LAB CHECK OFF-2

CARDIOVASCULAR ASSESSMENT
Case scenario:

Mr. Daniel Alexander (MRN-13006) is 53-year-old male farmer came to the hospital concerned
with mild chest pain. You are the assigned nurse for this patient and required to collect further
detailed history and do physical examination of the cardiovascular system to plan the nursing
care.

DOCUMENTATION
Patient name: Age: Sex: MRN:

Date Notes Name and Signature (to be written at

the end of the notes)
Subjective Data
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Past cardiac history

_________________________________________________________________________________
_________________________________________________________________________________

Family cardiac history

_________________________________________________________________________________
_________________________________________________________________________________

Patient-centered care / personal habits (cardiac risk factors)

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
 Objective Data
1. NECK VESSEL

Palpation: ________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Auscultation:______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. Jugular Venous pulse inspection
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Jugular Venous pressure estimation
_________________________________________________________________________________
_________________________________________________________________________________
3. THE PRECORDIUM
Inspection:________________________________________________________________________
_________________________________________________________________________________
Palpation:________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Auscultation:_____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Student’s Name : ____________________________________Signature:____________ Date:________