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I.verbal explanations
II.physical preparation
B.Verbal explanations
a.dorsal recumbent
i.the patient lies on the back with the legs separated, knees bent, and soles of the feet flat on the bed
ii.areas examined
a.head and neck, anterior thorax and lungs, breasts, heart, extremities, peripheral pulses
b.supine
i.the patient lies flat on the back with the legs together but extended and slightly bent at the knees
ii.areas examined
a.head and neck, anterior thorax and lungs, breasts, heart, abdomen, extremities, peripheral pulses
b.sitting
i.the patient sits upright in a chair or on the side of an examining table or bed or, if physically unable to maintain an upright position, may be supine in bed with
the head elevated
ii.areas examined
a.head and neck, posterior and anterior thorax, lungs, breasts, heart, upper extremities, and to take vital signs
b.lithotomy
i.the patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the feet supported in stirrups
ii.areas examined
i.the patient kneels, using the knees and chest to bear weight of the body
ii.areas examined
a.rectum
b.Sims'
i.the patient lies on either the right or left side with the lower arm behind the body, the upper arm bent at the shoulder and elbow, both knees bent, and the
uppermost leg more acutely bent than the lowermost leg
ii.areas examined
a.rectum, vagina
b.prone
i.the patient lies on the abdomen, flat on the bed, with the head turned to the side
ii.areas examined
I.an assessment technique in which the examiner deliberately, purposefully, and systematically observes an area of the body
II.uses of inspection
a.to determine the presence of normal and/or abnormal size, shape, color, symmetry, and/or position of an area of the body
II.when inspecting, need to take into consideration:
I.an assessment technique in which the examiner feels an area of the body with the palmar surface of the pads of the fingers and/or the dorsum of the hand
II.uses of palpation
a.light (superficial)
i.the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1/2" (1 centimeter) while moving
the hand in a circle
b.bimanual deep palpation
i.first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated
ii.second, the examiner places the fingerpads of the nondominant hand on the dorsal surface of the distal interphalangeal joints of the middle three
fingers of the dominant hand
iii.third, the examiner presses down gently 1" (2 centimeters) with the top hand while the lower hand remains relaxed to perceive the tactile sensations
b.single manual deep palpation
i.first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1" (2 centimeters) while
moving the hand in a circle
ii.second, the examiner uses the nondominant hand to support a mass or organ from below
II.helping a patient relax to facilitate palpation
a.gowning and/or draping to prevent unnecessary exposure, provide privacy, and keep the patient warm
b.positioning the patient comfortably
c.ensuring that your hands are warm before beginning
d.commencing palpation with areas that are not painful first
II.characteristics of masses determined by palpation
I.an assessment technique in which the examiner strikes an area of the body with the fingers
II.uses of percussion
a.to determine the borders of an underlying structure of the body by establishing the difference between tissue that is fluid-filled, air-filled, or solid
b.to determine the absence or presence of normal and/or adventitious sounds elicited while percussing over an area of the body
II.types of percussion
a.direct percussion
i.the examiner strikes an area of the body to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger
b.indirect percussion
i.first, the examiner places the middle finger of the nondominant hand, referred to as the pleximeter, firmly on the patient's skin over the area of the body to be
percussed
ii.second, the examiner strikes the distal interphalangeal joint of the pleximeter with the tip of the flexed middle finger of the dominant hand, referred to
as the plexor
II.sounds elicited by percussion
a.flatness
i.a soft, high-pitched, "dead stop of sound, absolute dullness" sound of short duration
ii.where found
i.a very loud, very low-pitched, "booming" sound of very long duration
ii.where found
I.an assessment technique in which an examiner listens to sounds produced from within an area of the body
II.uses of auscultation
a.to determine the absence or presence of normal and/or adventitious sounds produced from within an area of the body
II.types of auscultation
a.direct auscultation
i.the examiner listens to sounds produced within an area of the body by use of the unaided ear
b.indirect auscultation
i.the examiner listens to sounds produced from within an area of the body by use of a stethoscope
ii.parts of a stethoscope
a.earpieces
i.diaphragm
i.may cause a crackling sound that mimics an abnormal breath sound called crackles or rales
ii.if occurs, wet his chest hair before auscultating the area
b.avoid your own extra sounds, e.g.:
a.pitch
I.instruments
a.goniometer
b.nasal speculum
c.opthalmoscope
d.otoscope
e.reflex hammer
f.platform scale with heigh attachment
g.Snellen chart
h.sphygmomanometer and cuff
i.stethoscope
j.transilluminator
k.tuning fork
l.vaginal speculum
II.equipment and supplies
a.alcohol swabs
b.assorted containers and slides
c.assorted familiar items
d.ayre (cervical) spatula
e.cervical brush
f.cotton-tipped applicators
g.cotton balls
h.culture media
i.dental mirror
j.disposable pad
k.drape or sheet
l.gauze dressing (4 x 4)
m.fecal occult blood test materials
n.flashlight or penlight
o.gloves (sterile and unsterile)
p.lubricant
q.Rosenbaum Pocket Vision Screener
r.ruler marked in centimeters
s.skin-marking pen
t.skinfold caliper
u.smells
v.sterile safety pins
w.tape measure marked in centimeters
x.test tubes of hot/cold liquid
y.thermometer
z.tongue blades (depressors)
aa.watch with second hand
bb.Wood's Lamp
HEALTH HISTORY
I.to elicit information about all the variables that may affect the patient's health status
II.to obtain data that helps the nurse understand and appreciate the patient's life experiences
III.to initiate a nonjudgmental, trusting interpersonal relationship with the patient
B.Conducting a health history
a.ensure privacy
i.inform any support staff of your interview and ask that they not interrupt you
ii.discourage other health professionals from interrupting you with their need for access to the patient
b.adjust the physical environment
a.raise or lower the room temperature to a comfortable level for both you and the patient
ii.regulate the lighting of the room, e.g.:
a.raise or lower the window shades to eliminate excessive sun glare or shade
b.raise or lower the lights to eliminate excessive glare
c.adjust the bed lighting so that the patient does not feel as if he/she is under interrogation
ii.reduce the noise level of the room, e.g.:
i.it is impossible to remember everything said during a health history so some notes need to be taken
ii.however, there are disadvantages to note-taking. It:
a.keep note-taking to a minimum by only jotting down enough key words, short phrases, and dates to help you record the history later and not interrupt
the patient's spontaneous narrative
b.when using a written form, do not let it prevent you from following the patient's leads
c.when the patient is talking about sensitive or disturbing material, put your pen down and maintain eye contact with the patient
d.if note-taking makes the patient uncomfortable, explain that you are taking notes only to fulfill your desire to make an accurate clinical record
b.review your general appearance
i.should be clean, neat, consisting of conservative dress and an appropriate name tag
II.during the orientation phase
a.assist him/her in donning his/her eyeglasses, hearing aids, or dentures if they were removed
b.assist him/her in assuming comfortable position in bed
c.arrange his/her pillows to make him/her more comfortable
II.during the working phase
a.questions that allow a patient to tell his or her story spontaneously and do not presuppose a specific answer
b.examples:
i.Interviewer: "You mentioned earlier that your father has high blood pressure. Has he developed any complicatioons related to his high blood
pressure?"
ii.Patient: "Yes."
iii.Interviewer: "What sort of complications?"
iv.Patient: "Kidney failure. He was on dialysis for years before getting a kidney transplant"
ii.facilitation
a.technique of using a verbal or nonverbal response that encourages a patient to continue with his/her story while not directing him/her to a topic
b.examples:
i.verbal
a.technique of accepting pauses or silences that may extend for several seconds or minutes without interjecting any verbal response
ii.reflection
a.technique of using a response to mirror or echo that which has just been expressed by the patient
b.example:
i.Patient (sarcastically): "This is just great. I have my own business, I direct 20 employees everyday, and now here I am having to call you for
every little thing"
ii.Interviewer: "It must be hard - one day having so much control, and now feeling dependent on someone else"
ii.clarification
a.technique of summarizing the patient's words, simplifying the patient's words to make them clearer, repeating them back to the patient, and then
asking the patient if you are on the right track
b.example:
i.Interviewer: "Now as I understand you, this heaviness in your chest comes when you shovel snow or climb stairs, and it goes away when you
stop doing those things. Is that correct?"
ii.Patient: "Yes, that's pretty much it"
ii.confrontation
a.technique of using a response based on an observation of the interviewer to point out to the patient something striking about his/her behavior or
previous statement
b.examples:
i.Interviewer: "You say it doesn't hurt, but when I touch you here, you grimace"
ii.Interviewer: "It looks as though you are about to cry when you talk about your mother's Alzheimer's disease"
ii.interpretation
a.technique of confrontation based on the inference, rather than observation, of the interviewer that links events, makes associations, or implies cause
for a problem
b.example:
i.Patient: "I have decided I don't want to take any more treatments. But I can't seem to tell my husband that. Every time he asks me about it, I
tighten up and can't say anything"
ii.Interviewer: "Could it be that you are afraid of his reaction?"
ii.explanation
a.pitfall of the interviewer giving an automatic response to relieve his/her anxiety and give him/her the false sense of having provided comfort
b.example:
i.Patient: "Oh I just know this lump in my breast is going to turn out to be cancer"
ii.Interviewer: "Now don't worry. I'm sure you will be all right"
ii.giving unwanted advice
a.pitfall of the interviewer giving advice which shifts accountability for decision-making from the patient to him/her and does not allow the patient to
work out his/her own solution
b.example:
i.Patient: "Dr. Kline just told me my only chance of getting pregnant is to have an operation. I just don't know. What would you do?"
ii.Interviewer: "Well, Dr. Kline is one of the leading authorities in infertility. I would think that his recommendation would be the best
way to go"
ii.using avoidance language
a.pitall of the interviewer using professional terminology that sounds exclusionary and paternalistic
b.example:
a.pitfall of the interviewer asking questions that carry a suggestion of the kind of response he/she is looking for
b.example:
a.pitfall of the interviewer talking too much at the expense of the patient's need to express him/herself
ii.interrupting
a.pitfall of the interviewer cutting the patient off signaling that he/she is impatient or bored
ii.using why questions
a.pitfall of the interviewer asking questions that provide the answer to his/her question
b.example:
i.Interviewer: "Do you feel a burning sensation when you urinate?"
ii.using multiple questions
a.pitfall of the interviewer asking questions that have more than one point of inquiry
b.example:
i.Interviewer: "How many pregnancies have you had, are using any form of birth control, and when was your last pap smear?"
II.during the closing phase
a.name, address and phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, occupation, religious orientation, health care financing,
and usual source of medical care
II.source of history, e.g.:
a.person providing the information
b.interpretation of the reliability of the person providing the information
c.special circumstances
i.location
ii.quality or character
iii.quantity or severity
iv.timing
i.chickenpox, mumps, measles, rubella, rubeola, streptococcal infections, scarlet fever, rheumatic fever, poliomyelitis
b.adult illnesses, e.g.:
i.diabetes, hypertension, heart disease, sickle cell disease, cancer, seizure disorder, Parkinson's disease
b.accidents and/or injuries, e.g.:
i.how, when, and where the accident and/or injury occurred, type of accident and/or injury, treatment received, course of recovery, any complications
b.operations, e.g.:
i.reason for the surgery, date of the surgery, surgery performed, location of the hospital, name of the surgeon, course of recovery, any complications
b.hospitalizations, e.g.:
i.reason for the hospitalization, date of the hospitalization, location of the hospital, name of the physician, course of recovery, any complications
b.medications, e.g.:
i.name, dose, and schedule of all currently used prescription and over-the-counter medications, such as aspirin
b.allergies, e.g.:
i.allergens (e.g., medication, food, animals, insects, or other contact agents, such as fabric or environmental agents) and type of reaction (e.g., rash, itching,
runny nose, watery eyes, difficulty breathing)
b.immunizations, e.g.:
i.tetanus; pertussis; diphtheria; polio; measles; rubella; mumps; influenza; hepatitis B; Hemophilus influenzae, type b; pneumococcal vaccine
II.family health history, e.g.:
i.diabetes, hypertension, heart disease, hypercholesterolemia, renal disease, cancer, tuberculosis, stroke, anemia, gout, arthritis, mental illness, alcoholism,
seizures, obesity, allergies, jaundice, bleeding, ulcers, migraine
b.family genogram
II.lifestyle data
a.cigarettes, smokeless
ii.type, amount, duration of use of alcohol
a.Do you drink or take drugs to Relax, feel better about yourself, or fit in?
b.Do you ever drink or take drugs while you are Alone?
c.Do any of your closest Friends drink or use drugs?
d.Does a close Family member have a problem with alcohol or drugs?
e.Have you ever gotten into Trouble from drinking or taking drugs?
ii.type, amount, duration of use of caffeine-containing beverages, e.g.:
i.hobbies, vacations
b.impact of illness
II.social data
i.marital
a.form, e.g.:
a.form, e.g.:
i.nuclear, extended, two-career, single-parent, blended, adolescent parents, cohabiting, gay and lesbian, single adults living alone
b.structure, e.g.:
a.composition, e.g.:
a.high-risk behaviors
b.health-care practices
ii.nutrition
a.meaning of food
b.common foods and food rituals
c.dietary practices for health promotion
d.nutritional deficiencies and food limitations
ii.pregnancy and childbearing practices
a.dietary practices
b.medication practices
c.medical treatment practices
d.birth control and abortion practices
e.organ transplantation practices
f.death and dying practices
g.healing practices
h.perception of the relationship between religious beliefs and state of health
ii.impact of illness
b.educational, e.g.:
i.car, e.g.:
a.stressors, e.g.:
a.rating of major stressors on a scale of one (least stressful) to ten (most stressful)
ii.length of time major stressors have been experienced over the past year, e.g.:
i.coping strategies utilized to resolve major stressors over the past year, e.g.:
a.crying, getting angry, becoming verbally abusive, talking to some one, withdrawing from the stressful situation, praying, overeating, sleeping
ii.perception of the effectiveness of coping strategies in resolving major stressors over the past year, e.g.:
a.rating of coping strategies on a scale of one (least effective) to ten (most effective)
ii.length of time using coping strategies to resolve major stressors, e.g.:
a.facial expression; gestures; body movements; affect; tone of voice; posture; eye movements; voice volume, quality, pitch; use of touch
ii.congruence of nonverbal and verbal communication
iii.communication pattern, e.g.:
a.blocking, slow, rapid, quiet, halting, aphasic, continuity, excessive, detailed, stammering, circumstantial, tangential, long silences
ii.communication skills, e.g.:
a.openness, spontaneity, use of clarification, request for feedback, tolerance of silence, acceptance of confrontation
ii.feedback, e.g.:
i.role performance
a.sad, gloomy, estranged, elated, worried, apprehensive, furious, optimistic, up and down
ii.usual feeling state, e.g.:
a.sad, gloomy, estranged, elated, worried, apprehensive, furious, optimistic, up and down
ii.changes in feeling state
iii.relationship between present feeling state and current condition, e.g.:
a.congruent or incongruent
ii.impact of illness
II.review of systems
i.evaluate the past and present health state of each body system
ii.double-check in case any significant data were omitted in the present illness section
iii.evaluate health promotion practices
b.order of the review of systems
i.record only subjective data (e.g., client statements), not objective data (e.g., physical findings)
ii.record the "presence" or "absence" of all symptoms, not "negative"
b.components of the review of systems
i.general health
a.history of weight loss, weakness, feelings of fatigue, mood changes, night sweats, bleeding tendencies?
ii.skin
a.history of skin diseases such as eczema, psoriasis, acne; changes in pigmentation; tendency toward bruising; excessive dryness or moisture;
jaundice; itching, rashes, hives; change in color or size of a mole; open sores that are slow to heal?
ii.hair
a.history of frequent or severe headaches, fainting, syncope (dizziness) or vertigo, fall or accident resulting in unconsciousness?
ii.eyes
a.history of difficulty seeing, eye infection, eye pain, excessive tearing, double vision, blurring, sensitivity to light, cataracts, itching, spots in front of
eyes?
ii.ears
a.history of earaches, loss of hearing, pain, discharge, tinnitus (ringing in the ears), syncope (dizziness) or vertigo?
ii.nose and sinuses
a.history of frequent colds, nosebleeds, allergies or hay fever, sinus pain, tenderness, postnasal drip, change in sense of smell?
ii.mouth and throat
a.history of sore gums; frequent sore throats; bleeding gums; sores, lumps or white spots on mouth, lips, or tongue; toothaches, cavities, dysphagia
(difficulty swallowing); voice change or hoarseness?
ii.neck
a.history of pain, lumps or swelling, stiffness, limited movement, enlarged or tender nodes, goiter?
ii.breasts
a.history of breast diseases such as fibroid tumors, cancer; nipple discharge, scaling or cracks around nipples, dimples, lumps?
ii.respiratory
a.history of respiratory diseases such as tuberculosis, emphysema, asthma, bronchitis; chest pain; cough; sputum; shortness of breath; wheezing or
noisy breathing; hemotypsis (coughing up bloody sputum)
ii.cardiac
a.history of heart disease such as hypertension, coronary artery disease (CAD), congestive heart failure; palpitations; heart murmur; dyspnea on
exertion; paroxysmal nocturnal dyspnea; orthopnea; edema; anemia
ii.peripheral vascular system
a.history of peripheral vascular disease such as intermittent claudication, thrombophlebitis, stasis ulcers; varicose veins; coldness, numbess, tingling
of the extremities; edema (swelling) of the legs; discoloration in hands or feet?
ii.gastrointestinal
a.history of gastrointestinal disease such as gastric ulcers, gallstones, jaundice, appendicitis, ileitis, colitis; history of nausea, vomiting, loss of appetite,
indigestion, heartburn, bright blood in stools, tarry-black stools, diarrhea, constipation, abdominal pain, excessive gas, hemorrhoids, rectal pain,
ileostomy, colostomy, fistulas?
ii.urinary
a.history of urinary diseases such as kidney disease, kidney stones, urinary tract infections, benign prostatic hypertrophy; frequency; urgency; nocturia
(urination at night); dysuria (pain or burning upon urination); polyuria (increased amount of urine); oliguria (decreased amount of urine); hesitancy or
straining; narrowed stream; hematuria (blood in urine); cloudy urine; incontinence; pain in flank, groin, suprapubic region, low back?
ii.female genital system
a.history of female genital disease such as endometriosis, endometrial cancer; history of menstruation (age at menarche, last menstrual period, cycle
and duration, amount of flow); dysmenorrhea (painful menstruation), absence of menstruation (amenorrhea), premenstrual syndrome, bleeding
between periods, vaginal discharge, vaginal itching, vaginal infection?
ii.male genital system
a.history of male genital disease such as orchitis, testicular cancer; penile or testicular pain; penile discharge; penile or scrotal lumps or swelling,
lesions; inquinal hernias?
ii.sexual health
a.history of sexually transmitted diseases such as gonorrhea, herpes, chlamydia, venereal warts, acquired immune deficiency syndrome (AIDS),
syphilis; dyspareunia (painful intercourse); impotence (inability to obtain or maintain an erection); inability to ejaculate?
ii.musculoskeletal
a.history of musculoskeletal diseases such as rheumatoid arthritis, gout, herniated disc, degenerative joint disease; joint pain, stiffness, swelling,
deformity, limitation of range of motion, crepitis (noise with movement); muscular pain, cramps, weakness; back pain, stiffness, limitation of range of
motion?
ii.neurologic
a.history of neurologic diseases such as seizure disorder, myasthenia gravis, multiple sclerosis, stroke; fainting; weakness; tic or tremor; paralysis;
problems with coordination; gait disturbances; numbness, tingling, burning sensations; unconsciousness; speech problems; loss of memory;
disorientation; forgetfulness; unclear thinking; changes in emotional state?
ii.endocrine
a.history of endocrine diseases such as diabetes, hyper or hypothyroidism, goiter; heat or cold intolerance; polydipsia (excessive thirst), polyphagia
(eating), polyuria (excessive urination); change in skin pigmentation or texture; hirsutism (excessive hair growth)?
II.patterns of health care, e.g.:
a.all health care resources the client is currently using and has used in the past
b.whether the patient considers the health care being provided adequate
c.whether the patient considers access to health care a problem