History of Current Illness Documentation Quiz

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is being assessed when observing a patient's posture?

Alignment of hips and shoulders (correct)

Movement and gait pattern

Height and weight

Hair, skin, and fingernails

What might nonverbal communication of pain include?

Joint mobility

Gait pattern

Body build

Changes in skin color (correct)

What aspect of the patient's appearance is evaluated when looking at hygiene and grooming?

Clothing cleanliness

Posture

Body odor (correct)

Mobility

When assessing general appearance and behavior, what might suggest neurological problems?

Spontaneous movements Signup and view all the answers

What should be observed to assess body build in a patient?

Height and weight Signup and view all the answers

Why is it important to evaluate joint mobility during a general survey?

To identify possible neurological problems Signup and view all the answers

What is the purpose of medication reconciliation in healthcare?

To reduce errors and promote patient safety Signup and view all the answers

Which condition is NOT mentioned as part of the Past history associated with Serious or Chronic Illnesses?

Arthritis Signup and view all the answers

What should be noted for drug allergies specifically?

Only true allergic reactions, not side effects Signup and view all the answers

What information should be included when documenting Surgical history?

Type of surgery, date, surgeon's name, hospital's name Signup and view all the answers

Why do nurses incorporate review of system questions into physical examinations?

To enhance patient safety Signup and view all the answers

What is the importance of an accurate family history in healthcare?

It can reduce medical errors Signup and view all the answers

What critical characteristics should a nurse note when summarizing any symptom?

The precise site, specific descriptive terms, and intensity Signup and view all the answers

Why is it important to inquire about aggravating or relieving factors of a symptom?

To identify what worsens the symptom and what provides relief Signup and view all the answers

What is an example of a relevant past health event to inquire about in a patient's history?

Serious fever that required medical attention Signup and view all the answers

Why is past health history important in assessing a patient's current health state?

To assess the residual effects of past health events on the current health state Signup and view all the answers

Why should a nurse avoid recording 'usual childhood illnesses' in a patient's history?

Because these illnesses may have no impact on the current health state Signup and view all the answers

Why is it important to document accidents or injuries in a patient's past history?

To assess any lingering effects on the patient's current health state Signup and view all the answers

What does BMI stand for?

Body Mass Index Signup and view all the answers

How is BMI calculated?

Weight (kg) / [Height (m)]2 Signup and view all the answers

What weight status category does a BMI of 19.5 fall under?

Normal or Healthy Weight Signup and view all the answers

Which of the following is NOT one of the purposes of physical examination mentioned in the text?

To evaluate the psychological outcomes of healthcare Signup and view all the answers

Which framework is mentioned as the most common for a comprehensive assessment?

Head-to-Toe Assessment Signup and view all the answers

What should be used throughout a physical examination if patients present with infected wounds?

Standard precautions Signup and view all the answers

What is the primary purpose of percussion in a physical examination?

To vibrate underlying tissues and organs Signup and view all the answers

Which type of percussion involves striking a finger held against the body area to be examined?

Indirect percussion Signup and view all the answers

What does a dull percussion sound indicate?

Flat and stony dull sound Signup and view all the answers

Which condition can be suggested by flatness in percussion?

Muscle or bone tissue Signup and view all the answers

What is an example of a direct percussion technique?

Percussing an adult's sinuses Signup and view all the answers

Study Notes

Percussion

Percussion involves lightly tapping on the body surface to create vibrations that travel through tissues, allowing assessment of underlying tissue density.
Types of percussion:
Direct percussion: striking the area to be examined directly with fingertips.
Indirect percussion: striking a finger held against the body area to be examined.
Percussion sounds:
Tympany: drum-like, indicating air-filled tissues (e.g., bowel).
Resonance: hollow, clear, indicating air-filled areas with partial solidity (e.g., normal lung).
Hyperresonance: booming, indicating large air-filled areas (e.g., lung with emphysema).
Dullness: thud-like, indicating solid tissues (e.g., liver, heart, spleen, bladder).
Flatness: flat and stony, indicating dense tissues (e.g., muscle, bone).

Auscultation

Auscultation involves listening to body sounds using a stethoscope to assess heart, lung, bowel, and blood pressure.

Body Mass Index (BMI)

BMI is a measurement of a person's weight relative to their height, indicating total body fat.
Formula: BMI = weight (kg) / [height (m)]²
BMI categories:
Underweight: BMI < 18.5
Normal weight: BMI = 18.5-24.9
Overweight: BMI = 25.0-29.9
Obese: BMI ≥ 30.0

Purposes of Physical Examination

Obtain baseline data about the client's functional abilities.
Confirm or refute data obtained in the nursing history.
Obtain data for nursing diagnoses and plans of care.
Evaluate physiologic outcomes and client progress.
Make clinical judgments about the client's health status.
Identify areas for health promotion and disease prevention.

Head-to-Toe Framework

The most common framework for a comprehensive assessment.

Preparation for the Examination

Infection control: use standard precautions and follow agency hand hygiene policies.

General Survey

Involves observation of the client's general appearance and behavior, measurement of vital signs, height, and weight.
Components:
General appearance and behavior (e.g., signs of distress, nonverbal communication of pain).
Posture and mobility.
Hygiene and grooming.

Past History

Includes:
Serious or chronic illnesses (e.g., asthma, diabetes, heart disease).
Hospitalizations (e.g., cause, hospital name, treatment, physician).
Surgical history (e.g., type of surgery, date, surgeon, hospital).
Immunizations (e.g., vaccination history).
Allergies (e.g., medication, food, environmental agents).
Current medications (e.g., medication reconciliation).

Family History

Highlights diseases and conditions for which the patient may be at increased risk.

Review of Body Systems

Incorporates review of system questions into the physical examination of each system.