NURS 3315 Holistic Health Assessment
The abdomen: Subjective data Name ________________
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Current Symptoms
1. Abdominal pain present now or within the very recent past?
If yes, complete the COLDSPA elements.
2. Recent weight gain or loss?
Past History
1. Previous abdominal surgery/trauma/injury/medications?
2. Previous abdominal pain and treatment?
3. Results of any lab work or gastrointestinal studies?
Family History
1. Stomach, colon, or liver cancer?
2. Abdominal pain, appendicitis, colitis, bleeding, or hemorrhoids?
3. Person responsible for nutrition in family?
Lifestyle and Health Practices
4. Antacid use, amount?
5. Medication use?
6. Fluid intake?
7. Cause of stress in life that affects eating and elimination patterns?
8. Past self-initiated actions to treat abdominal pain or problems?
Musculoskeletal system: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Current Symptoms
1. Recent weight gain?
2. Difficulty chewing?
3. Joint, muscle, or bone throbbing?
Past History
1. Past problems or injuries to joints, muscles, or bones?
2. Past treatment: surgery, medications, physical therapy, exercise, rest?
3. Tetanus and polio immunizations?
4. Diagnosed with diabetes mellitus, lupus, or sickle cell anemia?
Family History
1. Family history of rheumatoid arthritis, gout, osteoporosis, psoriasis, infectious tuberculosis?
Lifestyle and Health Practices
1. Activities to promote musculoskeletal health?
2. Home remedies to relieve musculoskeletal problems?
3. Assistive devices to promote mobility?
4. Smoking?
5. Alcohol or caffeinated beverages?
6. Typical diet, drink milk, take calcium supplements?
7. Occupation?
8. Time in sunlight?
9. Routine exercise?
10. Difficulty with ADL?
11. Typical posture?
The abdomen: Objective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Abdomen
1. Inspect the skin, noting color, vascularity, striae, scars, and lesions (wear gloves to inspect lesions).
2. Inspect the umbilicus, noting color, location, and contour.
3. Inspect the contour of the abdomen.
4. Inspect the symmetry of the abdomen.
5. Inspect abdominal movement, noting respiratory movement, aortic pulsations, and/or peristaltic waves.
6. Auscultate for bowel sounds, noting intensity, pitch, and frequency.
7. Auscultate for vascular sounds and friction rubs.
8. Percuss the abdomen for tone.
9. Percuss the liver from the chest downward in the midclavicular line, and from the abdomen upward to locate the upper and lower borders. Measure the liver size. How does this compare with your textbook—see the section on liver percussion.
10. Percuss the spleen.
11. Perform blunt percussion lightly over the kidneys (from the back at the costo-vertebral margin).
12. Perform light palpation, noting tenderness or guarding in all quadrants.
13. Perform deep palpation, noting tenderness or masses in all quadrants.
14. Palpate the umbilicus.
15. Palpate the aorta. (Should this be palpable?)
16. Palpate the liver, noting consistency and tenderness (during respiration and between respiration). .
17. Perform the test for cholecystitis (Murphy sign)
18. Palpate the spleen, noting consistency and tenderness.
19. Palpate the urinary bladder.
20. Perform the tests for appendicitis.
Rebound tenderness
Psoas sign
Obturator sign
Hypersensitivity test
Musculoskeletal system: Objective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Documentation note:
Students may describe ROM as full or partial. If partial, describe how it is limited, or may give the movement in approximate degrees as described in textbook illustrations.
Gait
1. Observe gait for base, weight-bearing stability, feet position, stride, arm swing, and posture.
Temporomandibular Joint
1. Inspect, palpate, and test ROM.
Sternoclavicular Joint
1. Inspect and palpate for midline location, color, swelling, and masses.
Spine
1. Inspect and palpate cervical, thoracic, and lumbar spine for pain and tenderness.
2. Test ROM of cervical spine.
3. Test ROM of thoracic and lumbar spine.
4. Test for leg and back pain.
5. Measure leg length. (inches or cm)
Shoulders
1. Inspect and palpate shoulders for symmetry, color, swelling, and masses.
2. Test ROM of shoulders.
Wrists
1. Inspect and palpate wrists for size, shape, symmetry, color, swelling, tenderness, and nodules.
2. Test ROM of wrists.
3. Test for carpal tunnel syndrome and test the “anatomic snuffbox” for tenderness.
Hands and Fingers
1. Inspect and palpate hands and fingers for size, shape, symmetry, swelling, color, tenderness, and nodules.
2. Test ROM of hands and fingers.
Hips
1. Inspect and palpate hips for shape and symmetry.
2. Test ROM of hips.
Knees
1. Inspect and palpate knees for size, shape, symmetry, deformities, pain, and alignment.
2. Test knees for swelling. If small amount of fluid present, do “bulge test.” If large amount of fluid present, do “ballottement test.”
3. Test ROM of knees.
4. Perform McMurray test if client complains of “clicking” in knee.
Ankles and Feet
1. Inspect and palpate ankles and feet for position, alignment, shape, skin, tenderness, temperature, swelling, or nodules.
2. Test ROM of ankles and toes.
SBAR
Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from Module 4 assessments would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing. If your assessment partner has chronic health problems or pain, address one of those problems below.
SBAR
Situation
(What is the most important problem you have identified? When did it start, and how severe is it?)
Background
(The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.)
Assessment
(What do you think the problem is—which direction does it seem to be going? We are not diagnosing but can say that the patient appears to have something like ____, using a diagnosis, if that is the most concise way of putting it. “It looks like the patient could be experiencing TMJ disorder,” for instance.)
Recommendation
(What needs to happen next?)
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