HA-PRELIM

• Health History


  The first major interaction with the patient which sets the foundation and tone for the nurse-patient relationship, allowing you to see your patient through their eyes. It gives a holistic, qualitative picture of the patient and directs physical assessment.
• Purposes of Health History

  • Provides a subjective database
  • Identify the patient's strengths
  • Identify the patient's health problems, both actual and potential problems
  • Identify supports
  • Identify teaching needs
  • Identify discharge needs
  • Identify referral needs
• Types of Health History

  • Complete Health History
  • Focused Health History
• Components of Complete Health History

  • Biographical data
  • Past Health History
  • Family History
  • Review of Systems
  • Past and Current Problems
  • Psychosocial Profile
• Focused Health History


  More detailed assessment that relates to a current medical condition or a patient complaint and is more commonly performed in emergency situations or after a patient is diagnosed with a particular condition
• Key Points in Obtaining Health History

  • Listen to both verbal and nonverbal communication
  • Don't rush, allow enough time to obtain data
  • Ensure confidentiality
  • Provide a private, quiet, and comfortable environment
  • Avoid interruptions
  • Tell the patient how long the interview will take and why questions are asked
  • Do not be concerned about completing forms the patient has neglected
  • Start with what the patient perceives as a problem
  • Use open-ended questions about the patient's perspective
  • Attend any acute problems such as pain, before obtaining a detailed health history
  • Remember that quality is much more important than the quantity of information obtained
• Reasons for Seeking Healthcare

  • Primary
  • Secondary
  • Tertiary
• PQRST Pain Rate Scale

  • Precipitating/Palliative Factors
  • Quality/Quantity
  • Region/Radiation/Related Symptoms
  • Severity
  • Timing
• Review of Systems


  • General Health Survey
  • Integumentary
  • Head and Neck
  • Eyes
  • Ears
  • Nose and Sinuses
  • Mouth and Throat
  • Respiratory
  • Cardiovascular
  • Breasts
  • Gastrointestinal
  • Genitourinary
  • Male Reproductive
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic
• Physical Assessment


  A process where senses are used to collect objective data. Uses skills such as cognitive, interpersonal, ethical/legal, psychomotor, and affective. The nurse needs to know the normal findings to distinguish abnormal ones.
• Types of Physical Assessment

  • Complete Physical Assessment
  • Focused Physical Assessment
• Equipment for Vital Signs Measurement

  • Gloves
  • Sphygmomanometer
  • Stethoscope
  • Thermometer
  • Watch
  • Wong-Baker FACES Pain Rating Scale
• Other Equipment


  • Anthropometric Measurements
  • Skin, Nail, and Hair Examinations
  • Head and Neck Examination
  • Eye Examination
  • Ear Examination
  • Mouth, Throat, Nose, and Sinus Examination
  • Thoracic and Lung Examination
  • Heart and Neck Vessels Examination
  • Abdominal Examination
  • Female Genitalia Examination
  • Anus, Rectum, and Prostate Examination
  • Peripheral and Vascular Examination
  • Musculoskeletal Examination
  • Neurological Examination
• Physical Assessment Techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Physical Assessment Approach


  • Be systemic
  • Introduction
  • Examination takes time
  • Assemble equipment beforehand and make sure it is fully functional
  • Drape patients and expose only the necessary areas
  • Be conscious of non-verbal behavior
  • Maintain a professional demeanor and caring attitude while being sensitive to the patient's needs
  • Exam room should be quiet, private, and no interruption
  • Room should be warm and well lit
  • Ask the patient to void before examination
  • Wash hands and wear gloves (if needed)
  • Use the 4 assessment techniques
  • More private areas are assessed last
• Physical Examination Positions


  • Supine (Dorsal Recumbent)
  • Prone
  • Sims (Left Lateral) + Right Lateral
  • Knee-Chest
  • Standing
• Components of Physical Assessment

  • General Survey
• Signs and Symptoms of Pregnant Women

  • Presumptive Signs
  • Probable Signs
  • Confirmatory/Positive Signs
• Signs and Symptoms of Pregnant Women

  • Presumptive Signs
  • Probable Signs
  • Confirmatory/Positive Signs
• Presumptive Signs


  • Amenorrhea - Lack of menstrual period
  • Nausea and Vomiting
  • Frequent Urination
  • Breast Tenderness
  • Quickening - First fetal movement in the uterus. Feels like fluttering, bubbles, or tiny pulses
  • Skin changes
  • Fatigue
• Probable Signs


  • Abdominal Enlargement
  • Hegar's Sign - Compressibility and softening of the cervical isthmus (lower segment of uterus)
  • Goodell's Sign - Softening of the cervix
  • Chadwick's Sign - Characterized by a bluish discoloration of the cervix, vagina, and vulva
  • Braxton-Hicks Contractions - Sporadic contractions and relaxation of the uterine muscle. Referred to as prodromal or "false labor" pains
  • Pregnancy Test (Positive)
  • Ballottement - The fetus can be palpated by pressing a finger into the vagina and tapping gently

  
• Confirmatory/Positive Signs


  • Fetal heartbeat
  • Visualization of fetus
• Fundal Height Measurement


  Distance in centimeters from the pubic bone to the top of the uterus
• McDonald's Rule


  Used to determine if a baby is small for its gestational age
• Blood Pressure


  • Systolic = 90/139
  • Diastolic = 60/89
• Blood pressure in pregnancy


  Decreases around the second trimester, but returns to normal in 32-34 weeks
• Pulse


  • 60/90 beats/min
  • May increase 10/15 beats per minute
• Temperature


  • 97-98.6 ℉ or 36-7 ℃
  • 100 ℉ ↑
• Height and Weight Gain

  • First Trimester = 2.4 lbs ↑
  • Second and Third Trimester = 11-12 lbs ↑
  • Total Weight Gain = 12-25 lbs
  • 5 lbs/week ↑
  • 2 lbs/ month ↑
• Behavior


  • First Trimester - Tired, Ambivalent
  • Second Trimester - Introspective, Energetic
  • Third Trimester - Restless, Preparing, Labile Moods
  • Denial, Withdrawal, Depression, Psychosis
• Skin, Hair, and Nails

  • Linea Nigra
  • Striae Gravidarum
  • Chloasma (Mask of pregnancy)
  • Palmar Erythema
• Anemia


  If hemoglobin drops 10 g/dl, the patient is anemic
• Ears


  • Decreased hearing
  • Fullness in ears
  • Ear aches
• Mouth and Throat


  • Gum hypertrophy
  • Pregnancy epulis (gum swelling)
• Thorax and Lungs


  • Increased anteroposterior diameter
  • Slight hyperventilation
  • Shortness of breath
  • Clear lung sounds
• Breasts


  • Larger and nodular
  • Secreting colostrum
  • Hyperpigmentation of areola
  • Nipple inversion
  • Redness, pain, and warmth
  • Bloody discharge of nipple
• Peripheral and Vascular


  • Dependent Edema (third trimester)
  • Varicose
  • Calf pain
  • Homan's Sign - Calf pain at dorsiflexion of the foot
  • Diminished pulses
• Genitalia


  • Enlarged labia and clitoris
  • No discomfort
  • Scars from an episiotomy
  • Cervix should look pink and smooth
  • Fish Mouth - Metallic taste in mouth
  • Hegar's Sign
  • Chadwick's Sign
• Musculoskeletal


  • Forward lifting of the pelvis
  • Change in posture and walking
• Abdomen


  • Palpable uterus (10-12 weeks) - Fetus size should be an orange (10 weeks), Grapefruit (12 weeks)
  • Fetal movement (18-20 weeks)
  • Uterus is firm and contracts
  • Contractions should last 40-60 seconds with 5-6 min intervals
  • Fetal heart = 120-160 bpm
  • Uterine size should equal weeks of gestation