Solved: Comprehensive Assessment-Cardiovascular

DIRECTIONS

Visit the link to Joseph Lawrence’s chart on Canvas.

Comprehensive Assessment: CARDIOVASCULAR

Review Joseph’s medical chart including all physical assessment findings, past medical history, and vital signs. Note clinically significant data related to the patient’s medical diagnosis and post-cardiac catheterization findings.

1. Chart Review: 9 Total Assessment Groups
   • Cluster Joseph’s assessment data (both subjective and objective) that is clinically significant to the nurse. Create a table using the format below. Cluster the assessment data into the following sections:

1. Chief Complaint (CC)/ Presenting signs and symptoms (s/s)
2. General Appearance
3. Patient Medical History (PMH)
4. Vital Signs
5. Home Medications
6. Assessment Tools (i.e. EKG, telemetry)
7. Nursing Interventions (including treatments)
8. Post Cardiac Cath: Findings, Assessments, and Orders
9. Assessment Findings:
   • List each significant assessment finding individually arranged by Assessment Groups
   • DO NOT include lab and diagnostic findings for this question.
10. Analysis: What does it mean? How is this significant to the nurse?
    • Analyze the assessment data and describe the significance to the nurse including related pathophysiology and implications for nursing care.

Question #2:

1. Review all the ordered lab and diagnostic testing in Joseph’s chart.
2. List all pertinent laboratory and diagnostic studies including individual results for each exam.
3. What trends do you recognize? How do the trends relate to the patient’s condition?