Case Study Objective Data: Physical Examination
Physical examination findings of Lawrence Tan are as follows:
• BP, 98/70; apical pulse rate, 164; pulse irregular; respiratory rate, 20; temperature, 36.8°C; O2 saturation, 93% on room air
• Awake, alert, and oriented ×3
• Lungs clear on auscultation; systolic murmur present
• Cardiac monitor shows atrial fibrillation with a rapid ventricular response
• +1 pedal pulses bilaterally
• No peripheral edema, jugular venous distention, or heaves noted Throughout this chapter, consider diagnostic studies the nurse would anticipate being ordered for Mr. Tan.
Focused Assessment
Cardiovascular System
Use this checklist to make sure the key assessment steps have been done.
Subjectiv
Ask the patient about any of the following, and note responses:
Objective: Diagnostic Check the following laboratory test results for critical values: