Jarvis health assesment ch 4 (Review of Systems)

Purpose of ROS (review of system)

To evaluate the past and present health state of each body system. Double-check any omitted data from present illness section and evaluate health promotion practices.

General overall health state

refers to present weight, fatigue, weakness or malaise, fever, chills, sweats or night sweats.

skin, hair, and nails

History of skin disease (eczema, psiorasis, hives) pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion

skin, hair, and nails (health promotion)

includes limit sun exposure, use of sunscreen; method of self care for skin and hair.

Head

examines symptoms such as headaches, dizziness, or vision changes, and includes assessments of the scalp, face, and neck—any history of concussion.

eyes

assesses vision, visual changes, eye pain, redness, and history of eye diseases. Includes tests for visual acuity and peripheral vision.

Ears

evaluates earaches, infections, discharge, and balance issues (tinnitus or vertigo).

eye (health promotion)

The use of glasses or contacts to correct vision, regular eye exams to monitor eye health, and education on safety measures to prevent eye injuries.

ears (health promotion)

Hearing loss, hearing aid use, and how loss affects ADLs. Advice on exposure to environmental noise and methods of ear cleaning.

nose and sinuses

assesses discharge and its characteristics any unusually frequent or severe colds, sinus pain, nasal obstruction, snoring, nosebleeds, allergies or hay fever, or change in sense of smell.

Mouth and throat

assesses mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste

mouth and throat (health promotion)

pattern of daily dental care, use of dentures, bridge, and last dental checkup.

Neck

Assess for pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, and goiter. recent injuries

Breast

assess for pain, lump, nipple discharge, rash, history of breast disease, any surgery on breast.

Breast (health promotion)

performs breast self-examination? how frequent? method used? last mammogram?

Respiratory system

history of lung disease (i.e. asthma, emphysema, bronchitis, pneumonia, TB), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount).

Health promotion for respiratory system

Last chest x-ray? TB Skin test?

cardiovascular

assess for chest pain, pressure, tightness or fullness, palpitation, cyanosis, dyspnea on exertion (specifically amount of exertion [i.e., walking one flight of stairs, walking from chair to bath]. any previous cardiovascular history (i..e. heart murmur, HTN, CAD)

Health promotion for Cardiovascular

Date of last ECG or other cardiac tests, cholesterol screening.

Peripheral Vascular

Assess the Coldness, numbness and tingling, and swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications.

Health promotion for Peripheral vascular

Does the work involve long-term sitting or standing? Does the patient frequently cross legs at the knees? wear support hose?

G/I

assess appetite, food intolerance, dysphagia heartburn, indigestion, pain (associated with eating) other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomitting (character), vomiting blood, history of abdominal disease (liver, gallbladder, ulcer, jaundice, appendicitis, colitis) flatulence, frequency of bowel movement any recent change in stool, constipation or diarrhea, rectal bleeding, rectal conditions (hemorrhoids, fistula).

G/I health promotions

use of antacids or laxatives (alternatively, diet history and substance habits can be placed here)

Urinary system

assess frequency, urgency, nocturia (frequency at night), dysuria; polyuria or oliguria; hesitancy or straining, narrowed stream; urine color; incontinence; history of urinary disease (kidney disease, kidney stones, UTI, prostate) pain in flank, groin, suprapubic region, or low back.

Health promotion urinary system

measures to avoid or treat UTI, use of Kegel exercises after childbirth.

Male genital system

asses for any penis or testicular pain, sores or lesions, penile discharge, lumps, hernia

health promotions for male genital system

perform self-exam on testicles? how frequent?

Female genital system

assess menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting). vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms. postmenopausal bleeding.

Female genital system health promotion

Last gynecological check? last PAP test; HPV vaccine.

Musculoskeletal system

Assess for a history of arthritis or gout. in the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion? in the muscles: any muscle pain, cramps, weakness, gait problems, or problems with coordinated activities? in the back: any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disc disease? Any recent injuries to the joints, muscles or back?

Musculoskeletal system Health promition

Ask PT how much walking per day? any strength training (e.g., weight training, resistance training)? What is the effect of a limited range of motion on ADLs, such as grooming, feeding, toileting, and dressing? Any mobility aids used?

Neurologic system

Assess for a history of seizure disorder, stroke, fainting, and blackouts. Motor function: weakness, tic or tremor, paralysis, or coordination problems? sensory function: numbness, tingling (paresthesia) cognitive function: memory disorder (recent or distant disorientation?) Mental status: any nervousness, mood change, depression, or history of mental health dysfunction or hallucinations? Conduct suicide screening on all patients.

neurologic system health promotion

Alternatively, data about interpersonal relationships and coping patters are placed here

Hematologic system

Assess bleeding tendency of skin or mucous membranes, and excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.

Endocrine System

Asses for History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormone therapy.