The nurse should then concentrate her physical examination on the heart itself. Ausculation of the heart should be performed carefully with a stethoscope. In performing the assessment, the nurse should listen to normal heart sounds first before trying to identify murmurs on the patient (Anon., 2010). The aortic, pulmonic, tricuspid and mitral valves should be ausculated to identify the rate and rhythm of any murmurs or other irregularities.

While these primary assessments help to provide a general view of the patient's symptoms, the real severity of CHF is measured according to the left ventricular ejection fraction (LVEF). This measures the fraction of blood that is pumped out of the left ventricle of the heart and determines the degree of congestion (Karapolat et al., 2008). This measurement can be determined by performing a transthoracic echocardiography. A normal ejection fraction lies between 50 -- 70%. One below 40% is defiend as systolic heart failure (Dickstein et al., 2008). While this is not part of the nurse's responsibility, she may propose the procedure to the attending physician.

Holistic Nursing Considerations

In a holistic nursing assessment, the nurse should function as an integrater. She must balance the patient's self-evaluation of his ailments and guide him to finding the source of his pain. At the same time, she must make physical assessments to make a diagnosis of the patient's symptoms. While the nurse applies tools of Western Medicine, he or she should also consider alternative modalities as part of her evaluation. Given his different cultural background, it is necessary to consistently explain the medical evaluation and be open to traditional remedial practices offered by the patient himself. In the holistic domain, the nurse should gather the information with a sense of interrelatedness and an understanding of the cumulative effect of disparate factors on the patient's health.

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