Documentation of problem based assessment of the cardiac sy ✓ Solved

Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings.

Instructions: Content: Use of three sections: Subjective, Objective, Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format: Standard American English (correct grammar, punctuation, etc.)

Paper For Above Instructions

The assessment of the cardiac system is crucial for determining the health status and potential risks a patient may face. This involves both subjective and objective evaluations to ensure comprehensive patient care. This document will outline the problem-based assessment findings of the cardiac system, including subjective data obtained from patient interviews, objective data collected from physical examinations, and actual or potential risk factors as identified from these assessments.

Subjective Assessment

The subjective assessment involves gathering personal insights from the patient regarding their health, symptoms, and any previous medical history relative to cardiovascular health. In this case, the patient, a 62-year-old male, presented with complaints of intermittent chest pain, shortness of breath (dyspnea), and fatigue. The patient has a history of hypertension and hyperlipidemia, which are significant cardiovascular risk factors.

During the interview, the patient described the chest pain as a squeezing sensation that occurs particularly when engaging in physical activities, suggesting potential exertional angina. He reported that the pain usually subsides with rest, lasting approximately 10 to 15 minutes. Additionally, he indicated experiencing episodes of palpitations and anxiety when symptoms arise. The patient also disclosed adherence to prescribed medications, including a statin for cholesterol and a beta-blocker for blood pressure management, although he has intermittently missed doses due to forgetfulness.

Notably, the patient’s family history is significant for cardiovascular disease, with his father having suffered a myocardial infarction at the age of 55. This information highlights a possible genetic predisposition to cardiac issues, adding to the patient’s health concerns.

Objective Assessment

The objective assessment includes vital signs and physical examination findings that provide measurable data reflecting the patient's cardiovascular status. Upon examination, the patient's blood pressure was recorded at 145/90 mmHg, indicating Stage 1 hypertension. The heart rate was 78 beats per minute, which was regular, and respiratory rate was 18 breaths per minute.

Auscultation of the heart revealed a normal S1 and S2, however, S4 gallop was noted, which may be indicative of left ventricular hypertrophy or diastolic dysfunction. Peripheral pulses were strong and symmetrical, but there was slight edema noted in the lower extremities upon examination, possibly suggesting fluid retention due to cardiac inefficiency.

The patient was also screened for risk factors using the Framingham risk score, leading to the identification of additional risk factors such as smoking history (non-smoker), age (over 60 years), and dyslipidemia.

Actual or Potential Risk Factors

Based on the assessment findings, two significant potential risk factors have been identified:

1. Non-adherence to Medication: The patient mentioned missing doses of his prescribed medications, which can significantly increase the risk of adverse cardiovascular events. Non-compliance with antihypertensive and lipid-lowering medications is known to be a major contributor to increased morbidity and mortality in patients with cardiovascular diseases. Counseling on the importance of medication adherence and simplifying the regimen may be necessary to mitigate this risk.
2. Family History: The patient's father had an early onset myocardial infarction, which places the patient at a higher risk for developing cardiovascular conditions due to genetic predisposition. This family history necessitates enhanced monitoring and aggressive management of the patient's risk factors, including lifestyle modifications and potential early interventions.

In conclusion, thorough documentation of both subjective and objective findings in a problem-based assessment of the cardiac system is essential for effective patient management. By identifying and describing actual and potential risk factors, healthcare providers can better tailor treatment plans, enhance patient education, and ultimately improve patient outcomes.

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