Homework Clinic
Hands-on Clinic => Nursing and Clinical => Topic started by: drink on Jun 25, 2018
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You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided HF (L) or right-sided HF (R).
1. Fatigue, weakness, especially with activity
2. Jugular (neck) vein distention
3. Dependent edema (legs and sacrum)
4. Hacking cough, worse at night
5. Enlarged liver and spleen
6. Exertional dyspnea
7. Distended abdomen
8. Weight gain
9. S3/S4 gallop
10. Crackles and wheezes in lungs
Question 2
Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?
What would be an ideal response?
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Answer to Question 1
Assessment findings for left-sided HF: 1, 4, 6, 9, 10
Assessment findings for right-sided HF: 2, 3, 5, 7, 8
Answer to Question 2
Activity: What makes you tired? Do you sometimes feel like you can't get your breath?
Diet: What are your favorite foods? What did you eat within the past 48 hours? The biggest problem
usually is not added table salt. Many foods such as chips, peanuts, pizza, pickles, canned soups,
turkey dressing, and ham contain salt. Have you recently eaten any of these? Try to relate salt
intake to symptoms that started 2 days ago. Also ask about microwave meals, lunch meats,
canned foods, fast foods or restaurant foods, and entres.
Sleep: How many pillows do you sleep on at night? Do you wake up during the night with shortness
of breath?
Fluid retention: Have you gained weight, or has your urinary output decreased over the past few
days? Have you had trouble getting your shoes on? Do you weigh yourself daily?
Lungs: Do you have a cough? Do you cough anything up or is it productive? If so, describe the
sputum. What happens when you wake up at night, gasping for breath? How often does this
happen? How many pillows do you use at night when sleeping?
Cardiac rhythm: Are you having any strange feelings in your chest (palpitations)? Does your heart
race at times or flutter, skip beats, pause, or thump? Palpitations vary widely, as do individual
descriptions. Have you experienced dizziness, lightheadedness, or passing out?
Chest pain: Are you having any discomfort or numbness in your chest, back, shoulders, arms, hands,
or neck and jaws? If so, describe the sensations.
Smoking history: Have you ever smoked? Do you smoke now? If so, how many packs a day do you
smoke?
Occupational history: This question is critical with respect to smoking history. Watch for occupational
(or wartime) experience in mining, shipyard work, toxin exposure, or pulmonary irritant exposure
(e.g., asbestos, Agent Orange). Combined with smoking, these make a lethal combination for the
heart as well as lungs.