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Fill in this template below: Cardiac/Respiratory Systems Past Medical History Check for Concerning Symptoms: Respiratory: frequent colds, shortness of breath, wheezing, pain with breathing, cough, coughing up blood night sweats Cardiovascular and Peripheral-Vascular chest pain, palpitations, dyspnea, edema, coldness to extremities, discoloration, varicose veins, leg pain with activity, paresthesia Pertinent Family History Lifestyle, Personal, Social, Environmental Social Determinants of Health Medications SUBJECTIVE: CHIEF COMPLAINT (In the patient’s own words) Review of Systems ALLERGIES: HISTORY OF PRESENT ILLNESS Complete, clear, and chronologic account of the problems prompting the patient to seek care related to this body system. SYMPTOM ANALYSIS ITEM QUESTIONS TO ANSWER PATIENT RESPONSE Onset When did (does it start)? Setting in which it occurs including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed. Location Where is it? Does it radiate? Duration How long does it last? Characteristics What is it like? How severe is it? Associated Manifestations Have you noticed anything else that accompanies it? Relieving/Exacerbating Factors What makes it better? What makes it worse? Treatment What have you done to treat this? Was it effective? OBJECTIVE: VITAL SIGNS TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE SP02 PAIN (Numeric Scale of 0-10 with 10 being the worst) DIAGNOSTICS (Labs) NURSE PHYSICAL FINDINGS FROM EXAM CARDIAC RESPIRATORY ASSESSMENT CARDIOVASCULAR INSPECT General appearance, position, breathing effort Measure apical pulse and BP bilaterally FACE Inspection of face: color (pallor or cyanosis), orbital edema, expression NECK Inspection of neck: observe for carotid pulsations Inspection: Presence of Jugular Vein Distention (JVD) @ 35 degree angle HEART Inspect anterior chest wall for PMI, contour, pulsations, heaves (lifts) over precordium, and retractions PERIPHERAL VASCULAR Inspect the upper extremities for skin integrity, color, hair distribution and edema Color, expression, orbital edema Heaves/Lifts PMI JVD Extremities color, hair distribution, edema PALPATE General palpation of chest wall with finger pads for heaves (lifts) and chest wall for thrills with ball of hand, right 2nd ICS, PMI PERIPHERAL VASCULAR Palpate the upper extremities for skin turgor, temperature, and capillary refill and edema. (See text for details). Palpate brachial, ulnar and radial pulses note amplitude (absent, weak, thready, strong or bounding), rhythm and grade (See text for details). Inspect the lower extremities for skin integrity, color, hair distribution and edema, venous distention Palpate the lower extremities for skin turgor, temperature, firmness, capillary refill, and edema (See text for details). Palpate femoral, popliteal, posterior tibialis and dorsalis pedis pulses noting amplitude (absent, weak, thready, strong or bounding) , rhythm and grade 0-4 (See text for details). Precordium Thrills/Heaves Skin turgor, Temperature, Edema CRT Carotid arteries (one at a time) Brachial Pulse Radial Pulse Popliteal Pulse Posterior Tibial Pulse Dorsalis Pedis AUSCULTATE (with appropriate stethoscope placement) Positions: lying supine, lying left lateral decubitus position and sitting leaning forward, standing. S1 and S2 heart sounds in all 5 areas. Note rate, rhythm, & pitch. Note if audible, when, and at which anatomic location of any extra sounds, S3, S4, murmurs. Where S1 louder, S1 is is equal to S2, and where is S2 louder? (See text for details). Aortic—2nd ICS (RSB) Pulmonic—2nd ICS (LSB) Erb’s Point—3rd ICS (LSB) Tricuspid—4th ICS (LSB) Apical (Mitral)—5th ICS (MCL) Extra Heart Sounds Murmurs [Proper Positioning for S1 and S2 Murmurs] Carotid artery bruits RESPIRATORY INSPECT Inspection of facial expression, general appearance, posture, LOC, color, conjunctiva, neck, nails Observe respiratory rate, pattern and expansion Inspect shape symmetry and motion, muscle development, intercostal spaces, anterioposterior to transverse diameter and costal angle Posture Chest movement PALPATE Palpation over chest, thoracic muscles, intercostal spaces for tenderness and symmetry Palpate thoracic expansion Palpate for tactile fremitus 99 Tenderness PERCUSS Percussion of chest Percussion for diaphragmatic excursion Lung Fields Anterior Posterior AUSCULTATE Auscultate for breath sounds Auscultate transmitted voice sounds Lung Fields Anterior Posterior ASSESSMENT: SUMMARY OF MAJOR PROBLEMS (Provider narrative of relevant information gathered from analysis of the Subjective and Objective sections above. Must include all aspects of system assessment provided) PLAN: *Make sure to include preventative health maintenance and health promotion NURSING CARE PLAN FOR THE PATIENT BASED ON THE PROBLEMS IDENTIFIED IN “ASSESSMENT” (Provide the priority nursing interventions that would be performed for this patient next. Rationale for each nursing intervention needs to explain why this is the best intervention for this patient scenario, and must be evidence based.) 1. Rationale: 2. Rationale:

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