Health History Questions: Subjective Data
A good clinical history is important when making an assessment for new patients. A data needs to be collected that relates to the diagnosis or illness for which the patient is being seen. When gathering data for patients diagnosed with or are at risk for osteoporosis, following five areas of the body that need to be examined for further detailed findings.
1. Joints. Are there any problems with your joints? Any pain? If yes, which joints? Is the pain on one side of the joint or both sides? What does the pain feel like: aching, stiff, sharp or dull, shooting? How strong is the name? When did this pain start? What time of the day does the pain occur? How long does it last? How often does it occur? Is the …show more content…
Functional assessment. Do your joint (muscle, bone) problems create any limits on your usual activities of daily living (ADLs)? Which ones? Do you have any difficulty with bathing: getting in and out of the tub, turning faucets? Do you have any difficulty with toileting: urinating, defecating, able to get self on and off toilet, wipe self? Any difficulty with dressing: doing buttons, zipper, fasten opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit? Any difficulty with grooming: shaving, brushing teeth, brushing or fixing hair, applying makeup? Any difficulty with eating: preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking? Any difficulty with mobility: walking, walking up or down stairs, getting in and out of bed, getting out of house? Any difficulty with communicating: talking, using phone, and writing? (Jarvis, …show more content…
Note any heat, tenderness, swelling, or masses. Joints normally not tender to palpation. If any tenderness does occur, try to localize it to specific anatomical structures (e.g., skin muscles, bursae, ligaments, tendons, fat pads, or joint capsule) (Jarvis, 2014).
Range of Motion
1. Ask for active ROM while stabilizing the body area proximal to that being moved (Jarvis, 2014).
2. With each joint familiarize yourself with the type and its normal ROM so that you can recognize limitations. If you see a limitation, gently attempt passive motion (Jarvis, 2014).
3. Anchor the joint with one hand while your other hand slowly moves it to its limit. The normal ranges of active and passive motions should be the same (Jarvis, 2014).
4. If any limitation or any increase in ROM occurs, use a goniometer to measure the angles precisely. First, extend the joint to neutral or 0 degrees. Center the 0 point of the goniometer on the 0 line, and use the movable arm to measure; then flex the joint and measure through the goniometer to determine the angle of greatest flexion (Jarvis, 2014). Joint motion normally causes no tenderness, pain, or crepitation. Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend (Jarvis,
A good clinical history is important when making an assessment for new patients. A data needs to be collected that relates to the diagnosis or illness for which the patient is being seen. When gathering data for patients diagnosed with or are at risk for osteoporosis, following five areas of the body that need to be examined for further detailed findings.
1. Joints. Are there any problems with your joints? Any pain? If yes, which joints? Is the pain on one side of the joint or both sides? What does the pain feel like: aching, stiff, sharp or dull, shooting? How strong is the name? When did this pain start? What time of the day does the pain occur? How long does it last? How often does it occur? Is the …show more content…
Functional assessment. Do your joint (muscle, bone) problems create any limits on your usual activities of daily living (ADLs)? Which ones? Do you have any difficulty with bathing: getting in and out of the tub, turning faucets? Do you have any difficulty with toileting: urinating, defecating, able to get self on and off toilet, wipe self? Any difficulty with dressing: doing buttons, zipper, fasten opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit? Any difficulty with grooming: shaving, brushing teeth, brushing or fixing hair, applying makeup? Any difficulty with eating: preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking? Any difficulty with mobility: walking, walking up or down stairs, getting in and out of bed, getting out of house? Any difficulty with communicating: talking, using phone, and writing? (Jarvis, …show more content…
Note any heat, tenderness, swelling, or masses. Joints normally not tender to palpation. If any tenderness does occur, try to localize it to specific anatomical structures (e.g., skin muscles, bursae, ligaments, tendons, fat pads, or joint capsule) (Jarvis, 2014).
Range of Motion
1. Ask for active ROM while stabilizing the body area proximal to that being moved (Jarvis, 2014).
2. With each joint familiarize yourself with the type and its normal ROM so that you can recognize limitations. If you see a limitation, gently attempt passive motion (Jarvis, 2014).
3. Anchor the joint with one hand while your other hand slowly moves it to its limit. The normal ranges of active and passive motions should be the same (Jarvis, 2014).
4. If any limitation or any increase in ROM occurs, use a goniometer to measure the angles precisely. First, extend the joint to neutral or 0 degrees. Center the 0 point of the goniometer on the 0 line, and use the movable arm to measure; then flex the joint and measure through the goniometer to determine the angle of greatest flexion (Jarvis, 2014). Joint motion normally causes no tenderness, pain, or crepitation. Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over bone during motion, such as when you do a knee bend (Jarvis,