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DIARRHEA

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PHYSICAL INFORMATION

Vital signs, particularly lying, sitting, and standing blood
pressure ( if accessible) and pulse
Abdominal evaluation, including occurrence of abdominal pain,
tenderness, distension, guarding
Thorough account of bowel movements, including amount,
frequency, consistency (free, soft, watery, etc. ), severity,
contents (blood, pus, mucus) etc.
If there has been continuous oozing of liquid stool (paradoxical
diarrhea) perform a digital rectal evaluation to check for soreness,
tenderness, mass, or presence of hard, dry stool in the rectum
Any change in psychological status, function, mood, conduct, or level
of awareness
Signals of probable fluid amount depletion or dehydration (postural
pulse variation – increase from lying down to sitting or standing
of thirty beats per minute or more, tachycardia, quick weight loss,
cracked lip area, thirst, new attack or increased confusion, temperature)

HEALTH CARE HISTORY

Patient’s age and sex
Onset, timeframe, frequency, and intensity of signals and symptoms
Any GI symptoms including bloatedness, gas, cramping, fecal
urgency, or constipation alternating with diarrhea
Any adjustments in nutritional intake (spicy foods, high fiber foods,
caffeine containing drinks, etc. )
All current medications, including any recent changes,
especially recent or current antibiotic therapy and drugs
that are acknowledged to have an effect on bowel motility
All current diagnoses, especially history of upper or lower
gastrointestinal (GI) medical conditions, hx of bowel
obstructions, or of irritable bowel syndrome
Recent laboratory (electrolytes) or diagnostic test results

ABDOMINAL ASSESSMENT
Look: Look for alterations to the stomach such as
distension. Look at the skin for moisture, skin
breakdown, rash, bleeding.
Listen: Listen for bowel noises to see if they are
active and audible in all four quadrants. Place
the bell of the stethoscope gently over each one of
the four quadrants. Identify noises as typical,
hyperactive, hypoactive, lacking. It may take
about 5 minutes to pick up bowel sounds.
Feel: Lightly palpate above each of the 4
abdominal quadrants. Observe if ‘the stomach is
soft or firm. Look for tenderness, muscular stiffness,
warmth, and observe patient’s facial expressions
during palpation.
Contamination control measures such as hand
washing is very essential to decrease
the spread of infectious diarrhea. Illustrations of
infectious diarrhea are:
C. difficile is identified as a significant cause of
nosocomial diarrhea and most common
infectious cause of acute diarrhea in nursing
homes. It is transmitted via the oral-fecal path.
Noroviruses are highly transmittable, results in
illness 24 to 48 hours after subjection, and are
spread by the fecal to oral contamination of
drinking water and food.

DIZZINESS/LIGHTHEADEDNESS

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PHYSICAL INFORMATION

Vital signs, especially lying down, seated, and standing up
blood pressure (if accessible) and pulse
Neurological assessment, evaluate for weakness,
confusion, blurred or double vision
Description of attempt to stand and ambulate,
including whether or not the person staggers or tends
to fall to one side or another
Any significant alterations in function, disposition,
conduct, cognition, or level of awareness
Signs of vertigo (examine external ear for indications of
inflammation, drainage, swelling, etc. )
Basic appearance. Fidgeting and eyelid twitching
Blood sugar level

HEALTH CARE HISTORY

Patient’s age and sex
Detailed account of the indicators (lightheadedness versus vertigo, nausea, vomiting, etc. )
Starting point, length, frequency, and severity of signs
and indicators, elements that make it better or worse
(turning head, lying down, standing up, etc. )
All current prescription drugs, including any recent
adjustments
All present diagnoses
Recent lab or diagnostic test results
Fluid intake over past 7 days

Real vertigo, a sensation of rotational movement, may
indicate a condition called ‘benign positional vertigo’, a
sudden sensation of rotating usually when moving the
head, and infections or problems of the inner ear.
Lightheadedness may indicate cardiovascular problems,
hyperventilation, orthostatic hypertension, drug side
effect, anxiety, or depression.
When evaluating someone with dizziness or lightheadedness,
you may need to carry out a neurological assessment
and heart evaluation:
Observe for changes in degree of consciousness
Listen to the heart for rate, rhythm and to see if
there is a murmur. A murmur is a gentle blowing,
swooshing noise that can be observed on the chest
wall with a stethoscope
Observe for problems with gait
Record problems with alterations in pupils
Observe changes in facial proportion: ask the patient
to puff out cheeks, smile, frown
Recognition of changes which could be a swallowing
problem such as drooling, pocketing food, slow
eating, gulping, hacking and coughing or clearing throat after
eating or drinking, wet voice, grievances of food
sticking in throat
Observing arms and legs for weakness
Observe for changes in conversation such as failure
to speak, problems speaking, and inappropriate
responses.

DRUG LEVELS, ELEVATED OR TOXIC

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PHYSICAL DATA

Any indications of side effects associated to the higher than
the therapeutic level related to that particular
drug (for example, unsteady gait in someone
with antiepileptic toxicity or bleeding in someone
on anticoagulants with an increased Prothrombin
Time/INR)

MEDICAL BACKGROUND

Patient’s age and sex
Starting point, time-span, rate of recurrence, and intensity of signs
and indicators
Current and prior lab or diagnostic test outcomes
in regards to current and previous dosages
All current medications
All present diagnoses

Medicine amounts you may wish to keep an eye on are below. Fill in
the panic level as defined by your healthcare director, laboratory,
or corporate policy etc. in the areas below.

Term                                                                                           Definition
Acetaminophen                                                                     __________________
Carbamazepine                                                                       __________________
Digoxin (Lanoxin)(ns/ML)                                                __________________
Dilantin therapeutic level(mcg/ml)                             __________________
Lithium                                                                                     __________________
Phenobarbital                                                                        __________________
Phenytoin (dilantin)                                                           ___________________
Potassium (mEq/L)                                                             ___________________
Theophylline                                                                         ____________________
Valproic Acid                                                                         ___________________
*INR                                                                                           ___________________
*Even though an INR is not a drug level, its monitoring is important
enough to list here.

DYSPNEA

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PHYSICAL DATA

Vital signs, including change including increased/decreased
pulse rate and tempo, blood pressure, and respiratory rate and rhythm
Heart and lung examination including rales, wheezes, rhonchi,
and labored breathing, coughing, pursed lip breathing, O2 sat.
Signs of cyanosis, molting
Stomach evaluation for epigastric tenderness
Discomfort evaluation including quality (tightness or heaviness,
stress, vague soreness, etc. ), onset and length of time of the pain, and precipitating factors
Occurrence of ascites or edema of extremities or face
Description of signs or symptoms (occur with activity or rest continuous
or intermittent, started abruptly or gradually)

MEDICAL HISTORY

Patient’s age and sex
Onset, duration, regularity, and intensity of symptoms
If chronic, comparison of present to normal symptoms
Alleviating components (such as antacids or nitroglycerin, oxygen
administration, position adjustments, etc. )
Aggravating factors
All present medications
Related history of cardiac or GI difficulties, recent injury,
smoking
All current diagnoses, especially those relevant to heart and pulmonary problems
Any recent laboratory or diagnostic test results, including EKG results,
if accessible

Dyspnea Assessment Includes:
Listening to the heart for rate, beat and to
see if there is a murmur. A murmur is a mild
blowing, swooshing noise that can be heard on the chest wall with a stethoscope.
Listening to sounds of the bronchi, you want to
listen for:
Crackles: These are high pitched,
discontinuous noises similar to the sound
generated by rubbing your hair between your
fingers (also known as Rales)
Wheezes: These are generally high pitched and
“musical” in quality. Stridor is an inspiratory
wheeze connected with upper airway
obstruction (croup).
Rhonchi: These often have a snoring, or
“gurgling” quality Any extra noise that is not
a crackle or a wheeze is in all probability a rhonchi.

Paroxysmal Nocturnal Dyspnea (PND) comes about
with heart failure when lying down.

EARACHE

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PHYSICAL DATA

Vital signs
Pain examination (area, nature, severity, etc. ) of both outside
and interior ear
Does the earache worsen when patient changes positions
Any problem swallowing, hoarseness, neck pain, or discomfort when
opens mouth
Occurrence of bleeding or discharge from the ear canal
Current ability to hear noises and voices, in comparison to normal
Any ringing, swishing or other noise in ears, any diziness
Inspect external ear for redness, drainage, swelling or
deformity

HEALTH CARE BACKGROUND

Patient’s age and sex
Starting point, dynamics, timeframe, consistency, and intensity of indicators
Any recent trauma or ear damage, any soreness associated with
itching
Has showering triggered ear irritation
Any recent cold or difficulties with eyes, mouth, teeth, jaw,
sinuses, or throat
Background of partial or total hearing loss in one or both ears
All present medicines, including any recent variations
Any current or recent treatments connected to the ear
Use of hearing device
Any changes in gait or equilibrium

EAR ASSESSMENT
Some further questions to ask the affected person in the course of
an evaluation of earache:
Area of the earache – Does the earache
pain feel close to the outside of the ear or
much deeper in the canal?
Does the soreness come and go or is it constant?
Is the pain dull, aching, stabbing or well-defined?
Discharge from the ear indicates infection. For
instance:
External otitis – purulent, sanguineous, or
watery discharge.
Acute otitis media with *perforation – purulent
discharge.
. Cholesteatoma – a dirty yellow-gray discharge,
foul odor (cholesteatoma destructive and broadening
growth composed of keratinizing
squamous epithelium in the central ear and/or
mastoid process).
*Typically, with perforation the patient will experience ear pain
first which stops with a popping sensation, then the drainage
takes place.

ELECTROCARDIOGRAM (EKG), ABNORMAL

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Evaluate patient for chest pain.
After the initial interventions, additional
information can be obtained by performing a
heart and lung evaluation. Listen to the heart
for rate, rhythm and to see if there is a murmur.
A murmur is a gentle blowing swooshing sound
that can be heard on the chest wall with a
stethoscope.

Evaluate patient for lung sounds:
When listening to sounds of the lungs you want
to listen for:
Crackles: These are high pitched,
discontinuous sounds similar to the sound
produced by rubbing your hair between your
fingers (also known as Rales).
Wheezes: These are generally high pitched and
“musical” in quality. Stridor is an inspiratory
wheeze associated with upper airway
obstruction (croup).
Rhonchi: These often have a “snoring” or
“gurgling” quality. Any extra sound that is not
a crackle or a wheeze is probably a rhonchi.
Look to see if the resident is short of breath
or has an unusual breathing pattern. Look for
cyanosis, edema and clubbing.

EYE INJURIES

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PHYSICAL INFORMATION

Vital signs
Eye assessment, especially comprehensive account
of injured area including location (sclera,
conjunctiva, lid, etc. ) and associated findings
(discharge, bleeding, drainage, etc. )
Discomfort assessment (place, nature, intensity, etc.
Visual acuity and change in eyesight in comparison to
normal

HEALTH CARE HISTORY

Patient’s age and sex
Onset, time-span, and precipitating components
Any therapies administered so far
Symptoms of eye soreness (blurry or double vision,
damage of vision, etc. )
Background of glaucoma, cataract, retinal detachment

Evaluation of the eyes without injury:
Eyeballs are aligned normally in their sockets
Eyebrows are present bilaterally and move
symmetrically
Eyelids and lashes (skin is intact without
inflammation, puffiness, discharge or lesions)
Sclera is white
The iris appears flat with a circular regular
form
The pupils appear round, regular, equivalent,
reactive to light and accommodation
Test for accommodation by prompting the person to
focus on a distant item. This procedure dilates the
pupils. Then have the individual transfer their gaze to a
near item such as your finger and the pupils will
tighten.
Document the normal responses by utilizing PERRLA
(Pupils Equal Round Reactive to Light and
Accommodation.

HEMATOCRIT/HEMOGLOGIN, ABNORMAL

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PHYSICAL INFORMATION

Vital signs
Symptoms of hemorrhaging. Observe where bleeding is observed
if apparent.
Observe coloring and uniformity (bright red blood, brownish or
coffee ground in color)
Examine pupils for dilation and response to light
If Hct/Hgb is under regular range (anemia), examine for
indicators related to anemia, such as elevated heart rate,
shortness of breathing, palpitations, exhaustion, and physical
exercise intolerance.
lf Hct/Hgb is above typical range, measure for indicators of
hydration deficits, head ache, dizziness, or change in
degree of awareness

HEALTH CARE BACKGROUND

Patient’s age and sex
Current laboratory or diagnostic test outcomes,
particularly previously documented hematocrit, hemoglobin, serum
iron, serum potassium ferritin, transferrin saturation,
and renal functionality (BUN, Creatinine)
Test for GFR < 60ml/min, if Hct/Hgb is  less than 12g/dL in a woman
and less than 13g/dL in a man
Any background of cancer chemotherapy, gastrointestinal (GI) or
urinary hemorrhaging, or other bleeding  or clotting ailments
Recent and present food and fluid ingestion
All present diagnoses, including cancer, bone marrow
failure and renal illness
Alll present prescription drugs, inctuding any recent
alterations, particularly those linked with bone marrow
suppression or elevated bleeding threat

The World Health Organization defines anemia as hemoglobin of less than 12g/dL in females and less than 13g/dL in males
Indicators of anemia could consist of:
. Adjustments in cognitive level
. Change in disposition
. Persistent bacterial infections
. Decrease in ADL functionality
. Falls
. Exhaustion
. Head ache
. Increase in heart rate
. Insomnia
. Decline of desire for foods, weight loss
. Nutritionary issues
. Palpitations
. Shortness of breath

FAINTING

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PHYSICAL INFORMATION

Vital signs, particularly pulse rate and tempo,
orthostatic blood pressure, and O2 sat.
Neurological evaluation, which includes signs of
seizure activity (tongue biting, incontinence,
postictal confusion, etc. ) and duration of loss of
consciousness
Symptoms of injuries if affected person fell during fainting
episode
Any substantial changes in mood, conduct, or
cognition
Blood glucose (finger stick)

HEALTH CARE HISTORY

Patient’s age and sex
Particulars of the instance (onset, duration, while
sitting or standing, any nausea, perspiration,
muscular spasms, incontinence, etc. )
All current prescription drugs, including any recent
changes, particularly those connected with
dizziness, hypotension, altered heart rate/rhythm
or listlessness
Any history of comparable episodes
All present diagnoses
Any recent laboratory or diagnostic test outcomes

Syncope is a brief loss of consciousness triggered by
a temporary insufficiency of oxygen in the brain. Ask
patient:
Describe what you experienced just before you fainted?
Did you feel the room spinning? (objective vertigo)
Did you feel like you were spinning? (subjective
vertigo)
If this has took place on more than one occasion:
When did you begin to notice this?
Does it happen at a certain time of day?
Does it occur after taking certain prescription drugs?
How frequently does it occur?
Observe for:
Variations in level of consciousness
Difficulties with gait
Issues with alterations in pupils
Alterations in cosmetic symmetry; ask the patient to
puff out cheeks, smile, frown
Weakness in arms and legs
Alterations in speech such as lack of ability to speak,
problems talking, or inappropriate responses.

FALLS

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PHYSICAL DATA

Vital signs, particularly orthostatic blood pressure and
pulse
Indicators of injury, particularly bone fracture or head injury
Neuro assessment if head injury or unwitnessed fall
If diabetic, blood glucose (finger stick)
Evidence of joint deformity or change in usual range of
movement, weight bearing, etc.
Any alterations in cognition or degree of awareness
Evidence of localized weakness, inadequate coordination,
reduced equilibrium, unnatural gait
Discomfort assessment (spot, characteristics,
intensity, etc.)

HEALTH CARE BACKGROUND

Patient’s age and sex
Rate of recurrence and amount of falls since previous

doctor visit
Precipitating elements (dizziness, fainting, environmental
factois, etc.) and particulars of circumstances of the fall
All present prescription drugs, including any recent
alterations
particularly those linked with dizziness, hypotension,
or listlessness
New equilibrium difficulties
All present diagnoses
Any recent laboratory (esp hct/hgb, vit D level, TSH, T4) or diagnostic
examination results

Assessment to consist of:
Examine for injuries (particularly to the head, neck,
spinal column, and extremities) such as soreness, inflammation,
bruising, lacerations, reduced activity or range of motion
(if assessment displays difficulties, find matching
assessment card and carry out evaluation).
Observe for:
Alterations in level of awareness
Changes in gait
Changes in pupils
Changes in cosmetic evenness: ask the affected person to puff out
cheeks, smile, frown
Changes in muscular power

Start critical thinking:
Residents who are using anti-coagulants or have
disorders such as brittle bones have the prospective
to have a significant consequence of falling. Observe
very carefully for those implications.
Explain what you saw and be objective (for instance
what position was the resident in when you discovered him/
her).
How hard did they fall (for instance, impetus  of the
fall)?
What incidents transpired or did the patient complain of
anything at all prior to the fall?
It is not exceptional to have delayed difficulties soon after a
fall. The challenges may take place within a few days after
the fall, sometimes they can occur many weeks later.
Systematic intracranial hemorrhaging and fractures may
arise days to several weeks after an actual fall.