HEALTH ASSESSMENT ON CARDIOVASCULAR SYSTEM
HEALTH ASSESSMENT
ON
CARDIOVASCULAR
SYSTEM
PATIENT PROFILE
Name :
Age :
Sex :
IP No :
Unit :
Ward :
Date of Admission :
Religion :
Marital Status :
Educational :
Reason for hospitalization :
Present Medical History
C.O.L.D.S.P.A
Character : Describe signs and symptoms
Onset : When did it begins
Location : Where it radiates
Duration : How long does it lost?
Severity : How bad it is
Pattern : What makes better what makes it worse?
Associated factors : What other symptoms occurs with it.
Describe about chest pain - Pain/No Pain
When it starts / Type of Pain /
Rate the pain on pain scale
Perspiration / Palpitation / tiredness / Fatigue
Dyspnea : shortness of breath/ orthopnoea
Visual Analogue Scale
Shortness of breath 100mm
No shortness of breath
Subjective symptom:
On a scale 0 – 4
No distress 0 1 2 3 4
Much distress 0 1 2 3 4
Poor appetite 0 1 2 3 4
Worn out 0 1 2 3 4
Suffocation 0 1 2 3 4
Tightness 0 1 2 3 4
Congestion 0 1 2 3 4
A feeling of panic 0 1 2 3 4
New York Heart Association Classification
0 - Not at all breathless
1 - Breathless on heavy exercise (climbing 2 or 3 floors or waling
quickly)
2 - Breathless on moderate excursion
3 - Breathless on mild excursion
4 - Breathless on minimal excursion
5 - Breathless on minimal excursion
Past Health History:
Heart defect / mummer / Rheumatic heart disease / Previous history of cardiac surgery / intervention previous ECG / Blood test lipid profile / previous history of medication
Family History:
Family History of Hypertension / Myocardial infarction / coronary heart disease / elevated cholesterol level / Diabetes.
Life style and health care practices:
· Smoking history
· Packs per day
· Years of smoking
· Coping of stress mechanism
· Alcohol consumption in a day / week
· Exercise type of excessive
· Describe the daily activity / change in the past 5 – 10 years / limitation in the performance of daily activity.
· History of sexual activity
· Number of pillows used for sleep Nocturnal
· Anxiety regarding heart disease
· Importance of having healthy heart
HEAD TO FOOT ASSESSMENT
General appearance : Thin / Moderate built / obese
Height : in cm
Weight : in kg
Head
Face : Symmetrical / Asymmetrical
Edema : Present / Absent
Eye :
Eye brow : Equal distribution of hair/
Sparingly distributed /
Absent
Eye lashes : Equal distribution of hair/
Sparingly distributed /
Absent
Conjunctiva : Pale / yellow / pink / per orbital cyanosis
Eye lids : Able to open & close / ptosis
Pupils : PERLA
Eye
Position : Above the level of outer cantus /
At the level of outer canthus /
Below the level of outer canthus
Drainage : Present / Absent
Nostrils : Patent / Obstructed
Septum : Centre / deviated
Discharge : present / absent
Mouth
Lips : Dry / Moist / cyanosis
Gums : Health / Swollen / gingivitis
Odour : Present / Absent
Throat : Normal / inflamed
Neck
Trachea : Midline / deviated
Retraction : Present / Absent
Upper Extremity
ROM : Full / Limited
Abdomen
Inspection : Shape / Scar / Lesion
Auscultation : Bowel sound / Present /
Absent / Borborgymi
Percussion : Tymphony / resonant / dull
Palpation : Organomegali / tenderness
Lower Extremity
ROM : Full / limited
Capillary refill : <3 seconds / >3 seconds
Genitalia
External : Drainage / edema
Inflammation / odour
REVIEW OF SYSTEM
Preparing the patient for cardiac assessment
Explain and expose only the area to be evaluated.
Wear examination gown. Explain procedure.
Equipments:
· Stethoscope
· Small pillow
· Penlight or movable examination light
· Watch
· Centimeter ruler – 2
· Centimeter tape
· Stethoscope
· Tourniquet
· Gauze or tissue
· Water proof pen
· Blood pressure cuff
Cardiac land mark:
1. Aortic area
2. Pulmonic area
3. Mid pericardial area (Erb’s point)
4. Tricuspid area
5. Mitral area
Carotid inspection:
Pulsation / Cardiac land mark
Palpation:
For pulsation / thrills / Leaves
Auscultation:
Auscultate carotid artery –
No blowing / Swising / or other sound
Pulse equality or unequal
Pulse amplitude sound
0 = absent
1+ = weak
2+ = normal
3+ = increased
4+ = bounding
Auscultate pericardium
At the apex / sinus arrhythmia
Bradycardia - < 60 beats / minute
Tachycardia - > 100 beats / minute
Premature ventricular contraction / Arterial fibrillation / arterial flutter. Pulse rate deficit.
S1 - lub - loudest at the apex
S2 - dub - loudest at the base
Accentuated / diminished / varying / split sound
Extra sounds:
Ejections sound / click /
S3 - physiologic / pathologic
S4 - physiologic / pathologic
Murmurs:
Ø Innocent physiologic mid systolic murmur /
Ø Pathologic midsystolic / pan systolic / diastolic murmur
Ø Auscultation on change of position
HISTORY OF PRESENT HEALTH CONCERN
USE C.O.L.D.S.P.A
Character :
Onset :
Location :
Duration :
Severity :
Pattern :
Associated factors :
Present Medical History
· Change in color, temperature, or texture change in skin.
· Pain or cramping pain (aching / stabbing)
· How often
· Wake up from sleep
· Leg veins ropelike, bulging, contorted
· Any sores or open wounds, Location and pain
· Any swelling legs or feet. Time of swelling worst. Pain with swelling.
· Swollen glands or lymph nodes. Tender, soft or hard.
· Sex history.
Past Medical History
· Problems in the circulation of arms and legs.
· Any heart blood vessel surgeries or treatment.
Family History
Family history of diabetes / hypertension / coronary heart disease / elevated triglyceride levels.
Life style and health practices
· Smoking
· Pack per day
· Year of smoking
· History of exercise FITT
· Use of transdermal contraceptives.
· Describe the degree of stress
· Problems with circulation
· Leg ulcers, varicose veins – feeling about
· Medication history
· Support hose
APMS:
Physical assessment:
Inspection
Ø Observe arm size and venous pattern look for edema.
Bilaterally equal / No edema. Lymph edema
Ø Observe coloration of the hands and arms-
Bilateral coloration symmetrical. Pallar, cyanosis, redness.
Palpation
· Finger hands - Temperature – warm / cool
· Capillary refill time - 1- 2 seconds
>2 seconds.
· Radial pulse - 2+ /Increased / bounding / diminished
· Ulnar pulses - not deductable / inelastic
· Brachial pulses - equal / strength / symmetric
· lymph Node - not palpable / palpable
· Allens test - coloration 3-5 seconds / > 5 seconds / pale
LEGS
Color - pink / brown / pallor / Rubor cyanosis /
rusty brownies pigmentation
Distribution
Of hair - even distribution / loss of hair
Lesion or ulcers - free of ulcer / ulcer with smooth
Ulcer with irregular edges
Edema
· 1+ - slight pitting
· 2+ - deeper than 1+
· 3+ - deep + extremity looks larger
· 4+ - very deep gross edema extremity
· Bilateral / Unilateral
Temperature of the feet and legs
Warm / coolness / increased temperature
Superficial inguinal lymph nodes
Non tender / lymph node larger than 2 cm /
Femoral pulses : strong / equal / weak /
Auscultation : No sound / bruits /
Popliteal pulses : Palpable / not palpable /
Dorsalis pedis : Bilateral / weak / absent /
Posteriortibial pulses : Present / Bilateral / weak / absent /
Varicosities &
Thrompophlebitis : No varicosity / varicose veins / bulging /
Nodular /
Homan’s sign : Negative / Positive /
Special Test for aterial venous insufficiency
Position change
Test : pink / light pale / pallor coloration > 15 seconds
Trendlenberg
Test : Fill from below / fill from above
CENTRAL NERVOUS SYSTEM:
Level of consciousness : Alert and awake/ Letharg/Obtunded/Stupor/Coma.
Dress and Grooming : Neat/ Meticulous grooming.
Facial expression : Good eye contact/ Poor eye contact.
Speech : Moderate tone/ Slow / Repetitive.
Head ache : Present Absent.
RESPIRATORY SYSTEM:
Symmetry of chest wall : Symmetrical / Asymmetrical.
Rate/ Rhythm/Pattern : Resonant/ Hyper resonant.
INTEGUMENTARY SYSTEM:
Color of the skin : White skins/Darker skins/ Pallor/ Cyanosis.
Skin capillary refill : Pink tone return immediately,
/ < 3 seconds >3 Seconds.
Distribution of hair : Hair covers the scalp/ Hair loss.
MUSCULO SKELETAL SYSTEM:
Gait : Posture erect/ UN even weight bearing.
ROM : Full ROM against resistance/ Pain / Spasms
Swelling : No bulge/ Bulge of fluid.
Size / Shape / Deformities : Symmetric without deformities/ Redness/ heat/
Swelling / Deformities.
Muscle strength : Complete absence of contraction (0)/ Normal
Strength (5)/ (Scale 0 – 5)
GENITO URINARY SYSTEM:
Urethral discharge : Free of discharge/ a yellow discharge.
Inguinal hernia : Bulging or mass not seen/ A bulge or mass seen
VITAL SIGN:
Temperature :
Pulse :
Respiration :
B.P :
Pain scale : Numerical pain scale
0 1 2 3 4 5 6 7 8 9 10
NUTRITIONAL ASSESSMENT
A. Diet history
- Ask about a history of nausea, vomiting and abdominal pain
- Ask about increase or decrease in food or fluid intake
Excessive thirst : (present in Diabetes insipidus)
Salt craving : (present in Adrenal hypo function)
Increase in hunger & thirst : (present Diabetes mellitus)
Rapid change in weight : Diabetes mellitus / Thyroid problems
B. ANTHROPOMETRIC MEASUREMENTS
Height : in cm
Weight : in kg
BMI : Weight in Kg
M2
Normal limits : 20 – 25
Overweight : 25 - 29.9
Obese (class I) : 30 – 34.9
Moderately obese (class II) : 35 – 39.9
Extremely obese (class III) : > 40
Ideal body weight : Current weight
--------------------- X 100
Ideal body weight
Mild obesity : 20 – 40 %
Moderate obesity : 40 – 100 %
Morbid obesity : > 100%
Waist Hip Ratio : Waist in inches Female : 0.8 (normal)
Hip in inches Male : 1 (normal)
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