2-13
Area of Concern
Assessment Criteria
Chest
Does the patient
• have shortness of breath, wheezing, gasping, or noisy respirations? cough?
• have a dry, moist, hacking, productive, deep, or persistent cough?
• have white, yellow, rusty, or bloody sputum?
¯Is it thin and watery or thick and purulent (containing pus)?
¯How much is produced?
¯Does it have an odor?
• complain of chest pain?
¯Where is the pain?
¯Is the pain a dull ache, sharp, crushing, or radiating?
¯Is the pain relieved by resting?
¯Is the patient using medication to control the pain (i.e., nitroglycerin)?
Abdomen
Does the patient
• have an abdomen that looks or feels distended, boardlike, or soft?
• have a distended abdomen, and, if so, is the abdomen distended above or below the umbilicus or over the
entire abdomen?
• belch excessively?
• feel nauseated, or has he vomited?
¯If so, how often, and when?
¯What is the volume, consistency, and odor of the vomitus?
¯Is it coffee ground, bilious (containing bile), or bloody in appearance?
¯Is patient vomiting with projectile force?
Bladder & Bowel
Does the patient have
• bladder and bowel control?
• normal urination volume and frequency?
¯Does the urine have an odor?
¯Is the urine dark amber or bloody?
¯Is the urine cloudy; does it have sediment in it?
¯Is there pain, burning, or difficulty when voiding?
• diarrhea, soft stools, or constipation?
¯What is the color of the stool?
¯Does the stool contain blood, pus, fat, or worms?
¯Does the patient have hemorrhoids, fistulas, or rectal pain?
Vagina or Penis
Does the patient have
• ulcerations or irritations?
• a discharge or foul odor?
¯If there is a discharge present, is it bloody, purulent, mucoid (containing mucous), or watery?
¯What is the amount?
• associated pain?
¯If pain is present, where is it located?
¯Is it constant or intermittent?
¯Is it tingling, dull, aching, burning, gnawing, cramping, or crushing?
Food & Fluid Intake
Does the patient
• have a good, fair, or poor appetite?
• get thirsty often?
• have any kind of food intolerance?
Medications
Does the patient
• take any medications? (If so: what, why, and when last taken?)
• have medications with him?
• have any history of medication reactions or allergies?
Table 2–1.—Self-Questioning Techniques for Patient Assessment and Reporting¾Continued
