Health History & Interview
The chief complaint is documented in
Quotes
Oral, axillary, tympanic, temporal, or rectal
Routes to take a temperature
Shortness of breath
Dyspnea
Swooshing sounds similar to the sound the blood pressure makes
Bruits
Extends from the upper outer breast quadrant into the axillae.
Tail of Spence
Palpate one at a time
Carotid arteries
Liver, gallbladder, duodenum and head of the pancreas
Organs in the right upper quadrant
Method used to detect melanoma
Asymmetry, border irregularity, color variation, diameter of more than 6mm, and evolution of lesion (ABCDE)
To move away from midline
Abduction
The most sensitive indicator of a change in a patient's neurological status.
Level of consciousness
The ability to work effectively within the cultural context of the patient’s beliefs and values
Cultural competency
Acronym used to illicit the history of present illness
OLDCARTS
Begins with the first moment of the patient encounter and continues with each interaction that follows
General survey
The condition where patients awaken at night with shortness of breath
Paraoxysmal nocturnal dyspnea
Heart sound that correlates with carotid pulse
S1
Abnormal breast enlargement in males; may be hormone related
Gynecomastia
When one pupil reacts to light the other one does too
Consensual light reflex
Fluid collection in the abdomen
Ascites
Test used to assess circulatory status
Capillary refill
Decreased bone density, cartilage degeneration, joint stiffness, and muscle atrophy
Musculoskeletal changes with aging
Hypertension, heart disease, smoking, age, and gender
Risk factors for stroke
Social factors that contributes to health disparities
Social determinants of health
The main purpose of a comprehensive health history
To establish a baseline
A period of silence heard between Kortokoff sounds
Ausculatory gap
Pursed lip breathing, nasal flaring, gasping, grunting, retractions
Signs of respiratory distress
Smoking, high cholesterol, diet high in saturated fat, sedentary lifestyle, hypertension, diabetes, obesity
Cardiovascular risk factors
Hard, poorly delineated nodule that’s fixed to skin or underlying tissue.
Breast cancer
Age-related hearing loss
Presbycusis
Gnawing, burning, cramping, or aching pain that occurs when hollow organs are distended or stretched.
Visceral pain
Sensory perception, moisture, activity level, mobility, nutrition intake, and friction and shear potential
Components of the Braden Scale
The nurse assesses this by having the patient bend at the waist
Scoliosis
A nationally recognized acronym that is used to identify and activate early interventions of a suspected stroke
BEFAST
Clinical Institute Withdrawal Assessment Scale (CIWA)
Active listening, restatement, reflection, facilitation, silence, focusing, clarification, summarizing
Therapeutic communication skills
Deep, rapid respirations which may result from hypoxia, anxiety, exercise, or metabolic acidosis
Hyperventilation
Soft, low-pitched sounds found over fine airways near the site of air exchange
Vesicular breath sounds
Patient reports pain when walking that diminishes with rest is referred to as
Intermittent claudication
Age and ethnicity, ovarian and hormonal function, benign breast disease and family history
Nonmodifiable risk factors
Severe, one side, lasts 30min-2hr., piercing burning behind one eye.
Cluster headache
Method to assess kidney tenderness related to infection
Costovertebral angle percussion
Full-thickness skin and tissue loss with exposed adipose tissue
Stage 3 pressure ulcer
Inflammatory process resulting in cartilage destruction and bone erosion causing swelling, redness, warmth, pain at rest or after immobility, affecting all joints
Rheumatoid Arthritis
Ask patient to close their eyes and identify a familiar object placed in their hand
Stereogenosis
Unexplained bruises, injuries in different stages of healing, frequent ED visits, injuries inconsistent with given explanation
Child (physical) abuse
A patient that provides information that is consistent with existing records and is comprehensive in scope
Reliable historian
Difference between the systolic blood pressure and the diastolic blood pressure which reflects the stroke volume
Pulse pressure
Continuous, low-pitched, snoring sounds resulting from secretions in the airways. May clear with coughing.
Rhonchi
Jugular vein distention, weight gain, dyspnea, edema
Signs of heart failure
Soft tissue radiographic breast examination that starts at age 40 and annually after that
Mammogram
The sensation that you, or the environment around you, is moving or spinning
Vertigo
Increased bowel sounds associated with diarrhea and early intestinal obstruction
Borborygmi
Lesions are typically papular, nodular, or plaques on sun-exposed areas.
Squamous cell carcinoma
Small, pea-sized bony growths that occur on the joint closest to the tip of the finger, also called the distal interphalangeal joint. Associated with osteoartritis
Herberden's nodes
The nurse asks the patient to raise their shoulders against resistance to assess
Cranial Nerve XI (Spinal Accessory)
Pertains to matters of the human soul. State of mind; state of being in the world; journey of self-discovery; a place outside the five senses.
Spirituality