Cardiac and Peripheral Vascular Assessment

Topics: Heart, Pulse, Internal jugular vein Pages: 4 (581 words) Published: February 10, 2013
Jessica Li


✓ Identify patient by first and last name
✓ Introduce self and title
✓ Address patient by sur name
✓ Inquire about purpose of visit

✓ Wash hands
✓ Attention to safety and organization


REVIEW OF SYSTEMS (In the patient’s own words)

• Chest Pain: no tightness or pain indicated
• Shortness of breath (dyspnea): no shortness of breath • Number of pillows sleep with at night (orthopnea): sleeps with 2 pillows, denies orthopnea • Cough: coughs during the day or night; no mucus or blood tinged; coughs • Fatigue: no fatigue

• Skin ever turn bluish or ashen in color? (Cyanosis or Pallor): denies facial skin turn blue or ashen • Swelling in your ankles or feet (edema): no swelling of feet and legs • Ever awaken at night to urinate? How many times? (nocturia): no nocturia indicated • Past health problems with your heart? No past history of hypertension, obesity, diabetes or signs of coronary artery disease • Personal habits (cardiac risk factors)

o Nutrition (fats, calories, salt): consume limited amount of sodium intake o Exercise: does cardio workout every other day ; gym member o Smoking (current, former, pack hx, type): no history of smoking o Alcohol consumption? (how much, how often, type of alcohol): drinks socially on the weeknds

• Leg pain or cramps : no leg pain or cramps
• Skin changes or arms and/or legs: denies redness, pallor, blueness or brown discoloration • Swelling in arms or legs: no swelling in arms or legs • Swollen glands in your arms or legs (Lymph node enlargement): no swollen glands, no lumps or kernels



AA&O X7; pleasant and cooperative; grooming appropriate for season and setting with casual dress....
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