please help me with my physical assessment report

[weesie1244]

i hope someone can help me, ok i did my report my instructor is questioning me on my cardiovascular description, this is what i wrote:from 11/11 to 11/25 client's pulse ranged from 76-70b.pm. right radial pulse was +3 and left pulse was weaker with +1 and thready. heart rate is 82 and regular, no complaints of chest pain or sob, client states she feels fatigued at certain times of the day.. no weight gain or loss since being admitted into facility. client's b.p. from 11/11- 11/25 has ranged from 166/98 to 170/110. nail beds are incurvated and impede the skin. the mucous membranes in oral cavity are dry and without lesuions. no clubbing in nailbeds are noted and no edema is observed in the periphery or in the sacral areas. No calf tenderness when foot is flexed, neg. homan's sign; client does exsperience slight pain in the popliteal area due to arthritic joints. no distribution of hair on the lower extremities or on the toes, and no vericose veins are noted. clients pulse oximetry is 96% on room air. client has a history of diabetes mellitus and hypertension and hyperlipidemia and a past medical history of a CVA.

ok this is what i wrote can someone help me? also for my nursing dx i chose the following- ineffective tissue perfusion r/t decreased cardiac output aeb decreased peripheral pulses & cap. refill > 3secs.- disturbed sensory perception: visual r/t pathology of diabetes aeb client states " i can only see shadows"" and my last dx was risk for infection r/t a high glucose level of 489 on admission to the e.r. so can someone please help me!!!!

[SlyckRN]

Ok, that's a great start. Hopefully this post isn't too late. What else can you notice about cardiac? Did you hear any murmurs? Was the heart rate rhythm normal or did you hear gallops? What about pedal pulses? Are they on any cardiac medication or diuretic? Did they have any orthostatic hypotension? Cardiac and respiratory go together. Were the lungs clear to auscultation in x5 lobes?

Also, you can't write a nursing diagnosis related to a nursing dianosis. Doesn't exactly work like that. More like Ineffective tissue perfusion related to ( what causes it in nursing terms) aeb.....

Ineffective tissue perfusion r/t low hgb hct levels aeb 2x3x2cm leg ulcer.

Care plans always need to be the highest priorites. When you patient comes into the ER with heart problems or cardiac arrest, yes we will worry about his BS being in the 400's but it isn't out highest. Remember your ABC's.