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Cardiac Assessment

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14 views3 pages

Cardiac Assessment

Uploaded by

vishnupriya.78901
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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JITHIN.

J.K

A.K.G MEMORIAL CO-OP COLLEGE OF NURSING

CARDIAC ASSESSMENT FORMAT

I . BIODATA

II. CHIEF COMPLAINTS WITH DURATION

III. HISTORY OF PRESENT ILLNESS

SYMPTOMS

Chest pain:

When did the pain begin? What were you doing before pain begin, did anything you do make it better or worse, how
it feel like? Are you having any breathing difficulties, location of pain and intensity?

Palpitations:

Do you ever feel that your heart is racing or skipping beats

Syncope:

Fainting or blackout spells, light headed or dizziness

Edema:

Swelling in the ankles or feet, recent change in weight

Fatigue:

Any changes in the energy level, need to take naps throughout the day

Extremity changes:

Any experience of numbness and tingling of hands and fingers. Cold extremities, pain or crams in the extremities

Related symptoms:

Berating difficulty, shortness of breath, irritating cough

IV. PAST HEALTH HISTORY

Childhood illness – RHD, congenital heart defects, heart murmur

Chronic illness - DM, HTN,Hyperlipidemia, chronic respiratory disease, renal disease, bleeding disorders

Chest trauma

V . FAMILY HISTORY

History of DM, HTN, Hyperlipidemia, renal disease, mitral valve prolapse , genetically linked cardiac disorders

VI . PERSONAL AND SOCIOECONOMIC HISTORY

Life style, job, habits, sleep and rest pattern, activity and exercise pattern, nutrition, weight, sexuality, stress and
coping, social support
PHYSICAL ASSESSMENT
General appearance

Chronological age, posture, facial expression, dress and grooming, body stature, fatigue, confusion,
restlessness, irritability.

Vital Signs

HR- Check for pulse deficit, volume, strength, regularity

Pulse quality

 0- Pulse not palpable or absent


 +1 – Weak, thread pulse, difficult to palpate
 +2- Diminished pulse
 +3 - Easy to palpate, full pulse
 +4 - Strong, bounding pulse may be abnormal.

Blood pressure: Hypertension or Hypotension

Temperature

Respiration: Rate, Rhythm, depth

Height, weight, BMI

SKIN: Cyanosis (central cyanosis and peripheral cyanosis), rubor or pallor, jaundice, patechiae,
peripheral edema, anasarca, discoloration, ulcers.

NAILS: Capillary refill, clubbing, cyanotic nail bed, splinter hemorrhages

HEAD: Hair thinning or loss of hair

FACE: Edema, facial expressions

EYES: Periorbital edema, Xanthelasma, Arcus senilis, Sclera Icterus, Exopthalmos

NOSE: Flarring of nose, cyanosis, Nose bleeds

MOUTH: Cyanosis of lips, tongue and oral mucosa, dental carries, mouth ulcers, bleeding gum.

EAR: Cyanosis, Position

NECK:

Inspection: Neck vessels, carotid arteries and jugular veins, observe for large visible pulsations in the
neck, neck vain distention, JVP (JVP at 45 degree angle < 3 cm) thyroid enlargement.

Palpation: carotid pulse (rate, rhythm, symmetry)

Thrill: abnormal rushing vibration on palpation

Auscultation: Carotid bruit (humming or buzzing sound on auscultation)


PRECORDIUM

Inspection : size, shape (barrel chest, pectus excavation, symmetry of movement, use of accessory
muscles, pulsations at the apex, left lateral sterna border, epigastric area.

Palpation : Thrill, pulsations, PMI

Percussion : Dullness, resonance, flat-bone

Auscultation : Rate, rhythm, intensity, S1 and S2 , systolic and diastolic murmur, S3 and S4 gallop,
pericardial rub

ABDOMEN

Inspection : Ascitis, pulsation in the epigastric area

Auscultation : Bowel sounds, aortic bruit, renal bruit

Palpation : Ascitis, hepatosplenomegaly, hepato-jugular reflex.

Percussion : Dullness, tympani

EXTRIMITIES

Peripheral pulses: radial, ulnar, brachial, femoral, poplital, tibial, dorsalis pedius.

Ulcers , necrosis, gangrene

Vericosities

Allens test

Humans sign

INVESTIGATIONS

MEDICATIONS

PROBLEMS IDENTIFID

CONCLUSION

JITHIN.
J.K

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