Conduct An Assessment On The Following Body Systems: Heart

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Conduct an assessment on the following body systems: Heart & the lungs assessment. You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission. Collect both subjective and objective data using the process described in the textbook. Write a summary of the assessment (subjective & objective data in narrative note) and the skills utilized. Answer the following 3 questions in the summary. Do not disclose any patient identifiers. What skills (assessment techniques) were utilized during the assessment? What subjective data did you collect? (list your findings) What objective data did you collect? (list your findings) Summary on a WORD document. APA format isn't required.

Paper For Above instruction

Introduction

Assessment of the cardiovascular and respiratory systems is a fundamental part of physical examination, providing crucial insights into an individual’s health status. Conducting these assessments requires a combination of specific skills and techniques that ensure accurate and comprehensive data collection. For this assignment, I performed an assessment of a volunteer, focusing on both subjective and objective data related to the heart and lungs, utilizing various assessment skills as outlined in the textbook.

Assessment Techniques Utilized

Throughout the examination, I employed several key assessment techniques. These included inspection, palpation, auscultation, and percussion. Inspection involved observing the patient’s general appearance, skin color, and breathing pattern. Palpation was used to assess chest symmetry, tactile fremitus, and peripheral pulses. Auscultation was performed with a stethoscope to listen to heart sounds and lung sounds, while percussion was used to evaluate underlying lung fields for resonance and possible abnormalities. Additionally, I ensured the patient was in an appropriate position—seated upright—to facilitate optimal assessment conditions. Proper hand hygiene and environmental controls (quiet room) were maintained to enhance the accuracy of auscultation.

Subjective Data Collected

• The patient reported no chest pain, palpitations, or irregular heartbeat.
• The patient indicated occasional shortness of breath when climbing stairs but no difficulty breathing at rest.
• The patient denied dizziness, syncope, or fainting episodes.
• There were no reports of edema, weight gain, or history of cardiovascular or respiratory diseases.
• The patient mentioned a history of smoking but had quit five years ago.

Objective Data Collected

• Vital signs: Blood pressure was 118/76 mmHg, heart rate was 72 bpm, regular; respiratory rate was 16 breaths per minute; oxygen saturation was 98% on room air.
• Inspection: No visible distress, chest wall symmetry observed, no cyanosis or pallor.
• Palpation: Chest expansion symmetrical; tactile fremitus equal bilaterally; peripheral pulses present and strong.
• Auscultation: Heart sounds were normal with S1 and S2 heard clearly; no murmurs, rubs, or extra sounds detected. Lung auscultation revealed vesicular breath sounds and no abnormal sounds such as wheezes or crackles.
• Percussion: Resonant lung fields bilaterally; no dullness indicating consolidation or fluid accumulation.

Discussion

The assessment provided a comprehensive overview of the individual's cardiac and respiratory health. The subjective data suggested good functional capacity with minimal symptoms. Objective findings were within normal limits, indicating no immediate concerns. However, the history of smoking and occasional shortness of breath warrant ongoing monitoring and possibly further evaluation if symptoms develop.

Conclusion

In summary, the assessment utilized techniques of inspection, palpation, auscultation, and percussion effectively. Subjective data complemented objective findings, providing a holistic view of the patient’s cardiovascular and respiratory health. Accurate assessment skills are essential for early detection of potential issues and maintaining overall health.

References

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