Assessment of circulation

Assessment of circulation

Diagram shows assessment using look, listen, feel, investigate, measure approach, box showing steps for assessing CRT, manual palpation of radial pulse, noninvasive BP measurement, et cetera.

Assessment of circulation is the third step of the ABCDE approach. The nurse needs not only a sound knowledge of normal circulatory physiology (Chapters 22, 23 and 24) but must be cognisant of normal clinical parameters and be able to interpret even subtle changes. A systemic approach to data collection, using the ‘look, listen, feel, measure, investigate’ approach contributes to a comprehensive assessment (Figure 25.1).

Cardiovascular assessment: look

Focused observation of the patient can almost immediately yield clues as to their circulatory status. A relaxed, comfortable patient, readily engaging in conversation, has adequate perfusion of the brain and vital organs. Restlessness, with the unsettled patient fiddling with sheets or constantly moving to get comfortable, suggests that a more detailed assessment is required.

Noting the position of the patient, the possible use of accessory muscles signifies the extent to which the work of breathing and therefore the potential for respiratory compromise has increased. The respiratory and cardiovascular systems are interdependent; respiratory symptoms may be the presenting feature of cardiac problems. Severe dyspnoea (sensation of breathlessness) is a common feature of acute heart failure1

Apr 8, 2019 | Posted by in NURSING | Comments Off on Assessment of circulation
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