HISTORY OF PRESENT ILLNESS

advertisement
Health Assessment Reference Guide
HISTORY OF PRESENT ILLNESS
Description of the circumstances describing the chief
complaint. Expanding on the client’s chief complaint or
positive response in the review of systems, develop
questions to obtain information about the following:
Location/Radiation,
Quality,
Quantity,
Severity (1-10),
Onset and duration,
Frequency,
Aggravating Factors,
Relieving Factors,
Associated Symptoms,
Effect on client’s functional status in own
words.
REVIEW OF SYSTEMS:
Systematic collection of subjective data. Record pertinent
positive and negative responses during interview when
eliciting the client’s response to the following questions.
Elaborate as needed according to the focused
assessment guidelines.
Neurologic/Psychiatric
Convulsions, seizures, stroke, syncope, paralyses, tremor,
incoordination, parathesias, difficulties with memory or
speech, sensory or motor disturbances, or muscular
coordination (ataxia, tremor), Predominant mood
"nervousness" (define), emotional problems, anxiety,
depression, previous psychiatric care, unusual
perceptions, hallucinations.
Head/Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of onset, duration, precipitating
factors), vertigo, lightheadedness, injury
Blurred vision, double vision, tearing, blind spots, pain,
hearing loss, ear pain, and tinnitus. Nose bleeding, colds,
obstruction, discharge, Dental difficulties, gingival
bleeding, dentures, sore throat. Neck stiffness, pain,
tenderness, masses in thyroid or other areas. Intolerance
to extremes of hot and cold.
Cardiovascular
Chest pain, substernal distress, palpitations, syncope,
dyspnea on exertion, orthopnea, nocturnal paroxysmal
dyspnea, edema, cyanosis, hypertension, heart murmurs,
anemia, bleeding problems, history of heart disease
Peripheral vascular
Pain, numbness, swelling in extremities, temperature
changes, discoloration or changes in color, varicose veins,
infections, or ulcers. Claudication, asymmetry.
Respiratory
History of lung disease, pain (location, quality, relation to
respiration), shortness of breath, wheezing, stridor, cough
(time of day, of productive, amount in tablespoons or
cups per day and color of sputum), hemoptysis,
respiratory infections, tuberculosis (or exposure to
tuberculosis), fever or night sweats.
Gastrointestinal
Changes in appetite, dysphagia, indigestion, food
intolerances, abdominal pain, heartburn, nausea,
vomiting, hematemesis, jaundice, constipation, or
diarrhea, abnormal stools (clay-colored, tarry, bloody,
greasy, foul smelling), flatulence, hemorrhoids, recent
changes in bowel habits, use of laxatives, surgical
incisions, presence of drains. History of ulcers, cirrhosis,
gallbladder disease, appendicitis.
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria,
polyuria, oliguria, unusual (or change in) color of urine,
stones, infections, nephritis, hesitancy, change in size of
stream, dribbling, acute retention or incontinence, change
in libido, potency, genital lesions, discharge, venereal
disease, presence of indwelling catheters, stents.
(Female) Age of onset of menses, regularity, last period,
dysmenorrhea, menorrhagia, vaginal discharge, postmenopausal bleeding, dyspareunia, number and results of
pregnancies (gravida, para)
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints,
limitation, of motion, muscular weakness, atrophy,
cramps. History of arthritis, osteoporosis, calcium
supplementation, fractures, strains, sprains
Skin/Breast
Rash, itching, change in pigmentation, excessive moisture
or dryness, presence of wounds, presence of invasive
devices, alterations in texture, changes in hair growth ,
texture or loss, nail changes. Breast lumps, tenderness,
swelling, nipple discharge
VITAL SIGN MEASUREMENT
BLOOD PRESSURE, PULSE, RESPIRATIONS
TEMPERATURE
Record relevant readings from intermittent and
continuous monitors in the appropriate system
assessment.
PHYSICAL ASSESSMENT:
Systematic collection of objective data utilizing the IPPA
format.
I:
inspection
P:
palpation
P:
percussion
A:
auscultation
Neurologic/Psychiatric
Alert and oriented to person, place, time. Cooperative.
Speech clear, appropriate, posture relaxed. Recent/remote
memory intact. Cranial nerves II-XII intact. Sensation to
pinprick, light touch intact. Motor: no atrophy, weakness
or tremors bilaterally. Ambulates with steady gait.
Negative Romberg’s sign. Performs alternating
movement. DTR’s intact. Note if falls precaution is in
effect and restraints in use
Head/Eyes/Ears/Nose/Mouth/Throat
Normocephalic, atraumatic. Facies symmetric, no
weakness or involuntary movements noted.
Visual acuity intact.20/20/ OD, OS. Full visual fields
intact by confrontation. No ptosis, no lidlag, discharge
PERRLA. Corneal reflex symmetric no strabismus.
Conjunctive clear, sclera white. Pinna no masses, lesions,
tenderness, drainage. Whispered words heard bilaterally.
Rhinne: AC>BC. Weber: no lateralization. Nares patent,
no tenderness, lesions, discharge. Pharynx pink, no
lesions, dentition in good repair, uvula rises on midline,
positive gag reflex.
Cardiovascular
No JVD. No heaves, no thrills. Heart sounds: S1, S2 no
S3 S4 gallop or murmurs. Regular rate and rhythm.
Indicate cardiac rhythm on continuous cardiac
monitoring. If murmur note grade, timing, location,
quality and radiation. Record weight and I/O.
Peripheral vascular
Color pink, no lesions, varicosities, symmetric bilaterally.
Hair present. No edema, calf tenderness, all peripheral
pulses present (Grade +), no changes in temperature.
Capillary refill < 3 seconds. Note use of antithrombotics
devices
Respiratory
Respirations even and unlabored, no use of accessory
muscles. Trachea midline. Chest symmetric, AP diameter
not increased. No tenderness on palpation. Lung fields
resonant. Diaphragmatic excursion (4-7 cm) and =
bilaterally. Lungs clear to auscultation, no adventitious
sounds. Record presence of adjunct oxygen therapy,
use of pulse oximetry and presence of thoracic tubes.
Gastrointestinal
Abdomen flat, symmetric. No lesions, herniations, gas
patterns, venous patterns or pulsations. Normoactive
bowel sounds in all quadrants. Tympanitic to percussion.
Abdomen soft nontender. Liver span (7cm). Murphy’s
sign negative. No organomegaly. No rebound tenderness,
McBurney’s point negative. Femoral pulses present
bilaterally. No lymphadenopathy. No CVA tenderness.
Record bowel elimination pattern. Note presence of
gastrointestinal tubes, drains, and dressings. Indicate
tolerance to diet type and use of capillary blood sugar
measurements
Genitourinary
External genitalia no lesions or discharge. Describe
urinary pattern: continence, frequency, volume, color,
odor clarity. Document presence of indwelling catheter
noting size, type and if irrigation is in progress.
Note if menses is in progress, date of menstrual flow,
quality and quantity of bleeding.
Musculoskeletal
(TMJ, Neck, shoulders, elbows, wrists, hands, spine, hips,
knees, ankle, feet)
No joint pain, tenderness, FROM. Extremities
symmetric, no tenderness, weakness, discoloration, or
swelling. Maintains flexion against resistance. Vertebra
nontender, no curvature, no deformity.
Skin/Breast
Skin pink warm dry to touch. No lesions,
hyper/hypopigmentation. Hair even distribution, texture,
no pest inhabitants. Nails no clubbing, cyanosis, and
discoloration. Breasts symmetric: no lesions, lumps,
changes in pigmentation or nipple discharge. No
lymphadenopathy.
FOCUSED ASSESSMENT GUIDE
According to Carpenito-Moyet (2007), a focus assessment
is a directed query or examination determined by the
judgment of the nurse when a problem is suspected. It is
derived from the client’s baseline assessment but
generates specific data that either supports or refutes a
diagnostic label.
For the purpose of discussion, we will label a suspected
problem as a tentative nursing diagnosis or collaborative
problem. The query and examination are represented by
the defining characteristics of the tentative nursing
diagnosis or the presence of risk factors or clinical
manifestations of a collaborative problem (medical
diagnosis).
In order to prepare to collect the appropriate subjective
and objective data, the nurse categorizes the client’s
condition, researches the diagnoses and collaborative
problems associated with the condition and collects the
subjective and objective data that either supports or
rejects the presence of the diagnosis.
If history taking and examination reveals the presence of
the defining characteristics of the tentative diagnosis, then
the nurse can make the diagnosis and develop a plan of
care to treat it.
If the client’s condition strongly supports the risk of
experiencing the diagnosis but the defining characteristics
are not present, the nurse develops a ‘risk for’ diagnostic
statement and designs nursing actions that will control for
the development of the problem.
If the tentative diagnosis is not relevant to the client’s
condition, the diagnosis is not included in the plan of
care.
References:
Carpenito-Moyet, Lynda Juall (2007). Understanding Nursing
Process: Concept Mapping and Care Planning for Students.
Philadelphia, Pa. Lippincott Williams & Wilkins.
Jarvis, Carolyn (2003). Physical Examination and Health
Assessment, 4th Edition, Philadelphia, PA. W.B. Saunders Co.
This product is intended for use by registered nursing students. It
can not be sold, duplicated or distributed without permission of
the author. Inquiries should be directed to Susan McCabe at
[email protected]
Download