HEALTH ASSESSMENT OF

CARDIO VASCULAR SYSTEM
SUBMITTED TO : Mrs. Fiona Felecia Princy., M.Sc., (N) LECTURER SUBMITTED BY : RAMANUJAM. S M.Sc Nursing, 1st year

SUBMITTED ON:

Stroke. Thyroid Problems CARDIO VASCULAR:Do you have? Cardiac disease Chest pain/ tightness Dizziness/ light headache Dyspnea YES :  :  :  :  NO     . C. HTN. Moderate       Do you have stress? Exercise: Alcohol consumption: PAST HISTORY: Diet Any dietary restriction : Vegetarian or Non-vegetarian : Diabetic diet. HTN. IWMI. LAKSHMI. Bleeding Disorder. CAD. Renal disease. Obesity. Date of admission: 25th October 2012 REVIEW OF HISTORY RELATED TO HEART & CARDIO-VASCULAR SYSTEM GENERAL Smoking : Fatigue Weight : YES   NO   : Overweight. Fat restriction.HEALTH ASSESSMENT OF CARDIOVASCULAR SYSTEM GENERAL INFORMATION: Patient name Age Sex Marital status Occupation Diagnosis : Mrs.V : 71 years : Female : Married : Home maker : DM. Salt restriction. CAD? : Anemia. Fluid restriction. Low cholesterol Do you have any Other disease like : DM.

Sleep. Continuous. Back. Elimination or Emotional upset Aggravating Factor Reliving Factor : Activity. Jaw. : Sub Sternal. Burning. Moderate. None. PAST HISTORY: Previous hospitalization: Yes If yes. Localized. Exercise. Antacid. Gradual. Tightness. Morphine. Rest. Dizziness. Discomfort. Anxiety. Diffuse or radiating to Jaw Back and Arm Severity/ Intensity Precipitating Factor : Mild. Palpitation. and Severe : Awake at Rest. NTG. Light Headache. Temperature : Medication. With Eating. Edema and calf tenderness. Palpitation. Swelling. DM & HTN: 1992 Medication: Mentioned in table FAMILY HISTORY: History of : CAD. when: Admitted on 1992 and diagnosed as CAD. Swelling. Hardness. Aching. : Lasting in minutes. and angiogram done. HTN . Associated Symptom : Fatigue. Interrupted with Activity. Precordial. Periodical : Pressure. Breathing.Cough Irregular heart beat Palpitation Edema or cold hand or feet Leg pain (calf) : :        (right leg)    :  :  :  Skin color changes hands/ feet:  Nail clubbing Nocturia PRESENT HISTORY: Chief Complaints Onset Duration Character Location :  :  : Chest Pain. Vomiting : Sudden. Heart burn.

: 58kgs.8 degree F . skin turgor is good Visible pulsation : Present Scars Edema Nail clubbing : Nil : Not present : Nil Central cyanosis : Nil Temperature PALPATION: PMI (point of masaurin impulse) : Nil Apical impulse Palpable murmur Pulsation Capillary refill : Present : Thrills/ Heaven : Bounding/Thready/Absent/ Normal : Normal : 98.33kgm2 Blood pressure : Sitting Lying Standing : 160/90 mmHg : 160/95 mmHg : 155/90 mmHg INSPECTION: SKIN: Colour Symmetry Contain : Normal : Yes : Shiny.Specify : Her father had Hypertension. : 23. PHYSICAL EXAMINATION: Height Weight BMI Vital signs: Pulse Respiration : 102beats/min : 26breath/min : 158cms.

Normal. +2.PERCUSSION: Pericardial effusion : Present / Absent Plural effusion AUSCULTATION: Heart rate Rhythm : 102beats/min : Regular/Irregular/Pulse deficit : Present/ Absent Pulse quality : Absent. Effect of vessel quality on pulse: Temporal pulse : Present Carotid Brachial Radial Femoral Popliteal : Normal : Present : Present : Present : Present Dosalis pedis : Present Tibial artery Murmur Bruits : Normal : Nil : murmur/ unexpected sound/Nil Blood pressure: 140/90mmHg . +3. full pulse cannot be obliterated +4 strong.+1. cannot be obliterated +3 easy to palpate. +4 Grading of pulse: 0 pulse not palpable or absent +1 weak thread pulse difficult to palpate +2 diminished pulse. Pulse strength: 0. Bounding Pulse pressure: 50mmHg Heart sound : S1. S2 heard. Diminished. bounding pulses may be abnormal Jugular venous pulsation: Present / Absent Jugular vein: Normal/ Distended in supine position. Distended when head end is elevated Pulse configuration : Normal/ Feeble/ Water hammer pulse.

3. Right dominant system. AWMI . No abnormal EXTREMITIES: Edema : Nil : Nil : Nil : Nil : Nil : Nil Cyanosis : Nil INVESTIGATION S. 4. 5. shallow breathing: Normal breathing Rapid respiration Crackles Wheeze Hemoptysis Cough ABDOMEN: Ascites : Nil Bruits : Nil BLADDER: Urinary output : Adequate. 10. REPORT Normal Tachycardia. CABG=LAD-OM1 PTCA= LAD-LCX EF=58%. 6. 8.No 1. 9. 2.Ascites : Nil OTHER SYSTEM Lungs: Tachypnea : Nil Rapid. 7. DIAGNOSTIC TEST Chest x-ray Electrocardiogram Exercise treadmill Cardiac stress testing Echo cardio graphy Transesophageal echo carsiography Computer tomography Positon emission tomography Magnetic resonance imaging Coronary angiography YES    NO         CAD-DVD Acute RCA occlusion with thrombus.

12.0g/dl 2. 127 0.07mg/dl 0.4 gm% 29% 1200 cumm 3.  14.  . Cardiac enzyme analysis: creatinine kinase CK-MB CK Tropin T Complete Blood count: Hb PCV WBC RBC MCH MCV MCHC Platelet Differential count: Neutrophil Lymphocyte Monocyte Eosinophil Basophil Renal Profile Blood sugar Urea Creatinine Na K Blood biochemistry Total Bilirubin Direct bilirubin Total protein Albumin Globulin ALD ALT AST GTT  11.9 27 84 32 394000 cm3 73% 18% 08% 01% 00% 120mg/dl 57mg/dl 1.11.2mg/dl 133mg/dl 4.0mg/dl 1.041 9.8/dl 3.g/dl 6.2/dl 57u/L 37u/L 32u/L 31 u/L  13.45.