Physical Examination

Physical Examination: Approach and Overview

A.Purposes of the physical health examination I.to obtain baseline data about the patient's functional abilities II.to supplement, confirm, or refute data obtained in the nursing health history III.to obtain data that will help the nurse establish nursing diagnoses and plan the patient's care IV.to evaluate the physiologic outcomes of health care and thus the progress of a patient's health problem V.to screen for the presence of cancer B.Components of the physical health examination I.verbal explanations II.physical preparation B.Verbal explanations I.when the exam will take place II.where the exam will take place III.why the exam is necessary IV.who will conduct the exam V.what will happen during the exam VI.that privacy will be provided at all times during the exam VII.that confidentiality about the exam and results will not be breached B.Physical preparation I.emptying the bowel and bladder II.changing into a gown III.draping to prevent unnecessary exposure, provide privacy, and to keep the patient warm IV.assuming a special position a.dorsal recumbent

i.the patient lies on the back with the legs separated, knees bent, and soles of the feet flat on the bed ii.areas examined a.head and neck, anterior thorax and lungs, breasts, heart, extremities, peripheral pulses b.supine i.the patient lies flat on the back with the legs together but extended and slightly bent at the knees ii.areas examined a.head and neck, anterior thorax and lungs, breasts, heart, abdomen, extremities, peripheral pulses b.sitting i.the patient sits upright in a chair or on the side of an examining table or bed or, if physically unable to maintain an upright position, may be supine in bed with the head elevated ii.areas examined

a.head and neck, posterior and anterior thorax, lungs, breasts, heart, upper extremities, and to take vital signs b.lithotomy i.the patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the feet supported in stirrups ii.areas examined a.rectum and female genitalia b.genupectoral (knee-chest) i.the patient kneels, using the knees and chest to bear weight of the body ii.areas examined a.rectum b.Sims'

i.the patient lies on either the right or left side with the lower arm behind the body, the upper arm bent at the shoulder and elbow, both knees bent, and the uppermost leg more acutely bent than the lowermost leg ii.areas examined

a.rectum, vagina b.prone i.the patient lies on the abdomen, flat on the bed, with the head turned to the side ii.areas examined a.posterior thorax, hip joint movement B.Inspection I.an assessment technique in which the examiner deliberately, purposefully, and systematically observes an area of the body II.uses of inspection a.to determine the presence of normal and/or abnormal size, shape, color, symmetry, and/or position of an area of the body II.when inspecting, need to take into consideration: a.normal variations as a result of developmental age b.normal variations as a result of race B.Palpation I.an assessment technique in which the examiner feels an area of the body with the palmar surface of the pads of the fingers and/or the dorsum of the hand II.uses of palpation a.to determine texture (e.g., hair) b.to determine temperature (e.g., of a skin area) c.to determine vibration (e.g., of a joint) d.to determine the position, size, consistency, and mobility of organs or masses e.to determine distention (e.g., the urinary bladder)

f.to determine the presence and rate of peripheral pulses g.to determine tenderness or pain II.types of palpation a.light (superficial) i.the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1/2" (1 centimeter) while moving the hand in a circle b.bimanual deep palpation

i.first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated ii.second, the examiner places the fingerpads of the nondominant hand on the dorsal surface of the distal interphalangeal joints of the middle three fingers of the dominant hand iii.third, the examiner presses down gently 1" (2 centimeters) with the top hand while the lower hand remains relaxed to perceive the tactile sensations b.single manual deep palpation

i.first, the examiner extends the fingers of the dominant hand parallel to the skin surface to be palpated and presses down gently 1" (2 centimeters) while moving the hand in a circle ii.second, the examiner uses the nondominant hand to support a mass or organ from below II.helping a patient relax to facilitate palpation

a.gowning and/or draping to prevent unnecessary exposure, provide privacy, and keep the patient warm b.positioning the patient comfortably c.ensuring that your hands are warm before beginning d.commencing palpation with areas that are not painful first II.characteristics of masses determined by palpation a.shape (round, ovoid, tubular, irregular) b.size (measured in centimeters) c.consistency (firm, edematous, spongy, cytic) d.surface (smooth, nodular, granular)

e.mobiity (fixed or immobile, mobile) f.tenderness (amount of tenderness to touch) g.pulsatile (pulsations can or cannot be felt in the mass) B.Percussion I.an assessment technique in which the examiner strikes an area of the body with the fingers II.uses of percussion a.to determine the borders of an underlying structure of the body by establishing the difference between tissue that is fluid-filled, air-filled, or solid b.to determine the absence or presence of normal and/or adventitious sounds elicited while percussing over an area of the body II.types of percussion a.direct percussion i.the examiner strikes an area of the body to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger b.indirect percussion i.first, the examiner places the middle finger of the nondominant hand, referred to as the pleximeter, firmly on the patient's skin over the area of the body to be percussed ii.second, the examiner strikes the distal interphalangeal joint of the pleximeter with the tip of the flexed middle finger of the dominant hand, referred to as the plexor II.sounds elicited by percussion

a.flatness i.a soft, high-pitched, "dead stop of sound, absolute dullness" sound of short duration ii.where found a.typically over muscle, bone b.dullness

i.a medium, medium-pitched, "thudlike" sound of moderate duration ii.where found a.typically over the liver, heart b.resonance i.a loud, low-pitched, "hollow" sound of long duration ii.where found a.typically over the lung b.hyperresonance i.a very loud, very low-pitched, "booming" sound of very long duration ii.where found a.typically over the emphysematous lung b.tympany i.a loud, high-pitched, "musical" sound of moderate duration ii.where found a.typically over the stomach filled with gas B.Auscultation I.an assessment technique in which an examiner listens to sounds produced from within an area of the body II.uses of auscultation a.to determine the absence or presence of normal and/or adventitious sounds produced from within an area of the body II.types of auscultation a.direct auscultation

i.the examiner listens to sounds produced within an area of the body by use of the unaided ear b.indirect auscultation i.the examiner listens to sounds produced from within an area of the body by use of a stethoscope ii.parts of a stethoscope a.earpieces i.should fit snuggly into your ear canal ii.should slope forward toward your nose b.tubing i.should have the appropriate internal diameter a.about 4 millimeters (1/8 inch) thick ii.should be the appropriate length a.about 30 - 36 centimeters (12 - 14 inches) long b.amplifying devices i.diaphragm a.end of the amplifying device that is large, with a flat edge b.best for auscultating high-pitched sounds i.e.g., breath, bowel, and normal heart sounds b.when used, should be held firmly against the patient's skin i.e.g., firm enough to leave a slight ring afterwards ii.bell

a.end of the amplifying device that is small, with a hollow, cuplike shape b.best for auscultating soft, low-pitched sounds i.e.g., extra heart sounds and murmurs b.when used, should be held lightly against the patient's skin i.e.g., just hard enough that it forms a perfect seal ii.preparation for using a stethoscope a.eliminate any extra sounds in the patient's room, e.g.: i.turn off patient's or neighbor's radio, television ii.turn off noisy patient equipment that can safely be turned off for a short period of time a.e.g., pneumatic compression boots, continuous nasogastric suction equipment b.warm the stethoscope between your hand before placing it on the patient's skin c.male patient's chest hair i.may cause a crackling sound that mimics an abnormal breath sound called crackles or rales ii.if occurs, wet his chest hair before auscultating the area b.avoid your own extra sounds, e.g.: i.breathing on the tubing ii.thumping from bumping the tubing together II.description of auscultated sounds a.pitch i.the frequency of the vibrations of an auscultated sound b.intensity (amplitude)

i.loudness or softness of an auscultated sound b.duration i.length of an auscultated sound b.quality i.subjective description of an auscultated sound, e.g.: a.whistling, gurgling, snapping B.Instruments, equipment, and supplies used during the physical examination I.instruments a.goniometer b.nasal speculum c.opthalmoscope d.otoscope e.reflex hammer f.platform scale with heigh attachment g.Snellen chart h.sphygmomanometer and cuff i.stethoscope j.transilluminator k.tuning fork l.vaginal speculum II.equipment and supplies a.alcohol swabs b.assorted containers and slides c.assorted familiar items d.ayre (cervical) spatula

e.cervical brush f.cotton-tipped applicators g.cotton balls h.culture media i.dental mirror j.disposable pad k.drape or sheet l.gauze dressing (4 x 4) m.fecal occult blood test materials n.flashlight or penlight o.gloves (sterile and unsterile) p.lubricant q.Rosenbaum Pocket Vision Screener r.ruler marked in centimeters s.skin-marking pen t.skinfold caliper u.smells v.sterile safety pins w.tape measure marked in centimeters x.test tubes of hot/cold liquid y.thermometer z.tongue blades (depressors) aa.watch with second hand bb.Wood's Lamp HEALTH HISTORY A.Purposes of a health history I.to elicit information about all the variables that may affect the patient's health status II.to obtain data that helps the nurse understand and appreciate the patient's life experiences

III.to initiate a nonjudgmental, trusting interpersonal relationship with the patient B.Conducting a health history I.during the pre-interaction phase a.ensure privacy i.use a private room if possible ii.if a private room is not possible, draw the curtains around the patient's bed to create a sense of privacy b.refuse interruptions i.inform any support staff of your interview and ask that they not interrupt you ii.discourage other health professionals from interrupting you with their need for access to the patient b.adjust the physical environment

i.regulate the temperature of the room, e.g.: a.raise or lower the room temperature to a comfortable level for both you and the patient ii.regulate the lighting of the room, e.g.: a.raise or lower the window shades to eliminate excessive sun glare or shade b.raise or lower the lights to eliminate excessive glare c.adjust the bed lighting so that the patient does not feel as if he/she is under interrogation ii.reduce the noise level of the room, e.g.: a.turn down the volume of the patient's radio or television b.request that the volume of neighboring patients' radios or televisions be turned down ii.remove distracting objects from the room, e.g.: a.remove clutter, stacks of mail, files of other patients, your lunch ii.arrange equal status seating in the room, e.g.:

a.assure that you and the patient are at eye level by pulling up and positioning 2 chairs at 90 degree angles about 3 - 5 feet away from each other b.remove any physical barriers between you and the patient i.e.g., desk, bedside table b.prepare for notetaking i.it is impossible to remember everything said during a health history so some notes need to be taken ii.however, there are disadvantages to note-taking. It: a.breaks your eye contact with the patient b.shifts your attention away from the patient c.can interrupt the narrative flow of the patient d.impedes your observation of the patient's nonverbal behavior e.can make the patient uncomfortable ii.in order to diminish as many of the disadvantages of note-taking as possible: a.keep note-taking to a minimum by only jotting down enough key words, short phrases, and dates to help you record the history later and not interrupt the patient's spontaneous narrative b.when using a written form, do not let it prevent you from following the patient's leads c.when the patient is talking about sensitive or disturbing material, put your pen down and maintain eye contact with the patient d.if note-taking makes the patient uncomfortable, explain that you are taking notes only to fulfill your desire to make an accurate clinical record b.review your general appearance

i.should be clean, neat, consisting of conservative dress and an appropriate name tag II.during the orientation phase a.greet the patient and establish rapport i.greet the patient by name ii.shake hands with the patient if you feel comfortable doing so iii.if this is your first contact with the patient, clarify your role and relationship to his/her care

iv.address the patient with a title

a.e.g., Mrs. Jones, Mr. Tubbs, Ms. Anderson ii.if others are in the room where the interview is to be conducted: a.find out their identity and relationshlp to the patient b.ackowledge and greet them in turn c.ask permission of the patient to conduct the interview in front of them d.ask them to leave if the patient does not grant permission for them to be present when you conduct the interview b.provide for patient comfort during the interview, e.g.:

i.for a bedridden patient, if he/she desires: a.assist him/her in donning his/her eyeglasses, hearing aids, or dentures if they were removed b.assist him/her in assuming comfortable position in bed c.arrange his/her pillows to make him/her more comfortable II.during the working phase a.use the following technique to begin the narrative i.open-ended or indirect questions a.questions that allow a patient to tell his or her story spontaneously and do not presuppose a specific answer b.examples: i.Interviewer: "What problem has brought you to the hospital today?" ii.Interviewer: "Tell me how I can help you today" b.use the following techniques to assist the narrative i.closed-ended or direct questions

a.questions that clarify areas and add detail to the patient's story b.examples: i.Interviewer: "You mentioned earlier that your father has high blood pressure. Has he developed any complicatioons related to his high blood pressure?" ii.Patient: "Yes." iii.Interviewer: "What sort of complications?" iv.Patient: "Kidney failure. He was on dialysis for years before getting a kidney transplant" ii.facilitation

a.technique of using a verbal or nonverbal response that encourages a patient to continue with his/her story while not directing him/her to a topic b.examples: i.verbal a.Interviewer: "Uh-huh", "Go on" ii.nonverbal a.Interviewer: leans forward, nods head ii.silence a.technique of accepting pauses or silences that may extend for several seconds or minutes without interjecting any verbal response ii.reflection a.technique of using a response to mirror or echo that which has just been expressed by the patient b.example: i.Patient: "I'm here because of my water. It was cutting off" ii.Interviewer: "Cutting off?" iii.Patient: "Yes, yesterday it took me 30 minutes to pass my water. Finally I got a tiny stream, but then it just closed off" ii.empathy

a.technique of using a response to recognize, but not criticize, a patient's feeling and put it into words b.example: i.Patient (sarcastically): "This is just great. I have my own business, I direct 20 employees everyday, and now here I am having to call you for every little thing" ii.Interviewer: "It must be hard - one day having so much control, and now feeling dependent on someone else" ii.clarification

a.technique of summarizing the patient's words, simplifying the patient's words to make them clearer, repeating them back to the patient, and then asking the patient if you are on the right track b.example:

i.Interviewer: "Now as I understand you, this heaviness in your chest comes when you shovel snow or climb stairs, and it goes away when you stop doing those things. Is that correct?" ii.Patient: "Yes, that's pretty much it" ii.confrontation

a.technique of using a response based on an observation of the interviewer to point out to the patient something striking about his/her behavior or previous statement b.examples:

i.Interviewer: "You say it doesn't hurt, but when I touch you here, you grimace" ii.Interviewer: "It looks as though you are about to cry when you talk about your mother's Alzheimer's disease" ii.interpretation a.technique of confrontation based on the inference, rather than observation, of the interviewer that links events, makes associations, or implies cause for a problem b.example:

i.Patient: "I have decided I don't want to take any more treatments. But I can't seem to tell my husband that. Every time he asks me about it, I tighten up and can't say anything" ii.Interviewer: "Could it be that you are afraid of his reaction?"

ii.explanation a.technique of sharing factual and objective information with the patient b.example: i.Patient: "Did you get back the results of my blood tests?" ii.Interviewer: "Yes, I got back the results of your blood tests and all of them were normal" b.pitfalls to avoid when assisting the narrative

i.provding false assurance or reassurance a.pitfall of the interviewer giving an automatic response to relieve his/her anxiety and give him/her the false sense of having provided comfort b.example:

i.Patient: "Oh I just know this lump in my breast is going to turn out to be cancer" ii.Interviewer: "Now don't worry. I'm sure you will be all right" ii.giving unwanted advice

a.pitfall of the interviewer giving advice which shifts accountability for decision-making from the patient to him/her and does not allow the patient to work out his/her own solution b.example:

i.Patient: "Dr. Kline just told me my only chance of getting pregnant is to have an operation. I just don't know. What would you do?" ii.Interviewer: "Well, Dr. Kline is one of the leading authorities in infertility. I would think that his recommendation would be the best way to go" ii.using avoidance language

a.pitfall of the interviewer using euphemisms to avoid reality or hide feelings b.example: i.Patient: "My mother just died" ii.Interviewer: "What day did your mother pass on?"

ii.using professional jargon a.pitall of the interviewer using professional terminology that sounds exclusionary and paternalistic b.example: i.Patient: "I'm having problems having a bowel movement" ii.Interviewer: "What kind of problems are you having when you attempt to defecate?" ii.leading or biased questions a.pitfall of the interviewer asking questions that carry a suggestion of the kind of response he/she is looking for b.example: i.Interviewer: "You're exciting about your new baby, aren't you?" ii.Patient: "Well, I guess so" ii.talking too much a.pitfall of the interviewer talking too much at the expense of the patient's need to express him/herself ii.interrupting a.pitfall of the interviewer cutting the patient off signaling that he/she is impatient or bored ii.using why questions a.pitfall of the interviewer asking questions that carry a tone of accusation b.examples: i.Interviewer: "Why haven't you had a routine mammogram?" ii.Interviewer: "Why did you wait so long to seek treatment for this problem?" ii.using suggestive questions a.pitfall of the interviewer asking questions that provide the answer to his/her question b.example:

i.Interviewer: "Do you feel a burning sensation when you urinate?" ii.using multiple questions a.pitfall of the interviewer asking questions that have more than one point of inquiry b.example: i.Interviewer: "How many pregnancies have you had, are using any form of birth control, and when was your last pap smear?" II.during the closing phase a.ease into the closing phase, e.g.: i.Interviewer: "Is there anything else you would like to mention?" b.indicate that closing is imminent, e.g.: i.Interviewer: "Our interview is about over." b.do not introduce any new topics at this time c.give a summary or recapitulate what you have learned during the interview, including: i.the patient's positive health aspects ii.any patient health problems that have been identified iii.any future plan of action iv.an explanation of the physical examination, if to follow b.thank the patient for his/her time spent and cooperation B.Components of the nursing health history I.biographic data, or the patient's: a.name, address and phone number, age and birth date, birthplace, gender, marital status, race, ethnic origin, occupation, religious orientation, health care financing, and usual source of medical care II.source of history, e.g.:

a.person providing the information b.interpretation of the reliability of the person providing the information c.special circumstances i.e.g., use of an interpreter II.chief complaint or reason for seeking health care III.history of the present illness, e.g.: a.principle symptom(s) of the present illness described in terms of: i.location ii.quality or character iii.quantity or severity iv.timing a.onset, duration, frequency ii.setting iii.aggravating or alleviating factors iv.associated manifestations v.patient's perception II.past history, e.g.: a.general state of health (as patient perceives it) b.childhood illnesses, e.g.: i.chickenpox, mumps, measles, rubella, rubeola, streptococcal infections, scarlet fever, rheumatic fever, poliomyelitis b.adult illnesses, e.g.: i.diabetes, hypertension, heart disease, sickle cell disease, cancer, seizure disorder, Parkinson's disease b.accidents and/or injuries, e.g.:

i.how, when, and where the accident and/or injury occurred, type of accident and/or injury, treatment received, course of recovery, any complications b.operations, e.g.: i.reason for the surgery, date of the surgery, surgery performed, location of the hospital, name of the surgeon, course of recovery, any complications b.hospitalizations, e.g.: i.reason for the hospitalization, date of the hospitalization, location of the hospital, name of the physician, course of recovery, any complications b.medications, e.g.: i.name, dose, and schedule of all currently used prescription and over-the-counter medications, such as aspirin b.allergies, e.g.: i.allergens (e.g., medication, food, animals, insects, or other contact agents, such as fabric or environmental agents) and type of reaction (e.g., rash, itching, runny nose, watery eyes, difficulty breathing) b.immunizations, e.g.:

i.tetanus; pertussis; diphtheria; polio; measles; rubella; mumps; influenza; hepatitis B; Hemophilus influenzae, type b; pneumococcal vaccine II.family health history, e.g.: a.ages of siblings, parents, grandparents b.current state of health of siblings, parents, grandparents c.cause of death of siblings, parents, grandparents d.disorders that may be influenced by heredity or contact, e.g.: i.diabetes, hypertension, heart disease, hypercholesterolemia, renal disease, cancer, tuberculosis, stroke, anemia, gout, arthritis, mental illness, alcoholism, seizures, obesity, allergies, jaundice, bleeding, ulcers, migraine b.family genogram II.lifestyle data

a.personal habits, e.g.:

i.type, amount, duration of use of tobacco, e.g.: a.cigarettes, smokeless ii.type, amount, duration of use of alcohol a.the CAGE questionnaire i.useful for adults ii.consists of the following questions: a.Have you ever felt the need to Cut down on drinking? b.Have you ever felt Annoyed by criticism of your drinking? c.Have you ever felt Guilty about your drinking? d.Have you ever felt the need for a morning Eye-opener to steady your nerves or get rid of a hangover? b.the RAFFT questionnaire i.proposed for adolescents ii.consists of the following questions: a.Do you drink or take drugs to Relax, feel better about yourself, or fit in? b.Do you ever drink or take drugs while you are Alone? c.Do any of your closest Friends drink or use drugs? d.Does a close Family member have a problem with alcohol or drugs? e.Have you ever gotten into Trouble from drinking or taking drugs? ii.type, amount, duration of use of caffeine-containing beverages, e.g.: a.coffee, cola, cocoa, tea ii.type, amount, duration of use of illicit or recreational drugs, e.g.: a.marijuana, cocaine, crack cocaine, amphetamines, barbiturates ii.impact of illness

b.diet, e.g.: i.daily food intake pattern, e.g.: a.type, amount, time food is eaten b.type, amount, time snacks are eaten c.number of meals eaten out ii.daily fluid intake pattern, e.g.: a.type, amount, time fluids are ingested ii.dietary supplements, e.g.: a.type, dose, route, time of administration ii.food likes, dislikes, intolerances iii.foods causing indigestion, diarrhea, gas iv.food allergies, e.g.: a.type of food allergen, type of reaction ii.special diets, e.g.: a.medical (e.g., low fat, low cholesterol, low protein) b.religious (e.g., vegetarian, kosher) c.cultural ii.perception of diet, e.g.: a.nutritionally balanced or imbalanced ii.state of appetite, e.g.: a.usual, increased, decreased ii.food shopping, e.g.:

a.person responsible for purchasing food b.availability of transportation for purchasing food c.availability of facilities for purchasing food d.adequacy of money for purchasing food ii.food preparation, e.g.: a.person responsible for preparing food b.availability of facilities for storing food c.availability of facilities for preparing food d.ingredients used in preparing food, e.g.: i.salt, soy, MSG, prepackaged/prepared foods b.methods used in preparing food, e.g.: i.boiling, baking, frying, broiling, steaming ii.chewing difficulties iii.swallowing difficulties iv.impact of illness b.sleep/rest, e.g.: i.daily sleep/rest pattern, e.g.: a.amount of time spent in sleep b.amount of time spent awake c.number of hours of undisturbed sleep ii.naps, e.g.: a.number, time, duration of naps ii.bedtime rituals, e.g.: a.glass of hot fluid, reading, equipment, positioning aids

ii.sleep medications, e.g.: a.type, dose, route, time of administration ii.sleep environment, e.g.: a.darkness, temperature, noise, ventilation, position of door, nightlight ii.effect of sleep, e.g.: a.energy level, ability to perform activities of daily living, ability to concentrate ii.difficulties falling asleep iii.difficulties staying asleep iv.early rising from sleep v.impact of illness b.activity, e.g.: i.activities of daily living pattern, e.g.: a.self-care ability in eating b.self-care ability in dressing c.self-care ability in bathing d.self-care ability in toileting e.self-care ability in achieving urinary continence f.self-care ability in achieving bowel continence g.self-care ability in ambulating h.self-care ability in using a wheelchair i.self-care ability in transferring, e.g.: i.from a bed to chair, in and out of a bath, in and out of a car b.self-care ability in communicating c.impact of illness ii.daily exercise pattern, e.g.:

a.type, frequency, duration of exercise b.method of warming up prior to exercise c.method of monitoring body's response to exercise d.method of cooling down after exercise e.tolerance of daily exercise pattern f.impact of illness ii.daily leisure activity pattern, e.g.: a.type, frequency, duration of leisure activities, e.g.: i.hobbies, vacations b.impact of illness II.social data a.interpersonal relationships, e.g.: i.marital a.form, e.g.: i.traditional, alternative (e.g., gay, lesbian, communal) b.structure, e.g.: i.age, gender, roles/responsibilities of marital partners b.quality of marital relationship c.health status of marital partner ii.family a.form, e.g.: i.nuclear, extended, two-career, single-parent, blended, adolescent parents, cohabiting, gay and lesbian, single adults living alone

b.structure, e.g.: i.age, gender, roles/responsibilities of family members b.competence in performing family functions, e.g.: i.physical (e.g., providing a safe, comfortable environment for family members) ii.economic (e.g., providing financial aid to family members) iii.reproductive (e.g., giving birth to new family members) iv.affective/coping (e.g., providing emotional comfort to family members) v.socialization (e.g., transmitting beliefs, attitudes, coping mechanisms to family members) vi.mastery of developmental tasks, e.g.: a.expansion (unattached adult) i.stabilize image; development of independence b.expansion/unit formation (having children) i.develop mutual satisfaction ii.development of independence iii.adjust to child expectaton iv.adjust to birth or adoption of child b.expansion/unit formation (raising children) i.establish home for family ii.nurture growth and development iii.adjust to less privacy iv.encourage education of children v.develop community socialization b.expansion/unit formation (adolescents) i.balance freedom and responsibility

ii.promote adolescent's independence b.dispertion (assist children to move on; readjust unit) i.release children with appropriate assistance and stable home base ii.readjust own interests and careers iii.readjust the relationships b.replacement (aging, death, children becoming adults) i.maintain connection with other generations ii.cope with loss of job, signifcant others, friends, home iii.adjust to altered living space b.quality of family relationships c.health status of family members ii.social network a.composition, e.g.: i.friends, co-workers, church members b.quality of social network relationships, e.g.: i.ability to provide source of information ii.ability to provide affection iii.ability to provide affirmation iv.ability to provide tangible support, e.g.: a.money, physical help, materials ii.health status of social network members b.impact of illness b.cultural, e.g.: i.overview, inhabited localities, and topography

a.overview, inhabited localities, and topography b.heritage and residence c.reasons for migration and associated economic factors d.educational status and occupations ii.communications a.dominant language and dialects b.cultural communication patterns c.temporal relationships d.format for names ii.family roles and organization a.head of household and gender roles b.prescriptive, restrictive, and taboo behaviors for children c.family roles and priorities d.alternative lifestyles ii.workforce issues a.culture in the workplace b.issues related to autonomy ii.biocultural ecology a.skin color and biologic variations b.diseases and health conditions c.variations in drug metabolism ii.high-risk behaviors a.high-risk behaviors b.health-care practices ii.nutrition

a.meaning of food b.common foods and food rituals c.dietary practices for health promotion d.nutritional deficiencies and food limitations ii.pregnancy and childbearing practices a.fertility practices and views toward pregnancy b.prescriptive, restrictive, and taboo practices in the childbearing family ii.death rituals a.death rituals and expectations b.responses to death and grief ii.spirituality a.religious practices and use of prayer b.meaning of life and individual source of strength c.spiritual beliefs and health-care practices ii.health-care practices a.health-seeking beliefs and behaviors b.responsibility for health care c.folklore practices d.barriers to health care e.cultural responses to health and illness f.blood transfusion and organ donation ii.health-care practitioners a.traditional versus biomedical care b.status of health-care providers ii.impact of illness b.spiritual, e.g.:

i.religious affiliation ii.level of religious participation iii.religious beliefs, e.g.: a.symbols, holy days, sacraments, basic tenets ii.religious beliefs and influence on the following: a.dietary practices b.medication practices c.medical treatment practices d.birth control and abortion practices e.organ transplantation practices f.death and dying practices g.healing practices h.perception of the relationship between religious beliefs and state of health ii.impact of illness b.educational, e.g.: i.highest level of formal education obtained ii.significant educational training obtained iii.preferred learning method, e.g.: a.oral explanation, demonstration, use of written materials, video-tapes, computer-assisted instruction ii.literacy level iii.past difficulties with learning iv.impact of illness b.occupational, e.g.: i.past employment status, e.g.: a.types of job, length held

b.type of work performed c.number of days missed due to illness d.number of accidents on the job ii.hazards on the job, e.g.: a.machinery, chemicals, radioactivity ii.current employment status, e.g.: a.type of job, length held b.type of work performed c.number of days missed due to illness d.number of accidents on the job ii.hazards on the job, e.g.: a.machinery, chemicals, radioactivity ii.impact of illness b.economical, e.g.: i.principle wage earner a.type of job and length held b.type of work performed c.health status of principle wage earner ii.other wage earners a.type of jobs and length held b.type of work performed c.health status of other wage earners ii.perception of economic status and ability to maintain current lifestyle, e.g.: a.income sufficient or insufficient to meet the needs of current lifestyle

ii.perception of economic status and ability to obtain health care, e.g.: a.income sufficient or insufficient to meet the needs for health care ii.impact of illness b.environment/hazards, e.g.: i.car, e.g.: a.safety measures, e.g.: i.use of seat belts, airbags, antilock brakes b.adjustments that may be required due to health status, physical disability, etc. ii.home, e.g.: a.safety measures, e.g.: i.use of smoke alarms, carbon monoxide detectors b.hazards, e.g.: i.machinery, chemicals, medications b.adequate heat and utilities c.adjustments that may be required due to health status, physical disability, etc. ii.neighborhood a.safety measures, e.g.: i.use of neighborhood watch, police patrol, streetlights b.hazards, e.g.: i.pollutants, chemicals, radioactivity b.availability of neighborhood and community services

c.safety of neighborhood d.access to transportation e.involvement in community setting ii.workplace a.safety measures, e.g.: i.use of hard hats, protective goggles, ear shields b.hazards, e.g.: i.machinery, chemicals, radioactivity b.adjustments that may be required due to health status, physical disability, etc. ii.geographic exposure, e.g.: a.travel or residence in other countries b.time spend abroad during military service ii.impact of illness II.psychologic data a.stressors, e.g.: i.major stressors experienced over the past year, e.g.: a.life changes, losses ii.perception of the severity of major stressors experienced over the past year, e.g.: a.rating of major stressors on a scale of one (least stressful) to ten (most stressful) ii.length of time major stressors have been experienced over the past year, e.g.: a.one month, two months ii.impact of illness

b.coping, e.g.: i.coping strategies utilized to resolve major stressors over the past year, e.g.: a.crying, getting angry, becoming verbally abusive, talking to some one, withdrawing from the stressful situation, praying, overeating, sleeping ii.perception of the effectiveness of coping strategies in resolving major stressors over the past year, e.g.: a.rating of coping strategies on a scale of one (least effective) to ten (most effective) ii.length of time using coping strategies to resolve major stressors, e.g.: a.one month, two months ii.impact of illness b.communication style, e.g.: i.verbal communication, e.g.: a.e.g., content of message, themes, emotions, vocabulary, refusal or inability to speak ii.nonverbal communication, e.g.: a.facial expression; gestures; body movements; affect; tone of voice; posture; eye movements; voice volume, quality, pitch; use of touch ii.congruence of nonverbal and verbal communication iii.communication pattern, e.g.: a.blocking, slow, rapid, quiet, halting, aphasic, continuity, excessive, detailed, stammering, circumstantial, tangential, long silences ii.communication skills, e.g.: a.openness, spontaneity, use of clarification, request for feedback, tolerance of silence, acceptance of confrontation ii.feedback, e.g.: a.precise, pertinent, goal-directed, informative, solicited, positive, negative, clarified, opportune ii.barriers to communication, e.g.:

a.language deficits, sensory deficits, cognitive impairments, structural deficits, paralysis ii.impact of illness b.self-concept, e.g.: i.role performance a.type, number, and duration of roles b.changes in the ability to perform roles c.importance of changes in the ability to perform roles d.satisfaction with the current ability to perform roles e.impact of illness ii.self-esteem, e.g.: a.evaluation and judgment of self-worth b.changes in the evaluation and judgment of self-worth c.importance of changes in the evaluation and judgment of self-worth d.satisfaction with the current evaluation and judgment of self-worth e.impact of illness ii.body image, e.g.: a.feelings about the strength, function, appearance of the body b.changes in the strength, function, appearance of the body c.importance of changes in the strength, function, appearance of the body d.satisfaction with the current strength, function, appearance of the body e.impact of illness ii.personal identity, e.g.: a.sense of individuality and uniqueness b.changes in the sense of individuality and uniqueness c.importance of changes in the sense of individuality and uniqueness d.satisfaction with the current sense of individuality and uniqueness

e.impact of illness b.mood, e.g.: i.present feeling state, e.g.: a.sad, gloomy, estranged, elated, worried, apprehensive, furious, optimistic, up and down ii.usual feeling state, e.g.: a.sad, gloomy, estranged, elated, worried, apprehensive, furious, optimistic, up and down ii.changes in feeling state iii.relationship between present feeling state and current condition, e.g.: a.congruent or incongruent ii.impact of illness II.review of systems a.purpose of the review of systems i.evaluate the past and present health state of each body system ii.double-check in case any significant data were omitted in the present illness section iii.evaluate health promotion practices b.order of the review of systems i.cephalocaudal (head to toe) b.recording the review of systems i.record only subjective data (e.g., client statements), not objective data (e.g., physical findings) ii.record the "presence" or "absence" of all symptoms, not "negative" b.components of the review of systems i.general health

a.history of weight loss, weakness, feelings of fatigue, mood changes, night sweats, bleeding tendencies? ii.skin a.history of skin diseases such as eczema, psoriasis, acne; changes in pigmentation; tendency toward bruising; excessive dryness or moisture; jaundice; itching, rashes, hives; change in color or size of a mole; open sores that are slow to heal? ii.hair

a.history of itchy scalp, loss of hair, excessive body hair? ii.nails a.history of color changes, biting, clubbing, splitting? ii.head a.history of frequent or severe headaches, fainting, syncope (dizziness) or vertigo, fall or accident resulting in unconsciousness? ii.eyes a.history of difficulty seeing, eye infection, eye pain, excessive tearing, double vision, blurring, sensitivity to light, cataracts, itching, spots in front of eyes?

ii.ears a.history of earaches, loss of hearing, pain, discharge, tinnitus (ringing in the ears), syncope (dizziness) or vertigo? ii.nose and sinuses a.history of frequent colds, nosebleeds, allergies or hay fever, sinus pain, tenderness, postnasal drip, change in sense of smell? ii.mouth and throat a.history of sore gums; frequent sore throats; bleeding gums; sores, lumps or white spots on mouth, lips, or tongue; toothaches, cavities, dysphagia (difficulty swallowing); voice change or hoarseness? ii.neck

a.history of pain, lumps or swelling, stiffness, limited movement, enlarged or tender nodes, goiter?

ii.breasts a.history of breast diseases such as fibroid tumors, cancer; nipple discharge, scaling or cracks around nipples, dimples, lumps? ii.respiratory a.history of respiratory diseases such as tuberculosis, emphysema, asthma, bronchitis; chest pain; cough; sputum; shortness of breath; wheezing or noisy breathing; hemotypsis (coughing up bloody sputum) ii.cardiac

a.history of heart disease such as hypertension, coronary artery disease (CAD), congestive heart failure; palpitations; heart murmur; dyspnea on exertion; paroxysmal nocturnal dyspnea; orthopnea; edema; anemia ii.peripheral vascular system

a.history of peripheral vascular disease such as intermittent claudication, thrombophlebitis, stasis ulcers; varicose veins; coldness, numbess, tingling of the extremities; edema (swelling) of the legs; discoloration in hands or feet? ii.gastrointestinal

a.history of gastrointestinal disease such as gastric ulcers, gallstones, jaundice, appendicitis, ileitis, colitis; history of nausea, vomiting, loss of appetite, indigestion, heartburn, bright blood in stools, tarry-black stools, diarrhea, constipation, abdominal pain, excessive gas, hemorrhoids, rectal pain, ileostomy, colostomy, fistulas? ii.urinary

a.history of urinary diseases such as kidney disease, kidney stones, urinary tract infections, benign prostatic hypertrophy; frequency; urgency; nocturia (urination at night); dysuria (pain or burning upon urination); polyuria (increased amount of urine); oliguria (decreased amount of urine); hesitancy or straining; narrowed stream; hematuria (blood in urine); cloudy urine; incontinence; pain in flank, groin, suprapubic region, low back? ii.female genital system

a.history of female genital disease such as endometriosis, endometrial cancer; history of menstruation (age at menarche, last menstrual period, cycle and duration, amount of flow); dysmenorrhea (painful menstruation), absence of menstruation (amenorrhea), premenstrual syndrome, bleeding between periods, vaginal discharge, vaginal itching, vaginal infection? ii.male genital system

a.history of male genital disease such as orchitis, testicular cancer; penile or testicular pain; penile discharge; penile or scrotal lumps or swelling, lesions; inquinal hernias? ii.sexual health

a.history of sexually transmitted diseases such as gonorrhea, herpes, chlamydia, venereal warts, acquired immune deficiency syndrome (AIDS), syphilis; dyspareunia (painful intercourse); impotence (inability to obtain or maintain an erection); inability to ejaculate? ii.musculoskeletal

a.history of musculoskeletal diseases such as rheumatoid arthritis, gout, herniated disc, degenerative joint disease; joint pain, stiffness, swelling, deformity, limitation of range of motion, crepitis (noise with movement); muscular pain, cramps, weakness; back pain, stiffness, limitation of range of motion? ii.neurologic

a.history of neurologic diseases such as seizure disorder, myasthenia gravis, multiple sclerosis, stroke; fainting; weakness; tic or tremor; paralysis; problems with coordination; gait disturbances; numbness, tingling, burning sensations; unconsciousness; speech problems; loss of memory; disorientation; forgetfulness; unclear thinking; changes in emotional state? ii.endocrine

a.history of endocrine diseases such as diabetes, hyper or hypothyroidism, goiter; heat or cold intolerance; polydipsia (excessive thirst), polyphagia (eating), polyuria (excessive urination); change in skin pigmentation or texture; hirsutism (excessive hair growth)? II.patterns of health care, e.g.:

a.all health care resources the client is currently using and has used in the past b.whether the patient considers the health care being provided adequate c.whether the patient considers access to health care a problem