chapter 14 principles of assessments Flashcards
information gathered regarding the patient’s health problems in the past.
past medical history (PMH)
the patient’s statement that describes the symptom or concern associated with the primary problem the patient is having.
chief complaint
the events and or mechanism leading up to the patient’s current problem.
history of the present illness/injury (HPI)
OPQRST
a memory aid in which the letters stand for questions asked to get a description of the present illness: onset, provocation, quality, region/radiation, severity, time.
SAMPLE
signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness.
bulging of the neck veins.
jugular (JUG-yuh-ler) vein distention (JVD)
a description or label for a patient’s condition that assists a clinician in further evaluation and treatment.
diagnosis
a list of potential diagnoses compiled early in the assessment of the patient.
differential diagnosis
3 heart history assessment questions
Are they taking their medication?
Does this issue match previous episodes?
Does discomfort change with position?
3 assessments for the heart.
Check for JVD, look for difference in arm systolics (20 mmHg and above can mean aortic aneurysm), Narrowing of systolic and diastolic difference.
3 assessments of the lung.
Observe chest wall movements, Differences in lung sounds (wheezing for narrowing, popping and crackling for fluids), use pulse oximetry and look for edema.
history assessments of the lung.
Determine the onset. Many respiratory conditions can be differentiated by how abruptly or slowly they came on. Asking a simple question such as “How long have you had this shortness of breath?” can significantly help in making a diagnosis.
Dyspnea on exertion—Is it increasingly difficult for patients to catch their breath after they have exerted themselves (e.g., climbing a flight of stairs)? Do not ask patients to exert themselves to determine this.
Weight gain—Does the patient report recent, rapid weight gain or that the patient’s clothes fit more tightly? This may indicate fluid buildup (heart failure).
Orthopnea—Does the patient have difficulty breathing when lying down? This occurs in several respiratory conditions, including heart failure.
Does the patient sleep on pillows? Has the patient required more pillows recently?
Does the patient have a cough? Has the cough been productive? If so, what does the patient cough up?
Has the patient had any respiratory conditions recently (e.g., flu, bronchitis, or cold)?
Does the patient have a chronic illness that affects the respiratory system (e.g., asthma or emphysema/COPD)?
4 history assessments of endocrine issues.
Do they have diabetus, are they taking their medications and keeping us with their blood sugars (i.e, regularly keeping up with needed insulin and monitoring as needed), do they have an insulin pump?
Have they been eating more or less than normal?
Are they exercising for or less?
5 assessments of endocrine issues.
Is their breath an unnatural, maybe sweet odor?
Is their intakes matching the output?
Any recent illness or medication that might throw off their endocrine balance needing more or less regulation from medicine?
Take note of their pupils.
Monitor mental status over time.
4 history assessments of gastrointestinal issues.
Is their input volume different than normal?
Are they pooping differently than normal, if vomiting how much and often?
What does their excretions look like?
What’s the pain like and does it get better after eating?
4 assessments of gastrointestinal issues
Inspect vomitus or feces if available.
Assess abdomen by palpating quadrants doing the PAINFUL AREA LAST.
Observe position, legs curled and hand of stomach is a sign of abdominal pain.
If listening for bowel sounds do before palpation.
3 history signs for immune system issues
Were they in a situation or ingested something that could cause this reaction?
Is this reaction normal to reactions they have had in the past how does the differences in severity change that?
Do they have asthma?
