Documentation Of Problem-Based Assessment Of The Cardiac Sys

Documentation of problem based assessment of the cardiac system.

Clients Presentation: subjective Data (4 points): Objective Data (4 points): Describe 2 Actual/Potential Risk Factors (2 points): Income Statement Anne's Beauty Salon, Inc Note, Income Statements should be monthly. This Income Statement is for training purposes, ONLY! Income Statement For the Year 2015 Sales (Revenue) $ 125,000.00 Cost of Sales $ 25,000.00 Gross Profit $ 100,000.00 Payroll Expense $ 67,500.00 Sales, General, Administrative Expense $ 5,000.00 Rent Expense $ 1,400.00 Utilities Expense $ 1,670.00 Insurance Expense $ 500.00 Depreciation Expense $ 2,500.00 Total Operating Expense $ 78,570.00 Total Operating Income $ 21,430.00 Taxes 30% $ 6,430.00 Net Income $ 15,000.00 Michael LaFountain: Rounding due to taxes.

Balance Sheet Anne's Beauty Salon, Inc Balance Sheet At December 31, 2015 Assets Liabilities Current Assets Current Liabilities Cash $ 949.50 Accounts Payable $ 5,000.00 Accounts Receivable $ 11,948.00 Unearned Revenue $ 200.00 Supplies $ 20,500.00 Total Current Liabilities $ 5,200.00 Prepaid Rent $ 8,400.00 Prepaid Insurance $ 6,000.00 Total Current Assets $ 47,797.50 Note Payable $ 15,000.00 Equipment $ 25,000.00 Less: Accumulated Depreciation $ (5,000.00) $ 20,000.00 Total Long-Term Assets $ 20,000.00 Stockholders' Equity Common Stock $ 30,000.00 Retained Earnings $ 17,597.50 Total Assets $ 67,797.50 Total Liabilities and Stockholders' Equity $ 67,797.50

Statement of RE Anne's Beauty Salon, Inc Statement of Retained Earnings For the Month Ending December 31, 2015 Retained Earnings, December 1 $ 5,000.00 Add: Net Income $ 15,000.00 Subtract: Dividends $ (2,402.50) Retained Earnings, December 31 $ 17,597.50

Title: Documentation of problem based assessment of the cardiac system.

Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings. Course Competency: Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems. 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from > Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31 (9), 30. Retrieved from > Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Emerging Competence Proficiency Mastery Subjective (4 Pts) Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data. Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points: 4 Objective (4 Pts) Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”. Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation for findings. Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. Contains all objective information. Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information Points: 1 Points: 2 Points: 3 Points: 4 Actual or Potential Risk Factors (2 pts) Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Points: 0.5 Points: 1 Points: 1.5 Points: 2

Paper For Above instruction

The assessment of the cardiac system is a crucial component in diagnosing and managing cardiovascular diseases. Proper documentation of subjective and objective data provides a comprehensive understanding of the patient's condition, facilitates accurate diagnosis, and guides appropriate interventions. This paper presents a problem-based assessment of a patient's cardiac status, emphasizing the importance of detailed documentation, identification of abnormal findings, and recognition of risk factors.

Subjective Data

The subjective assessment begins with the chief complaint, which for this case involved the patient reporting episodes of chest discomfort and dyspnea on exertion over the past two weeks. The patient described the chest pain as a pressing sensation, radiating to the left arm and jaw, which is characteristic of anginal pain. Further inquiry revealed the patient’s history of hypertension and hyperlipidemia, both significant risk factors for coronary artery disease. The patient stated that the discomfort occurs during physical activity and is relieved with rest. Additional subjective data included the patient’s age, which is 58 years old, and lifestyle factors such as smoking history and sedentary behavior, contributing further to cardiovascular risk. The patient’s medications included antihypertensives and statins, which are relevant in understanding ongoing management and risk modification.

Objective Data

The physical examination revealed a regular heart rate of 88 beats per minute and a blood pressure of 142/90 mm Hg, indicating slightly uncontrolled hypertension. Inspection showed no visible chest deformities, and no cyanosis or pallor was observed. Palpation of the carotid arteries was symmetrical, with no thrills or bruits noted. Auscultation identified a regular rhythm with a cadence of S1 and S2, and no murmurs, rubs, or gallops were heard. Peripheral vascular examination was normal, with symmetrical peripheral pulses and no edema. The brain palpation was unremarkable, and no abnormal heart sounds or extra sounds like S3 or S4 were detected. Laboratory tests such as lipid profile were not available at the time but are important for ongoing assessment. The objective data highlights vital signs and physical examination findings consistent with cardiovascular health, but also shows areas needing further evaluation, such as blood pressure control and lipid management.

Actual or Potential Risk Factors

Two significant risk factors identified in this patient include uncontrolled hypertension and hyperlipidemia. Uncontrolled hypertension increases the risk for hypertensive heart disease, stroke, and myocardial infarction due to increased vascular strain and potential for arterial damage. Hyperlipidemia contributes to atherosclerosis, increasing the likelihood of coronary artery blockage, which can lead to angina and myocardial infarction. These risk factors are directly linked to the patient's presenting symptoms and physical examination findings and are modifiable through lifestyle modifications and medication adjustments. Addressing these risks is essential for preventing progression of cardiovascular disease and improving patient outcomes.

References

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