Escolar Documentos
Profissional Documentos
Cultura Documentos
B/S bv Chapter 5
– Patient info
– Look at the pt’s. records: labs, med. HX, diagnostic tests,
medical/nurse’s notes
– What was said in nursing report (SBAR)
– What is the “reported” chief complaint(s)?
– The Patient’s environment
– What is the setting?
– Are medical documents available or on file? Are they assessable?
– What is the setting like?
– Is the patient undergoing medical therapy or under medication at the
time of interview?
Identifying Data (Biographical data)
•Name, age, DOB, Sex
•Race/ cultural factors/ religious practices
•Current care provides
•Language preferences
– / cultural factors
•Current care provides – address parents of children in order to establish trust
– The Chief complaint
What is the single most critical concern to the pt.?
– “What seems to be the problem today?”
– “What can I help you with today?”
– Which system (origin) do you believe to be affected by the Chief Complaint?
– Do you clearly understand the pts. chief complaint or complaints?
Review of Systems
R.O.S. – is an overview of the pt’s general health - usually subjective
– System reviews is usually focused by the chief complaint
- questions are asked about each major body systems in terms of past
or
- present symptoms.
– “Are you having any problems with your bladder?” (nocturia,)
– You want to Act on the chief complaint by
– Directing immediate care as appropriate
– Hx taking may need to be temporarily deferred (ex: respiratory distress)
– Interpret the feedback and Act
– What do I think of these responses the patient is making?
– Do they make sense?
– Am I missing something?
– Do I need clarification?
– Use your knowledge of A&P and pathophysiology to assess and ask
questions
– Why is the pt. experiencing these signs and symptoms?
– Create a picture of what is happened to this pt. today
Sensitive Topics
Topics such as: abuse, rape, personal issues
Is it the right location or place to talk privately with the patient
– Does anyone present make the pt. feel uncomfortable
Can you gain their trust?
Choosing appropriate words to show sensitivity
Understand the pts. feelings related to the sensitive nature
Be very professional
The silent patient
– Short periods of silence may be normal
– Allow them time to collect their thoughts
– Provide reassurance and encouragement
– Consider:
– That the patient may be frightened; or perhaps you frightened them
– Are you dominating the discussion?
– Have you offended the pt.?
– Is there is a physical or mental disorder? Or a lack of understanding?
The overly talkative pt.
– Allow the pt. to speak
– If necessary, politely interrupt and focus the discussion
– Focus on more critical issues
– Ask specific, closed-ended questions
– Summarize the pt’s. story and move on
– Don’t display your impatience
The anxious frightened patient
– Look for signs of anxiety or fear
– Try to alleviate concerns and develop trust
– Do not give false reassurance
– “Everything is going to be fine”
– Identify the source of anxiety/fear
– Try to understand the pts. Feelings – “I don’t know why you are so
anxious, would you like to talk about it?”
The Angry Hostile Patient.
– These are common feelings associated with stress or fear
– Understand the source of these feelings
– Respond in a professional & caring manner.
– Personal safety is a primary concern!!!
– Distance
– Assistance
– Firm but let your verbal and body language show that you care
The intoxicated Patient
– Irrational
– Altered sense of right and wrong
– May become violent
– If the pt. is shouting,
– Increased potential for violent behavior
– Listen
– Don’t respond back with shouting
The Depressed or Suicidal pt.
– Know the warning signs
– Explore the specific feelings of the pt.
– Be direct and specific
– Question regarding thoughts of suicide or personal harm
– Talk openly and specifically about suicide plans
The Patient with a Confusing
History or Behavior
– The entire story does not add up
– Assess mental status
– Consider possible dementia or delirium
– Identify cause if possible
– Consider specific causes based upon behavior
The Patient with a Language Barrier
– Extremely difficult to assess
– Enlist friends or family to act as interpreter
– Use pre-established questions in the pts. Language
– Language lines
Summary
– Obtaining the history guides the physical exam
– History taking is accomplished along with the physical exam and
therapies
Role of Nurse
• Nurse obtains health history
– Biographical data – age, wt./ht., culture, religious practices,
– Past health history
– Family history – genogram (family tree diagram of identifying family
illnesses)
– Review of systems (subjective)
– Patient profile
Genogram
• Used to record history of family members
• Includes: age, cause of death or if living; their current health status
• Subjective data - what the patient tells you
• Objective data- perceptible to other persons; able to be analyzed,
counted or measured.
INSPECTION
• Posture - the posture that a pt. assumes may be indicative of illness.
(abnormal gait, bent over, ) Posture and stature are usually addressed on
admission.
• Pts. With breathing difficulties may prefer to sit or they may lie perfectly
still if having abdomen pain.
• The pt. may prefer to pace if anxious or having renal colic
• Patients with meningitis may c/o head and neck pain upon flexing the
neck
• Body movements - Tremors may be due to Parkinson’s or other causes.
Asymmetrical movements may occur as a result of CNS disorders or CVA.
• There may be drooping of one side of the face,
• weakness or paralysis of one extremity or foot dragging.
• Spasticity may be present in Multiple Sclerosis; or advance Parkinson’s
with dystonia
Nutrition- obesity may be generalized or specifically localized in the trunk in
those with endocrine disorders (Cushing’s syndrome), or those taking
corticosteroids for a extended period of time.
• Or perhaps they are having G.I dysfunctions or illnesse (diarrhea, vomiting,
megacolon, bowel obstruction, esophageal atresia)
• Weight loss may be due to inadequate calorie intake over a long period
of time or in diseases that produce muscle wasting as in disorders that affect
protein synthesis.
Speech patterns- may be slurred due to CNS disorders or damage to the
cranial nerves.
• Recurrent damage to the laryngeal nerve will produce hoarseness.
• Speech may be slurred, halting or interrupted in flow (as in Multiple
Sclerosis).
Vital signs- must be recorded as part of any physical examination. Values that
deviate from norms are reported to the physician. The 5th v.s. (pain) is also
evaluated and documented. Temperatures may vary slightly from one
individual to another. Some are normal at 98 while others are normal at 99.
temperatures vary slightly with the time of day (lowest in the morning, rising
1-2 degrees during the day hen dropping back down at night).
• Need to know that 37°C is the same as 98.6°F
Physical Examination
Infants & Children
• Consider the pt’s continuum of growth & development, as well as the age
range
• Think about the different rates of growth of various systems of the body.
• What are the normal and abnormal patterns of growth and development
(i.e. a Babinski response is abnormal beyond 2yrs.).
Pediatric Assessment
• The examination of the adolescent patient is essentially the same as the
adult.
• Develop your own method for examination that varies with the age,
illness, etc.
• You may write the steps on index cards until you memorized the method.
Repetition will help you master the assessment without omissions. Remember,
pts. Do not usually need a complete assessment every day.
• DDST measurements are usually done at well child visit (or more
frequently) during the first two years.
• More frequent measurements are taken when a patient is not keeping up
with the growth parameters or begins to fall behind the expected patterns of
growth.
• Consider four developmental levels:
– Infancy (the first year)
– Early childhood (1-4 yrs.)
– Late childhood (5-12 yrs.)
– Adolescence (13-20 yrs.)
• Resp. rate- has a greater range and is more responsive to exercise and
emotion.
– Newborn- 30-80
– Early childhood- 20-40
– Late childhood- 15-25
– Reaching adult levels by age 15
Observe respirations for longer than the usual 30-60 secs.
In infancy and early childhood, diaphragmatic breathing is predominant
In older children observe for chest movement by placing hand on chest to feel the
movement.
Nutritional Assessment
• What are they eating? Regular diet vs. special diet?
What type of infant formula? Are they nursing? How well are they
tolerating food?
How many meals/ snacks do they eat a day?
• Allergies – what kind of reaction do they present?
• Drink alcoholic beverages? How much sweet drinks do children drink?
• Drinking plenty of fluids? How much?
• Does it correlate with urine output?
• Diarrhea or constipation? How many bowel movements do they normally
have a day?
• Have they ever been consulted by a nutritionist? For what?
• Ht. and Wt? BMI
• Teenagers go on fad diets and junk food binges. Eating disorders?
• Anorexia or bulimia
• Pica (ice, dirt cravings)
• Who cooks at home? Where do they buy groceries? Do they require in-
home assistance and some one to cook?
• What condition are their teeth in? Do children have their teeth developed
aged appropriately? Do dentures fit well?
• Condition of the mouth? Sores, S/P surgery, etc. that hinders eating.
• Consult the dietician.
• Physical conditions and illnesses
• Burns
• Wounds
• Renal disease, liver disease, diabetes, cardiac disease
• GI diseases - N/V, Celiac disease, esophageal atresia, megacolon,
parasites
GI disturbances & obstructions
• Metabolic disorders
• Deformities: cleft palate