Nurs 550- Health Assessment
focus exam consists of? - ANS-chief complaint (CC), history of present illness (HPI),
allergies, medicines, past history, pertinent family history, pertinent personal/social
history, pertinent review of systems, physical exam of pertinent system, focused
assessment, focused plan
comprehensive exam consists of? - ANS-chief complaint (CC), HPI, allergies,
medicines, past history, family history, personal/social history, full review of systems,
physical exam (all systems), assessment, plan
OLDCARTS for HPI - ANS-onset, location, duration, character, alleviating/aggravating
factors, radiation, time of occurrence, severity
who to ask about on family medical history - ANS-parents, grandparents, children, and
siblings
- want alive/dead, age, problems and cause of death and age of death
Personal and Social History - ANS-- health promotion and maintenance: screenings,
immunizations, sleep, exercise, diet, nutrition
- tobacco use, alcohol use, illict drug use
- sexual history: 5 ps (partners, practice, protection, past history of sti, pregnancy plans)
- home/living situation
- accessibility to healthcare- afford, transportation
nociceptive (somatic) pain - ANS-damage to tissue or viscera but sensory nerves
- dull, pressing, pulling, throbbing, boring, spasmodic, colicky
neuropathic pain - ANS-direct trauma to the peripheral or central nervous system
- shock like, stabbing, burning, pins and needles
idopathic pain - ANS-pain with an unknown cause
psychogenic pain - ANS-related to factors that influences the patients report of pain-
psychiatric conditions, coping, cultural norms, social support
chronic pain - ANS-over 3-6 months and lasting 1 year after course of illness or
reoccuring
, BMI categories - ANS-Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater
patient presents with a 6 day history of rapid weight gain, what is the most likely
explaination? - ANS-accumulation of body fluids
patient comes in for routine visit, BP is elevated, what do you do next? - ANS-repeat bp
and check in bilateral arms
a 50 yr old patient reports smoking 1 pack of cigarettes per day since age 20. how
would you document this information? - ANS-30 pack years
a superficial burn pain is considered what type of pain? - ANS-nociceptive or somatic
OPQRST - ANS-onset, precipitating and palliating factors, quality, region or radiation,
severity, timing or temporal characteristics
Parital pain - ANS-inflammatory
- from the hollow or solid organs that affect the parietal peritoneum
- more severe and easily localized
- deep intense pain worsening with movement or coughing
- ex: appendicitis
referred pain - ANS-originates at different sites but shares innervation from the same
spinal level
- ex: gallbladder pain- pain in shoulder
Murphy's sign - ANS-Pain with palpation of gall bladder (seen with cholecystitis)
- pain on palpitation of RUQ just under ribs- hook method
Grey tuners sign - ANS-associated with pancreatitis
- discoloration of left flank
Cullen's sign - ANS-association with pancreatitis
- discoloration surrounding umbilicus
Obturator sign - ANS-lay on right side then rotate hip inward with knee bent
focus exam consists of? - ANS-chief complaint (CC), history of present illness (HPI),
allergies, medicines, past history, pertinent family history, pertinent personal/social
history, pertinent review of systems, physical exam of pertinent system, focused
assessment, focused plan
comprehensive exam consists of? - ANS-chief complaint (CC), HPI, allergies,
medicines, past history, family history, personal/social history, full review of systems,
physical exam (all systems), assessment, plan
OLDCARTS for HPI - ANS-onset, location, duration, character, alleviating/aggravating
factors, radiation, time of occurrence, severity
who to ask about on family medical history - ANS-parents, grandparents, children, and
siblings
- want alive/dead, age, problems and cause of death and age of death
Personal and Social History - ANS-- health promotion and maintenance: screenings,
immunizations, sleep, exercise, diet, nutrition
- tobacco use, alcohol use, illict drug use
- sexual history: 5 ps (partners, practice, protection, past history of sti, pregnancy plans)
- home/living situation
- accessibility to healthcare- afford, transportation
nociceptive (somatic) pain - ANS-damage to tissue or viscera but sensory nerves
- dull, pressing, pulling, throbbing, boring, spasmodic, colicky
neuropathic pain - ANS-direct trauma to the peripheral or central nervous system
- shock like, stabbing, burning, pins and needles
idopathic pain - ANS-pain with an unknown cause
psychogenic pain - ANS-related to factors that influences the patients report of pain-
psychiatric conditions, coping, cultural norms, social support
chronic pain - ANS-over 3-6 months and lasting 1 year after course of illness or
reoccuring
, BMI categories - ANS-Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater
patient presents with a 6 day history of rapid weight gain, what is the most likely
explaination? - ANS-accumulation of body fluids
patient comes in for routine visit, BP is elevated, what do you do next? - ANS-repeat bp
and check in bilateral arms
a 50 yr old patient reports smoking 1 pack of cigarettes per day since age 20. how
would you document this information? - ANS-30 pack years
a superficial burn pain is considered what type of pain? - ANS-nociceptive or somatic
OPQRST - ANS-onset, precipitating and palliating factors, quality, region or radiation,
severity, timing or temporal characteristics
Parital pain - ANS-inflammatory
- from the hollow or solid organs that affect the parietal peritoneum
- more severe and easily localized
- deep intense pain worsening with movement or coughing
- ex: appendicitis
referred pain - ANS-originates at different sites but shares innervation from the same
spinal level
- ex: gallbladder pain- pain in shoulder
Murphy's sign - ANS-Pain with palpation of gall bladder (seen with cholecystitis)
- pain on palpitation of RUQ just under ribs- hook method
Grey tuners sign - ANS-associated with pancreatitis
- discoloration of left flank
Cullen's sign - ANS-association with pancreatitis
- discoloration surrounding umbilicus
Obturator sign - ANS-lay on right side then rotate hip inward with knee bent
