CARDIOVASCULAR ASSESSMENT TOOL

BIOGRAPHIC DATA:

Name : Hospital :
Age : Ward :
Sex : Unit :
Religion : IP No. :
Nationality : Bed No. :
Education : Date of Admission :
Occupation : Diagnosis :
Income : Doctor’s Name :
Address :

Chief Complaints:-

1
2
3
4
5

History of present illness:-

1. Pain:

Onset___________ duration_____________location_____________
frequency_______severity_______Aggravating factors____________
Relieving factors_____________ precipitating factors_____________
2. Cough expectoration:-

Colour_____________ Consistency______________
Odour_______________ onset___________________

3. Dysphagia :- Yes______ No_______

4. Hoqrseness of voice :- Yes______ No_______

If yes specify_____________________

5. Dysphasia :- Yes______ No_______

If yes specify_____________________

6. Haematemis :- Yes______ No_______

If yes specify_____________________

7. Heart Burn :- Yes______ No_______

If yes specify_____________________

8. Vomiting :- Yes______ No_______

If yes specify__________________

PAST MEDICAL HISTORY

Past Health History:- Any history of

➢ Chest Pain :- Yes_____ No_____ If yes Specify______

➢ Shortness of breath :- Yes_____ No_____ If yes Specify_________
➢ Fatigue :-
➢ Alcohol & Tobacco use :-
➢ Anaemia :-
➢ Rheumatic fever :-
➢ Streptococcal throat infections :-
➢ Congenital Heart disease :-
➢ Stroke :-
➢ Palpitations :-
➢ Dizziness with position changes:-
➢ Syncope :-
➢ Hypertension :-
➢ Thrombophlebitis :-
➢ Intermittent claudication :-
➢ Varicosities :-
➢ Edema :-
Medications:- Assess patient’s current and past use of medications

➢ Over-the-counter(OTC) drugs :
➢ Herbal Supplements :
➢ Prescription drugs :

List of drugs:
1. _____________
Dosage _____________ Time of last dose___________
Patient’s understanding of drug’s purpose______ side effects_______
2. _____________
3. _____________
4. ______________
Surgery or other treatments:
➢ Any specific treatments:
Treatment received ______________ Reason______________
➢ Past Surgeries:
Surgery Name____________ Indication for surgery_____________
Date of Surgery ___________ Result of Surgery_______________
➢ Previous hospital admissions related to CVS:
Date of admission:________________
Reason for admission:_______________
Outcome:____________________
➢ Any outpatient procedures:-
Date____________
Reason______________
Socio-Economic History:-
➢ Family Relationships:__________________
➢ Relationships with neighbours:__________________
➢ Education:_________________
➢ Occupation:________________
➢ Income_________________
➢ Housing____________
Kutcha___ Pucca_____no. of rooms________ no. of windows____
➢ Lighting:________ Ventilation :- Good:______________
Adequate:___________
Poor:_______________
➢ Drainage: Closed_________ Opened:_____________
➢ Sources of Water Supply:
Pump line______ Well___________ Rivers_________
Family History:-
Type of Family : Nuclear________Joint________ Extended______
Martial Status : Married______ Un-Married_____
Consanguineous : Yes _____ No______
S.No. Relation Age/Sex Education Occupation Income Health Status

Family Tree:- Keys:-

Personal History:-
➢ Bath:-
➢ Brushing:- No. of times _____ Type of Brush_____________
➢ Voiding:- Frequency__________
➢ Defecation:- Regular/Irregular/Constipation
➢ Sleep:- Usual bedtime_____ time of awaking_______
Nature of sleep:- Sound/Disturbed/Insomnia.
➢ Bed time rituals:- Yes/No, If Yes specify____________
History of sensitive skin:-___________
➢ Obesity_________
➢ Tattos and piercings:-_______________
Exposure to new soap:-____________
Foods:-______________
 Pets:-_______________
Plants:-_____________
Recent travel:-________
➢ Use of drugs for sleep: Yes/No. If yes, Specify__________
➢ Psychological factors: Fear/Anxiety/Depression
➢ Smoking: Yes/No. If yes, Specify how many per day_____
Since how many years_____
➢ Alcohol:- Yes/No. If yes, number of pegs per day____
➢ Daily exercise:- Yes/No
➢ Hobbies:-
➢ Sexual activity:- Satisfactory Yes/No

Dietary History:-
Vegetarian/Non-Vegetarian
Staple Food:____________
Quantity of fluid intake per day:________
Tea/coffee_______ no. of cups____
Review of systems:-
Health History of Cardio-Vasular System:
Health Perception-Health Managment pattern:
Ask the patient about presence of major cardiovascular risk factors
➢ Abnormal Serum lipids: Yes/No
➢ Hypertension: Yes/No since how many years
➢ Sedentary life style: Yes/No
➢ Diabetes Mellitus: Yes/No
➢ Obesity: Yes/No
➢ Tobacco Use: No. of packs per day:
➢ Alcohol abuse:
 Type of alcohol:
Amount:
Frequency:
➢ Use of habit-forming drugs:
➢ Allergies:
Food allergies:
Environmental allergies:

Any previous
Drug reaction:
Allergic reaction:
Anaphylactic reaction:
Any allergic reaction to contrast media:

Any family members who developed cardiac disease younger than age 55.
1.
2.

Any family history of non-cardiac problems such as

➢ Asthma
➢ Renal Disease
➢ Liver disease
➢ Obesity

Nutritional-Metabolic Pattern

Weight History:-
- Last one year in relation to ht:
- Amount of salt/day
- Saturated fats/day
Elimination pattern:- Any history of
- Incontinence
- Constipation
- Prescribed & OTC for constipation
- Any swelling of lower extremities

Activity-Exercise Pattern:
Type of exercise
Duration:
Intensity
Frequency:
Any symptoms during exercise like:
Eg: Chest pain:
SOB:
Claudication:
Sleep-Rest Pattern:-
Parpxysmall nocturnal dyspnea -
Cheyne-stokes respiration -
No.of pillows needed to sleep -
Sleeping upright -
Sleep apnea -
Nocturia -
Self-perception-self-concept pattern
Level of activity
Normal
Reduced
Role-Relationship pattern

Marital status:
Role in the household:
Employment status:
No. of children:
Ages of children:
Living environment :
Caregivers – present/ absent:
Level of satisfaction with life roles – satisfied/not satisfied:
Sexuality – Reproductive Pattern:
Male Patients:-
Erectile dysfunction –
Use of drugs for ED –
Female patients:-
Use of oral contraceptives –
Hormone therapy for menopause –
Dry therapy for breast cancer –
Coping – Stress Tolerance Pattern:
1. Areas causing stress –
Health concerns, Marital relationships, family & friends, occupation,
finances, work related stress, depression, inadequate social support.
Methods of coping with stress
Support systems like
Family –
Extended Family –
Friends –
Counsellors –
Religious groups –
Values – belief pattern:-
Patients belief about disease –
Objective data:-
Physical examination:-
Vital signs:- Measure BP bilaterally
B.P
Right –
Left –
B.P H.R
Supire –
Sitting with –
Legs dangling –
Standing –
Peripheral Vascular System:-
Inspection:-
Skin: Colour –
Hair distribution –
Venous pattern –
Extremities:-
Edema –
Dependent rubor –
Clubbing of the nail beds –
Varicosities –
Lesions –
Large Veins:- Inspect while patient is gradually elevated from
Internal Jugular vein
External Jugular vein
Palpation:- Palpate upper & lower extremitives
Upper extremitivies Lower extremitivies
Temperature Temperature
Moisture Moisture
Pulses(refer cardiac assessment) Pulses
Edema

Edema
Pitting
- Non-pitting
If pitting edema
Grades
1+ Detectable 2mm depression, immediate rebound
2+ 4mm deep pit, few seconds to rebound
3+ 6mm deep pit, 10-12 sec to rebound
4+ 8mm very deep pit, ( > 20 sec to rebound)
Palpate pulses for arterial blood flow
Absent Normal Increased Fully bounding Thrill
Carotid
Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

Capillary Refill:-
Less than 2 seconds –
More than 2 seconds –
Auscultation:-
Aortic area -
Pulmonic area -
Tricuspid area -
Mitral area -
Erb’s Point -

Investigations:-
S.No. Name of the test Findings Normal Value

Treatment:-