History Taking and Physical Examination PDF

HISTORY TAKING AND PHYSICAL EXAMINATION 1. Recognizing sets of cues (Normal vs. Abnormal): ○ Nurses evaluate patient data to determine if findings are typical for the situation or indicative of potential problems. For instance, a high heart rate during physical act...

HISTORY TAKING AND PHYSICAL EXAMINATION 1. Recognizing sets of cues (Normal vs. Abnormal): ○ Nurses evaluate patient data to determine if findings are typical for the situation or indicative of potential problems. For instance, a high heart rate during physical activity may be normal, while th. 2. Identify warning signs of problems and changes in patient condition: ○ Warning signs such as altered mental status, changes in vital signs, or new symptoms (e.g., sudden shortness of breath) alert the nurse to potential deterioration requiring immediate action. 3. Subjective Data (Symptoms): ○ This includes what the patient reports about their experience, such as pain, fatigue, or nausea. It cannot be measured directly and relies on patient communication. i. Ex. patient complains of nausea and dizziness for 3 days 4. Objective Data (Signs): ○ Observable or measurable data, such as a high temperature, visible swelling, or abnormal heart rhythms, gathered through assessments or diagnostic tools. 5. Health History – Components and Purpose: ○ Components: A comprehensive health history includes current complaints, past medical history, family history, social history, and review of systems. ○ Purpose: to guide care by understanding the patient’s baseline health and risk factors. 6. Functional Assessment – Components and Purpose: ○ Components: This evaluates how a patient’s health affects their ability to perform daily activities, like walking, cooking, ADLs, bathing ○ Purpose: determine impact of illness 7. Cultural Assessment – Purpose: ○ Ensures that care respects the patient’s cultural beliefs and practices. This may include dietary preferences, spiritual practices, and views on medical treatments, helping build trust and adherence to care plans. 8. Identify Social Determinants of Health (SDOH) / Barriers to Care: ○ Purpose: Identifying these barriers helps address inequalities in care and improve patient outcomes. ○ SDOH/barriers to care: housing, employment, education, and access to transportation, access to medical care, social norms, environment. ○ Which practices are important: Planned Parenthood, WIC, EBT, low income housing, 9. Use of Therapeutic Communication: ○ Effective communication builds rapport and gathers accurate information. Techniques like active listening, open-ended questions, and empathy ensure patients feel heard and understood. Used for patient interactions. Professional communication is used for coworkers.  ○ Therapeutic: i. Using silence ii. Accepting iii. Giving recognition iv. Offering self v. Giving broad openings vi. Offering general leads vii. Placing the event in time or sequence viii. Making observations ix. Encouraging description of perceptions x. Encouraging comparison xi. Restating xii. Reflecting xiii. Focusing xiv. Exploring xv. Seeking clarification and validation xvi. Presenting reality xvii. Voicing doubt xviii. Verbalizing the implied xix. ]Attempting to translate words into feelings xx. Formulating a plan of action ○ Non-therapeutic: i. Giving false reassurance ii. Rejecting iii. Approving or disapproving iv. Agreeing or disagreeing v. Giving advice vi. Probing vii. Defending viii. Requesting an explanation ix. Indicating the existence of an external source of power x. Belittling feelings expressed xi. Making stereotypes comments xii. Using denial xiii. Interpreting xiv. Introducing an unrelated topic VITAL SIGNS 1. Temperature: ○ Body temperature reflects core physiological function. ○ Axillary for children  ○ Rectal temperatures: used sparingly due to invasiveness and risk for harm. 2. Pulse: ○ Adult: 60-100 bpm ○ Neonate: 110-160 ○ Increases with fever, pain, anxiety, and stimulants can increase heart rate 3. Respirations: ○ Count for one full minute to account for irregular patterns. ○ Normal RR: 12-20 breaths per minute in adults ○ a rate below 12 is concerning unless the patient is asleep, and a rate above 20 suggests distress or an underlying issue. 4. Blood Pressure (BP): ○ Increases with stress, pain, and fluid volume overload (FVO) ○ Decreases with dehydration, shock, or fluid volume deficit (FVD). ○ It’s important to measure BP accurately, ensuring the cuff size and patient positioning are correct. 5. Oxygen Saturation (O2 Sat): ○ Normal levels are 95-100% ○ Below 90%: hypoxemia, requiring investigation and intervention. Low O2 saturation could result from conditions like pneumonia or chronic obstructive pulmonary disease (COPD) (88%-92%) 6. Pain (6th Vital Sign): ○ Pain assessment uses the OPQRST mnemonic: Onset: When did the pain start? Provocation/Palliates: What makes it worse or better? Quality: How does it feel (sharp, dull)? Region/Radiation: Where is it, and does it spread? Severity: How severe is it (e.g., scale of 1-10)? Timing: Is it constant or intermittent? PHYSICAL ASSESSMENT 1. Purpose: ○ A physical assessment gathers baseline data, identifies abnormalities, and monitors changes over time. It enables nurses to create tailored care plans based on objective findings to detect and document normal and abnormal findings. 2. Techniques (Inspection, Palpation, Percussion, Auscultation): ○ Inspection: Observing general appearance, posture, and skin. ○ Palpation: Using hands to assess texture, temperature, and tenderness. ○ Percussion: Tapping body parts to evaluate underlying structures (e.g., hollow vs. solid sounds). ○ Auscultation: Listening with a stethoscope for heart, lung, and bowel sounds. 3. Abdomen Techniques (Inspect, Auscultate, Percuss, Palpate): ○ Always auscultate before palpating to avoid disrupting bowel sounds. Listen for abnormalities such as hyperactive sounds in diarrhea or absent sounds in ileus. 4. General Impression: ○ Includes overall observations like body position, level of distress, tone, and ability to communicate. These give insight into the patient’s immediate condition and mental status. ○ Ex: speech, thoughts, mental status 5. HEENOT (Head, Eyes, Ears, Nose, Oral, Throat): ○ Assess cranial nerves (PERRLA, EOMI, facial symmetry, tongue movement, eye movement) ○ Hydration status (e.g., dry tongue indicating dehydration) ○ Abnormalities like pallor (anemia) or yellow sclera (jaundice). 6. Thorax/Chest (Cardiac and Lungs): ○ Cardiac assessment involves auscultating heart sounds (S1, S2, S3, S4) and identifying murmurs. ○ APeTM: Aortic, pulmonic, erb’s point, tricuspid, mitral. ○ Apical Pulse: palpate and listen for 1 minute for rate and regularity. 5th ICS left of sternum ○ Chest wall: crepitus (rice krispies), tactile fremitus, chest expansion (should be equal) ○ Lung assessment identifies abnormal sounds like wheezes (airway constriction), rhonchi (fluid or mucus), and crackles (fluid). 7. Abdomen – Percussion Sounds: ○ Listen to all 4 quadrants THEN palpate ○ Percussion helps distinguish between bone (flat sound), solid organs like the liver (dull sound), and air-filled structures like the stomach (tympany). 8. Genitalia- Skin Integrity: ○ Discharge, rash, pain 9. Extremities – Pulses and CSMP (Color, Sensation, Mobility, Perfusion): ○ Check for adequate circulation, sensation, and movement, especially distal to an injury. ○ Assess capillary refill (normal < 2 seconds) and look for signs of arterial or venous insufficiency. ○ Skin Assessment: i. Changes like pallor (anemia), cyanosis (low oxygen), jaundice (liver dysfunction), or rubor (inflammation) can indicate systemic issues. ○ Chronic Arterial Insufficiency: i. Symptoms include pale, cool, and hairless skin, pain with elevation, and poorly healing ulcers. Dependent rubor (redness when legs are lowered) is a hallmark sign. ii. Six Ps of Acute Arterial Occlusion/Compartment Syndrome:  1. Pain/Pressure, Pallor, Paresthesia, Paralysis, Poikilothermia, and Pulselessness. These signs indicate impaired blood flow requiring immediate action. ○ Chronic Venous Insufficiency: i. Presents with brown, flaky skin, swelling, and wet, pink ulcers (typically medial lower legs). Compression therapy can help reduce symptoms. FOCUSED ASSESSMENTS 1. Purpose: ○ Focused assessments target specific complaints or injuries. For example, a patient with chest pain would require a cardiac-focused assessment, including checking heart rate, rhythm, and oxygenation. i. Use prioritization ii. Check pulses, perfusion, address pain iii. Inspect an injury prior to palpation iv. CSMP/Vital signs (follow hospital policy for vitals and per nursing judgment) 2. Shock vs. Increased ICP: ○ Shock: Signs include tachycardia, hypotension, and cool, clammy skin. Early indicators are restlessness and decreased urine output due to reduced perfusion. ○ Increased ICP: Symptoms include bradycardia, widened pulse pressure, and unequal pupils. i. Anxiety, restlessness, headache, changes in mental status ii. Cushing’s triad (bradycardia, hypertension, and bradypnea) signals severe pressure on the brain. FLUID VOLUME BALANCE 1. Fluid Volume Deficit (FVD): ○ S/S: i. Adults: Dry/cracked mucous membranes, tenting/poor skin turgor. ii. Pediatrics:sunken fontanelles (under 1), sunken orbits iii. Hypovolemia includes hypovolemic shock: tachycardia, tachypnea, and hypotension. 2. Fluid Volume Overload (FVO): ○ S/S: i. Adults: edema, crackles in the lungs, weight gain, and jugular vein distension (JVD). ii. Pediatrics: bulging fontanelles (under 1), orbital edema. PSYCHIATRIC MENTAL HEALTH NURSING 1. Mental Health and Mental Illness as a Continuum: ○ Mental health exists on a spectrum, from healthy coping to maladaptive behaviors. Mental illness occurs when stressors overwhelm the ability to adapt (maladaptation), leading to impaired function and self-care deficits. 2. Ego Defense Mechanisms: ○ These unconscious processes help manage stress but can distort reality: Denial: Refusing to accept reality (e.g., “I’m not sick”). Displacement: Redirecting emotions (e.g., snapping at a colleague after a stressful day). Rationalization: Justifying behavior with logical reasons (e.g., “I missed work because the weather was bad”). Suppression/Repression: Avoiding thoughts consciously (suppression) or unconsciously (repression). 3. Therapeutic Communication: ○ Techniques like the SOLER method (Sit squarely, Open posture, Lean in, Eye contact, Relax) establish trust. Open-ended questions (e.g., “Can you tell me more about that?”) encourage dialogue, while avoiding judgment or nontherapeutic phrases (e.g., “It’s not that bad”) maintains rapport. 4. Safety as a Priority: ○ Identify any immediate life threats ○ Suicide: ask thoughts, intentions, plans, and means ○ Person with a plan = risk of completing 5. Depression: ○ Major depressive disorder (MDD): acute episodes of low mood ○ Dysthymia: chronic/constant ○ Symptoms include hopelessness, lack of energy, and altered sleep. ○ Treatments include therapy (CBT), medications, and monitoring for suicidal ideation in the first 4 weeks (increased energy but no mood change) ○ Lithium (salt): Therapeutic level: 0.8-1.2 Maintain constant fluid and salt intake Avoid excess caffeine or diuretics Report s/s of toxicity: N/V, lethargy, tremors 6. Bipolar Disorder (BPD): ○ Characterized by alternating episodes of mania and depression. Mania: Hyperactivity, impulsivity, poor judgment, hypersexuality, bright colors, insomnia, problems concentrating. Manipulation and management can be taxing on staff Safety is a priority during manic episodes due to risk-taking behaviors. Lithium Use: Requires consistent fluid and salt intake to avoid toxicity. Signs of lithium toxicity include tremors, confusion, and seizures. 7. Schizophrenia:  ○ A severe disorder with disturbances in thought (e.g., delusions, hallucinations). ○ Present reality ○ Treatment: antipsychotics like Clozaril (clozapine) Requires careful lab monitoring for agranulocytosis (dangerously low white blood cells). 8. Body Dysmorphic Disorder: ○ Gross distortion of body parts or features ○ Avoid social situations 9. Delirium: ○ ACUTE usually identifiable cause ○ Medications, infections, injuries 10. Dementia: ○ CHRONIC, slow and progressive, not reversible 11. Anxiety Disorders: ○ Generalized Anxiety Disorder (GAD): Chronic, excessive worry. Buspirone may help reduce symptoms but does not cure. Important to work towards recognizing and avoiding triggers ○ Phobias: Anxiety tied to specific triggers, such as agoraphobia (fear of leaving safe spaces and being “trapped” or unable to be rescued). ○ OCD (Obsessive-Compulsive Disorder): Obsessions are intrusive thoughts; compulsions are repetitive actions to manage anxiety. ○ Use therapeutic communication, remain calm and reassuring, keep instruction short and specific 12. Eating Disorders: ○ These are anxiety-based and include: Anorexia Nervosa: Fear of obesity, leading to severe food restriction. Bulimia Nervosa: Binging and purging cycles. Binge Eating Disorder: Binging without purging. ○ Goal: healthy eating habits and avoid triggers ○ Monitor patients after meals (1 hour) to prevent purging and aim for a safe weight gain of 1-2 pounds per week. 13. PTSD (Post-Traumatic Stress Disorder): ○ PTSD: Emotional trauma that was not resolved (lack of support or resources) ○ Flashbacks, hypervigilance, and avoidance behaviors. ○ Treatments like Eye Movement Desensitization and Reprocessing (EMDR) can help resolve symptoms. Trauma-informed care avoids triggering memories or retraumatization. ○ Trauma Informed Care: avoid retraumatization, think of potential triggers 1. Somatoform Disorders: ○ Avoidance of addressing anxiety, unconsciously converts anxiety into physical symptoms (e.g., chest pain without a cardiac cause). ○ They are unaware of the psychological origin and may resist mental health care. 2. Illness Anxiety Disorder:  ○ Characterized by excessive worry about having a serious illness despite normal test results. ○ This impairs daily functioning and often involves frequent doctor visits. 3. Factitious Disorder (Munchausen’s Syndrome): ○ The patient intentionally fabricates symptoms to gain attention or medical care. In extreme cases (Munchausen’s by proxy), a caregiver fabricates illness in another person (e.g., a child). 4. Dissociative Identity Disorder (DID): ○ Stemming from severe childhood trauma, this disorder involves multiple distinct personalities. Treatment focuses on integrating identities and processing trauma. 5. Personality Disorders: ○ Personality disorders develop when personality traits are rigid and maladaptive. ○ Significant functional impairment but are not psychotic. A: Cluster – Odd and Eccentric: ○ Paranoid Personality Disorder: Distrust and suspicion of others. ○ Schizoid Personality Disorder: Emotional detachment and preference for solitude. ○ Schizotypal Personality Disorder: Odd beliefs, behaviors, and difficulty forming close relationships. B: Cluster – Dramatic and Erratic: ○ Antisocial Personality Disorder: Disregard for others' rights, impulsivity, and lack of remorse. ○ Borderline Personality Disorder: Emotional instability, fear of abandonment, and impulsive behaviors. ○ Histrionic Personality Disorder: Excessive emotionality and attention-seeking behavior. ○ Narcissistic Personality Disorder: Grandiosity, need for admiration, and lack of empathy. C: Cluster – Anxious and Fearful: ○ Avoidant Personality Disorder: Social inhibition and feelings of inadequacy. ○ Dependent Personality Disorder: Excessive reliance on others for support and decision-making. ○ Obsessive-Compulsive Personality Disorder: Preoccupation with orderliness, control, and perfectionism. SUBSTANCE USE 1. CNS Depressants:  ○ Substances like alcohol and benzodiazepines slow the central nervous system. Overuse leads to AMS, bradypnea (slow breathing) and bradycardia (slow heart rate). ○ Withdrawal can cause (stimulation) symptoms like tachypnea, tachycardia, anxiety, restlessness, agitation, hypertension, and tremors. ○ Tolerance and Recovery: i. Tolerance develops as larger doses are needed to achieve the same effect. Recovery involves honesty, accountability, and addressing underlying causes of use. 2. RN Diversion: ○ If a home: will be absent frequently (especially after weekend or long periods off) ○ If at work: will come to work, take frequent breaks to use, offer to medicate patients for you, avoid witnesses on wastes. Will have higher volume of controlled substance removal and waste than other nurses MATERNAL-NEWBORN NURSING 1. Antepartal Period – a. Ethical dilemmas exist in MNN. Always the possibility of a conflict in maternal and fetal rights. b. National goals to promote and provide early access to prenatal care for all c. Inquire about safety, personal habits, drug and alcohol use, immunizations d. Offer genetic testing and counseling as appropriate e. Offer screening as appropriate (blood, CVS, amniocentesis) i. Teach about timing for exams and what they screen for f. TORCH Infections: i. Includes infections like toxoplasmosis (from cat litter or raw meat), rubella, and cytomegalovirus. These can cause severe fetal harm, especially during organogenesis (weeks 2-8). g. Teratogens: fetus most susceptible during organogenesis (2-8 weeks) h. Fetal circulation/shunts: R to L through atria to bypass lungs i. Monitor fetal growth with U/S, measuring fundal height i. IUGR: smaller than expected ii. LGA: larger than expected 2. GTPAL: a. G (Gravida): Total number of pregnancies, regardless of the outcome, including the current pregnancy. b. T (Term births): Number of pregnancies carried to term (37+ weeks of gestation). c. P (Preterm births): Number of pregnancies delivered preterm (20–36 weeks of gestation). d. A (Abortions): Number of pregnancies ending in spontaneous or induced abortion before 20 weeks.  e. L (Living children): Number of living children. 3. Naegel’s Rule: calculate estimated date of delivery using LMP a. Take the first day of the woman’s last menstrual period (LMP). b. Subtract 3 months. c. Add 7 days. d. Adjust the year if necessary. 4. Fetal Circulation/Shunts: a. Fetal circulation bypasses the lungs via the ductus arteriosus, ductus venosus, and foramen ovale. After birth, these structures close as the newborn begins to breathe. 5. Fetal Heart Rate (FHR) Monitoring: a. Normal range: 110-160 bpm. b. NST (non-stress test), Contraction Stress Test c. Ruptured membranes (check fluid), and apply EFM (external fetal monitor) d. Variable Cord Compression e. Early Head Compression f. Accelerations Okay! g. Late Placental Insufficiency h. Intermittent decreases in FHR (less than 30 minutes) = sleeping i. Sustained Tachycardia = stimulation (maternal fever, stimulant use) j. Tachy then Brady = HYPOXIA k. Tier 1: continued to monitor l. Tier 2: intervene (reposition) m. Tier 3: intrauterine resuscitation and prepare for delivery ANTEPARTAL COMPLICATIONS Hyperemesis gravidarum: excessive vomiting during pregnancy Placental abnormalities: ○ Previa: placenta attaches to lower part of uterus partially or fully covering cervical opening Bright red PAINLESS bleeding ○ Abruptions: detachment of placenta from uterine wall Dark red PAINFUL bleeding ○ Accreta: placenta attaches too deeply into uterine wall Hypertension in Pregnancy (PIH and Preeclampsia): ○ Monitor Labs: proteinuria, CBC, CMP ○ HELLP syndrome: Hemolysis, elevated liver enzymes, low platelets Bleeding, RUQ pain, dyspnea, N/V, neuro changes ○ Preeclampsia: hypertension (>140/90 new onset after 20wks), proteinuria, and signs like headache and blurred vision. ○ Treatment: antihypertensive, deliver baby, corticosteroids if early delivery ○ Severe cases may progress to eclampsia, requiring magnesium sulfate to prevent seizures.  Monitor for magnesium toxicity (e.g., loss of deep tendon reflexes, respiratory depression, decreased urine output, flushing). INTRAPARTAL PERIOD: 1. Labor: a. Cervical changes (thinning) b. Effacement (0-100%) c. Dilation (0-10 cm) d. Station: (- above, 0 at ischial spines, + below further down) 2. Labor Stages: a. First Stage: longest (cervix effaces and dilates) b. Second Stage: pushing delivers a baby. c. Third Stage: Placenta is delivered. d. Fourth Stage: Recovery, monitoring for complications like hemorrhage. 3. Induction and Augmentation: a. Cervical ripening: misoprostol b. Contraction stimulation and augmentation: pitocin c. Goal is to create active labor (contractions 2-3 minutes lasting 60 seconds) that fetus can tolerate (tier 1) 4. Preterm Labor and PPROM: a. Preterm labor involves contractions and cervical changes before 37 weeks. b. Premature prelabor rupture of membranes (PPROM) increases infection risk; treatment includes antibiotics and corticosteroids to promote fetal lung maturity. 5. GBS and Vaginal Culture: a. Give maternal IV antibiotics prior to delivery or keep baby for 48 hours to observe for s/s of sepsis (tachycardia, fever, tachypnea, low BP, rigors) b. Can cause pneumonia and meningitis = SEPSIS POSTPARTUM PERIOD 1. Postpartum Hemorrhage: a. Early hemorrhage: uterine atony (failure to contract). (1st 24 hours) i. Empty bladder, fundal massage, oxytocin, call for help. b. Late hemorrhage (subinvolution): retained placenta fragments or metritis. 2. Infection: a. BUBBLE assessment: Breast, uterus, bowels, bladder, lochia, edema b. Teach s/s of UTI (urinary frequency, burning with urination), metritis (red/brown foul smelling discharge, pelvic inflammation and pain), wound infections (REEDA: redness, ecchymosis, erythema, discharge, approximation) NEWBORN 1. Preterm, Term, Post-term: ○ Very Premature: