Profile of the Adult Flashcards
DEMOGRAPHIC DATA
- Client’s initials:
- Gender:
- Age, Birthdate and Birthplace:
- Marital (Civil) Status:
- Nationality:
- Religion:
- Address and Telephone Number:
- Educational Background:
- Occupation (usual and present):
- Usual Source of Medical Care:
- Date of Admission:
- Handedness (for neurologic patient):
RELIABILITY ISSUES IN HISTORY TAKING
Informant
Circumstances
History taker/interviewer
A.C., a 77-year-old male, right-handed, Filipino, Roman Catholic, widower, businessman, born and presently residing in Dasmarinas City, Cavite was admitted to the De La Salle University Medical Center for the 2nd time last January 16, 2024, at 4:00 AM
DEMOGRAPHIC DATA
The patient was competent to provide the information. The patient’s reliability is excellent. She was able to speak clearly, conscious and coherent throughout the interview.
RATING THE RELIABILITY
● It is the reason why the patient sought medical attention or why the patient was brought to the hospital/clinic
● A statement in the patient’s own words of the index symptom you selected from the interview material as being chief or principal
CHIEF COMPLAINT
● Descriptive chronological narration of the events which happened from the onset of first symptom up to time of interview
● The objective of the history of present illness is to obtain all the details related to the chief complaint.
HISTORY OF PRESENT ILLNESS
● Location/Radiation
● Quality
● Quantity/Intensity/Frequency
● Time/Timing
● Aggravating Factors
● Alleviating Factors
● Setting/Relationship to Menses/Relationship to
Occupation
● Precipitating Factors
● Associated symptoms
● Inconstant Dimension (color, clarity, consistency,
etc.)
DIMENSION OF A SYMPTOM
OPQRST
O - ________
P - ________
Q - ________
R - ________
S - ________
T - ________
● ONSET
● PROVOKING AND
PALLIATING FACTORS
● QUALITY
● RADIATION
● SITE AND
SEVERITY
● TIMING
● E.g. for abdomen — it can be divided into four quadrants or nine regions
● Specific landmarks (e.g. McBurney’s Point, etc.)
BODY LOCATION
● Pulsating/throbbing
● Aching
● Colicky
● Gnawing
● Burning
QUALITY
● Sudden
● Insidious
DETAILS OF ONSET
● Waxing and Waning
● Intermittent (asymptomatic short periods)
● On and off (asymptomatic over longer periods)
● Plateauing
● Progressive
INTERVAL HISTORY
● Eating
● Hunger
● Fatty foods intake
● Coughing
● Jarring movements
● Deep inspiration
AGGRAVATING FACTORS
● Food, antacid intake
● Vomiting
● Lying still
● Bending forward
● Passage of flatus
RELIEVING FACTORS
● While everything else is well
● Presence of prodrome (flu-like syndrome)
● Presence of aura
SETTING
The patient was apparently well until one day prior to consultation when she suddenly experienced a frontal, compressive “band-like” headache for the first time. The patient said this occurred after her incessant crying because of the death of her relative. The severity on a scale of 1 to 10 was grade 6. The pain did not radiate to any part of her head. There was no accompanying blurring of vision, vomiting, numbness or weakness. She self-medicated with Mefenamic acid 500 mg which gave temporary relief.
A few hours prior to admission, the headache recurred which was both throbbing and compressive. The intensity was about 9 on a scale of 1 to 10. Relief was obtained after her husband massaged her head. No other symptoms such as nausea, vomiting, stiffness of the neck and fever was noted by the patient. The headache did not radiate to another part of the head. After drinking coffee, it intensified again prompting her to seek consultation at the emergency department of De La Salle University Medical Center for further treatment and evaluation.
DIMENSION OF A SYMPTOM
● Summary in an outline form of listing of the patient’s previous medical/surgical diseases, injuries, allergies, immunizations and current medications.
THE PAST MEDICAL HISTORY
The patient has been known hypertensive since 2009. He is maintained on Amlodipine 10 mg/tablet once a day to which he is compliant. Usual BP is 120-130/80-90 mmHg. He is not diagnosed with diabetes, asthma, pulmonary tuberculosis, cardiovascular, hematologic, gastrointestinal and neurologic diseases. He has no allergies to food and medications. He was previously hospitalized in 2004 due to hemorrhoids and subsequently underwent hemorrhoidectomy. He had a history of vehicular accident, which resulted in laceration over the left eyebrow in 1990. He had a varicella infection when he was 10 years old. He has not received any adult vaccination
THE PAST MEDICAL HISTORY
● A graphic representation of a family tree
FAMILY GENOGRAM
● A description of the patient as a person and as a member of the community.
● The objective is to develop an understanding of the patient as a member of the family and community.
SOCIOECONOMIC HISTORY/PERSONAL AND SOCIAL HISTORY
The patient is an elementary graduate and is currently retired. He previously worked as a mechanic. He eats three times per day and prefers eating fish and vegetables and drinks purified water. He lives in a 2-story concrete house with his family. Water supply is coming from a deep well and garbage is disposed of once per week. He is a non-smoker, a previous alcoholic beverage drinker who stopped 10 years ago and denied use of any illegal drugs.
SOCIOECONOMIC HISTORY/PERSONAL AND SOCIAL HISTORY
Includes mental, emotional, social, and spiritual dimensions.
PSYCHOSOCIAL ASSESSMENT
Is developed through:
● Provision of needs
● Consistency in the primary
caregiver (parents)
● Talking to the child
Infancy:
Trust vs Mistrust (0-1 y.o)
Infancy:
Trust vs Mistrust (0-1 y.o)
Virtue - __________
HOPE
Autonomy is developed through:
● Offering choices
● Routines
● If developed, results to sphincter control: Toilet Training
In cases of temper tantrums: Ignore
Toddler:
Autonomy vs. Shame & Doubt (1-3 y.o.)
Toddler:
Autonomy vs. Shame & Doubt (1-3 y.o.)
Virtue - __________
WILL
Is developed through:
1. Allowing the child to try new things
2. Encouraging household chores
Thinking and imaginative
Preschool:
Initiative vs. Guilt (3-6 y.o.)
Preschool:
Initiative vs. Guilt (3-6 y.o.)
Virtue - __________
PURPOSE
Is developed through:
● Rewards for accomplishments
● Success in healthy competitions
School Age:
Industry vs. Inferiority (6-12 y.o.)
School Age:
Industry vs. Inferiority (6-12 y.o.)
Virute - __________
COMPETENCE
Is developed through:
● Sense of “I”
● Belonging to a group
● Body Image is very important
● Independence from parents and dependence to peers
Adolescence:
Identity vs. Role Confusion (12-20 y. o.)
Adolescence:
Identity vs. Role Confusion (12-20 y. o.)
Virtue - _________
FIDELITY
Is developed through:
● Finding new & meaningful relationships
● Gaining career stability
Young Adulthood:
Intimacy vs. Isolation (20-35 y. o.)
Young Adulthood:
Intimacy vs. Isolation (20-35 y. o.)
Virtue - __________
LOVE
Is developed through:
● Maintaining healthy life patterns
● Developing a sense of unity with mate
● Helping growing and grown children to be responsible adults
Middle Adulthood:
Generativity vs. Stagnation (35-65 y. o.)
Middle Adulthood:
Generativity vs. Stagnation (35-65 y. o.)
Virtue - __________
CARE
Is developed through:
● Retrospection: people look back on their lives and accomplishments
● Developing feelings of contentment
Late Adulthood:
Ego Integrity vs. Despair (65 y. o. and above)
Late Adulthood:
Ego Integrity vs. Despair (65 y. o. and above)
Virtue - __________
WISDOM
Assists the nurse in collecting, organizing and categorizing data
FUNCTIONAL ASSESSMENT
Was proposed by Marjorie Gordon (1987) as a guide for establishing a comprehensive nursing database.
Gordon’s Functional Health Patterns
● Person’s description of his current health
● Activities done to improve or maintain health
● Person’s knowledge about links between lifestyle choices & health
● Extent of person’s problem on financing healthcare, if any
● Person’s knowledge of current medications taken and their purpose/s
● Activities done to prevent allergies, if any
● Person’s knowledge of medical problems in his family
● Any important illnesses or injuries
HEALTH PERCEPTION & HEALTH MANAGEMENT PATTERN
● Person’s nourishment
● Person’s food choices in comparison with recommended food intake
● Any disease that affects nutritional metabolic function
NUTRITION-METABOLIC PATTERN
● Data collection is focused on excretory patterns (bowel, bladder, skin).
● Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified
ELIMINATION PATTERN
● Weekly pattern of activities, leisure, exercise and recreation
● Any disease that affects patient’s cardio-respiratory & musculoskeletal systems
ACTIVITY-EXERCISE PATTERN
● Description of the person’s sleep-wake cycle
● Person’s general physical appearance (rested or relaxed)
SLEEP-REST PATTERN
● Presence of any sensory deficit
● Presence of pain & causes, if any
● Ability to express oneself clearly & logically
● Person’s education
● Any disease that affects mental
COGNITIVE AND PERCEPTUAL PATTERN
● Description of the person’s feeling state
● One’s personality & self- esteem
SELF-PERCEPTION AND SELF-CONCEPT PATTERN
● Description of the person’s various roles in life
● Positive role models of his roles, if any
● Important relationships at present
● Any big changes in role or relationship
ROLE-RELATIONSHIP PATTERN
● Person’s satisfaction with his situation related to sexuality
● Any disease/dysfunction of the reproductive system
SEXUALITY-REPRODUCTIVE PATTERN
● Sources of stress
● Coping mechanisms used & their effectivity
● Presence of emotional distress & treatment, if any
COPING-STRESS TOLERANCE PATTERN
● Person’s identification with any cultural, ethnic, or religious group
● Principles that the person believes in from childhood up to now
● Support system
VALUE-BELIEF PATTERN
Checklist of symptoms involving the various organ systems and include general or constitutional symptoms and symptoms of specific organ
systems
REVIEW OF SYSTEMS
REVIEW OF SYSTEMS resuslts in __________ responses
Subjective
