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A thorough health history and physical assessment are essential for identifying cardiovascular disease (CVD) symptoms and distinguishing them from other health issues.
Initial Enquiry
Ask the patient about their primary concern and thoroughly explore all reported symptoms.
Medical History
Investigate past illnesses affecting the cardiovascular system, such as angina, anemia, rheumatic fever, congenital heart disease, stroke, thrombophlebitis, dysrhythmias, varicosities
Inquire about symptoms such as shortness of breath (dyspnea), fatigue, dizziness when changing positions, syncope, edema, leg pain during exercise (intermittent claudication), palpitations
Check for allergies to drugs, food, or the environment and any history of drug reactions, especially to contrast media.
Medications
Assess current and past medication use, including:
Note any non-cardiac drugs impacting the cardiovascular system. Ask about specific treatments, surgeries, or hospital admissions related to cardiovascular problems, and record any procedures performed, including ECGs or chest x-rays.
Risk Factors
Investigate major cardiovascular risk factors, such as:
Estimate tobacco use in pack-years and record alcohol use, including type, amount, and frequency. Ask about recreational or habit-forming substances. Note genetic or familial tendencies toward cardiovascular issues and the age of onset in family members. Assess weight history and dietary habits, particularly salt and saturated fat intake. Discuss their attitudes and plans for diet and weight management.
Lifestyle and Habits
Ask about urinary habits, especially if taking diuretics, and any issues with incontinence or constipation. Teach patients with heart problems to avoid straining during bowel movements. Check for swelling in the lower extremities and if it resolves with elevation. Record exercise types, duration, intensity, and frequency.
Functional Health Patterns in Cardiovascular Assessment
Evaluating functional health patterns provides a holistic view of cardiovascular health. Key areas include:
Health Perception-Health Management:
Activity-Exercise:
Sleep-Rest:
Cognitive-Perceptual:
Role-Relationship:
Stress and Coping:
Sexual Activity:
From Chapter 13:
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