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Vital signs, including changes such as increased/decreased
pulse rate and tempo, blood pressure, and respiratory rate
Heart and lung evaluation, including any rales, wheezes,
rhonchi, labored inhaling and exhaling, jugular vein distension, and
peripheral edema
Stomach evaluation for epigastric discomfort to palpation
Pain assessment including quality (tightness or heaviness,
pressure, radiating localized, or vague discomfort), starting point and
length of the pain, and precipitating, irritating (such as
enhanced pain with motion or contact), and relieving components
Evidence of musculoskeletal discomfort
Signs of dizziness, palpitations, queasieness, or heartburn,
Skin (cool and clammy, diaphoretic)


Patient’s age and sex
Onset, timeframe, rate of recurrence, intensity of signs or symptoms
If continual, comparison of current to typical symptoms
Relieving factors (such as antacids or nitroglycerin, position
changes, etc. )
All current medications, including any recent adjustments
Relevant history of heart or GI troubles
All current diagnoses
Recent lab or diagnostic test results, including EKG results, if

Following the preliminary interventions, additional
information regarding chest pain can be obtained
by carrying out a heart and lung assessment.

Listen to the heart for a rate, rhythm and to see if there is a murmur. A murmur is a soothing-blowing;
swooshing sound that can be observed on the chest wall with a stethoscope.
When listening to sounds of the lungs you want to listen for:
Crackles: These are high pitched,
discontinuous noises similar to the sound
generated by rubbing your hair in between your fingers (also known as Rales).
Wheezes: These are normally high pitched and
“musical in quality. Stridor is am inspiratory
wheeze associated with upper airway
obstruction (croup).
Rhonchi: These often have a “snoring”, or
“gurgling” quality. Any extra sound that is not
a crackle or a wheeze is probably a rhonchi.
Look to see if the resident is short of breath or has an uncommon breathing pattern or is cyanotic.

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