Module 09 lab assignment – documentation of a cardiovascular system | physical assesment
Subjective Findings:
- Ask the patient about any current cardiac symptoms, such as chest pain, shortness of breath, palpitations, dizziness, or fatigue.
- Inquire about their medical history, including any previous cardiac conditions, surgeries, or interventions.
- Ask about family history of cardiac disease, as well as any risk factors such as smoking, high blood pressure, high cholesterol, or diabetes.
- Inquire about the patient’s lifestyle, including diet, exercise habits, and stress levels.
Objective Findings:
- Check the patient’s vital signs, including blood pressure, heart rate, respiratory rate, and temperature.
- Inspect the patient’s skin for color, temperature, and moisture.
- Palpate the patient’s peripheral pulses, including the radial, brachial, femoral, popliteal, and dorsalis pedis pulses.
- Auscultate the patient’s heart sounds, including the S1 and S2 sounds and any murmurs, clicks, or gallops.
- Assess the patient’s lung sounds for any crackles, wheezing, or diminished breath sounds.
Identified Risks:
Based on the patient’s history, lifestyle, and objective findings, some identified risks may include:
- Increased risk of coronary artery disease due to a family history of cardiac disease, smoking, and high cholesterol levels.
- Potential for arrhythmias or heart failure due to a history of previous cardiac conditions or surgeries.
- Risk of hypertension and complications such as stroke or kidney disease.
- Risk of stress-related cardiac symptoms due to high levels of stress in their lifestyle.
In summary, a cardiac assessment should include both subjective and objective findings to identify any current cardiac symptoms, past medical history, and potential risk factors. Based on these findings, actual or potential risks can be identified, and appropriate interventions can be recommended to improve the patient’s cardiac health.