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1、If you only have 5 minutes PHYSICAL ASSESSMENT PEARLS,Barb Bancroft, RN, MSN, PNP,The patient history,The most important part of any patient assessment is the patient history Components of the history are numerous, but remember, since you ONLY have FIVE minutes, a detailed 2-hour history is not poss
2、ible Pick and choose the parts of the present and past history that are relevant to their current problem,For example,Someone with new onset muscle aches and pains on a statin drug vs. someone who starts a statin drug but has had muscle aches and pains for 15 years New onset cough since the drug lis
3、inopril was prescribed for hypertension, or has the patient had the cough for 6 years from asthma and hay fever,What is the patient telling you in his/her own words?,“Ive had a terrible cough for 3 weeks” “I cant catch my breath” “I am having awful pain in my chest” “My head feels like its going to
4、explode” “My ankle is swollen” “Ive got this shooting pain down the back of my leg” “My cat bit me and my hand is swollen”,To characterize the “chief complaint” start with the PQRST mnemonic,PPrecise location? Where?Pinpoint the location? Show mePrecipitate the problem? What were you doing when it s
5、tarted?Palliate the problem? Did anything help?,History,Patient: “My shoulder hurts” Nurse: “Show me where it hurts, point to where it hurts” Patient pointing to the shoulder joint: ”It hurts right here” Nurse: “Do you know what caused your shoulder to hurt?” Patient: “ George hit me with a baseball
6、 bat” Nurse: “duhno wonder it hurts”,History,Patient rubbing the area of the shoulder next to the neck: “My shoulder hurts” Nurse: “Do you know what caused your shoulder to hurt?” Patient: “It started hurting when I smashed into the car in front of me and I slammed into the steering wheel” Nurse: “u
7、h-oh” Why “uh-oh?.more in a minute,To characterize the “chief complaint” start with the PQRST mnemonic,Quality of the pain?Help them out with this oneis it deep, burning, lancinating (shooting), cramping, crushing, vice-like, sharp, dull, explosive Quantitiy of the (blood, vomit, sputum)? Is it a te
8、aspoon (size of your first thumb joint)? Is it a cup? Quart?,Q is for quantity,CC”spitting up gunk from my lungs”chronic bronchitis (daily production of a tablespoon or more of sputum every day for at least 2 months in 2 successive years vs. bronchiectasis, a chronic, advanced inflammation with inte
9、rmittent production of purulent sputum in large quantities, as much as a quart/day,To characterize the “chief complaint” start with the PQRST mnemonic,Radiate? Where does it go? Up the jaw? Down the arm? One side of the head? To the back? Down the back of the leg? To the groin? Referred pain? Embryo
10、logic origins of pain,Referred pain,Embryologic origins The diaphragm (C3,4) The phrenic nerve Shared afferents with the shoulder What causes diaphragmatic irritation? Above and below the diaphragm,Referred pain another example,The ureters, kidney stones and the scrotum Does a woman have a scrotum?,
11、To characterize the “chief complaint” start with the PQRST mnemonic,Swhat is the Severity of the pain?Adults? 1 to 10 with 1 being the least painful and 10 being the most painfulPeds? Smiley to “frowney” faces,To characterize the “chief complaint” start with the PQRST mnemonic,Twhat is the Time fram
12、e or Temporal sequence? Clarify which symptom came first and the order in which others follow. Temporal relationships between associated symptoms are also most helpful. The simultaneous occurrence of equally intense symptoms or the development of symptoms while others regress suggest pathophysiologi
13、c mechanisms which in turn imply specific diagnoses,Time or Temporal sequence,Did the pain last for an hour, 15 minutes, 5 minutes, or less than 5 minutes? Did the pain start before you vomited? After you vomited? Did the vomiting stop the pain? Symptoms persisting for years are unlikely to be cause
14、d by a catastrophic infection, cancer, or other illness,Temporal sequence and an ischemic stroke,Patients may wake up with a “stroke in progress” You have a 4.5 hour “window” to give tissue plasminogen activator (alteplase) You need to know WHEN the stroke symptoms started? Bed at 11? Woke up at 7 w
15、ith symptoms? Bed at 11? Woke up at 5, perfectly fine, to go to the bathroom? Woke up again at 7 with symptoms?,The AsAssociated symptoms , Absent symptoms or events or ALARM symptoms,What else can you tell me about your problem? Has anything happened in your life that you think might be related to
16、your fatigue?My mom passed awaymy husband is in Iraqmy boyfriend dumped meall my kids have the flu”, everybody in my family has diabetes” Nausea, vomiting, weight loss, blurred vision, cough”worst headache I have every had”,Chief complaint “Severe chest pain for 25 minutes”first thought? Is this an
17、acute coronary syndrome?,FIRST THINGS FIRST: Any patient with a suspected acute coronary syndrome should chew 160-325 mg of ASA; one simple therapy is associated with a 35-day mortality reduction exceeding 20%) Now, thinkwhat structures are located in the chest and how should I go about considering this specific patient with chest pain?,
