Exam 1 Study Guide

Components of Health Hx

-Identifying data + source

-Chief Complaint(s) (CC)

-History of Present Illness (HPI)

-Past Med/Surgical Hx

-Family Hx

-Review of Systems (ROS)

-Health Patterns

All Health Histories are considered…

Subjective Information!

What is included in the Identifying Data + Source part of Health Hx?

Name, Age, Gender, Birthday, Marital/Relationship status, Occupation, Education Level, Primary language

What is included in the Chief Complaint (CC) part of Health Hx?

Symptoms, Concerns, or Goals causing the pt. to seek care

What is included in the History of Present Illness (HPI) part of Health Hx?

Tells more about the CC

-complete, clear, chronological

-use of OLDCART

What is included in the Past Medical/Surgical Hx part of Health Hx?

Allergies, Meds, Childhood illness, Medical, Health Maintenence…

**w/ allergies ask abt SYMPTOMS they experience

When asking about drugs, alcohol, abuse issues, how should you respond to a patient asking: “Why do you want to know?”

I ask everyone the same questions—it gives a picture of your life.

What is included in the Family History part of Health Hx?

Age, health of immediate relatives (parents, grandparents, siblings), cause of death of an immediate relative, review of common diseases among family members

ex) HTN, DM, CVA, CA, Asthma

Why is taking a Family History important?

-Can ID diseases the pt. is at risk for (genetics, family health patterns)

-Drives education + screenings

What is included in the Review of Systems (ROS) part of a Health Hx?

EACH BODY SYSTEM! from head → toe!!!

HEENT, Neck, Breasts, Respiratory, Cardio/peripheral vascular, Gastrointestinal, Urinary, Reproductive, Musculoskeletal, Integument, Neurological, Psychiatric, Hematologic, Endocrine

In clinic settings, the client may often fill out the Review of Systems (ROS). What is important for the nurse to do???

The nurse should clarify discrepancies or other info.

Ex: Under reproductive, a woman may circle that she has fibroids. (benign uterine tumors) With questioning, she has been told she has fibrocystic changes in her breasts.

*Therefore, the nurse should clarify all responses for accurate documentation.

In hospital settings, the RN/LVN completes the ROS. This is a Head-to-Toe Hx. All data is considered…

SUBJECTIVE!!!!!!!!!!!!!!!!!!!!!

What is included in the Health Patterns part of the Health Hx?

ID values, routines, changes, motivation

Sexual Hx, Mental Health Hx

Communication Tips for Asking Uncomfortable Questions

Be matter of fact in questioning

Use specific language

Make NO ASSUMPTIONS about the patient

Consciously acknowledge discomfort. Denying your discomfort may lead you to avoid the topic altogether.

When asking about Mental Health Hx, if a patient seems depressed, you should ask about…

suicidal thoughts

If abuse is suspected, it is important to do what…

spend part of the encounter alone with the patient

Physical abuse should be considered in several scenarios. What is an example of a sign of physical abuse?

If a partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous.

Types of Health Histories

1) Comprehensive → used for new admits / or when its been a long time since a pt. was seen

2) Focused or Problem-Oriented → used in follow ups and emergencies

How is a Comprehensive Health Hx done?

-We ask all the questions

-In some settings, the client may complete the form

-Hospital settings—nurse completes

Why do we do a comprehensive Health Hx?

To get a full picture of the pts. health status

How is a Focused or Problem-Oriented health hx done?

-Smaller in scope than a comprehensive

-Focuses on main issue, not all the questions.

*concerns or symptoms restricted to specific body systems

Why do we do a Focused or Problem-Oriented Health Hx?

We already know the other parts…we just need to know the current problem(s)

OLDCART → helps develop HPI

Onset: When did it start?

Location: Where is it? Does it radiate?

Duration: How long does it last?

Characteristics: What is it like? How severe? 0-10?

Associated Symptoms: What else accompanies it?

Relieving/Exacerbating Symptoms: What makes it better/worse?

Treatment: What have you done to treat it? Seen anyone? RX, OTC

What is considered Subjective Info?

What the PATIENT SAYS
EVERY COMPONENT OF A HEALTH HX

What is considered Objective Info?

What the PROVIDER OBSERVES or MEASURES, including physical exam findings and diagnostic test results.

4 Assessment Techniques in ORDER

Inspect, Palpate, Percuss, Auscultate

Information gathered during INSPECTION

purposeful looking, starts w/ your first impression, compare side-to-side, observe for symmetry, movement, appearance

Information gathered during PALPATION

texture, temperature, moisture, organ location/size, masses or tenderness

light palpation - 1 cm

deep palpation - 2-3 inches

*use bimanual palpation as needed

Information gathered during PERCUSSION

location, size, tissue density, presence of pain

Information gathered during AUSCULTATION

sounds from heart, lungs, blood vessels

*always listen skin-to-skin

The Diaphragm of the stethoscope is used for?

auscultating high-pitched sounds

The Bell of the stethoscope is used for?

auscultating low-pitched sounds (e.g., murmurs)

Steps for Cardiovascular Assessment

Inspection, Palpation, Auscultation

CV Assessment: What to look for in Inspection?

• Jugular vein distention (JVD) → assess with head elevated 45°

• Anterior chest → look for pulsations/apical pulse

• Arms: Color, Capillary refill, Hands should be pink and warm

• Legs: Size and symmetry, Color, Warmth, Capillary refill, Edema, Varicosities, Sores/ulcers, Skin changes

CV Assessment: What to look for in Palpation?

You feel for abnormalities.

Carotid arteries: Palpate one side at a time, Normal = 2+

Apical pulse / PMI: Usually 4th or 5th intercostal space, About midclavicular line, 1 × 2 cm, Short, gentle tap

Precordium: Use palm of hand, Should NOT feel a thrill

Radial pulses

Lower-extremity pulses: doralis pedis, post. tibial, popliteal, femoral,

Edema

CV: What to look for in Auscultation?

Assess: Carotid artery for bruits, Heart sounds, S1 and S2, Extra heart sounds, Murmurs, Rate and rhythm

For the carotid: Use the bell, Ask patient to hold their breath, Listen for a bruit

Normal Heart Sounds

S1 + S2

S1 Heart Sound - “Lub”

-AV valves close

beginning of SYSTOLE

-loudest at APEX
-should coincide w/ carotid pulse

S2 Heart Sound - “Dub”

-SL valves close

End of systole/beginning of DIASTOLE
-loudest at BASE

Assessing Fatigue Associated w/ CV Problems

Ask: “Do you tire easily?”

follow up with more questions… e.g.,

“When did it start?”

“Is it related to a particular time of day?”

Subjective Data needed for CV Assessment

Pain, Dyspnea, Cough, Fatigue, Edema, Color, Cardiac history, Family history, Risk factors

*know specific questions for each - OLDCART

OLDCART - Questions to ask regarding Dyspnea

• Do you get short of breath?

• When did it start?

• Does it originate in your throat or chest?

• Is it constant?

• Does it occur at a particular time of day?

• Does it awaken you from sleep?

• Mucus?

• Urge to cough?

• Wheezing?

• Chest pain?

• Nausea?

• Is it related to position?

• Orthopnea: How many pillows do you sleep with?

• What treatment have you had?

OLDCART - Questions to ask regarding Cough

• Do you have a cough?

• When did it start?

• How long has it lasted?

• How frequently does it occur?

• Productive or nonproductive?

• Associated manifestations?

• What makes it better/worse?

• What treatment have you had?

OLDCART - Questions to ask regarding Edema

• Any swelling in feet or legs?

• When did it start?

• Where is it located?

• How long has it been present?

• Any recent changes?

• What time of day?

• Do your shoes feel tight at the end of the day?

• How much swelling?

• Associated symptoms?

• Is swelling decreased in the morning?

• What treatment have you had?

Asking about Cyanosis/Pallor

"Have you noticed, or has anyone ever told you, that your face has turned blue/gray?"

Using OLDCART to assess chest pain

O = Onset → When did it start?

L = Location → Where is it? Can you point to it?Does it radiate?

D = Duration →How long does it last? Is it constant or intermittent?

C = Characteristics → What does it feel like?

A = Associated symptoms → What other symptoms occur with it?

R = Relief → What makes it better or worse? Rest?Movement? Breathing? Lying flat?

T = Treatment → What treatment have you had?

5 Valve Positions

“All Physicians Enjoy Taking Money”

Aortic, Pulmonic, Erb’s Point, Tricuspid, Mitral

Location of Aortic valve

2nd R ICS

Location of the Pulmonic valve

2nd L ICS

Location of Erb’s Point

3rd L ICS

Location of Tricuspid Valve

4th L ICS

Location of Mitral Valve

5th ICS, midclavicular line

Listening to the 5 Valves

Start with diaphragm to listen for S1 + S2

then repeat same areas with bell side to listen for low pitched, potential S3 + S4 sounds (or murmurs)

When you use percussion over the lungs you should hear

Resonance

Assessing a thrill

using: palpation

feel: vibrations

Assessing a murmur

using: auscultation listen for: sounds of turbulent blood flow

Assessing a lift/heave

using: inspection / palpation

-indicates ventricular hypertrophy

-increased workload

Modifiable risk factors for CV Disease - HTN

obesity, physical inactivity, smoking, excess dietary Na+, lack of dietary K+, excess alcohol consumption

Nonmodifiable factors for CV Disease - HTN

age, family Hx of HTN or CVD

Modifiable factors for CV Disease - CHD

diabetes, systolic/diastolic HTN, smoking, obesity, physical inactivity

Nonmodifiable factors CV Disease - CHD

increasing age, Hx of CVD, Family Hx of early HD

PV Exam - Normal Findings for Arms/Hands

Pink, Warm, Capillary refill < 3 seconds, Radial pulses present bilaterally, Normal pulse amplitude = 2+

You may perform an Allen test if indicated.

PV Exam - Normal Findings for Legs/Feet

Equal/symmetrical leg size, Pink, Warm, Capillary refill < 3 seconds, No abnormal edema, Check for varicosities

Pulses to Palpate in Legs/Feet

• Dorsalis pedis pulse

• Posterior tibial pulse

• Popliteal pulse

• Femoral pulse

Pulse Amplitude Scale

3+ = bounding

2+ = normal

1+ = weak/diminshed

0 = unable to palpate

Edema pitting scale

1+ = 2 mm

2+ = 4 mm

3+ = 6 mm

4+ = 8 mm

Pitting vs Nonpitting edema

Pitting edema = pressing the swollen areas leaves an indention

Nonpitting edema = pressing does not leave an indention

Significant Jugular Vein Distension (JVD) is an indicator of…

CHF

Assessing JVD

make sure head is at 45 degree angle

Why is it important to palpate one carotid artery at a time

to avoid compromising blood flow to the brain

Normal Carotid Pulse

smooth, rapid upstroke, slower downstroke

2+ = moderate/normal

Auscultating Carotid Pulse

-use bell of stethoscope

-ask pt to hold their breath so their breathing is not mistaken for a bruit

Bruits

an abnormal “swishing” sound heard when listening to an artery (outside of the heart)

-due to turbulent blood flow that comes with narrowing/occulusion

Hearing Bruits

30-50% occlusion → bruit becomes audible

60-70% occlusion → bruit becomes louder

100% occlusion → bruit sound disappears (bc no flow! its completely blocked!)

Steps of Respiratory Assessment

Inspection, Palpation, Percussion, Auscultation

Inspection Step of Respiratory Assessment

Look for…

General appearance → distress, mental status

Respiratory Pattern → rate, depth, labor, accessory muscle use, audible noises

AP:T diameter → ratio/shape/skin

Cap refill, fingers/toes clubbing, skin/lip color, sputum/cough?

Use of respiratory assist → O2, artificial airway, ventilatior

During the Inspection step of respiratory assessment, the chest should expand in what manner?

EVENLY, BILATERALLY

at the same timeeeeeeeeeee

Palpation Step of Respiratory Assessment

-examine the trachea → should be midline

-hands on back to assess for even chest expansion

Percussion Step of Respiratory Assessment

used to determine what is underneath the chest wall based on the sound produced

normal lung = resonance sound

Pneumothorax

air stuck in pleural space

-unilateral movement, moved thorax, possible lung collapse

5 Adventitious Lung Sounds to Know

(All abnormal!)

crackles, wheeze, rhonchi, pleural friction rub, stridor

Crackles — Adventitious sound

fine/course?

sounds heard during inhalation, indicating fluid in the alveoli.

sounds like crackling

Wheeze — Adventitious sound

high-pitched, musical sound

heard during exhalation, associated w/ narrowed airways

Rhonchi — Adventitious sound

low-pitched, snoring sound
heard during exhalation, often due to mucus in larger airways.

Pleural Friction Rub — Adventitious sound

grating sound

like “fingers on a balloon” or “walking through snow”

Stridor — Adventitious sound

High-pitched, crowing sound

heard during inhalation, indicating upper airway obstruction.

*sometimes heard w/o a stethoscope

*originates in trachea

THINK ABOUT THE PATHOPHYSIOLOGY:

Asthma: constriction of airway

Inspection - tachypnea, dyspnea

Percussion - hyperresonance

Auscultation - wheezes, prolonged expiration

THINK ABOUT THE PATHOPHYSIOLOGY:

Lobar Pneumonia: consolidation in lobe(s)

Inspection - fatigue, fever (infection)

Percussion - dullness when over consolidated areas

Auscultation - inspiratory crackles

THINK ABOUT THE PATHOPHYSIOLOGY:

Pneumothorax: air in pleural space

Inspection - shifted away affected side

Palpation - decreased excursion, unilateral movement

Percussion - tympanic over air space

Auscultation - decreased to absent over air space, possible pleural friction rub

What sound would you expect to hear when percussing a pt. w/ COPD?

hyperresonance

What sound would you expect to hear when percussing a pt. w/ Pneumonia?

dullness when over consolidated areas

What sound would you expect to hear when percussing a pt. w/ Pleural Effusion?

dullness over fluid accumulated areas

What sound would you expect to hear when percussing a pt. w/ Mass? (tumor)

dullness over the mass area

Social Hx Questions to ask → For respiratory complaints

home environment, work environment/exposure, smoking, second hand smoke exposure, tobacco use, recreational drug use, travel history, hobbies

Questions to ask to determine cardiac vs respiratory chest pain

use of OLDCART to determine… and also ask

SOB/Dyspnea? lying flat? movement? rest?

Health Promo. Activities to decrease respiratory illness/problems

Tobacco Cessation → use is linked to CA, Emphysema, Asthma, SIDS, infertility, issues with birth, CVA, CAD, COPD, Lung CA

Flu Vaccine

Tdap Vaccine “Pertussis”

Pneumococcal Vaccine

Incentive Spirometer (IS)

opens alveoli w/ deep breaths

measures inhaled air capacity

Flutter valve

works with expiration

clears mucus

Peak flow meter (asthma)

measures max expired air

Condition with shifted / deviated trachea

Pneumothorax