Peripheral Vascular System

Heart, Neck Vessel, Peripheral Vascular System and Lymph Assessment
Ardis A. Halvorsen, RN
South Dakota State University

Abstract
This purpose of this report is to present regional write-ups of the cardiovascular system including the neck vessels and heart, the lymph system, and the peripheral vascular system. The evaluation is performed on a 26-year-old male that works in the construction and asphalt industries and works five to six days a week. This report is submitted using a SOAP format of documentation. Physical examination occurred on 11 September 2013 in the gentleman’s home. The SOAP format utilized both subjective data and objective results by examination. A nursing diagnosis is included utilizing one of
Neither the external or internal jugular veins are observed using room light and a direct light, at 30- and 45-degree angle and in a supine position with no elevation. Precordium. An apical impulse, which is caused by the movement of the left ventricle during the systole phase, is seen without any problem and a gentle tap is palpated at the fifth intercostal space about 2.5cm medially from the midclavicular line and is about the size of the examiners little finger pad (1 x 2 cm). Skin color is pink and warm; no sores or lesions. No other pulsations are palpated; no evidence of thrill. No lift or heave is seen at the apex or sternal border . Auscultation. The patient allowed the marking of his chest to draw the anatomical location of the heart and where valve sounds were heard; sounds are produced in the blood flow direction . Auscultation, using a clock diagram, proceeded from 11 o’clock, 1 o’clock, 2 o’clock, 8 o’clock, 6 o’clock and 5 o’clock positions and then about 2.5cm medially from the 4 o’clock position. Each location was assessed for rate, which was 60, consistently and verified via the radial pulse. The rhythm is regular and even with no irregularities or arrhythmias noted at any time. S1 and S2 were distinguished throughout auscultation. At 11 o’clock S2 was louder than S1 and at 5 o’clock S1 was louder than S2, which are normal findings. The carotid pulse was synchronous with the S1 at the 5 o’clock position or the apex. No
A food diary would be helpful to this man to reveal food group choices, calories consumed, and emotional state when eating. At 5’11” and 190 pounds, his BMI is 26.5; this is considered overweight. Suggest the DASH diet. Recommend websites such as www.choosemyplate.gov and www.mypyramid.gov for interactive education regarding calories, food groups, and food choices. Provide the most current dietary guidelines . To provide accountability, a consult with a dietician would be advantageous. Education on alcohol consumption and “empty calories” would be beneficial to weight loss for this patient. Exercise. Recommend exercise that he likes to do, thus, increasing the chance of him -actually doing it. Suggestions like riding bikes or swimming would be a good family exercise activity for him since this couple has a 10-month-old son.
Health Promotion. Education on health promotion is obvious with the family history of obesity, hypertension and diabetes. Commendation for quitting chewing tobacco could strengthen his resolve to remain tobacco free. An annual or even bi-annual physical with blood work and the opportunities for health screenings would be another