STILL
UNDER CONSTRUCTION!
1. IS PATIENT IN ACUTE DISTRESS?
2. DOES PATIENT'S APPEARANCE MATCH STATED AGE?
3. BODY DEVELOPMENT? (Normal, obese or thin?)
4. POSTURE(STATURE)?
5. GAIT(MOBILITY)?
6. BREATH/BODY ODORS?
7. WHAT IS CHARACTER OF PATIENT'S SPEECH?
8. WHAT IS PATIENT'S MOOD AND AFFECT?
9. IS PATIENT COOPERATIVE?
10. WHAT IS PATIENT'S DRESS, GROOMING AND HYGIENE?
11. TAKE VITAL SIGNS
12. MEASURE HEIGHT AND WEIGHT
CHIEF COMPLAINT: e.g., "PRURITIS", ASK ABOUT:
1. LOCATION
2. QUALITY
3. ASSOCIATED MANIFESTATIONS
4. AGGRAVATING FACTORS
5. ALLEVIATING FACTORS
6. SETTING
7. TIMING
8. LESIONS:
1) Location
2) Quantity
3) Morphology
4) Associated Manifestations
5) Aggravating Factors
6) Setting
7) Timing
PAST MEDICAL HISTORY
SURGICAL HISTORY
MEDICATIONS
ALLERGIES
ENVIRONMENTAL EXPOSURE
FAMILY HISTORY
SOCIAL HISTORY(Habits, travel, hobbies, stress, economics)
HEALTH MAINTENANCE ACTIVITIES
1. GENERAL APPROACH--Introduce self, put patient at ease, ensure privacy, drape appropriately, make sure room is warm, explain all procedures, be gentle, use good lighting, gather equipment, proceed head to toe
2. INSPECTION--all skin surfaces, folds, mucous membranes
1) Color--terms: pink, cyanosis, rubor, pallor, icteric, dusky, albinism, vitiligo, ashen, bronze, cafe au lait spots
2) Bleeding, ecchymosis, vascularity--terms: petechiae, purpura, ecchymosis, angiomas
3) Lesions--Note location, color,grouping, elevation, presence of exudate, describe morphology, measure with cm. ruler.
3. PALPATION: All nonmucous membrane skin surfaces for moisture using dorsal surfaces of hands and fingers:
1) Moisture--xerosis, diaphoresis
2) Temperature--hands and feet may be slightly cooler than body, but should feel equal to each other
3) With pads of fingers, assess Texture of skin
4) Gently pinching an area of skin below the clavicle, check for Turgor-- "tenting" is abnormal
5) Check for Edema--press fingers against area and observe for "pitting"(see scale in book); if present, check for symmetry and measure circumference of affected extremities
4. DOCUMENT FINDINGS
1. INSPECTION
1) Color--depends on amount of melanin
2) Distribution(vellus and terminal)--alopecia? hirsutism?
3) Lesions--wear gloves and lift scalp hair by segments to inspect the scalp for lesions and to check for infestations
2. PALPATION--CHECK TEXTURE:
1) Palpate between fingers and note condition and resiliency
1. INSPECTION
1) Color
2) Shape
3) Configuration--nail base angle should be 160 degrees(no "clubbing")
4) Consistency--uniform thickness, no splintering or brittle edges
2. PALPATION
1) Texture of base--firm?
2) Capillary refill--compress nail bed; color should return after compression within 2-3 sec.
1. WRINKLING
2. LOSS OF SUBCUTANEOUS FAT AND THERMOREGULATION--thinning, fragile skin
3. DIMINISHED PERCEPTION OF PAIN
4. PROLONGED HEALING--less efficient immune system
5. HYPERPIGMENTATION--lentigo or liver spots
6. HAIR GROWTH CHANGES--men/women
7. NAIL THICKENING
a. Physical appearance--posture, movements, gait
b. Dress, grooming, physical hygiene--appropriate for setting, weather, age, socioeconomic background?
c. Facial expression--match speech content and symmetrical
d. Affect--emotional responses? appropriate to conversation?
descriptive terms: flat, blunted, labile
e. Communication--is speech coherent, articulate,spontaneous, make sense, is of a normal pitch and volume; can patient follow commands, write sentences, name objects accurately, read?
f. LOC(Level of Consciousness)
Apply stimulus and observe patient's best response: verbal, touch, shake, pain; if able to respond verbally, check orientation to time, place, person and situation(oriented X3 or X4)
Tools for documentation: Glasgow Coma Scale(GCS), Neuro check sheets(uses terms for different levels of consciousness like: lethargic, drowsy, obtunded, stuporous, semi comatose,comatose)
g. Cognitive abilities and mentation: attention, concentration, memory(immediate, short term and long term), spatial perception, calculation
Tool for testing and documentation: Folstein Mini-Mental status exam(see University of Fl. site under Mental Status testing :
h. Judgment, Insight, Abstract Reasoning, Thought process and content: Delirium vs. Dementia vs. Depression
a. Do early in exam
b. Check corresponding areas on body bilaterally
c. Have patient close eyes during sensory checks
d. Check if dermatome* distribution for deficits
e. The borders of any deficit should be mapped
a. Exteroceptive sensations(superficial sensations that originate in the sensory receptors in the skin and mucous membranes). These include include light touch, superficial pain and temperature.
b. Proprioceptive sensations(deep sensations with sensory receptors in the muscles, joints, tendons, and ligaments). These include testing of motion, postion, and vibration sense.
c. Cortical sensations(require cerebral integrative and discriminative abilities). These include testing for stereognosis, graphesthesia, two-point discrimination, and extinction.
a. Test superficial sensation by having patient supine and exposing arms, legs, abdomen; light touch: use cotton balls, go from distal to proximal; assess superficial pain--ability to differentiate between "dull" and " sharp" in the same fashion; also, check for temperature perception.
b. Test proprioception by moving thumb and big toe in space and have patient tell you which way it is being moved; check vibration with tuning fork (low pitch).
c. Test for stereognosisby having patient identify common object (such as a key or paper clip or coin) placed in hand; test for graphesthesia by drawing a number with your finger in the handof the patient and having him name it; test for two point discrimination by touching fingers with two points(ends of cotton tipped applicators) and increasing the distance apart until the patient can discriminate the two points(can also check back of hand); test for extinction by simultaneously touching both sides of the the patient's face with cotton balls and then on one side and asking the patient to state if, when and where one or two points were felt.
1. If patient is conscious, test bilateral hand grasps and pedal pushes; also check for pronator or palmar drift.
2. If patient is unconscious, check type of response to pain: purposeful, non- purposeful, posturing(decorticate or decerebrate) or no response. Also, watch for spontaneous movement.
3. Cerebellar function(Coordination, Station and Gait):
a. Tests for Coordination: fingertip-to-nose touch, rapid alternating hand movements, heel slide, figure eight
b. Station or Posture--Chapter 17, p. 503
c. Gait--Chapter 17, p. 503, and Romberg's Test
4. Reflexes:
a. DTRs--Deep Tendon Reflexes: (graded 0 to 5)
1) Biceps--causes contraction of biceps and flexion of elbow
2) Brachioradialis--observe for flexion and supination of forearm
3) Triceps--contraction of triceps and extension of arm
4) Patellar--contraction of quadriceps and extension of knee
5) Achilles--contraction of calf muscles and plantar flexion; check for Clonus
b. Superficial Reflexes:
1) Abdominal
2) Plantar--called "positive Babinski" if abnormal
3) Cremasteric
4) Bulbocavernosus
c. Pathological Reflexes:
1) Babinski
2) Clonus
3) Autonomic Dysreflexia(High Spinal Cord Injuries)
d. Protective Reflexes: In a patient with decreased LOC, make sure his corneal or blink reflexes and swallowing or gag reflexes are intact; otherwise, use nursing interventions to compensate for loss of these.
e. Reflexes in the infant--rooting, sucking, palmar grasp, tonic neck, stepping, plantar grasp, babinski's, moro, gallant, placing and landau reflexes(pp. 756-758)
CC: Chest pain, cough, shortness of breath--use "O.L.D. C.A.R.T." (Onset, Location, Duration, Characteristics, Aggravating and Alleviating Factors, Routine--how is this interfering with their daily routine?--and Treatment) to obtain pertinent information
Past History: Thoracic trauma or surgery, Hospitalizatons for respiratory disorders, history of allergies, previous chest xrays or oxygen therapy, TB exposure and testing?
Family History: TB, CA, Cystic Fibrosis, Asthma, Allergies, Emphysema
Personal and Social History: Environmental Hazards, Occupation, Tobacco Use(Pack years=number of years of smoking x number of packs smoked per day), Other drug abuse, especially marijuana and/or cocaine, Exercise tolerance
Anatomical Landmarks: Identify suprasternal notch, Angle of Louis,Ribs 2-7, Intercostal spaces, Costal angle, Vertebra prominens, Clavicles, Thoracic Vertebrae, CVA(Costovertebral Angle) and the imaginary lines: Midsternal line, R & L midclavicular lines, R & L anterior axillary lines, R & L midaxillary lines, R & L posterior axillary lines, vertebral line, R &L scapular lines
Inspection:
Palpation:
Percussion:
