Download NURS 8020 Cardiac Assessment and more Assignments Nursing in PDF only on Docsity!
NURS 8020 – Fall, 2025
Cardiac Assessment
CARDIAC ASSESSMENT
HEART & PERIPHERAL VESSELS
Pt. Initials: VI Gender: Female Age: 32
Subjective :
CC
“I noticed that my heart is skipping beats.” HPI The patient is a 32-year-old Caucasian female who reports feeling intermittent “skipped heartbeats” for the past 2 weeks. She describes them as “brief pauses followed by a stronger beat”, occurring several times a day, more noticeable at rest. She denies chest pain, syncope, or shortness of breath, but occasionally experiences mild lightheadedness when the episodes occur. No recent illness, caffeine intake has increased to 3 cups of coffee daily. Denies illicit drug use. No palpitations with exertion. PMH Medical/Chronic Issues: No history of hypertension, diabetes or thyroid disease. No prior cardiac disease or hospitalizations. Seasonal allergies. Surgical History: None. Medications: Prescribed: Loratadine 10 mg orally as needed for seasonal allergies OTC/Supplements: Occasional acetaminophen 650 mg for mild headaches Allergies: NKDA. Denies allergies to latex or foods. Reports seasonal allergies. Last Exams: PCP: January, 2025 OBGYN: March, 2025 Dentist: July, 2025 Eye: 2022 Vaccines: Flu: October, 2024 Pneumonia: Never
NURS 8020 – Fall, 2025
Cardiac Assessment
Tdap: Unsure Childhood Vaccinations: Reports all childhood vaccinations were received. Psych Hx: Denies history of depression or anxiety. SH: Tobacco: Denies current or past tobacco use. Alcohol: Drinks socially, 1-2 glasses of red wine/week. Drugs: Denies current or past recreational drug. Diet: Follows Paleo diet. Exercise: 1hr CrossFit/weights/high intensity exercise three times/week for the past 3 years. Occupation: Advertising/Marketing. Sedentary job. FH: Father: hypertension and hyperlipidemia Mother: hypothyroidism Paternal grandmother: died of stroke at 83. Denies family history of diabetes mellitus, cardiac disease or COPD. ROS: General: Denies fever, chills, or recent weight changes Cardiac: Reports palpitations/“skipped beats,” denies chest pain, orthopnea, paroxysmal nocturnal dyspnea, syncope Respiratory: Denies cough, wheezing, or dyspnea GI: Denies nausea, vomiting, abdominal pain Neuro: Reports mild lightheadedness during palpitations, no weakness, numbness, or headaches MS: Denies muscle or joint pain Endocrine: Denies heat/cold intolerance, polyuria, polydipsia Psych: Reports increased work stress, denies anxiety or depression
Objective:
T: 98.4/36.9 - temporal HR: 84bpm R: 16 BP: 118/76 – left arm, sitting Wt: 142lbs Measured Ht: 65in BMI: 23. General appearance: 32-year-old Caucasian female, alert and oriented ×3, well-nourished, in no acute distress. Appears stated age. Calm and cooperative during exam. Normal hygiene and grooming. Good historian.
NURS 8020 – Fall, 2025
Cardiac Assessment
Renal: None Iliac: None Femoral: None Color: Skin pink, consistent with ethnicity; no pallor, cyanosis, or mottling. Clubbing: Absent. Capillary Refill: < 2 seconds in upper and lower extremities. Temperature: Warm and equal bilaterally in upper and lower extremities. Edema: None noted. Ulcerations: None present. Allen Test: Normal. Hand flushed promptly (<5 seconds) after release of ulnar artery with radial artery compressed bilaterally, indicating adequate collateral circulation.
