Nursing 202

• - established the subjective data base
• - helps in developing in a problem list
• - helps to establish a diagnosis

• 1. biographical data
• 2. reason for seeking care or chief complaint (CC)
• 3. Present health Status or History of Present Illness (HPI)
• - OLD CART
• 4. Previous Medical History
• a. Childhood illnesses
• b. serious or chronic illnesses
• c. hospitalizations
• d. accidents or injuries
• e. operations
• f. blood transfusions
• g. obstetric history
• h. immunizations
• i. screening tests
• j. health care maintenance
• k. allergies
• l. current medications
• 5. Family History
• 6. Personal and social history
• 7. Reveiw of System (ROS)
• 8. Problem list

• - may focus on illness or wellness needs (e.g. routine physical exam or sore throat)
• - usually one sentence stating problem and its duration
• - for clinic patients, ask why you are here today (you may need to focus on the most important problem)

• - well pt (short statement of general health)
• - ill pt
• -provide a symptom analysis and describe the characterisitics of the symptoms (OLDCART, PQRST)
• - pt's perception
• - what do you think is wrong?
• - What are your concerns?
• - how are you affected by the illness, etc.

• 1. have you ever had these symptoms before
• 2. Did you find out what was wrong?
• 3. What diagnostic tests were done? What were the results?
• 4. How were you treated? Was the treatment effective?

• O Onset
• - date/time
• - sudden/gradual
• - predisposing factors (e.g., exposure to "sick contacts")

• L Location
• - point with one finger
• - Where does the pain radiate?

• D Duration
• - how long does it last?
• - Frequency (How often does it occur?)
• -Constant/intermitten (if intermittent, does it subside completely between episodes?)
• C Character
• A Aggravating Factors/Associated Factors
• R Relieving factors
• T treatment

• Quality
• - e.g. sharp, dull throbbing, vise-like, pressure, etc.
• - e.g. bright red blood on tissue; black, sticky, tar-like stools

• Quantity/Severity (Quantify measurments when possible)
• - e.g. blood (saturated 2 pad per hour)
• - e.g. pain (scale [e.g. 0=no pain and 10=severe pain)
• - ask regarding ability to do activities of daily living (ADL)

• patient description
• - "it feels like an elephant is sitting on my chest"
• - "This is the worst headache I've every had"
• -

• - Aggravating factors (What makes the pain worse?)
• -e.g. bending forward, lifting, walking up stairs, running
• - e.g. eating (any food-fatty food-spicy food)
• -Associated Factors
• -e.g. chest pain (nausea, vomiting, diaphoresis, dyspnea and L arm pain) r/o MI
• - e.g. dysuria (shaking chills and fever)- r/o infection

What makes the symptoms better? (e.g. position)

• What has the pt tried; what was the effect
• - 70-90% of all illnesses are treated first with self-care

• - may affect current health status
• - may affect how the pt responds to illness

List the illnesses and date [or age] of occurrence; additional details should be identified in the review of systems.

"list" the illnesses and date [or age] or occurence; additional details should be identified in the Review of Systems

• Dates, nature of event and resulting disability
• - burns
• - fractures
• - lacerations
• - loss of consciousness
• - penetrating wounds

• List procedure
• indication for procedure (if unclear), date [or age]
• e.g. hysterectomy for uterine fibroids, age 35, complicated by incisional wound infection

• Note the dates.
• - may help in the identification of infectious disease transmission.

• 1. gravida (number of pregnancies)
• 2. Para (carrying a pregnancy to a 500 g weight or 20 wks gestation, regardless of survival.
• 3. Still birth (loss of baby after 20 weeks gestation)
• 4. Abortion (loss of baby before 20 weeks gestation)
• - spontaneous (SAB)= miscarriage
• - Induced (TAB)= therapeutic AB
• 5. Multiple births (twins,etc.) are counted as one para
• - e.g. one pregnancy with twins= G1P1
• 6. sample documentation
• P2G1SAB1
• 7. Deliveries (dates, type of delivery, sex, birthweight, condition of infant, complications)

List all dates (if known) or year of last immunization and adverse reactions

- some immunizations may not be appropriate due the person's age or situation "not applicable"

• 1. tetanus-diptheria (Td) every 10 years
• 2. Tdap-give one time instead if Td if <65 yo and never received
• 3. MMR if susceptible
• 4. Hep B if at risk
• 5. Influenza-annually for age 50 and over
• 6. Zostavax- single dose vaccine for herpes zoster prophylaxis (indicated for adults > 60 yo)

• 1. Hepatitis B (if not previously received)
• 2. Influenza-annual (ethical responsibility; protect your pts)
• 3. MMR if not immune
• 4. Varicella if not immune

Hep B series for all (3 injections)- today, in one month, in six months

• DPt, Tdap, MMR, Polio. Hflu [HIB], varicella
• - hep A is now recommended 12-23 months old

• -series of 2 injections given 6 months apart
• -given for those at risk (e.g. foreign travel, MSM)
• - there is also a combo immunization for Hep A and Hep B

• - college freshman living in dorms or military recruits
• - other high risk individuals (e.g. after splenectomy)

age 65 and other high risk individuals

• Include the dates and results
• 1) blood tests (titers)
• -assess immunity or infection
• - assess for infection (HCV, RPR, HIV)
• - assess for lead poisoning in children
• 2) TB Surveillance (by skin test or blood test)

• - Positive PPD indicates TB infection, but does not differentiate between active TB and inactive TB
• - Inactive TB is called latent TB infection (LTBI)
• - If a PPD is positive, then a chest XRAY is done to see if there is evidence of active TB.

• - list the dates and results of the last exam or indicate "never done"
• 1. eye exam
• 2. hearing test
• 3. dental exam
• 4. mammogram
• 5. chest x-ray
• 6. ECG
• 7. Lipid panel (cholesterol, LDL, HDL, triglycerides)
• 8. Physical exam
• 9. PAP smear
• 10. Other (rectal exam, prostate exam, occult blood test, sigmoidoscopy, colonoscopy)

• (allergens and reactions
• NKA= no known allergies
• NKDA= no known drug allergies
• 1. Medications
• 2. Vaccines
• 3. Foods
• 4. Animals/insects
• 5. Seasonal (pollens, etc.)
• 6. Occupational

Preceiption, OTC, herbal, vitamins, calcium

• 1. Drug name
• 2. dose
• 3. route
• 4. frequency
• 5. rationale and duration of use

• - not all OTC drugs are harmless
• - drug interactions (Coumadin and ASA)
• - Confusion with generic and trade names (pt may not know that Motrin and Ibuprofen are the same, therefore may be taking both)

• -achieving peak bone mass before age 25 can decrease the risk of osteoporosis.
• - 9 out of 10 teenage girls fail to consume adequate calcium

• 4-8 yo: 800 mg/day
• 11-24 yo: 1200-1500 mg/day
• > 25 yo: 1000 mg/day
• postmenopausal & men >65 1500 mg/day

• - identify age of family members, age at which an illness occurred, age of death and cause of death
• - if family member is healthy without illness, document as alive and well
• - record medical problems such as cancer, heart disease, diabetes, asthma, mental illness, high blood pressure, stroke, kidney disease, alzheimer's disease, thyroid disease, obesity, vision/hearing loss, birth defects, blood disorders, genetic diseases, substance abuse, etc

• 1. habits (past and present)
• 2. Housing and living situation
• 3. Occupational history
• 4. Economic status

• 1. Tobacco (cigarettes, cigars, pipe, smokeless; indicate if never
• smoked, current smoker, or date of cessation; document pack year
• cigarette history if applicable.
• - pack year history= ppd x # of years smoked
• 2. Alcohol (type, amount, frequency, duration): don't record as social drinker
• 3. Drug Abuse (type, amount, frequency, duration)
• 4. Sleep (quantity, quality, problems)
• 5. exercise (type, frequency, duration)

• -list household members and relationships, marital history and children
• - describe the pattern and quality of family relationships/interactions and h/o domestic violence. Describe support systems.

• - list you jobs for the past 5 years and the dates for each
• - describe you level of current job satisfaction and job stress (physical and mental)
• - current number of hours per week

• 1. general overall health
• 2. skin, hair and nails
• 3. head and neck
• 4. eyes
• 5. ears
• 6. nose and sinuses
• 7. mouth and throat
• 8. breast
• 9. heart and peripheral vascular
• 10. gastrointestinal
• 11. urinary
• 12. musculoskeletal
• 13. neurologic
• 14. psychological
• 15. endocrine
• 16. hematologic
• 17. female
• 18. male
• 19. sexual health

• 1. list past resolved problems
• 2. List chronic unresolved problems
• 3. List acute problems (current problems of less than 6 weeks duration)
• 4. Risk assessment (list potential or high risk) problems)
• - i.e. increased risk of osteoporosis related to inadequate calcium intake

• 1. most data obtained from the adult, but include the child when appropriate (indicate the source of info (parent?)
• 2. Parental concerns
• 3. Prenatal data (mother's health status), labor and delivery and postnatal problems
• - mother smoking (smaller birth wt)
• - ETOH abuse (fetal alcohol syndrome)
• - difficult delivery (effect on mental development)
• 4. ask parents who the child manifests symptoms (e.g. earache)-behavior?
• 5. Ask regarding parent's coping ability (may affect the child)
• 6. Ask regarding parent's health problems (genetic predisposition, e.g. asthma)
• 7. Current developmental tasks (infants and yound children)
• - gross motor, fine motor, lanuage, social skills
• 8. past health included developmental milestones (growth, toilet training, etc)- were these events on the normal growth and development schedule?
• 9. Review of Systems
• - birthmarks, ability to see the blackboard at school, problems, immunizations

• - use the pediatric data base until age 12-14, then use the adult health history
• - parents may or may not be present during history taking depending on the age of the child

• 1. may understate their symptoms (may think its part of getting old) e.g. may fail to mention fatigue and decreased activity tolerance which may be an early sign of CHF
• 2. Polypharmacy (consider potential drug-drug interactions and numerous side effects)
• 3. Review of Systems
• - dentures, dry skin, decreased sensation in feet, appetite changes, elder abuse, hearing and vision loss, etc.
• 4. functional assessment-measures the pt's self-care ability and ability to live independently