Health History: Present Health Status Any chronic diseases that affect your GI or urinary systems? Describe. Medications? What and how often? Taking as prescribed? do you drink alcohol? how much? how often? when was last drink? do you leak urine when cough, laugh, or exercise?
Health History: Present Health Status Any chronic diseases that affect your GI or urinary systems? Describe. Medications? What and how often? Taking as prescribed? do you drink alcohol? how much? how often? when was last drink? do you leak urine when cough, laugh, or exercise?
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Health History: Present Health Status Any chronic diseases that affect your GI or urinary systems? Describe. Medications? What and how often? Taking as prescribed? do you drink alcohol? how much? how often? when was last drink? do you leak urine when cough, laugh, or exercise?
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online from Scribd
Health History: Past Medical History • Have had problems with abdomen or digestive system? Esophagus? Stomach? Intestines? Liver? Gallbladder? Pancreas? Spleen? Describe • Surgery of abdomen or urinary tract? Describe. Change in routines, changes in food/bowel or urinary elimination? Able to cope with ostomy?
Health History: Family History • Family history of diseases of GI system— gastroesophageal reflux disease (GERD)? Peptic ulcer disease? Stomach/colon cancer? • Family history of diseases of urinary tract such as kidney stones? Kidney/bladder cancer?
Nausea and Vomiting • Nausea or vomiting for how long? Frequency? • How much do you vomit? What does it look like? Contain blood? Have an odor? • Females: Could you be pregnant? • Nausea without vomiting? • Foods eaten in last 24 hours? Where? How long after eating did you vomit? Anyone else had these symptoms over same time period? • Other symptoms: Pain? Constipation? Diarrhea? Change in stool/urine color? Fever or chills?
Indigestion • Indigestion/heartburn for how long? Where? Stomach? Chest? How often? • What makes it worse? Change of position? • What relieves the pain? Antacids or acid blockers? • Other symptoms: Radiating pain? Sweating? Lightheadedness?
Procedures and Techniques with Normal Findings • Inspect surface for movements – Peristalsis not visible—midline pulsation if thin – Client raises head—rectus abdominus muscle prominent with midline bulge • If ostomy—remove bag; inspect stoma – Red/moist, area were bag is attached to skin; well healed, without lesions
Procedures and Techniques with Normal Findings • Auscultate for bowel sounds – Auscultate before palpating/percussing – Quiet environment • Diaphragm of stethoscope—systematically – Sounds every 5-15 seconds, last 1 to several seconds – High pitched gurgles/clicks
Procedures and Techniques with Normal Findings • Palpate abdomen (light) for tenderness, muscle tone, and surface characteristics – All quadrants—pads of fingers; 1-2 cm – No tenderness, muscles should be relaxed (anxious clients may have muscle resistance on palpation) – If abdominal pain, palpate area of pain last
Age-Related Variations: Older Adults • Health history – Had abdominal pains not felt before recently? – Constipation? How defined? Liquids drunk/day? Bulk or fiber eaten? Taking laxatives? How often? – Do you unintentionally leak urine? When? What do you do to stay dry?
Age-Related Variations: Older Adults • Examination: procedures and techniques same as those for younger adult • Normal and abnormal findings – Increased fat deposits over abdomen/less subcutaneous fat over extremities – Abdomen soft (loss of abdominal muscle tone)—organ palpation easier – Note distention/concavity associated with general wasting signs or anteroposterior rib expansion
Common Problems Alimentary Tract • Gastroesophageal reflux disease – Flow of gastric secretions up into esophagus – Weakened lower esophageal pressure or increased intraabdominal pressure – Complaints of heartburn, regurgitation, and dysphagia (difficulty swallowing) that are aggravated by lying down or relieved by sitting up, taking antacids, or eating
Common Problems Alimentary Tract • Hiatal hernia – Protrusion of stomach through esophageal hiatus of diaphragm into mediastinal cavity – Muscle weakness is a primary factor • Pregnancy, obesity, and ascites • More common in women and older adults – Clinical manifestations same as GERD: heartburn, regurgitation, and dysphagia
Common Problems Alimentary Tract • Peptic ulcer disease – Lower end of esophagus, stomach, or duodenum • Duodenal ulcer most common; break in mucosa that forms scar – Gastric/duodenal ulcers—H. pylori infection – Gastric ulcers also caused by stress, medications (corticosteroids, aspirin, NSAIDs)
Common Problems Urinary System • Urinary tract infections – Urinary bladder (cystitis), urethra (urethritis), or renal pelvis (pyelonephritis) – Gram-negative organisms such as E. coli, Klebsiella proteus, or pseudomonas • Originate/ascend from intestine through urethra to bladder – More common in women (short urethra); rectal bacteria colonize perineum and vaginal vestibule – Sexual intercourse major precipitating factor
Common Problems Urinary System • Urinary tract infections – Clinical findings • Symptoms of urethritis: frequency, urgency, and dysuria • Symptoms of cystitis: same plus signs of bacteriuria/fever • Clients with pyelonephritis—flank pain, dysuria, nocturia, and frequency
Common Problems Urinary System • Glomerulonephritis – Inflammation of renal glomeruli caused by autoimmune process – Clinical findings • Fever, chills, nausea, malaise, and arthralgia • Costovertebral angle tenderness is present