Page 239 - Cardiac Nursing

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C HAPTER 1 0 / History Taking and Physical Examination 215
Resources and Support System. It is important to consider ■ What things do you believe are important to maintain your health?
the patient’s strengths and support system when planning care Nutrition–Metabolism. Collect the following information:
across the continuum: environmental resources, such as the prox-
imity to the hospital; personal—social support, such as a spouse to ■ What do you like to eat (including cultural or ethnic favorites)?
provide home care; and economic support, such as adequate in- ■ How are your foods prepared (canned or commercially pre-
surance, are all examples. Needed resources that are not readily pared foods versus fresh foods)?
available also must be considered. Knowledge of the patient’s ■ Do you usually eat in a restaurant, fast-food outlet, or at home?
health benefits and financial status assists the health care team in ■ Who shops for groceries?
designing an affordable therapeutic regimen (e.g., the avoidance of ■ Who prepares the meals?
expensive combination or sustained-release medications when ■ Are you on a special diet?
other drugs and dosage forms that are as effective and less costly are Elimination. Collect the following information:
available).
■ Is the amount that you urinate normal for you?
Review of Systems ■ Do you ever get up at night to use the bathroom? If so, how
To ensure that all important areas have been considered, a sys- many times?
tematic review of all body systems is conducted. Lists of major ■ If there was a change in elimination pattern, when did you no-
symptoms associated with each body system are included in tice it?
8
health assessment textbooks. Some clinicians prefer to conduct ■ Do you sometimes lose urine or find that you cannot quite
the review of systems simultaneously with the physical examina- make it to the bathroom?
tion. For the patient with chest discomfort, the review of the car- ■ Do you take a diuretic? If so, when do you take it?
diac, pulmonary, and gastrointestinal systems is logically included ■ What is your usual frequency of bowel movements? When was
in the history of present illness. your last movement?
■ Are there things you do to maintain that pattern?
Functional Patterns Activity–Exercise. Collect the following information:
Clinical information related to function is collected in the follow-
9
ing areas : ■ Have you noticed a change in your usual or desired activity level?
■ Do you have sufficient energy for your desired activities?
■ Health perception–health management
■ What is the most strenuous activity you perform on a regular
■ Nutrition–metabolism
basis? How often and how long? What stops you?
■ Elimination
■ What leisure or recreational activities do you enjoy? Are you
■ Activity–exercise
currently able to participate in these activities? What prevents
■ Cognitive–perceptual
your participation?
■ Sleep–rest
■ Are you satisfied with your current level of activity?
■ Self-perception–self-concept
■ Roles and relationships Cognitive–Perceptual. Collect the following information:
■ Sexuality
■ Do you have any difficulty with seeing or hearing? Glasses or
■ Coping–stress
hearing aid?
■ Values–beliefs
■ Do you think as fast as you used to? As clearly?
Information collected within these functional patterns does ■ In general, what is the easiest way for you to learn new mate-
not duplicate information collected within other areas of the rial? Any learning difficulties?
health history. The sequence of data gathered in the functional as- ■ Do you understand why you are in the hospital?
sessment is determined by the patient’s clinical condition and the ■ What does your diagnosis mean to you?
purpose of the encounter. Relevant data obtained earlier in the ■ What is your understanding of the treatment plan?
history should not be repeated. ■ Do you understand the risk factors for heart disease and how to
For the acutely ill cardiac patient who is admitted to the hospi- modify them?
tal, areas that affect the hospital experience are assessed first. As the ■ Do you understand how long you will be in the hospital and
patient is able, all functional patterns are assessed. To facilitate the when you can return to your usual activities of daily living?
gathering of subjective information for the functional assessment, Sleep–Rest. Collect the following information:
examples of questions, using the sample symptom of chest discom-
fort, are listed below. Functional assessment is an ongoing process ■ How many hours do you usually sleep? What hours?
that evaluates the effect of intervention on patient outcome. ■ Do you have difficulty falling asleep or staying asleep? Has this
been a change for you or have you always had this difficulty?
Health Perception–Health Management. Collect the fol- ■ Do you follow a specific bedtime routine or ritual?
lowing information:
■ Do you snore loudly?
■ What concerns do you have about your health or hospitaliza- ■ Do you feel rested when you wake up in the morning? 10
tion? ■ Are you tired and excessively sleepy during daytime hours? 10
■ What things are important to you while you are hospitalized?
Self-Perception–Self-Concept. Collect the following in-
How can we make this experience as easy as possible for you?
■ What do you think caused this illness (symptom)? formation:
■ Compared with others your age, how would you rate your gen- ■ How would you describe yourself? Your personality? Your ap-
eral health? proach to life?