Subjective assessment- Subjective clinical data is generally presented by the patient in his own wordings and as per his own perception and understandings (Ha 2016, pp. 11-17). For carrying out an extensive cardiovascular assessment for a 55-year-old male, following questions can be asked from the patient under the below-mentioned sub-headings.
This is to make sure that the patient is not having current primary concerns. This aspect can cover following question to be asked from the patient:
Is anyone in your family having a history of heart disease or any underlying cardiovascular issue?
Objective assessment- This comprises of the clinical assessment carried out by a professional nurse to note for the adverse clinical signs and symptoms present in the patient (Hunt 2020, pp. 102-179). Objective assessment can be inclusive of the following points:
Blood pressure reading
SOAP assessment is an acronym for Subjective, Objective, Assessment and Plan (Sando 2017, pp. 576-584). This is one of the most effective methods which is used by the healthcare professionals to document the details of the patient through a detailed and structured manner. The data for the patient included as per various sub-headings include as follow:
The patient in the give case study is a 65-year-old female. She appears alert and oriented to the time and place. She is visiting the clinical setting as she is experiencing shortness of breath on exertion. The patient has been experiencing these symptoms over the last few days. This is accompanied with increased chest pain and cough with green coloured sputum. Patient mainly feels breathless while lying flat. Patient is also having anxiety and hopes to see her son very soon.
Patient is having a diagnosis of cardiorespiratory symptoms. The patient is having a diagnosis of Chronic Obstructive Pulmonary Disease and overall cardiac insufficiency.
The patient intervention planning has to be drafted in sync with both cardiac and pulmonary aspect. Following intervention planning can be carried out for the patient:
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