History Taking, Physical Examination, and Psychiatric Mental Health Nursing Study Guide PDF

**Study Guide: History Taking, Physical Examination, and Psychiatric Mental Health Nursing** **HISTORY TAKING AND PHYSICAL EXAMINATION** **1. Recognizing Cues & Evaluating Patient Condition:** - Recognize sets of cues to determine if they are normal or abnormal for the patient. - Identif...

**Study Guide: History Taking, Physical Examination, and Psychiatric Mental Health Nursing** **HISTORY TAKING AND PHYSICAL EXAMINATION** **1. Recognizing Cues & Evaluating Patient Condition:** - Recognize sets of cues to determine if they are normal or abnormal for the patient. - Identify **warning signs** and **changes in patient condition**. **2. Subjective vs. Objective Data:** - **Subjective Data:** Symptoms (what the patient reports). - **Objective Data:** Signs (what is observed or measured), includes **assessment findings** and **medical records**. **3. Health History:** - **Components:** Current medical condition, family history, lifestyle factors, medications. - **Purpose:** To understand baseline health, risk factors, and medical history. **4. Functional Assessment:** - **Components:** Physical, emotional, and social functioning. - **Purpose:** To evaluate patient's daily activities and ability to live independently. **5. Cultural Assessment:** - **Purpose:** To understand cultural beliefs and practices that might influence health and care. - Identify **SDOH (Social Determinants of Health)** and **barriers to care** (e.g., financial, language, transportation). - Determine **important cultural practices** (e.g., dietary restrictions, preferences). **6. Therapeutic Communication:** - Establish trust and rapport with the patient. - Use active listening, open-ended questions, and empathy. - Avoid nontherapeutic communication techniques (e.g., giving advice, judgmental comments). **VITAL SIGNS** **1. Temperature:** - **Axillary:** Preferred for babies. - **Temporal or Tympanic:** Common for children and adults. - **Rectal:** Only for core temperature measurement. **2. Pulse:** - **Newborn:** 110-160 bpm. - **Adult:** 60-100 bpm (slows with age). - **Increased:** Fever, pain, anxiety, activity, stimulants. - **Decreased:** Sleep, medications, certain conditions (e.g., heart block). **3. Respirations:** - **Count for 1 full minute.** Observe **rate, depth, patterns, and effort**. - **Normal RR:** \>12/min (except when asleep). - **Decreased RR:** Opioids, benzodiazepines, anesthesia. **4. Blood Pressure:** - **Increased:** Pain, stimulant use, fluid overload (FVO). - **Decreased:** Fluid volume deficit (FVD), dehydration, shock. **5. O2 Saturation:** - Measure for sufficiency of oxygen in the blood. **6. Pain (6th Vital Sign):** - Use **OPQRST** assessment: - **O:** Onset - **P:** Provocation/Palliation - **Q:** Quality - **R:** Radiation - **S:** Severity - **T:** Timing **PHYSICAL ASSESSMENT** **1. Purpose of Physical Assessment:** - To gather data on the patient's health status, identify abnormalities, and guide care planning. **2. Techniques:** - **Inspection:** Observe the patient for visible signs. - **Palpation:** Feel for abnormal masses, tenderness, or changes in temperature. - **Percussion:** Tap areas to assess underlying structures (e.g., dullness, tympany). - **Auscultation:** Listen to heart, lung, and bowel sounds. **For Abdomen:** - **Inspect, Auscultate, Percuss, Palpate** (order is important to avoid altering bowel sounds). **3. General Impression:** - **Appearance:** Posture, facial expression, hygiene, tone. - **Position:** How the patient is positioned or moving. - **Distress Level:** Is the patient in pain or discomfort? - **Mental Status:** Speech, thoughts, alertness. **4. HEENOT (Head, Eyes, Ears, Nose, Throat):** - **Cranial Nerve Assessment** - **PEARRLA:** Pupils Equal and Reactive to Light and Accommodation. - **EOMI:** Extraocular Movements Intact. - Tongue and mucosa: Indicators of hydration. - Palate: Check for pallor (anemia), jaundice. **5. Chest/Thorax:** - **Cardiac:** Listen for heart sounds (S1, S2, S3, S4), murmurs, and palpate for PMI. - **Chest Wall:** Check for crepitus, tactile fremitus, and chest expansion. - **Lungs:** Auscultate for abnormal sounds like rhonchi, wheezes, crackles, pleural friction rub. **6. Abdomen:** - **4 Quadrants:** Inspect and palpate for abnormalities. - **Percussion Sounds:** - **Flat:** Bone. - **Dull:** Solid organ. - **Tympany:** Hollow organ. **7. Extremities:** - **CSMP:** Check **Color, Sensation, Mobility, Perfusion** (skin color, temperature, capillary refill, pulses). - **6 Ps of Compartment Syndrome:** - Pain, Pressure, Paresthesias, Paralysis, Pulselessness, Pallor. - **Chronic Arterial Insufficiency:** Pale, cold, thin skin, no hair growth, pain with elevation. - **Chronic Venous Insufficiency:** Edema, brownish skin, ulcers. **8. Skin:** - Check for **pallor, jaundice, cyanosis**, and **erythema**. **FOCUSED ASSESSMENTS** **1. Purpose:** - Focus on specific complaints, injuries, or problems. - Prioritize care based on urgency. **2. Common Assessments:** - **Check Pulses and Perfusion.** - **Assess pain.** - **Inspect injury first**, then palpate (to avoid worsening damage). **SHOCK vs. INCREASED ICP** **1. Shock:** - **Signs:** Tachycardia, tachypnea (shallow), hypotension, restlessness, anxiety, pale, cool, clammy skin, decreased urine output. **2. Increased ICP:** - **Signs:** Bradycardia, bradypnea, hypertension with widening pulse pressure, unequal or dilated pupils, anxiety, restlessness, headache. - **Cushing's Triad:** Hypertension, bradycardia, irregular respirations. **FLUID VOLUME BALANCE** **1. Fluid Volume Deficit (FVD):** - Signs: Tenting/poor turgor, dry cracked tongue, tachycardia, tachypnea, hypotension. - **Pediatrics:** Sunken fontanelles, sunken orbits. **2. Fluid Volume Overload (FVO):** - Signs: Edema, crackles, JVD, weight gain, tachycardia, tachypnea, hypertension. - **Pediatrics:** Bulging fontanelles, orbital edema. **PSYCHIATRIC MENTAL HEALTH NURSING** **1. Mental Health and Mental Illness:** - **Mental illness** occurs when a person cannot adapt to stress, causing functional impairment. - **Ego defense mechanisms:** Denial, displacement, rationalization, repression. **2. Therapeutic Communication:** - **SOLER Technique:** Sit, Open posture, Lean forward, Eye contact, Relax. - Use **broad openings, general leads**, and avoid non-therapeutic communication techniques. **3. Suicide Risk:** - Ask about **thoughts, intentions, plans, and means**. - Person with a plan and access to means is at high risk. **4. Bipolar Disorder:** - **Lithium:** Monitor fluid and salt intake, avoid excess caffeine or diuretics. - **Mania:** Priority is safety; manage nutrition and monitor for hyperactivity, poor judgment. **5. Schizophrenia:** - Major disturbances in **thought**: Delusions, hallucinations. - **Clozaril:** Requires lab monitoring for agranulocytosis. **6. Anxiety and Phobias:** - Use **therapeutic communication** and remain calm and reassuring. - **Generalized Anxiety Disorder:** Buspirone may help. - **Phobias:** Trigger-specific; anxiety worsens even by thinking about the phobia. **7. Substance Use:** - **CNS Depressants (e.g., alcohol, opioids):** Bradypnea, bradycardia, AMS. - **Withdrawal:** Tachycardia, tachypnea, anxiety, restlessness. **8. Personality Disorders:** - Cluster **A** (Odd and Eccentric): Paranoid, Schizotypal. - Cluster **B** (Dramatic/Erratic): Antisocial, Borderline, Narcissistic. - Cluster **C** (Anxious/Fearful): Avoidant, Dependent, Obsessive-Compulsive. **MATERNAL NEWBORN NURSING** **1. Antepatal Care:** - Inquire about safety, personal habits, drug use, and immunizations. - Offer genetic testing, screening (e.g., CVS, amniocentesis), and education on TORCH infections and teratogens. - Monitor fetal growth with **ultrasound** and **fundal height** measurements. **2. Intrapartal Care:** - **Labor Stages:** - 1st stage: Cervix effaces and dilates. - 2nd stage: Pushing and delivery. - 3rd stage: Placenta delivery. - **Preterm labor:** Administer **steroids** for fetal lung maturity, and antibiotics for PPROM. **3. Postpartum Care:** - **Hemorrhage:** Uterine atony (first 24 hours) vs. subinvolution (after 24 hours). - **Infection:** Monitor for UTI, mastitis, metritis, and wound infection. **4. Newborn Care:** - **APGAR scoring:** Assess HR, respiration, muscle tone, reflex, color at 1 and 5 minutes. - **Preterm babies** are at higher risk for apnea, bradycardia, and cold stress. - **NAS babies:** Monitor for withdrawal signs (e.g., sneezing, tremors, irritability).