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Heart and Cardiovascular Assessment

Heart and Cardiovascular Assessment

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Published by vHORSEY

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Published by: vHORSEY on Mar 27, 2009
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04/28/2013

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Heart and Cardiovascular System Page 1 of 4 ©2007 Pearson Education, Inc.
Heart and Cardiovascular Assessment
Name: _________________________________________________ Date: _____________ Age: __________ Gender: _____________ 
History
Review of history related to heart and cardiovascular system: 
YES/NOIf YES, provide details:General
Smoking ______________________________________________ Fatigue _______________________________________________ Overweight/obesity ______________________________________________ Level of stress ______________________________________________ Exercise ______________________________________________ Alcohol consumption ______________________________________________ Diet ______________________________________________ Diabetes mellitus _______________________________________________ 
Cardiovascular
Cardiac disease history ______________________________________________ Chest pain or tightness ______________________________________________ Irregular heartbeat ______________________________________________ Unexplained dizziness _____________________________________________ Blood pressure problems ______________________________________________ Shortness of breath ______________________________________________ Orthopnea ______________________________________________ Cough ______________________________________________ Edema or cold hands or feet _______________________________________ Color changes/hands ______________________________________________ Color changes/lower legs or feet ______________________________________________ Swelling/ankles or legs ______________________________________________ Nocturia ______________________________________________ 
 
Heart and Cardiovascular System Page 2 of 4 ©2007 Pearson Education, Inc.
Focused symptom analysis of current problem:Reason for visit: ___________________________________________________________  _______________________________________________________________________________ Character: ___________________________________________________________ Onset: ___________________________________________________________ Duration: ___________________________________________________________ Location: ___________________________________________________________ Severity: ___________________________________________________________ Associated problems: ___________________________________________________________ Efforts to treat: ___________________________________________________________ 
Current medications (note hormones):  ________________________________________________________________Social history (fitness/exercise, stress reduction, nutrition):  ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________Sleep/rest patterns: ________________________________________________________________ __________________________________________________________________________________Family history of heart or cardiovascular system (especially cardiac arrest), or diabetes mellitus:  ___________________________
 _______________________________________________________  ___________________________________________________________________________________  ___________________________________________________________________________________ 
 
Heart and Cardiovascular System Page 3 of 4 ©2007 Pearson Education, Inc.
Physical Assessment
Height and weight:
Height in inches: ___________Weight in pounds: _____________ BMI: ______________ 
TIME OF ASSESSMENTHour
AMPMAMPMAMPMAMPM
Pulse R = RadialA = ApicalRhythm
      R      i     g      h      t
BPSystolicDiastolic
      L     e      f      t
BPSystolicDiastolic
Cardiovascular System: Inspection and Palpation 
General characteristics
(skin color, temperature and tone, cyanosis, nail clubbing or spooning,venous stasis): __________________________________________________________________ 
 _______________________________________________________________________________ Anterior chest
(color, symmetry, contour, scars, venous pattern, apical impulse,pulsations/thrills/heaves): __________________________________________________________ 
 _______________________________________________________________________________ Carotid and jugular vessels
(pulsations, distention): ___________________________________ 
Abdominal vessels
(aorta, iliac, renal pulsations): ______________________________________ 
Peripheral circulation
(arms, legs, hands and feet for temperature, color and pulses, ulcers andskin condition):
 __________________________________________________________________  _______________________________________________________________________________ 

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might be it should be much better than this
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