Nursing comprehensive

SUBJECTIVE DATA

DOCUMENTATION

2. 5 POINTS

EACH

#1

Date of Visit (2

ID info -Name (fictitious), DOB, age in years, gender, occupation

Informant/Reliability

Chief Concern (CC) – reason for visit written as: Patient states. “….” Always in the patient’s own words.

#2

Past Medical Hx

childhood illness / infectious dz’s, immunizations (age appropriate),

adult illnesses (chronic/recurrent), mental illness, operations (for what?),

injuries (year/age), hospitalizations,

reproductive hx (chicken pox – shingles/pregnancy, rheumatic fever – valves, mumps – sterility),

gyne (LMP, onset menses), family planning, obstetric hx, STDs,

male – STDs, GU illness

#3

Family Hx – at least 3 generations, siblings, and include those with significant history such as a maternal aunt with breast and ovarian cancer, age at diagnosis

chronic illness, cancer, substance abuse, mental illness onset

siblings, parents, grandparents- include age at death

#4

Medications

Generic names, who prescribed, dosage, frequency, route of intake (oral, sublingual, other)

OTCs / Herbals / Home remedies

Allergies

To meds / food /environment

Type of reaction

#5

Recreational Drugs

Name, amount, frequency of use

Alcohol

What kind, How much, How often

CAGE 1. Need to CUT down

2. ANNOYED by criticism of

3. Felt GUILTY about use

4. Need for EYE opener

Tobacco

Smoking/ chewing/cigars/vaping

How many per day, Number of years

Caffeine –

Coffee, tea, sodas, caffeine pills, How much per day

#6

Nutrition

Describe a typical day of intake

Fat, Ca+, fiber, fruits, vegetables

snacks / sweets

Water intake

Exercise

What type, How often, For how long? “What do you do for fun?”

Sleep

Hours uninterrupted, Hard to fall asleep, fall back to sleep if awakened

#7

Eye / dental exams

how often

Sunscreen use

Protective gear for sports

Self-breast / testicular exams

#8

Environment / Occupational

Chemicals, dusts, paint, fumes & fibers @ work / home

Travel & hobbies

Needle stick exposure

#9

Screening

Vaccines

Colorectal

Mammogram

Pap smear

Dental

#10

Social

Safe environment

“Tell me about a typical day?”

Employment

Cultural – religion / spiritual

Family – who lives with, where nuclear, extended, who keep in close contact with

Support received from whom, Health surrogate/decision maker

Health care proxy, living will

Domestic violence: how getting along with

Stressors / coping (rate 1-10/10)

Developmental stage

Functional assessment (ADL’s)

Finances

#11

Sexual History

In a relationship, with whom Do you feel safe Any chance you may have been exposed to a STI

Would you like testing

Have you ever had sex with same gender Use protection, what kind?

Ever been sexually abused/raped

Adult: sexual problems,

Males: interest, function, satisfaction, fertility

Females: menarche, menstrual regularity, duration, GPFPAL, Adolescent: confidential except reportable incidents

#12

Constitutional – pain, fatigue, weight gain/loss, appetite, fever, n/v, night sweats

#13

Integumentary (Derm)

Rashes, skin discoloration, pruritus (itchy)

#14

HEENT headaches, dizziness, masses, seizures

Eyes: visual changes, visual field defects

Ears: tinnitus, vertigo, hearing loss

Nose: epistaxis (nosebleeds), d/c, sinus disease

#15

Respiratory cough, SOB, sputum, hemoptysis

#16

Cardiovascular chest pain, orthopnea (diff breathing lying down), paroxysmal nocturnal dyspnea, dyspnea on exertion, claudication, edema, palpitations – rate the edema using scale

#17

Gastrointestinal dysphagia, abd pain, n&v, change in bowel habits, diarrhea, constipation, melena, hematemesis

#18

Genitourinary dysuria, frequency, hesitancy, hematuria, d/c

#19

Gynecological (OBGYN) GTPALM

D, LMP, frequency, duration, menarche, menopause, dysmenorrheal, vag bleeding, breast masses

#20

Neurological (NEURO) LOC, seizures, head injury, change in cognition, memory, numbness, tingling, balance, coordination

Psychological depression, mental illness, memory changes

#21

Musculoskeletal (MSK) joint pain, swelling, arthritis, myalgias (muscle pain or tenderness)

#22

Endocrine (ENDO) polyuria, polydipsia, skin or hair changes, heat/cold intolerance, goiter

#23

Hematological/Immune anemia, bleeding disorders, HIV, bruising, blood transfusions, allergies, unexplained swollen glands

OBJECTIVE DATA

STUDENT DOCUMENTATION

POINTS

#24

Communication – introduce self

· explains procedure

· respects privacy

· attends to physical comfort

#25

General survey – brief mental status exam (memory, judgment & orientation by self-report; cognition by testing)

· alertness and orientation

· general appearance / signs of distress

· weight / height

· TPR & BP

· Inspect skin during entire exam

#26

Head & face – inspect size, shape , scalp, facial symmetry

· palpate skull, scalp

· inspect skin on face, neck

#27

Eyes - √ contacts/glasses

· visual acuity (Snellen eye chart)

· inspect lacrimal ducts, lids, palpebral tissue, conjunctiva, sclera, cornea

· palpate lacrimal gland / ducts

· perform Hirschberg (corneal light reflex) or cover/uncover

· √ cornea w. tangential light

· pupils (direct/consensual light response) PERRLA

· test EOMs (CN III, IV, & VI); √ nystagmus

· √ accommodation

· √ red reflex bilaterally

· perform fundoscopic exam

#28

Ears – inspect external ear

· palpate external ear / tragus

· screen hearing (CN VIII)

- perform otoscopic exam

#29

Nose / Sinuses – ask about smell (CN I)

· check nostril patency

· inspect septum, turbinates, mucosa, & discharge w. nasal speculum

#30

Mouth, Throat, Cranial Nerves

· ask about taste (CN VII, CN IX)

· inspect lips, buccal, mucosa, gums, teeth

· inspect hard & soft palates, tonsils, pharynx

· inspect tongue & tongue protrusion (CN XII)

· inspect uvula movement w/ phonation (CN IX, X, XII)

· palpate lips, mouth, tongue

· test strength of tongue (CN XII)

· √ overbite; strength of temporal / masseter muscles & TMJ

· √ facial muscles (frown, smile, raise eyebrows, close eyes, puff cheeks)

· test shoulder shrug (CN XI)

· √ spinal accessory muscles (against examiners hands)

#31

Neck – inspect for symmetry, masses, scars

· test for ROM

· palpate cervical & supraclavicular nodes

· inspect & palpate trachea

· inspect & palpate thyroid

· move behind patient & palpate thyroid when swallowing

#32

Hands, Arms, Shoulders

– radial pulse bilaterally for rate & regularity

· inspect nails & skin

· palpate DIP, PIP, MCP joints

· √ grip

· palpate wrists / upper extremities

· palpate olecranon process through ROM of forearm

· palpate epitrochlear nodes

· √ active and passive ROM shoulder – rate ROM use scale

· √ strength of deltoid

- √ strength of biceps / triceps

#33

Back & Lungs – inspect skin

· inspect shape of spine, respiratory movement of thoracic cage

· palpate thoracic expansion

· palpate spine, ribs & muscles for tenderness

· √ for CVA tenderness

· percuss posterior lung fields

· auscultate posterior lung fields

· auscultate anterior lung fields

#34

Heart – auscultate heart w. diaphragm

· inspect precordium tangentially

- palpate all areas of precordium

· determine PMI (5th ICS @ MCL)

· palpate & auscultate carotid arteries (bell) w/ patient holding breath

· auscultate precordium w. diaphragm & bell

- auscultate ventricle w. bell in LLD position

#35

Abdomen –pt. with knees flexed & arms @side

· inspect for shape, symmetry, scars, & lesions

· auscultate bowel sounds w/ diaphragm

· auscultate w/ bell aorta, renal, iliac, femoral arteries for bruits

· percuss entire abdomen

· percuss liver span in MCL

· percuss for splenic enlargement at 10th ICS, Left AAL

· lightly palpate entire abdomen

· palpate deeply (aorta, liver, spleen, kidney, masses)

· palpate for hernias, inguinal & femoral nodes

#36

Lower Extremities & Neuro

· inspect symmetry & skin

· palpate DP/ PT pulses – rate pulses using scale , √ cap refill

· √ passive and active ROM hip / knee/ ankle

· √ sensation – upper & lower extremities (distal only)

· √ DTRs: biceps, triceps, patellar, ankle & plantar joints – rate with scale

· √ vibratory sensation (distal only)

· √ proprioception (at least one exercise)

· √ active and passive ROM & strength of lower extremities

· √ Romberg (guard against fall)

· √ gait, then heel to toe, then toe & heel walk

· observe spine; √ for scoliosis, lordosis, kyphosis

· √ ROM of spine

*Genitourinary & Breast

#37

Male Genitourinary Exam lesions, circumcision, phimosis, testicle size, descended, any tenderness or masses

#38

Male Breast Exam

Enlargement, nipple discharge, masses, any tenderness

#39

Female Pelvic Exam

External lesions, discharge, any genital mutilation, speculum exam and note any cervical lesions, discharge, bimanual exam and check for uterine size, tenderness, deep felt abdominal masses

#40

Female Clinical Breast Exam

Symmetry, lesions, dimpling, discharge, augmentation