Kidneys

The usual daily urine volume in the adult is 1 to 2 L. A

general rule is that the output is approximately 1 mL of urine per kilogram of body weight per hour (1 mL/kg/h) in all age groups. Skin Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from 0 to 1,000 mL or more every hour, depending on the environmental

Adult Physical Assessment

THE PATIENT HISTORY
GENERAL PRINCIPLES The first step in caring for a patient and in soliciting

active cooperation is to gather a careful and complete history.

In all patient concerns and problems, an accurate history

is the foundation on which data collection and the process of assessment are based. The comprehensiveness of the history elicited depends on the information available in the patient's record and the reliability of the patient.

Adult Physical Assessment

Time spent early in the nurse-patient relationship

gathering detailed information about what the patient knows, thinks, and feels about the problems prevents time-consuming errors and misunderstandings later. Skill in interviewing affects both the accuracy of information elicited and the quality of the relationship established with the patient.

Adult Physical Assessment

This point cannot be overemphasized; the reader is

encouraged to consult other sources for detailed discussion of techniques of health interviewing. The purpose of the interview is to encourage an exchange of information between the patient and the nurse. The patient must feel that his words are understood and that his concerns are being heard and dealt with sensitively.

INTERVIEWING TECHNIQUES
Provide privacy in as quiet a place as possible and see

that the patient is comfortable. Begin the interview with a courteous greeting and an introduction. Address the patient as Mr., Mrs., or Ms. and shake hands if appropriate. Explain who you are and the reason for your presence. Make sure that facial expressions, body movements, and tone of voice are pleasant, unhurried, and nonjudgmental, and that they convey the attitude of a sensitive listener so the patient will feel free to express his thoughts and feelings.

INTERVIEWING TECHNIQUES
Avoid reassuring the patient prematurely (before you

have adequate information about the problem). At times, a patient gives cues or suggests information, but does not tell enough. It may be necessary to probe for more information to obtain a thorough history; the patient must realize that this is done for his benefit. Guide the interview so the necessary information is obtained without cutting off discussion. Controlling a rambling patient is often difficult but, with practice, it can be done without jeopardizing the quality of the information

INTERVIEW TECHNIQUE Composition of Body Fluids

Avoid reassuring the patient prematurely (before you

have adequate information about the problem). It may be necessary to probe for more information to obtain a thorough history; the patient must realize that this is done for his benefit. Guide the interview so the necessary information is obtained without cutting off discussion. Controlling a rambling patient is often difficult but, with practice, it can be done without jeopardizing the quality of the information Electrolytes: anions and cations

INTERVIEW TECHNIQUE
, Accuracy and reliability of informantthis is a judgment based on the consistency of responses to questions and on a comparison of information in the history with your own observations in the physical examination. Explain the reasons why the information is needed to help put the patient at ease.
fluid concentrations, osmotic pressure

usiontranspor

COMPONENTS
Identifying Information Date and time.

Patient's name, address, telephone number, race, religion,

birth date, and age. Name of referring practitioner. Insurance data. Name of informantthe patient may be the person giving the history; if not, record the name, address, telephone number, and relationship to the patient of the person giving the history. (The patient's facility or clinical record may also be a valuable resource.)

RegulatioChiefComplaint brief statement of the patient's primary problem or nAof Electrolytes: Cations
concern in the patient's own words, including the duration of the complaint. Example: hacking cough 3 weeks. Purpose is to allow the patient to describe his own problems and expectations with little or no direction from the interviewer and to identify the overriding problem for which the patient is seeking help (there may be numerous complaints). To obtain information, ask the patient a direct question such as, For what reason have you come to the facility?

Lab ValChief Complaintues

Write down what the patient says using quotation

marks to identify patient's words. or What seems to be bothering you most at this time?
Avoid confusing questions such as, What brings you

here? (The bus.) or Why are you here? (That's what I came to find out.) Ask how long the concern or problem has been present; for example, whether it has been hours, days, or weeks. If necessary, establish the time of onset precisely by offering such clues as Did you feel this way a month (6 months or 2 years) ago?
Mosby items and derived items 2005 by Mosby, Inc.

Present illness
A detailed chronological picture, beginning with the

time the patient was last well (or, in the case of a problem with an acute onset, the patient's condition just before the onset of the problem) and ending with a description of the patient's current condition. If there is more than one important problem, each is described in a separate, chronologically organized paragraph in the written history of present illness.

rInvestigate the chief complaint by eliciting more information through the use of the pneumonic OLD CARTS:
Onset (setting, circumstances, rapidity, or manner in

which it began) Location (exact place where the symptom is felt, radiation pattern) Duration (how long; if intermittent, the frequency and duration of each episode) Character/course (nature or quality of the symptom, such as sharp pain, interference with activity, how it has changed or evolved over time; ask to describe a typical episode) Aggravating/associated factors (medications, rest, activity, diet; associated nausea, fever, and other symptoms)

Biological regulation of acid-base balance

Relieving factors (lying down, having bowel movement)

Acid-Base Balance methods attempted and their outcomes)

severe on scale of 1 to 10)

Treatments tried (pharmacologic and nonpharmacologic Severity (the quantity of the symptom; for example, how

Alternately, use the pneumonic PQRST:

provocative/palliative factors, quality/quantity, region/radiation, severity, timing. Obtain OLD CARTS data for all the major problems associated with the present illness, as applicable. Clarify the chronology of the illness by asking questions and summarizing the history of present illness for the patient to comment on.
lobin

Past Medical History

PTo determine the background health status of the patient, including present status, recent health conditions, and past health conditions that will serve as a basis for nursing care planning for holistic patient care. General health and lifestyle patternssleeping pattern, diet, stability of weight, usual exercise and activities, use of tobacco, alcohol, illicit drugs. Childhood illnesses, such as infectious diseases (if applicable). Immunizationpolio, diphtheria, pertussis, tetanus, measles, mumps, rubella, Haemophilus influenza type b, hepatitis B, hepatitis A, pneumococcal, influenza, varicella, meningitis, human papilloma virus, herpes zoster, last purified protein derivative or other skin test, abnormal or unusual reactions (give date when possible).

Past medical history

Operationindications, diagnosis, dates, facility,

surgeon, complications. Previous hospitalizationsphysician, facility data (year), diagnosis, treatment. Injuriestype, treatment, outcome. Major acute and chronic illnesses (any serious or prolonged illnesses not requiring hospitalization) dates, symptoms, course, treatment. Medicationsprescription drugs from all providers (including ophthalmologist and dentist); nonprescription drugs including vitamins, supplements, and herbal products; include dosage, length of use, and adherence.

Past medical History

Allergiesenvironmental allergies, food allergies,

drug reactions; give type of reaction (hives, rhinitis, local reaction, angioedema, anaphylaxis). Obstetric history (may appear in review of systems).
Pregnancies, miscarriages, abortions. Describe course of pregnancy, labor, and delivery; date,

place of delivery.

Psychiatric history (may appear in review of

systems)treatment by a mental health provider, diagnosis, date, place, medications.

Family History
Purpose is to present a picture of the patient's family

health, including that of grandparents, parents, brothers, sisters, aunts, and uncles. It involves the health of close relatives because some diseases show a familial tendency or are hereditary. Include age and health status (or age at and cause of death) of maternal and paternal grandparents, parents, siblings.

Family History
History, in immediate and close relatives, of heart

disease, hypertension, stroke, diabetes, gout, kidney disease or stones, thyroid disease, pulmonary disease, blood problems, cancer (types), epilepsy, mental illness, arthritis, alcoholism, obesity. Genetic disorders, such as hemophilia or sickle cell disease. Age and health status of spouse and children

Review of Systems
Purpose is to obtain detailed information about the

current state of the patient and any past symptoms, or lack of symptoms, patient may have experienced related to a particular body system. May give clues to diagnosis of multisystem disorders or progression of a disorder to other areas. Include subjective information about what the patient feels or sees with regard to the major systems of the body.

Client Assessment

Review of Systems Skinrash, itching, change in pigmentation or texture, sweating, hair growth and distribution, condition of nails, skin care habits, protection from sun Skeletalstiffness of joints, pain, deformity, restriction of motion, swelling, redness, heat (If there are problems, ask the patient to specify any activities of daily life that are difficult or impossible to perform.) Headheadaches, dizziness, syncope, head injuries Eyesvision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent change in appearance or vision, glaucoma, cataracts, glasses or contact lenses worn, date of last refraction, infection

 Review of System Earshearing acuity, earache, discharge, tinnitus, vertigo,

Nursing Diagnoses

history of tubes or infection Nosesense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain or therapy, use of nose drops or sprays (type and frequency) Teethpain; bleeding, swollen or receding gums; recent abscesses, extractions; dentures; dental hygiene practices, last dental examination Mouth and tonguesoreness of tongue or buccal mucosa, ulcers, swelling Throatsore throat, tonsillitis, hoarseness, dysphagia Neckpain, stiffness, swelling, enlarged glands or lymph nodes

Mosby items and derived items 2005 by Mosby, Inc.

 Endocrinegoiter, thyroid tenderness, tremors, weakness,

Planning

tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, easy bruising, muscle cramps, polyuria, polydipsia, polyphagia, hormone therapy, unexplained weight change Respiratorypain in the chest with breathing, dyspnea, wheezing, cough, sputum (character, quantity), hemoptysis, last tuberculin test or chest X-ray and result (indicate where obtained), exposure to tuberculosis Cardiovascularpain (aggravating and alleviating factors), palpitations, dyspnea, orthopnea (note number of pillows required for sleeping), history of heart murmur, edema, cyanosis, claudication, varicose veins, exercise tolerance, blood pressure (BP; if known), last electrocardiogram and results (indicate where obtained) Hematologicanemia (if so, treatment received), tendency to bruise or bleed, thromboses, thrombophlebitis, any known abnormalities of blood cells

 Lymph nodesenlargement, tenderness, suppuration,

Implementation

duration and progress of abnormality Gastrointestinalappetite and digestion, intolerance to foods, belching, regurgitation, heartburn, nausea, vomiting, hematemesis, bowel habits, diarrhea, constipation, flatulence, stool characteristics, hemorrhoids, jaundice, use of laxatives or antacids, history of ulcer or other conditions, previous diagnostic tests, such as colonoscopy Urinarydysuria, pain, urgency, frequency, hematuria, nocturia, polydipsia, polyuria, oliguria, edema of the face, hesitancy, dribbling, loss in size or force of stream, passage of stones, stress incontinence Male reproductivepuberty onset, sexual activity, use of condoms, libido, sexual dysfunction, history of sexually transmitted diseases (STDs)

 Female reproductivepattern and characteristics of

IV Therapy

menses, libido, sexual activity, satisfaction with sexual relations, pregnancies, methods of contraception, STD protection Breastspain, tenderness, discharge, lumps, mammograms, breast self-examination Neurologichistory of loss of consciousness, seizures, confusion, memory, cognitive function, incoordination, weakness, numbness, paresthesia, tremors, muscle cramps Psychiatrichow patient views self, mood changes, difficulty concentrating, sadness, nervousness, tension, irritability, change in social interaction, obsessive thoughts, compulsions, manic episodes, suicidal or homicidal thoughts, hallucinations General constitutional symptomsfever, chills, night sweats, malaise, fatigability, recent weight loss or gain

 Personal and Social History

To develop a plan of care that fits the patient. Here

the interviewer finds out the many personal and family Blood Replacement resources Determine personal statusbirthplace, education, armed service affiliation, position in the family, education level, satisfaction with life situations (home and job), personal concerns. Identify habits and lifestyle patterns.
Sleeping pattern, number of hours of sleep, difficulty

sleeping. Exercise, activities, recreation, hobbies. Nutrition and eating habits (diet recall for a typical day).

 Alcoholfrequency, amount, type; CAGE questionnaire

for problem drinking:

Interventions for Acid-Base Imbalances

Have you ever thought you should Cut down on your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning (ie, an Eye opener)?

Caffeinetype and amount per day. Illicit drugs (illegal or improperly used prescription or

over-the-counter medications). Tobaccopast and present use, type (cigarettes, cigars, chewing, snuff), pack, years. Sexual habits (can be part of genitourinary history) relationships, frequency, satisfaction, number of partners in past year and lifetime, STD and pregnancy prevention.

Restorative Care

Home conditions. Marital status, nature of family relationships. Economic conditionssource of income; health insurance, Medicare, Medicaid. Living arrangements and housing (owning or renting, heating, sewage, pets). Involvement with agencies (name, case worker). History of physical or sexual abuse. Occupationpast and present employment and

working conditions, including exposure to stress and tension, noise, chemicals, pollution. Cultural beliefs, religion or faithits importance in coping and health practices.

 TECHNIQUES OF EXAMINATION AND ASSESSMENT

1. Inspection Begins with the first encounter with the patient and is the most important of all the techniques. It is an organized scrutiny of the patient's behavior and body. With knowledge and experience, the examiner can become highly sensitive to visual clues. The examiner begins each phase of the examination by inspecting the particular part with the eyes

Other fingers touching the surface will damp the sound. Be consistent in the degree of firmness exerted by the hyperextended finger as you move it from area to area or the sound will vary.

TECHNIQUES OF EXAMINATION AND ASSESSMENT

2. Palpation Involves touching the region or body part just observed and noting whether these are tender to touch and what the various structures feel like. With experience comes the ability to distinguish variations of normal from abnormal. It is performed in an organized manner from region to region.

Techniques of assessment & examination

3. Percussion By setting underlying tissues in motion, percussion helps in determining the density of the underlying tissue and whether it is air-filled, fluid-filled, or solid. Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner. The five basic notes produced by percussion can be distinguished by differences in the qualities of sound, pitch, duration, and intensity The technique for percussion may be described as follows: Hyperextend the middle finger of your left hand, pressing the distal portion and joint firmly against the surface to be percussed.

Techniques in Assessment & examination

Auscultation This method uses the stethoscope to augment the sense

of hearing. The stethoscope must be constructed well and must fit the user. Earpieces should be comfortable, the length of the tubing should be 10 to 15 inches (25 to 38 cm), and the head should have a diaphragm and a bell.
The bell is used for low-pitched sounds such as certain

heart murmurs. The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds such as breath sounds. Extraneous sounds can be produced by clothing, hair, and movement of the head of the stethoscope