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
