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236 Cards in this Set
- Front
- Back
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Phases of an Interview
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Introduction: introduce yourself, tell length/what's going on
Discussion: client centered, client reaction, beliefs/concerns Summary: check how you understood *avoid we |
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Open and Closed Ended Questions
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Open ended: ex: how do you feel? allows for broader conversations
Close ended: after more direct, precise information |
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Components of a Health History
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More medically modeled
Biographic data Reason for seeking care Present health status (OLDCARTS) Past medical history Family history Personal and psychosocial history Review of all body systems |
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Variations in Health History with Age
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Pediatric: immunizations, prenatal care, school, diseases, developmental history, safety precautions, anticipatory guidance
Pregnancy: nutrition, previous children/complications, drug use, medication, pets (cat), occupational history Older adults: screening, assistant tools, dietary history, daily activities, medications; don't care about what happened as children or family history |
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Risk Factors for TMJ Dysfunction
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Female
Mechanical factors (gum, grinding) |
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Risk Factors for Gout
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Male
Age 30-50 Positive family history Thyroid dysfunction Obesity Hypertension Diuretics Alcohol |
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Risk Factors for Osteoarthritis
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Age 30-40 w/out symptoms
Under 55 males = females Gender Weight Repeated cartilage damage Joint injury Physical activity |
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Risk Factors for Osteoporosis
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Age: over 35
Gender: females more than males Race: Caucasians and Asians Bone structures/body weight Family history Lifestyle: drugs and diet Medication Estrogen Deficiency |
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Musculoskeletal Health History
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Subjective data: history of current health problems, past heath, family history; lifestyle and health practices
Problem-based history: pain, problems with movement, problems with daily activity |
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Musculoskeletal Examination
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Compare
Inspect alignment Inspect muscles Palpate bones, joints, and muscles Observe major joints and adjacent muscles Test muscle strength Assess for carpal tunnel syndrome: Pahlen's sign and Tinel's sign Equipment: tape measure, goniometer, scoliometer |
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Musculoskeletal Examination Age Variations
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Infants: movement, hips, feet, palsy
Children: development over time Older adults: slower, decreased muscle strength |
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Fracture
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Partial or complete break in continuity of bone
Closed: skin not broken Open: open skin (compound) Comminuted: fragments Compression: vertebrate Pathological: due to disease |
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Osteoporosis
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Loss of bone density
Decreased bone strength Increase risk for fractures |
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Rheumatoid Arthritis
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Chronic autoimmune inflammatory disease of connective tissue
Clinical findings: bilateral joint involvement, pain, edema, stiffness, joint changes Boutonniere deformity of thumb, ulnar deviation of metacarpophalangeal joints, swan-neck deformity of fingers can all occur during late stages |
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Osteoarthritis
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Degenerative changes
Weight bearing joints Unilateral or bilateral Clinical findings: joint edema, aching pain, joint deformities |
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Gout
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Increase in serum uric acid
Hereditary disease Uric acids accumulate Clinical findings: erythema/edema of joints, limited ROM, pain, tophi |
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Signs and Symptoms
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Sign: objective data from examination
Symptoms: subjective, primary vs secondary source |
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Subjective and Objective Data
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Subjective: data obtained from a health history or provided to the nurse by the client
Objective: data obtained from examination, measurements, or diagnostic tests; observable by the nurse |
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Comprehensive Assessment
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Detailed history and physical exam performed at onset of care or admission; encompasses health problems, health promotion, disease prevention and assessments
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Problem-Based/Focused Assessment
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Involves a history and examination limited to a specific problem/complaint. Most commonly used in walk-in clinic and er
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Episodic/Follow Up Assessment
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Usually done when a client is following up with a health care provider for a previously identified problem.
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Screening Assessment
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Short, usually inexpensive examination focused on disease detection. May be done in a health care provider's office or at a health fair
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Body System and Functional Health Pattern History and Assessment
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Body system: history/assessment done system by system
Functional health: framework for organizing data by 11 areas of health status or function (health perception/management, nutrition/metabolism, elimination, activity/exercise, sleep/rest, cognitive/perceptual, self perception/self concept, role/relationship, sexuality/reproduction, coping/stress tolerance, value/belief |
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Health Promotion Levels
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Primary prevention: protection to prevent occurrence of disease
Secondary prevention: early identification of disease before it becomes symptomatic in order to halt the progression of pathological process Tertiary prevention: minimize severity and disability from disease through appropriate therapy for chronic diseases |
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OLDCARTS
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Onset
Location Duration Characteristics Aggravating and alleviating factors Related symptoms Treatment Severity |
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Skin, Hair, and Nails Health History
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General: present health status; chronic illnesses, medications, skin care, changes in skin; past health and family history such as problems with skin and family w/ related skin problems
Problem based history: -skin: pruritis, rash, pain/discomfort, skin texture, lesions, wounds, changes -hair: changes or problems, contributory factors (stress, fever, itching, illness), diet, changes in distribution -nails: problem or changes, chemical exposure, brittleness/pittness, infection, trouble keeping clean/look dirty |
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Skin, Hair, and Nails Examination Techniques
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Key assessment points: skin color, temperature, moisture, texture, integrity, lesions; hair condition, loss or unusual growth; nail bed condition and capillary
Physical assessment: inspect and palpate |
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Early Signs of Melanoma
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ABCDEF
Asymmetry: not round or oval Border: poorly defined or irregular Color: uneven, variegated Diameter: usually greater than 6mm Elevation: recent change Feeling: itching, tingling, stinging |
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Cyanosis
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Light: grayish blue tone esp in nail beds, earlobes, lips, mucous membranes, palms, and soles of feet
Dark: ashen-gray color; easily seen in conjuctiva of the eye, oral mucous membranes, and nail beds |
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Ecchymosis (bruise)
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Light: dark red, purple, yellow, or green color (depending on age)
Dark: deeper bluish or black tone, difficult to see |
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Erythema
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Light: reddish tone w/ evidence of increased skin temperature
Dark: deeper brown or purple skin tone with evidence of increased skin temperature |
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Jaundice
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Light: yellowish color of skin, sclera of eyes, fingernails, palms of hands, and oral mucosa
Dark: yellowish green color, obviously seen in sclera of eye, palms of hands and soles of feet |
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Pallor
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Light: pale skin that may appear white
Dark: skin tone appears lighter than normal |
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Petechiae
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Light: lesions appear as small, reddish purple pinpoints
Dark: difficult to see, may be evident in buccal mucosa of the mouth or sclera of the eye |
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Rash
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Light: may be visualized as well as felt with light palpation
Dark: not easily visualized but may be felt with light palpation |
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Scar
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Light: narrow scar line
Dark: frequently has keloid development, resulting in a thickened, raised scar |
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Lesion Characterisics Noted
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Location
Size Color Shape: round/oval, annular, iris, gyrate Borders Elevation Characteristics: odor, oozing, drainage Pattern: singular/discrete, confluent, cluster, target, linear, polycyclic, steriform |
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Patterns of Lesions
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Singular/discrete: single lesion, demarcated lesions that remain separate
Grouped/clustered: lesions that bunch together in little groups Polycyclic: annular leasions that come in contact with one another as they spread Confluent: lesions that merge and run together over large areas Linear: lesions that form a line Zosteriform: lesions following a nerve Generalized: lesions that are scattered all over the body |
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Macule
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A flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter
Ex: freckles, flat moles, petechiae, measles, scarlet fever |
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Papule
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An elevated, firm, circumscribed area less than 1 cm in diameter
Ex: wart, elevated moles, skin tag, cherry angioma |
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Patch
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A flat, nonpalpable, irregular-shaped macule more than 1 cm in diameter
Ex: vitiligo, port wine stains |
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Plaque
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Elevated, firm, and rough lesion with flat top surface greater than 1 cm diameter
Ex: psoriasis, eczema |
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Wheal
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Elevated irregular-shaped area of cutaneous edema; solid, transient, variable diameter
Ex: insect bites, allergic reaction |
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Nodule
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Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter
Ex: melanoma, hemangioma |
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Tumor
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Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter
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Vesicle
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Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter
Ex: varicella |
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Bulla
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Vesicle greater than 1 cm in diameter
Ex: blister, impetigo |
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Pustule
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Elevated, superficial lesion; similar to vesicle but filled with purulent fluid
Ex: acne, herpes simplex |
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Cyst
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Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material
Ex: sebaceous cyst |
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Pressure Ulcer Characteristics
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Stage 1: patch of redness, unbroken skin
Stage 2: Broken/breaking skin, skin loss Stage 3: through skin completely, "crater", thickness loss Stage 4: full thickness loss, invades deeper tissue, hidden areas of damage also |
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Skin Assessment Age Variations
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Infants/Children: assessment is same, skin lesions that are common are milia, erythema toxicum, diaper rash, and allergen rashes
Adolescents: most common lesion is acne Older adults: lesions more common, skin cancer incidence increase |
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Atopic Dermatis
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Chronic superficial inflammation of the skin
Clinical findings: erythema, sclaing, lichenification; localized to hands, feet, arms, and legs |
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Psoriasis
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Chronic skin disorder that can occur at any age and cause is unknown
Clinical findings: well-circumscribed lesion, slightly raised, erythematous plaques with silvery scales on surface |
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Pediculosis (Lice)
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Parasites that invade the scalp, body, or pubic hair
Clinical Findings: eggs are small, white particles at the base of the hair shaft; skin under may be red/excoriated |
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Skin Lesions of Abuse
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Bruises
Bites Burns: most common is immersion burn (immersed in scalding hot water); another common is contact burn |
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Clubbing
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Angle of the nail base exceeds 180 degrees
Caused by proliferation of the connective tissue resulting in an enlargement of the distal fingers Most commonly associated with chronic respiratory or cardiovascular disease |
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Inspection
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Visual examination of body
Component of every assessment Avoid preconceptions Instruments facilitate process |
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Palpation
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Use of hands
Texture: palmar surface Size and shape: palmar surface Consistency: palmar surface Location Vibration: ulnar surface Temperature: dorsal surface Bimanual technique |
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Percussion
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Evaluate size, borders, consistency, tenderness, extent of fluid
Direct: sinuses and CVA tenderness Indirect: thorax and abdomen Striking produces vibrations 5 percussion tones: tympany (hollow organs), resonance (lungs), hyperresonance (over-air filled lungs), dullness (muscle), flatness (bones) |
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Auscultation
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Listening for sounds
Stethescope: bell is for low-pitched sounds, diaphragm is for high-pitched sounds Sound characteristics: intensity, pitch, duration, quality |
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Percussion Tones
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Resonant: loud, low-pitched, long, hollow; heard over lungs
Flat: soft, high-pitched, short, extremely dull; hear over bone and muscle Dull: medium, medium-high pitched, medium duration, thudlike; heard over viscera and liver borders Tympanic: loud, high-pitched, medium duration, drumlike; heard over stomach/intestines Hyperresonant: very loud, very low pitched, longer duration, booming; hear over air trapped in lungs |
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Ausculation Characteristics
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Intensity: loudness of the sound; soft, medium, or loud
Pitch: frequency of sound; high pitched, low pitched, medium pitched Duration of sound vibrations: short, medium, long Quality: description of sounds |
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8 Positions for Examination
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Sitting
Supine: on back Dorsal recumbent: on back w/ knees up Lithotomy: on back with legs in stirrups Sims: laying on stomach with knee/hip flexed to the side Prone: laying on stomach Lateral recumbent: laying on side Knee-chest: laying on stomach with knees up to chest |
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Thermometers
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Oral: safe and relatively accurate; electric thermometer
Tympanic: measure from tympanic membrane within ear; cerumen causes inaccuracy Axillary: common in infants/children; accuracy is questionable Rectal: not common, less comfortable, more time consuming, increased risk of infection |
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Temperature
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Regulated by the hypothalamus
Normal ranges from 96.4 to 99.1 Changes result from normal variations and activities |
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Heart Rate
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Palpated using the finger pads of the index and middle fingers
Averages/ranges: -Newborn: 140, 120-160 -Toddler: 110, 90-140 -School-age: 85, 75-100 -Adolescent: 70, 60-90 -Adult: 70, 60-100 |
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Respiratory Rate
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Counting the number of times the client completes a ventilatory cycle each minute
Ranges: -Newborn: 30-60 -Toddler: 24-40 -School-age: 18-30 -Adolescent: 12-16 -Adult: 12-20 |
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Blood Pressure
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Force of blood against arterial walls
Systolic is the max pressure exerted on arteries when ventricles eject blood from heart Diastolic is the min amount of pressure exerted on the vessels when the ventricles relax Ranges: -Newborn: 60-90 and 20-60 -Toddler: 80-112 and 50-80 -School age: 84-120 and 54-80 -Adolescent: 94-140 and 62-88 -Adult: 110-140 and 60-90 |
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Oxygen Saturation
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Measured by a pulse oximeter; estimates the oxygen saturation of hemoglobin in blood
Levels lower than 90% are abnormal |
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Blood Pressure Factors
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Age
Gender Race Diurnal variations Emotions Pain Personal habits Weight |
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HEENT Health History
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General Health History:
-Present health status: changes in overall health, changes to eyes/ears/nose/mouth, chronic conditions -Medications: what/how often -Last routine examinations -Describe daily practices -Any occupation or recreational risks for injury to HEENT -Nicotine and alcohol use Past Medical History: -injury to HEENT -surgery involving HEENT Family History: -cancer -conditions impacting hearing, vision, or thyroid |
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Hearing Loss Risk Factors
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Age
Environmental factors Otoxic meds Family history Autoimmune disorders Congenital hearing loss |
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Cataract Risk Factors
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Age: 65-74
Gender: females > males Ethnicity: African Americans Smokers Alcohol Light exposure Medication Chronic disease (ex diabetes) |
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Oro-Pharyngeal Cancer Risk Factors
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Age: +40, 64-74
Gender: males 2x more likely Ethnicity: African Americans Tobacco: 90% more chance Alcohol Sunlight exposure: lips Previous cancer Immunosuppression |
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Headache Problem Based History
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How long, how often, how long does it last
Location of pain: single area or generalized Other symptoms with the headache Triggers Treatment: what meds, effective, how often are they taken |
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Dizziness/Vertigo Problem Based History
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Describe sensation
When did it begin, how often, how long Define what they mean when reporting history of dizziness Does it interfere with activities Ever fallen? Are symptoms experienced when driving/operating machinery? |
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Vision Difficulty Problem Based History
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Type of vision difficulty
When did it begin? Sudden or gradual? One eye or both? Constant or intermittent? Other symptoms What makes it worse/better What treatments are tried Interfere with daily life? |
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Hearing Loss Problem Based History
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How long?
What tones or sounds are hard to hear? Onset sudden or gradual? Other symptoms Interfere with daily routine |
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Earache Problem Based History
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How long
What may be causing the pain Location of pain Discharge from ear: describe What does the pain feel like |
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Sore Throat Problem Based History
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How long
Describe Hurt to swallow Associated with fever, cough, fatigue, painful lymph nodes? Anyone around you sick? Treatments tried |
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Types of Dizziness
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Presyncope: feeling of faintness and impending loss of consciousness; often CV symptom
Disequilibrium: feeling of falling; often locomotor problem Vertigo: sensation of movement; subjective is sensation that one's body is rotating in space; objective is sensation that objects are spinning around body; cardinal symptom of vestibular dysfunction Light-headedness: vague description of dizziness that does not fit in any other categories; usually idiopathic or psychogenic |
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Routine Assessment of HEENT
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Head: inspect, palpate, auscultate temporal artery, movement, ROM of TMJ
Neck: inspect skin, observe carotid arteries and jugular veins, palpation of trachea, thyroid gland, test ROM/strength Palpate lymph nodes Ear: alignment, shape, inflammation/drainage, inner ear, eardrum, inspect/palpate external ear, assess hearing, Weber and Rinne test, otoscopic exam Eyes: visual acuity, occular structures position/color, light reflex, eye movement, PERRLA Nose: palpate for tenderness/midline, assess patency, inspect nasal cavity, palpate sinuses Mouth/Pharynx: inspect structures |
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Migraine
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2nd most common
Findings: aura, throbbing, unilateral pain, nausea, vomitting May last up to 72 hours |
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Cluster Headaches
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Most painful
Normally in adolescents to middle age Findings: excrutiating unilateral pain, lasts 1/2 to 1 hour, may repeat, |
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Tension Headache
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Age 20-40 they are the most common
Findings: bilateral, may be diffuse or confined to the frontal, temporal, parietal, or occipital area, gradual onset |
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Posttraumatic Headache
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Occurs secondary to head injury
Findings: dull, generalized head pain, lack of ability to concentrate, giddiness, or dizziness |
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Conjunctivitis
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Inflammation of the palpebral or blublar conjunctiva cause by local infection of bacteria or allergic rxn
Findings: red eye, thick sticky discharge, eyelids stuck together |
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Cataract
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Opacity of crystalline lenses
Most commonly caused by denaturation of lens protein by aging Findings: clouded/blurred vision, no red reflex, poor night vision, cloudy lens |
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Acute Otitis Media
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Infection of middle ear
One of the most common of all childhood infections Findings: acute onset, otalgia (ear pain), erythema, possible effusion, limited TM mobility, air-fluid level |
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Allergic Rhinitis
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Inflammation of nasal mucosa by inhalant allergy, sensitive to dusts/molds, family history
Findings: after exposure sneezing, nasal congestion, nasal drainage, itchy eyes, cough, fatigue |
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Tonsillitis
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Infection of the tonsils
Common bacterial pathogens include beta-hemolytic and other streptococcus Findings: sore throat, pain with swallowing (odynophagia), fever, chills, tender cervical lymph nodes |
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Hyperthyroidism
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Excessive production and secretion of the thyroid hormone
Graves disease is the most common cause Findings: most body systems affected; increased metabolism, enlargement of thyroid gland, exophthalmos |
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Hypothyroidism
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Decreased production of thyroid hormone
Most common thyroid problem Findings: overall decreased metabolism, depressed affect, goiter (increase in thyroid-stimulating hormone) |
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Psychological Changes During NREM and REM Sleep
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NREM: regular respirations, low HR/BP, no body movement, slow regular brain activity
REM (active sleep): irregular respirations, variable HR/BP, eye movement, twitching, *dreaming |
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Nursing Concepts Related to Sleep Patterns
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With decreased sleep, patient may have problems with coping, decreased immune system, fatigue, decreased concentration, short term memory loss, perceptual difficulties, increased anxiety
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Insomnia
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Causes: stress, depression, caffeine, discomfort, napping, withdrawal from addictive substances
Clinical findings: difficulty getting to sleep/staying asleep, wakefulness during night, early morning waking |
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Sleep Apnea
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Central: infants or adults older than 45 (rare)
Central is cessation of respiratory effort; no airflow (gradual decreased respiratory effort then gradual increase) Obstructive: closure of upper airway continued with respiratory effort Apnea ends when awakened to open airway Sleepiness: subtle decrease in alertness, may fall asleep in middle of conversation Clinical findings: loud snoring/daytime sleepiness, nocturnal episodes of coughing/gasping; systemic/pulmonary hypertension |
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Sleep Health History
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General health history:
-Present health statue: chronic problems that interfere, sleep patterns and schedule -Hours/day; what hours -Feel rested; naps (how many/how long) -Involuntary sleeping -Bedtime routine -Medications |
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Sleep Examination
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Interview: mental status, thought/speech
Observe: facial appearance, gross motor movement/posture Inspect: nasal septum (patency, deviation), neck (size), pharynx (tonsillar hypertrophy) Measure: BP and weight |
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Age Related Variations of Sleep
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Typical Adult: asleep in 8-10 min, 7.5-8 hrs, 30 minutes deep REM, 2 hrs dreaming, 3-5 sleep cycles
Neonates: sleeps up to 20 hrs, half time in REM, back to sleep Infants: sleep pattern by 3-4 months, several naps, 8-10 hours night sleep, predominantly REM; health history includes position of infant for sleep, breast or bottle fed, naps Children: Age 2 sleeps 12 hrs through night with daily naps; children vary with activity/health; health history includes bedtime rituals, wake up frightened, resistance to bed b/c of fears, fall asleep at school, wake up frequently, nocturia Adolescents: 8-9hrs sleep, 2 hrs in REM, stay up late, sleep late, rapid growth/activity causes fatigue Young old adult: decreased night sleep, onset delayed, more awakenings, increased daytime sleepiness Old old adult: 18-20 min to fall asleep, 6 hrs of sleep, more frequent awakening, may need daytime nap |
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Nutrition Health History
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Current health status: chronic illnesses, meds, unexplained changes in weight over 6 months, food intolerance or allergies, problems obtaining/preparing/eating foods, use of street drugs/alcohol
Past medical history and family history Concerns have you had regarding weight or eating problems? what measures did you take to correct problems Risk factors |
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Insomnia Risk Factors
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Age: people over 60 to 65 years
Chronic diseases Medications Gender: women more then men Psychological factors Lifestyle |
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Sleep Apnea Risk Factors
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Obstructive:
-Gender: male -Age: older than 65 -Anatomic factors: narrowed airways, tonsillar hypertrophy, thick neck, enlarged tongue -High blood pressure -Lifestyle Central: -Gender: male -Heart disorders -Neurological disorders -Neuromuscular disorders -High altitudes |
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Obesity Risk Factors
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Excess intake of fat, sugar, calories, or nutrients
Alcohol abuse Sedentary lifestyle Decreased knowledge or skills about food preparation and recommendations |
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Malnutrition Risk Factors
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Chronic disease, acute illness, or injury
Multiple medications Food insecurity - lack of free access to adequate and safe food Restrictive eating due to chronic dieting, disordered eating, faddism, or food beliefs Alcohol abuse Depression, bereavement, loneliness, social isolation Poor dental health Decreased knowledge or skills about food preparation and recommendations Extreme age |
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Eating Disorders Risk Factors
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Preoccupation with weight
Perfectionist Poor self-esteem Self-image disturbances Peer pressure Athlete Compulsive or binge eating |
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Dietary Intake Assessments
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24-hour recall: client recalls what he/she has eaten in the last 24 hours
Typical food intake: client describes what types of food they typically eat at specified times Food diary: client is asked to record all food eaten for a specified length of time Food frequency questionnaires: client indicates frequency of intake of certain foods over a period of time Comprehensive diet history: an in-depth interview that provides detailed information regarding food intake |
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Main Components of MyPyramid Food Guide
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Grains (half whole): 6 oz every day
Vegetables (vary): 2.5 cups every day Fruits (focus): 2 cups every day Milk (calcium-rich foods): 3 cups every day Meat and Bean (go lean with protein): 5.5 oz every day Exercise |
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Nutritional Assessment Techniques
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Diet history: intake, food habits/customs, meal patterns, food beliefs and skills, supplement use, medical conditions affecting nutritional status
Objective data: anthropometric measurements (height, weight, BMI, waist circumference, triceps skinfold measures), swallowing evaluation |
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Obesity
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Occurs when energy input is greater than need
Causes include genetics, overeating, and inactivity Health risks of obesity: diabetes, heart disease, stroke & HTN, some cancer, osteoarthritis, sleep apnea |
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Hyperlipidemia
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Elevated serum lipids including cholesterol, triglycerids, and phospholipids
Causes: excessive dietary fat, genetics, cholesterol over 200 mg/dL |
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Anorexia Nervosa
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Preoccupation with being thin and dieting leading to excessive weight loss
Appears very thin with symptoms of protein calorie malnutrition, behavioral assessment Many exhibit excessive exercise, cold intolerance, dry brittle skin, hair loss, SOB, low BP, dysrhythmias, constipation, amenorrhea |
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Binge Eating and Bulimia
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Binge eating: consumption of large quantities of food until uncomfortably full; feelings of being out of control during binge
Bulimia: uncontrolled binge eating alternated with purging in an attempt to lose weight; intense feelings of guilt and shame, preoccupation with body weight, electrolyte imbalances, chronic irritation/erosion of pharynx, esophagus, and teeth |
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Nociceptive and Neuropathic Pain
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Nociceptive:
-Somatic pain: from bone, muscle, joints, skin, or connective tissue; aching or throbbing, well localized -Visceral pain: from organs secondary to tumor or obstruction, cramping, poorly localized Neuropathic: caused by abnormal processing of sensory input from peripheral or CNS, neuropathies, phantom pain -Referred pain: pain felt in a different area from the originating problem -Phantom pain: after healing from amputation, pain may be experienced as if the limb is still present |
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Pain Threshold and Pain Tolerance
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Threshold: point when a stimulus is perceived as pain
Tolerance: duration or intensity of pain a person may suffer before showing outward signs of the pain |
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Acute and Chronic Pain Manifestations
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Acute:
-Less than 6 months duration -Caused by tissue damage, usually resolved when damage heals -Elicits generalized stress response (SNS) of mild to moderate pain: increas hr, bp, rr, muscle tension, dilated pupils, decreased GI motility, sweating -Deep/severe pain: PNS stimulation, pallor, muscle tension, decreased hr, rapid/irregular breathing, nausea/vomitting, weakness/exhaustion Chronic: -Intermittent or constant pain for more than 6 months -Does not elicit a stress response as there is adaptation to the pain -Symptoms will be irritability, depression, withdrawal, and insomnia |
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Pain Health History
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Present health history: chronic illnesses, medications, pain description (COLDSPA), location, quality, quantity, chronology, setting, associated symptoms, alleviating/aggravating factors
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Pain Assessment
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Is person holding a body part, in strange position, still or constant motion?
Facial expression: relaxed or wrinkled, closed eyes, grimace, clenched teeth, biting lip Sounds: groans/moans, grunting, screaming, crying, gasping, no sounds Skin Vital signs: systolic BP and pulse may increase, rr/patern may be sloow and deep to rapid and shallow Pupillary size: may be dilated or constricted from ANS reaction |
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Pain Age Related Variations
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Neonates: respond w/ increase pulse, BP, decreased O2 sat, pallor, sweating
Infants: us NIPS scoring to assess Young children: may not understand pain/procedures that cause, but have a basic ability to describe/locate pain; improves as child ages Older adults: experience in coping w/ pain, may believe pain is part of aging |
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Lungs/Respiratory System General Health History
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Present health history
Past medical history Family history Home environment Occupation environment Travel |
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Cough Problem Based History
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When started/happened
Intermittent or constant Changes Description Sputum Other symptoms Treatment |
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Shortness of Breath Problem Based History
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How long and when
Description Interference w/ activities Triggers Sleep positions Other symptoms Treatment |
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Chest Pain w/ Breathing Problem Based History
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How long and how started
Where is pain Description of pain Association with infection/injury Alleviating/aggravating factors Treatment |
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Risk Factors for Lung Cancer
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Smoking: including 2nd hand
Asbestos Workplace exposure Marijuana Personal and family history Gender Air pollution |
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Breath Sounds
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Bronchial: high pitch, loud intensity, inspiration<expiration (1:2), over trachea
Bronchovesicular: moderate pitch, medium intensity, inspiration = expiration (1:1), 1st and 2nd ICS at sternal border anteriorly, posteriorly at T4 medial to scapula Vesicular: low pitch, soft intensity, inspiration > expiration (2.5:1), peripheral lung fields |
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Chest Wall Findings
|
Barrel Chest: horizontal ribs, increased AP diameter, costal angle greater than 90 degrees
Pectus Carinatum (pigeon chest): prominent sternum Pectus Excavatum (funnel chest): sternum indented above xiphoid Scoliosis: lateral curvature and rotation of thoracic and lumbar spine Kyphosis: exaggerated posterior curvature of the thoracic spine |
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Chest Wall Differences with Age
|
Adult: elliptical shape, lateral to AP diameter is 2:1
Child: chest is of adult proportion by age 6 Infant: rounded shape, equal lateral to AP diameters |
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Adventitious Sounds
|
Fine crackles: fine, high-pitched crackling/popping noises; pneumonia, heart failure, asthma, restrictive pulmonary diseases
Medium crackles: medium pitched, moist sound heard through inspiration Coarse crackles: low-pitched, bubbling/gurgling sounds Wheeze: high-pitched, musical sound similar to squeak; narrowed airway diseases Stridor: shrill, harsh sound heard during inspiration and caused by layngeal obstruction |
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Acute Bronchitis
|
Inflammation of bronchial trees; can be viral or bacterial
Findings: nonproductive to productive cough, substernal chest pain aggravated by coughing, fever, malaise, tachypnea, rhonchi herad on auscultation |
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Pneumonia
|
Infection of the terminal bronchioles and alveoli
Findings: viral have nonproductive cough/clear sputum, bacterial has productive cough w/ white, yellow, or green sputum; fever,malaise, pleuritic chest pain, inspiratory crackles, increased tactile fremitus, egophony, and whispered pectoriloquy |
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Asthma
|
Hyperactive airway disease, bronchoconstriction, airway obstruction, inflammation response to inhalation of allergens or pollutants
Findings: increased rr, prolonged expiration, audible wheeze, dyspnea, tachycardia, anxious, use of accessory muscles, cough |
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Emphysema
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Destruction of the alveolar walls causes permanent abnormal enlargement of the air spaces
Findings: underweight, barrel chest, short of breath w/ minimal exertion, diminished breath/voice sounds, possible wheezing/crackles |
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Pneumothorax and Hemothorax
|
Pneumothorax: air in the pleural spaces
-Three types: closed (spontaneous, traumatic, iatrogenic), open (penetration of the chest), tension (air leaks) -Findings: signs vary; minimal collapse is short of breath, anxious, chest pain; large collapse is severe respiratory distess Hemothorax: blood in the pleural space caused by injury to chest -Findings: similar to pneumothorax |
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Lung Cancer
|
Uncontrolled growth of anaplastic cells in the lung
Findings: persistent cough, weight loss, congestion, wheezing, hemoptysis, labored breathing, dyspnea, diminished lung sounds |
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Heart and Peripheral Vascular System Health History
|
Present health history: chronic diseases, medications, exercise, personality type, eating habits, alcohol/caffeine/cigarette use
Past medical and family history: childhood diseases, high cholesterol/trigylcerides, heart or blood vessel surgery, heart tests, family history |
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Chest Pain Problem Based History
|
Location
Description Severity Timing: when does it happen Associated symptoms Alleviating/aggravating factors |
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Shortness of Breath Problem Based History
|
How long
When How often Interfering with activities Different/other symptoms Alleviating factors |
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Nocturia Problem Based History
|
How long
How many times do you have to get up at night What have you tried |
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Fatigue Problem Based History
|
When noticed
Sudden or gradual onset When is it worse Iron deficiency anemia Other symptoms Neurological symptoms |
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Fainting Problem Based History
|
What were you doing
Loss of consciousness Occurred before Preceded by other symptoms |
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Leg Cramps/Pain Problem Based History
|
Pain description
Severity Aggravating/alleviating factors Change in skin |
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Hypertension Risk Factors
|
Family history
Race (African Americans) Gender (males) Age (older) Elevated serum levels Obesity Smoking Alcohol Diabetes |
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Coronary Artery Disease
|
Family history
Race (African Americans) Gender (males) Age (majority +65) Smoke (2x) Hypertension Elevated serum levels Obesity Physical activity Diabetes |
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Pitting Edema Scale
|
+1: a barely perceptible pit (2mm)
+2: a deeper pit, rebounds in a few seconds (4mm) +3: a deeper pit, rebounds in 10-20 sec (6mm) +4: a deeper pit, rebounds in >30 seconds (8mm) |
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Pulse Characteristics
|
Rate
Rhythm: spacing between beats Amplitude: 0+ absent, 1+diminished/barely palpable, 2+normal, 3+full volume, 4+ full volume/bounding hyperkinetic Contour: smooth and rounded |
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Lift, Heave, Thrill, & Retraction
|
Lift: sustained thrust during systole
Heave: prominent thrust during systole Thrill: palpable vibration over the precordium or artery Retraction: visible sinking in of tissues between and around ribs |
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Types of Chest Pain
|
Stable angina: precordial/retrosternal; radiates L>R arm & jaw, epigastric,interscapular, pressure, burning, dull, sharp, associated w/ sweating, nausea, weakness, palpations, SOB
Unstable angina/MI: also squeezing and crushing Peptic Ulcer disease: epigastric radiation to lower bilateral chest; burning, gnawing; associated with nausea and abdominal tenderness Costochondritis: 2nd and 4th costochondral junction, xiphoid, radiates |
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Angina Pectoris
|
Chest pain due to ischemia of the myocardium
Usually caused by antherosclerosis within the coronary arteries Findings: squeezing, suffocating, or constriction pain, hypertension or hypotension |
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Myocardial Infarction
|
Myocardial ischemia is sustained resulting in death of myocardial cells
Findings: worst chest pain every experienced, pain may radiate to left shoulder, dysrhythmia, heart sounds distant, thready pusle, women have pain/discomfort in center of chest, shortness of breath, cold sweat, nausea/vomiting, lightheadedness |
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Heart Failure
|
Either ventricle fails to pump blood efficiently into aorta or pulmonary arteries
Findings of left ventricular failure: fatigue, shortness of breath, orthopnea, dyspnea on exertion, paroxysmal noctrunal dyspnea Findings of right ventricular failure: precordial movement at xiphoid or left sternal border, elevated jugular venous pressure, dependent peripheral edema, S3 at lower left sternal border, systolic murmur, weight gain |
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Hypertension
|
Two or more properly measured seated blood pressure readings on each of two or more occasions that are above 120/80 mmHg in an adult over 18 years
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Venous Thrombosis/Thrombophlebitis
|
Thrombus (clot) develops within a veins is venous thrombosis.
Inflammation of a vein is thrombophlebitis Findings: dilated superficial veins, edema and redness of extremity, increased circumference of involved leg |
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Aneurysm
|
Localized dilation of an artery caused by weakness in the arterial wall
Findings: depend on location; thoracic usually asymptomatic w/ deep diffuse chest pain; aortic produce hoarseness; abdominal are most common and may be asymptomatic |
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Arterial Insufficiency vs Venous Insufficiency
|
Arterial:
-Symptoms: pain that is worse when active, intermittent claudication, rest pain leads to increased occlusion, better in dependent position -Signs: edema, coldness, pallor, hair loss, skin tight shiny hard, decreased/absent pedal pulse, sores are round minimal drainage and no odor Venous: valve allows blood to go back down -Symptoms: pain, worse in dependent position -Signs: edema, warmth, redness, tenderness, ulcers (noncircular, wetness) |
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Esophageal Cancer Risk Factors
|
Age: increases with age, peaks b/w 70-80
Gender: men 3x more likely Race: African Americans Tobacco Alcohol Barrett's esophagus Diet |
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Stomach Cancer Risk Factors
|
Age: over 65
Gender: males Race: Asians/Pacific Islanders, Hispanics, African Americans Blood type: type A Family history Previous stomach surgery Infection: with Helicobacter pylori Diet Tobacco Alcohol |
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Colon Cancer Risk Factors
|
Age: over 50
Family history Ethnicity: Jews of Easter European descent Preexisting condition |
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Bladder Cancer Risk Factors
|
Smoking
Age: over 68 Gender: males Race: Caucasian Chronic bladder inflammation |
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Abdomen and GI System Health History
|
Present Health Status:
-any chronic disease -medications -alcohol/smoking -appetite change -gas (excessive) -weight change -bowel movements -urine leakage Past Medical History: -problems w/ abdomen or digestive system -surgery -change in routines -able to cope with ostomy -problems with urinary tract Family History: -of diseases of GI system -of diseases of urinary tract |
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Gastroesophageal Reflux Disease
|
Flow of gastric secretions in the esophagus
Caused by weakening of the lower esophageal sphincter or increased intraabdominal pressure Findings: heartburn, regurgitation, dysphagia |
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Peptic Ulcer Disease
|
Ulcer occurring in the lower end of the esophagus, in the stomach, or in the duodenum
Findings: burning pain in left epigastrium and back 1 to 2 hrs after eating for gastric ulcers, burning pain 2-4 hrs after eating and at midmorning, midafternoon, and midnight for duodenal ulcers |
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Cholecystitis with Cholethiasis
|
Inflammation of the gallbladder, and with gallstones it is cholelithiasis
Bile duct becomes obstructed either by edema from inflammation or by gallstones Findings: RUQ colicky pain that may radiate to midtorso or right scapula, indigestion, mild transient jaundice |
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Cirrhosis
|
Chronic degenerative disease of the liver, in which diffuse destruction and regeneration of hepatic parenchymal cells occur
Findings: liver becomes palpable/hard, ascites, jaundice, cutaneous spider angiomas, dark urine, tan-colored stools, spleen enlargement |
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Urinary Tract Infections
|
Infection that may involve urinary bladder, urethra, or renal pelvis
Findings: -Urethritis: frequency, urgency, dysuria -Cystitis: same as urethritis plus signs of bacturia and some fever -Pyelonephritis: flank pain, dysuria, nocturia, frequency Older adults have manifestations that include confusion or delirium |
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Mental Health/Status Health History
|
Health status
Self concept Interpersonal relationships Stressors Anger Alcohol/drug use Past medical history Family history |
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Depression Risk Factors
|
Gender: female
Age: 25-45 Genetics Psychosocial environment Personal characteristics |
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Anxiety Risk Factors
|
Genetics
Physical health Psychosocial environment |
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Depression/Anxiety Problem Based History
|
Feel down, depressed, hopeless
Sleep problems Other symptoms of depression/anxiety |
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Alcohol and Drug Abuse Problem Based History
|
Number of drinks
CAGE: cut down, annoyed, guilty, eye opener Recreational drug use |
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|
Mental Status Assessment
|
Reaction to name
Speech: articulation, voice quality, comprehension |
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|
Rapid Eye Test
|
General observation
Pupil size Pupil reaction to light Nystagmus Convergence Corneal reflex |
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Major Depression
|
Mood state
Once or recurrent 2 weeks + depressed mood, lost interest or pleasure plus Distress plus At least 4 clinical signs |
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Anxiety
|
Uneasiness or discomfort (mild to panic)
No specific source or object 4 levels: mild, moderate, severe, panic Physical: sympathetic nervous system |
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Delirium
|
Disturbances of consciousness
Change in cognition Rapid change Autonomic nervous system signs Reversible |
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Dementia
|
Acquired, progressive intellectual impairment
Loss of short term memory Disorientation Usually irreversible |
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Stroke Risk Factors
|
Age
Gender Family history Race Smoking Previous history Hypertension Diabetes Atherosclerosis Hypercholesterolemia Obesity Excessive alcohol intake TIA's Atrial fibrillation Cocaine use |
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|
Cranial Nerve Tests
|
I Olfactory: smell
II Optic: vision III Oculomotor: pupil reflex, eye movement IV Trochelar: eye muscle movement V Trigeminal: face sensations, mandible movement VI Abducens: eye muscle movement VII Facial: facial movements VIII Sensory: sense of balance, sense of hearing IX Glossopharyngeal: gag and swallowing reflexes X Vagus: throat and mouth muscles XI Acessory: shrug shoulders and move neck against resistance XII Hypoglossal: tongue movement |
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Glasgow Coma Scale
|
Eyes, Verbal, and Motor Responses 4-1
-No eye response = elicit pain -Verbal: oriented 5-1 -Motor: obeys 6-1 -Posture: deceribite and decrdicite Add up score: perfect is 15 |
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Parkinsons Disease
|
Develops slowly as the brain's dopamine producing neurons in the substantia nigra of the basal ganglia degenerate
Findings: resting tremor, bradykinesia, rigidity, masklike facies, trunk-forward flexion, muscle weakens, shuffling gait, finger pill-rolling tremor |
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Bell's Palsy
|
Acute unilateral paralysis of the facial nerve
Findings: history of pain behind the ear or on the face a few hours or days before onset, eye does not close, forehead does not wrinkle, client unable to whistle or smile |
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Meningitis
|
Inflammation of the meninges that surround the brain and spinal cord
May be bacteria, viruses, fungi, parasites, or other toxins causing it Findings: severe headache, fever, generalized malaise |
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Encephalitis
|
Inflammation of the brain tissue and meninges; caused by bacteria, viruses, fungi, and parasites
Findings: variable, onset may be sudden or gradual, symptoms of headache and nausea, signs of fever, nuchal rigidity, lethargy, irritability, vomiting |
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Breasts Health History
|
Present health status
Past health history Family history Problem history: pain/tenderness, lump, skin changes, pain or lumps in axillae Male Problems: enlargement (gynecomastia) or swelling, pain or mass, nipple discharge |
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Reproductive System Health History
|
Present health status
Past medical history Family history Sexual history OB history: menstruation, pregnancy Male problem history: pain, urination, penile lesions/discharge, erection difficulty Female problem history: problems w/ menstruation, lower abdominal/pelvic pain, vaginal discharge, changes in urination, menopause, STD lesions/discharge |
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Breast Pain Problem Based History
|
Where does it hurt, one or both, specific location, pain generalized, when did it begin?
Describe pain Any activities that bring it on Any changes in breasts Breast tenderness associated with swollen feeling to breasts |
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Breast Lump Problem Based History
|
Where is it, when did you first notice it?
Always present or come and go? Tender to touch? Any recent breast injury? Any associated symptoms? |
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Nipple Discharge Problem Based History
|
When first noticed, every noticed before, one or two nipples?
Describe the discharge Occur spontaneously? Any other symptoms? |
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Axillary Lumps Problem Based History
|
First noticed?
Location? Do you shave underarms/how often? Self treatments? |
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Breast Swelling/Enlargement in Men Problem Based History
|
Describe change
Any other symptoms |
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Breast Cancer Risk Factors
|
Gender: females
Age: increases with age Race: Caucasians Genetic Family history Personal medical history Exposure to ionizing radiation Reproductive history Breast density Estrogen replacement Alcohol intake Obesity |
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|
Cervical Cancer Risk Factors
|
Gender: women
Age: 40-50 Sexual history Infection with HPV or HIV Smoking |
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|
Testicular Cancer Risk Factors
|
Age: 20-34
Cryptorchidism Family history History of testicular cancer in other testicle Ethnicity and culture: Caucasian |
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|
Prostate Cancer Risk Factors
|
Age: older
Family history Ethnicity: African American |
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|
STDs Risk Factors
|
Sexual activity with new/multiple partners/prostitutes
Sex with individual who has had multiple partners Sex with individual with history of STD Failure to consistently and correctly use protective barrier |
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|
Breast Self Exam
|
Look in mirror and palpate their breasts and axillae on monthly basis. Primary goal is to increase self-awareness
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|
Breast Mass Characteristics
|
Location
Size Shape Consistency Tenderness Mobility Borders Retractions |
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|
Fibrocystic Breast Changes
|
Variety of conditions associated with multiple benign masses within the breast caused by ductal enlargement and the formation of fluid-filled cysts
Findings: one or more palpable masses that are round, well delineated, mobile, tender |
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Invasive Breast Cancer
|
Most common type; invasive malignancy arising from the ducts or the lobules
Findings:solitary, unilateral, nontender lump, thickening, or mass; breast asymmetry, discoloration, unilateral vein prominence, peau d'orange, ulceration, dimpling, puckering, skin retraction |
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Mastitis
|
Inflammatory condition of the breast usually caused by a bacterial infection
Findings: one area, red, edematous, tender, warm to touch, hard, axillary lymph nodes enlarged/tender, fever, chills, malaise |
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|
Paget's Disease
|
Uncommon intraductal carcinoma
Spreads by way of the lactiferous sinuses to nipple epidermis |
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|
Candidiasis
|
Fungal infection caused by Candida albicans
Findings: asymptomatic infections, frequently experience vulvar pruritus associated w/ thick, cheesy, white vaginal discharge, vaginal sornees, external dysuria, erythema and edema to labia and vulvar skin |
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|
Chlamydia
|
Most common STD in USA
Findings for women: asymptomatic in majority; urinary symptoms, vaginal symptoms, purulent or mucopurulent cervical discharge, cervical motion tenderness, or cervical bleeding Findings for men: usually in urethra or rectum, dysuria, discharge, urethral itch |
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Herpes Genitalis
|
Sexually transmitted virus infection caused by herpes simplex virus
Findings for women: burning/pain w/ urination, pain in genital area, fever, single or multiple vesicles that can rupture into ulcers Findings for men: lesions around shaft of penis or near glands, red superficial vesicles, painful |
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Pelvic Inflammatory Disease
|
Polymicrobial infection of upper reproductive tract in women
Findings: can by acute or chronic: -acute: tender adnexal areas, severe pain, fever, chills, dyspareunia, vaginal discharge -chronic: tender, irregular, fixed adnexal areas |
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Premenstrual Syndrome
|
Group or cluster of recurrent symptoms experienced by women associated with their menstrual cycle
Findings: emotional, cognitive, and physical symptoms; mood swings, difficulty concentration, confusion, forgetfulness, excessive energy or fatigue, nausea, appetite change, insomnia, back pain, headaches, fluid retention |
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|
Cervical Cancer
|
Cancer of the cervix usually caused by HPV infection
Findings: abnormal vaginal bleeding, lesion w/ hard granular surface |
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|
Ovarian Cancer
|
Highest mortality rate, typically undetected
findings: usually no symptoms until advanced stage; abdominal distention or fullness |
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|
Invasive Breast Cancer
|
Most common type; invasive malignancy arising from the ducts or the lobules
Findings:solitary, unilateral, nontender lump, thickening, or mass; breast asymmetry, discoloration, unilateral vein prominence, peau d'orange, ulceration, dimpling, puckering, skin retraction |
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Mastitis
|
Inflammatory condition of the breast usually caused by a bacterial infection
Findings: one area, red, edematous, tender, warm to touch, hard, axillary lymph nodes enlarged/tender, fever, chills, malaise |
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|
Paget's Disease
|
Uncommon intraductal carcinoma
Spreads by way of the lactiferous sinuses to nipple epidermis |
|
|
Candidiasis
|
Fungal infection caused by Candida albicans
Findings: asymptomatic infections, frequently experience vulvar pruritus associated w/ thick, cheesy, white vaginal discharge, vaginal sornees, external dysuria, erythema and edema to labia and vulvar skin |
|
|
Chlamydia
|
Most common STD in USA
Findings for women: asymptomatic in majority; urinary symptoms, vaginal symptoms, purulent or mucopurulent cervical discharge, cervical motion tenderness, or cervical bleeding Findings for men: usually in urethra or rectum, dysuria, discharge, urethral itch |
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Herpes Genitalis
|
Sexually transmitted virus infection caused by herpes simplex virus
Findings for women: burning/pain w/ urination, pain in genital area, fever, single or multiple vesicles that can rupture into ulcers Findings for men: lesions around shaft of penis or near glands, red superficial vesicles, painful |
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|
Pelvic Inflammatory Disease
|
Polymicrobial infection of upper reproductive tract in women
Findings: can by acute or chronic: -acute: tender adnexal areas, severe pain, fever, chills, dyspareunia, vaginal discharge -chronic: tender, irregular, fixed adnexal areas |
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|
Premenstrual Syndrome
|
Group or cluster of recurrent symptoms experienced by women associated with their menstrual cycle
Findings: emotional, cognitive, and physical symptoms; mood swings, difficulty concentration, confusion, forgetfulness, excessive energy or fatigue, nausea, appetite change, insomnia, back pain, headaches, fluid retention |
|
|
Cervical Cancer
|
Cancer of the cervix usually caused by HPV infection
Findings: abnormal vaginal bleeding, lesion w/ hard granular surface |
|
|
Ovarian Cancer
|
Highest mortality rate, typically undetected
findings: usually no symptoms until advanced stage; abdominal distention or fullness |
|
|
Testicular Cancer
|
Most common malignancy in men ages 20-34
Findings: painless testicular mass; when pain is initial symptom that means mass has caused bleeding |
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|
Prostatitis
|
Inflammation of the prostate gland
Findings: variable, fever, chills, back/rectal/perineal pain, obstructive symptoms, enlarge prostate |
|
|
Prostate Cancer
|
Leading site of cancer in men
Findings:usually asymptomatic; urinary obstruction resulting in difficulty urinating; prostate feels hard/irregular |
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|
Hemorrhoids
|
Dilated veins of the hemorrhoidal plexus resulting from increased portal venous pressure
Findings: external are flaps of tissue, localized itching, bleeding, blue/purple shiny masses; internal may not be seen until they are thrombosed, prolapsed or infected |
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Indirect Inguinal Hernia
|
Sac herniates through the internal inguinal ring. Can remain in inguinal canal, exit through the external canal or pass into scrotum
Findings: feels like soft swelling, complains of pain w/ straining |
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|
Stool Colors
|
Bright red: hemorrhoidal or lower rectal bleeding
Tarry black: upper intestinal tract bleeding or excessive iron or bismuth ingestion Light tan or gray: obstruction of biliary tract Pale yellow: malabsorption syndrome |
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|
Differences in Elder History Taking
|
Present health status: no differences
Past health status: want to know, meds, chronic disease Family history: not important Personal and psychosocial history: similar, focus on role change Review of systems |
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|
Fall Risk Factors in Elders
|
Gender: male
Mental status Poor muscle strength, balance, dizziness, vertigo Altered elimination: have to rush Adverse effects of meds Lifestyle |
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|
Malnutrition Risk Factors in Elders
|
Institutionalization
Poverty Social isolation Chronic illness Alcoholism Depression, dementia Decreased functional abilities Anorexia Feeding problems Multiple medications |
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|
Changes with Older Adults
|
Sleep: trouble falling, less time, more early awakening
Integument: dry, less sweat, wrinkling, subcu fat moves, decreased melanin, nails thicker brittle yellow HEENT: dry eyes, presbyopia, dry cerumen, hearing loss, decreased smell, muscle weakness, thyroid decreases, smaller lymph nodes Respiratory: kyphoscoliosis, decreased muscle strenglthi, less elastic/more fibrous alveoli Cardiovascular: decreased heart size, sclerosis of SA node, mitral, and aortic valves GI: slowed motilitiy, weakend muscle, decreased peristalsis, decreased liver size, decreased bladder size shape tone, atrophied prostate gland Musculoskeletal: decreased height, bone mass, tendon/muscle elasticity/tone Neurological: decrease in short term memory, changes in sensory/motor function memory cognition proprioception Female GU: uterus and ovaries decrease Male GU: prostate hyperplasia Breasts: glandular tissue atrophies, hang more loosely, replaced by fat and connective tissue |
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|
Assessment of Activities of Daily Living
|
Chart:
Self care Mobility Communication Eating Housekeeping, laundry, house upkeep Medications Access to community Other |
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|
Balance and Gait Assessment
|
Tinetti Balance and Gait Assessment Tools
|
|
|
Macular Degeneration
|
Macula degenerates: central vision impairment
Findings: loss of central vision, dark spot in center of vision, straight lines appear curved |
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|
Urinary Incontinence
|
Risk factors: multiple pregnancies, abd. wall weakness, CVA, obesity, UTIs
Findings: immediate urge to void (urge), leakage with laugh, cough, sneeze (stress), leakage at night (nocturnal enuresis) |
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|
Assessing Family Strengths/Resilience
|
Family is an essential part of context in which illness occurs
Assessed not to improve family function, but to strengthen families |
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|
Family Resilience Factors
|
Positive outlook
Spirituality Family member accord Flexibility Family communication Financial management Family time Shared recreation Routines and rituals Support network |
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|
Methods of Assessing a Family
|
Components:
-Family structure: internal, external, context -Family development: life-cycle stages and tasks -Family functions: instrumental, affective and socialization, expressive, health care Interview techniques: manners, therapeutic questions/conversation, family genograms/ecomaps, commendations |
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|
Violence Theories
|
Biological: violence is innate characteristic of humans based on neurophysiological state species
Psychoanalytical: violence results from need to discharge hostility Social Learning: both aggression and violence are learned behaviors which are positive or negative Cultural Attitudes: attitudes influence violence |
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|
Walker's Cycle of Violence
|
Phase 1: criticism
Phase 2: acute battering Phase 3: honeymoon |
