NURSING 1I02 Lecture Notes - Lecture 6: Chest Pain, Dysphagia, Shortness Of Breath
Biographical Data:
1. Name
2. Age
3. Sex
4. Birthday
5. Ethnicity
6. Phone number
7. Address
8. Occupation
9. Marital status
Reason for seeking care?
Current health status:
Neurological Q’s
1. Headaches
2. Lightheaded
3. Tremors
4. Weakness
5. Coordination
6. Falling
7. Tingling
8. Numbness
9. Swallowing
10. Speaking
“Hey larry tonight we
could flee together
not since sunday”
Muskuloskeletal
Q’s
1. Pain
2. Stiffness
3. Bone/joint
deformity
4. Swelling
5. ROM
6. Cramping
7. Numbness
8. Tingling
“PS BS Cause No
Time (for) ROM”
-Pain, stiffness,
bone deformities,
swelling,
Cramping,
Numbness,
Tingling, ROM
Cardiac Q’s
1. Chest pain
2. Shortness of
breath
3. Use many
pillows
4. Cough
5. Easily tired
6. Blue skin
7. Leg swelling
8. Urinate at
night
“ABCDEFG”
“Airway (open/cough,
SOB)
Blue (cyanosis)
Chest (chest pain)
Dyspnea (orthopnea,
pillows)
Easily tired
Frequent urination
Growth (swelling of
legs)
Respiratory Q’s
1. Cough
2. Phlegm
(colour)
3. Shortness
of breath
4. Chest pain
5. Paroxymal
nocturnal
dyspnea
(PND)
6. Orthpnea
“CCC-DIE COPS”
-Cough
-Chest pain
-(Phlegm)Colour
-Dyspnea
-Infection
-Environmental
Factors
-COPD
-Shortness of
Breath
Abdominal Q’s
1. Appetite
2. Diet
3. Dysphagia
4. Food
intolerance
5. Nausea
6. Vomiting
7. Bowel habits
“Very Fking BADD”
-Vomitting, Food
Habits, Bowel
Movements,
Appetite, diet,
dysphagia
Past Health History:
“BALD-CHASM”
-Blood pressure, Arthritis, Lung disease, Diabetes, Cancer, Heart disease, Alcoholism, Stroke, Mental health-
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Document Summary
Biographical data: name, age, sex, birthday, ethnicity, phone number, address, occupation, marital status. Neurological q"s: headaches, lightheaded, tremors, weakness, coordination, falling, tingling, numbness, swallowing, speaking. Hey larry tonight we could flee together not since sunday . Q"s: pain, stiffness, bone/joint deformity, swelling, rom, cramping, numbness, tingling. Cardiac q"s: chest pain, shortness of breath, use many pillows, cough, easily tired, blue skin, leg swelling, urinate at night. Respiratory q"s: cough, phlegm (colour, shortness of breath, chest pain, paroxymal nocturnal dyspnea (pnd, orthpnea. Abdominal q"s: appetite, diet, dysphagia, food intolerance, nausea, vomiting, bowel habits. Blood pressure, arthritis, lung disease, diabetes, cancer, heart disease, alcoholism, stroke, mental health- Cardiac q"s: heart disease history, family history of heart disease, adl problems, any cardiac risk factors (smoking, poor nutrition, alcohol, drugs, no exercise) Abdominal q"s: past copd, past history, family. Copd history: adl abdominal history, family abdominal history problems, adl problems, medications, smoking habits, alcohol consumption. Personal abdominal history, family abdominal history, adl,