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Lab Assessment Exercise Nur 361 Assessment

646 words - 3 pages


History of:

Yes No (Explain all ?Yes? responses)
Chest pain or pressure ___At rest ___With Exercise
___Waking at Night ___Climbing Stairs
Edema, dependent ? feet or ankles
Paroxysmal nocturnal dyspnea
Dyspnea on exertion
History of heart disease
History of heart surgery
Heart murmur
Sleep apnea
Leg pain/cramps
Congestive heart failure
Myocardial infarction
Coronary artery disease
Bleeding disorders
Diabetes mellitus
Congenital heart defects
Coldness in extremities
Numbness or tingling sensations
Discoloration in hands or feet
Varicose veins
Intermittent claudication
Ulcers on legs or feet
Decreased sensation in extremities
Sickle Cell Anemia or Trait
Easy bruising
Blood Clotting Problems
# Pillows Needed for Sleep ___________
Mitral Valve Prolapse
Blood Clots/DVT/PE/Thrombophlebitis
Irregular heart beats
Exercise intolerance
Have you ever had a: _____Stress Test _____ECG
_____Heart Catheterization _____Echocardiogram
Other _____________________________________

Health Promotion Behaviors:
Practices this behavior: (Explain all ?No? responses)
Yes No
Maintains weight appropriate for height
Maintains active lifestyle
Engages in regular aerobic exercise
Avoids saturated fats and trans fatty acids
Does not smoke
Avoids exposure to second-hand smoke
No recreational drug use
Manages stress
If on cardiac medications, takes as prescribed

(Explain all unexpected findings including location, size, description. Descriptors provided not the only possibilities, simply suggestions)
1. Assess general appearance for:
Signs of distress ? None ? Mild ? Moderate ? Severe
Skin color Color: ___________ ; ? Cyanosis ? Pallor ? Jaundice
Capillary refill ? Brisk(<2-3 seconds) ?Slow:____ ? Absent

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