Cardiovascular Health Assessment Write-Up

This is a Health Assessment write up examining the heart, neck vessels, and peripheral vascular system. Falling under the learning category of providing holistic care, the key theme of this document is health promotion and disease prevention. By identifying abnormal cues,making risk nursing diagnoses, I can help clients to recognize possible health complications in the future. Working with the client a care plan can be implemented based upon this evidence.

Methodist College of Nursing




Date of Examination: 9-24-11

Age _______48_  Race: Caucasian     Culture_Western Current Diagnoses: Urinary Incontinence

Height___5’6’’__Weight_208lbs Weight change?__Loss of 104 lbs in past year Smoker?n/a_ETOH?n/a_

Current Medications: (list) Effexor 75mg twice daily, Calcium 1000mg daily, Ibuprofen 800 mg PRN, Vicadin PRN

Medical History: Chickenpox- 1965, Chin laceration-age 9, childbirth- 1986,1989, Cholecystectomy age 40, Right meniscus repair age 46, Hysterectomy/Bladder tuck age 48

Client’s color: Beige, pink undertones

Complaint?_Pain and cramping related to recent hysterectomy and bladder tuck

Pulse__64 Respirations_12_Blood Pressure_124/80_Temperature__98F_____Pain (0-10)__3_______




Auscultate carotid arteries for bruits, amplitude, contour of pulse, elasticity, thrills


Amplitude of carotid arteries 2+ normal, no bruits auscultated

Contour smooth and rapid on upstroke and slow on downstroke

Elasticity normal with no thrills

AInspect jugular venous pulse


Jugular venous pulse visible upon supine position of client but not fully distended



Inspect for visible pulsations, thrills, vibrations, size, strength, duration of pulsations, dyspnea


Apical pulse not visible, no thrills, heaves or lifts observed

Vibrations regular and even, pulsations equal

No dyspnea reported or observed

Palpate at apex, left sternal border, base


Amplitude at apex small and duration brief

No pulsations/vibrations palpated in the areas of the apex, left sternal border or base

Auscultate heart sounds S1, S2, for rate, rhythm, location, strength, pattern, splitting


S1 and S2 auscultations are normal and distinct with loudest sound at apex

Pattern and rhythm are normal, no split in sounds or accentuated sounds.

Auscultate for extra heart sounds S3, S4, clicks, rubs, murmurs, - intensity, grade, pitch, quality, shape, pattern, location, transmission, effect of ventilation, position, tachycardia, bradycardia


No extra heart sounds heard

Absence of clicks, murmurs, and rubs

Client reports recent tachycardia when moving from bed to restroom post op.

No bradycardia reported

Auscultate left lateral, sitting, leaning forward, exhaling.


Auscultation of apex and left sternal border: S1 and S2 present and normal

Auscultate: Aortic, Pulmonic, Erb’s Point, Tricuspid, Mitral areas


Auscultation reveals no abnormal extra heart sounds or murmurs, clicks, rubs






Inspect bilaterally for size, edema, venous patterning, color, fingertip clubbing, ulcerations, hair distribution, texture of skin


Inspection reveals bilateral symmetry, minimal shape and size variation

No edema, or venous patterning, color is normal beige with pink undertones, skin is warm to touch and bilaterally from upper arm to fingertip

No ulcerations, hair distribution continues along arm

Palpate fingers, hands, arms for temperature, capillary refill time


Fingers cooler than hands and arms but not in excess

Capillary refill time in 2 seconds or less

Palpate radial, ulnar, brachial pulses , quality (0 – 4+) bilaterally


Radial pulse bilaterally strong of 3+ and walls resilient

Ulnar pulse resilient and strong of 3+

Brachial pulses equally strong bilaterally




Inspect color, hair distribution, ulcers, drainage, odor, edema bilaterally – pitting/non-pitting 1-4+, temperature


Hair covers skin of legs, and dorsal surfaces of toes

Legs free of ulcers with drainage, odor or edema present bilaterally symmetrical

Toes cool; feet and legs equally warm bilaterally

Palpate femoral, popliteal, dorsalis pedis, posterior tibial.


Femoral pulse difficult to palpate, but appears strong and equal bilateraly

Popliteal pulse not found with client position; client was beginning to report pain from surgery at this time

Dorsalis pedis pulse present, bilaterally strong

Posterior tibial present and bilaterally strong

Inspect for varicosities, thrombophlebitis, Homan’s Sign

No varicose veins visible, No redness or discoloration on skin over veins, Homan’s sign indicates no pain or tenderness when performed



This was done two days after surgery; client was still in pain so most of exam was done with client in bed.



One Related Actual Nursing Diagnosis:

Bathing-Hygiene self-care deficit: Level II related to hysterectomy and bladder tuck as evidenced by impaired ability to cleanse body parts.


One Related Risk Nursing Diagnosis:

Risk for Infection: Urinary Tract related to self-catherization.


One Related Wellness Nursing Diagnosis:

Readiness for Enhanced coping: Client will employ effective means of managing stressors.