2-13Area of Concern Assessment CriteriaChestDoes 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)?AbdomenDoes 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 theentire 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 & BowelDoes 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 PenisDoes 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 IntakeDoes the patient• have a good, fair, or poor appetite?• get thirsty often?• have any kind of food intolerance?MedicationsDoes 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
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