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You are the admitting nurse: Complete a cardiac assessment and document using the following information: H.J. is a 56-year-old obese male with a past medical history of myocardial infarction (heart attack) 6 months ago. He has had hypertension (high blood pressure) for 30 years and has smoked cigarettes for 40 years (2 packs per day). Current medications include a blood pressure medicine, aspirin, and a medication for increased cholesterol. H.J. is at the clinic today for a 6-month follow-up with his cardiologist. He is reporting increased breathlessness, nocturia, and fatigue for the past 2 weeks. Family history: father with heart attack resulting in death at age 50, mother died in childbirth at age 21, brother with hypertension and “some type of heart thing”. Vital Signs: T: 98.6 P: 130 R: 26 BP: 96/60 mm Hg 02: 93% Weight: 260 lbs Height: 5’10” Pain level: needs to be assessed. Thinking Hint: What technique(s) would be included in your focus assessment? What questions would you ask this patient? Patient information Cardiac assessment Information/Documentation: Page 1 of 3 Physical Assessment Documentation Assignment Assessment Subjective data Assessment Objective data Actual/Potential Risk Factor And why this choice? Actual/Potential Risk Factor And why this/those choices?
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