medical professional.

What is a vein test?

A “vein test” can refer to various medical procedures or diagnostic tests related to veins. Here are some common vein-related tests:

1. Venous Doppler Ultrasound:
   • This test uses ultrasound technology to create images of the veins and assess blood flow. It is often used to diagnose conditions such as deep vein thrombosis (DVT) or chronic venous insufficiency.
2. Venography:
   • Venography involves injecting a contrast dye into a large vein, typically in the leg, and then taking X-ray images. This test helps visualize the veins and can identify blockages or other abnormalities.
3. D-dimer Test:
   • The D-dimer blood test measures the presence of a substance that is released when a blood clot breaks up. It is often used as a screening test to rule out conditions like DVT or pulmonary embolism.
4. Trendelenburg Test:
   • This is a physical examination where a person lies flat on their back, and the healthcare provider raises one leg to check for incompetent valves in the veins. It is often used to assess the competence of the valves in the superficial veins of the legs.
5. Capillary Refill Test:
   • While not exclusive to veins, this test involves pressing down on a fingernail or toenail and observing how quickly the color returns. It provides information about peripheral circulation, which includes the veins.
6. Venous Filling Test:
   • As mentioned earlier, this test involves observing the time it takes for veins to refill with blood after they have been emptied. It helps assess the efficiency of venous circulation.

Heart and peripheral vascular system assessment

A heart and peripheral vascular system assessment is a comprehensive examination conducted by healthcare professionals to evaluate the health and functioning of the heart and the peripheral blood vessels throughout the body. This assessment is crucial for identifying cardiovascular conditions, assessing blood flow, and understanding overall vascular health. Here are key components of such an assessment:

1. Patient History:
   • Gathering information about the patient’s medical history, including any existing conditions, family history of cardiovascular diseases, lifestyle factors (such as smoking or physical activity), and symptoms like chest pain or shortness of breath.
2. Vital Signs:
   • Recording vital signs, including blood pressure, heart rate, respiratory rate, and body temperature, to establish baseline physiological parameters.
3. Physical Examination:
   • Conducting a thorough physical examination, which may include:
     • Inspection: Observing for signs like edema (swelling), skin color changes, or visible veins.
     • Palpation: Feeling for pulses, checking for temperature differences in extremities, and assessing for tenderness or abnormalities.
     • Auscultation: Listening to the heart and blood vessels using a stethoscope to detect abnormal sounds such as murmurs or bruits.
4. Cardiac Assessment:
   • Evaluating the heart’s structure and function through techniques such as palpation, percussion, and auscultation.
     • Checking for the point of maximal impulse (PMI), heart sounds, and any abnormal rhythms.
5. Peripheral Vascular Assessment:
   • Assessing blood vessels in the extremities, including arteries and veins.
     • Palpating peripheral pulses (e.g., radial, femoral, dorsalis pedis).
     • Checking for signs of arterial insufficiency (e.g., diminished pulses, cool skin) or venous insufficiency (e.g., edema, varicose veins).
6. Neurovascular Assessment:
   • Evaluating neurological function in conjunction with vascular assessment, particularly in extremities.
     • Assessing sensation, motor function, and capillary refill time.
7. Laboratory Tests:
   • Ordering blood tests, such as lipid panels, to assess cholesterol levels, and other tests to screen for conditions like diabetes.
8. Imaging Studies:
   • Utilizing imaging modalities, including echocardiography, electrocardiography (ECG or EKG), and vascular imaging (e.g., Doppler ultrasound), to visualize the heart and blood vessels.
9. Functional Tests:
   • Conducting functional tests like stress tests or ambulatory monitoring to assess cardiac performance during physical activity or over an extended period.

Peripheral vascular disease subjective data

Subjective data related to peripheral vascular disease (PVD) refers to information obtained directly from the patient through verbal communication. This information helps healthcare providers understand the patient’s symptoms, experiences, and relevant medical history. Here are common subjective data points associated with peripheral vascular disease:

1. Pain:
   • Ask about the presence, location, and characteristics of pain. Patients with PVD often experience pain or discomfort in the affected limbs, which may include cramping, aching, or sharp pain.
2. Claudication:
   • Inquire if the patient experiences claudication, which is pain or cramping in the muscles during physical activity and is relieved with rest. This is a classic symptom of arterial insufficiency.
3. Rest Pain:
   • Ask about pain that occurs at rest, particularly in the feet and toes. Rest pain is a more severe symptom and may indicate advanced stages of PVD.
4. Temperature Changes:
   • Inquire about any noticeable temperature changes in the affected limbs. Patients may report that the affected limb feels cooler than the other limb.
5. Color Changes:
   • Ask if there are any changes in skin color, such as pallor or bluish discoloration (cyanosis). Poor blood circulation can affect the skin’s color.
6. Swelling:
   • Explore whether there is swelling in the legs or feet. Edema can be a sign of venous insufficiency.
7. Skin Changes:
   • Inquire about any skin changes, including dryness, shiny appearance, or the presence of sores or ulcers. Poor blood flow can lead to skin changes and delayed wound healing.
8. Numbness or Tingling:
   • Ask if the patient experiences numbness or tingling in the affected areas. Neurological symptoms can be associated with compromised blood flow.
9. Risk Factors:
   • Discuss potential risk factors for PVD, such as smoking, diabetes, hypertension, high cholesterol, or a family history of vascular diseases.
10. Medical History:
    • Obtain information about the patient’s medical history, including any previous diagnoses or treatments for vascular conditions.
11. Functional Limitations:
    • Inquire about any limitations in daily activities due to PVD symptoms. Patients may report difficulty walking long distances or climbing stairs.
12. Changes in Nail or Hair Growth:
    • Ask about any changes in nail or hair growth on the affected limbs, as poor circulation can affect these aspects.

What is physical assessment of PVD?

The physical assessment of Peripheral Vascular Disease (PVD) involves a thorough examination of the patient’s body, with a focus on the vascular system, to identify signs and symptoms of compromised blood flow in the peripheral arteries and veins. Here are key components of the physical assessment for PVD:

1. Inspection:
   • Skin Appearance: Examine the skin for color changes. Pallor may indicate arterial insufficiency, while a bluish discoloration (cyanosis) can suggest reduced oxygenation.
   • Hair and Nail Changes: Note any changes in hair growth and nail condition, as reduced blood flow can affect these.
2. Palpation:
   • Peripheral Pulses: Assess peripheral pulses, including radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Diminished or absent pulses may indicate arterial occlusion.
   • Temperature: Feel the temperature of the skin in different areas of the extremities. Coolness may indicate poor arterial circulation.
3. Auscultation:
   • Use of a Doppler Ultrasound: Employ a Doppler ultrasound device to listen to blood flow sounds in the arteries. This can help identify abnormal sounds such as bruits (indicative of arterial stenosis).
4. Capillary Refill:
   • Nailbed Capillary Refill: Check capillary refill time by pressing down on a fingernail or toenail and observing how quickly color returns. Prolonged refill time may indicate poor circulation.
5. Edema:
   • Assessment of Swelling: Evaluate for the presence of edema, particularly in the lower extremities. Swelling may be associated with venous insufficiency.
6. Skin Changes:
   • Ulcerations and Sores: Examine the skin for ulcerations, sores, or wounds, especially on the feet and lower legs. Poor circulation can lead to delayed wound healing.
7. Muscle Atrophy:
   • Assessment of Muscle Mass: Observe for signs of muscle atrophy, especially in the calf muscles. Chronic ischemia can lead to muscle wasting.
8. Neurological Assessment:
   • Sensation and Motor Function: Assess sensation by testing for touch, pain, and temperature. Evaluate motor function by checking for strength and the ability to move the limbs. Neurological symptoms can be associated with compromised blood flow.
9. Functional Testing:
   • Walking Assessment (Claudication): Have the patient walk and observe for claudication, which is pain or cramping during physical activity that improves with rest. This is common in arterial insufficiency.
10. Trendelenburg Test:
    • Valve Competency: Perform the Trendelenburg test to assess the competence of venous valves. This involves raising the patient’s leg and observing for the presence of reflux, which may indicate venous insufficiency.
11. Measurements:
    • Circumference Measurements: Measure the circumference of the limbs to detect asymmetry or changes indicative of edema.

What are the 6 P’s of peripheral vascular assessment?

The “6 P’s” of peripheral vascular assessment are a mnemonic used in healthcare to remember key signs and symptoms associated with acute limb ischemia. These indicators help healthcare professionals quickly assess and identify potential vascular emergencies. The 6 P’s are:

1. Pain:
   • Severe and sudden onset of pain in the affected limb is a significant sign. The pain may be out of proportion to any visible injury and may not be relieved with typical pain management measures.
2. Pallor:
   • Pallor, or paleness, of the skin in the affected limb may be indicative of reduced blood flow. The limb may appear whitish or blanched.
3. Pulselessness:
   • Absence or diminished pulses in the affected limb suggest compromised blood flow. Healthcare professionals typically check pulses at various sites, including radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses.
4. Paralysis:
   • Sudden weakness or inability to move the affected limb may occur due to decreased oxygen and nutrient supply to the muscles.
5. Paresthesia:
   • Paresthesia refers to abnormal sensations, such as tingling, numbness, or a “pins and needles” feeling. These sensations may indicate nerve involvement due to ischemia.
6. Poikilothermia:
   • This term refers to the inability of the affected limb to regulate its temperature. The limb may feel cooler than the surrounding areas due to reduced blood flow and oxygen delivery.

What are the five classic peripheral signs of PVD?

Peripheral Vascular Disease (PVD) is a condition characterized by impaired blood flow to the extremities, usually the legs. The five classic peripheral signs associated with PVD include:

1. Intermittent Claudication:
   • Intermittent claudication is a common symptom of PVD and is characterized by pain, cramping, or fatigue in the muscles of the legs during physical activity, such as walking or climbing stairs. The pain typically resolves with rest and is caused by inadequate blood flow to the muscles.
2. Diminished or Absent Pulses:
   • Impaired blood flow in the arteries can result in diminished or absent pulses in the affected limbs. Healthcare professionals often check pulses at various locations, such as the femoral, popliteal, dorsalis pedis, and posterior tibial arteries, to assess vascular status.
3. Skin Changes:
   • Changes in the skin of the lower extremities are common in PVD. These changes may include pallor (pale color), coolness, and thin or shiny skin. In severe cases, the skin may appear dusky or cyanotic (bluish discoloration) due to reduced oxygenation.
4. Hair Loss and Nail Changes:
   • Reduced blood flow can lead to hair loss on the legs and changes in the nails, such as thickening or a slower growth rate. The nails may become brittle or develop a bluish tint.
5. Delayed Wound Healing and Ulceration:
   • Poor blood circulation in the extremities can result in delayed wound healing and the formation of ulcers. Even minor injuries may take longer to heal, and chronic wounds or ulcers may develop, especially on the feet and lower legs.