Term
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Definition
| Brief statement in patient's own words |
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Term
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Definition
OLDCARTS
Affects client's usual lifestyle
Summaries current health status/health promotion/disease prevention if no presenting problems |
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Term
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Definition
| General state of health as patient percceives it; childhood illnesses; major adult illnesses, psychiatric illnesses, accident & injuries, surgeries |
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Term
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Definition
| Medications, allergies, tobacco, alcohol, drugs, nutrition, screening tests, immunizations, sleep patterns, exercise, hobbies, environmental, use of safety measure, diabilities |
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Term
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Definition
age, health, age and cause of death of immediate family
Heart Dx, HTN, CVA, DM, CA, Epilepsy, Kidney DX, Endocrine, pulmonary, blood disorders, congenital anormalities, mental illness
Adoption |
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Term
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Definition
| Living conditions, support system, stressors, domestic violence, religious beliefs, outlook on present and future |
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Term
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Definition
| Home, Education, Activities, Drugs, Sex, Suicide |
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Term
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Definition
Gravity, Parity, GTPAL
Infertility treatment |
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Term
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Definition
Menarche, regularity, frequency, duration, amt
LMP, PADS, Tampons, douching
DUB, PMS, Amenorrhea, Perimenopausal, Age of menopause, hormonal therapy, postmenstrual bleeding |
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Term
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Definition
| Age, History of abuse, assault, sexual orientation |
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Term
| Current Sexual Relationships |
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Definition
| Freq, satisfaction, Dysparenunia, orgasmic, libido |
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Term
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Definition
| Total sexual partners, Sexual contact, Use of condoms, Previous Hx of STI, Use of drugs, Sex while drinking, stoned, drugs, HIV |
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Term
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Definition
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Term
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Definition
| Hysterectomy, not sexually active, females, menopausal, current use=how long, satisfaction, previous method use, length, reason for discontinuation |
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Term
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Definition
Endocrine: menes, breast, pregnancy, thyroid, menopause
GU: Des exposure, Uterine or ovarian problems
History of STI or pelvic infection
Hx or sx of vaginal infection
HX of abn PAP, date treatment
UTI: treatment
Urinary incontinence: KEGEL |
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Term
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Definition
| Gender, age, ethnic, family HX, Environmental, Lifestyle, Geographic, Inadequate preventive health care |
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Term
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Definition
S:subjective; O: objective; A: assessment of S & O; P: plan
Problem list: lists each identied or potential problems: onset, resolution |
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Term
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Definition
Inspection: sight and smell
General survey and body systems
Auscultation: Diaphragm: high pitch: S1S2
Bell: low pitch: large blood vessels
Percusion: light brisk tapping: size shape, location, density
Tympany: loud, high pitch drum
Hyperresonance: very loud, boom sound, lungs: emphysema
Resonance: healthy lung
Dull: liver, heart
Flat: muscle, bone
Palpation: Light, 1 cm; Deep, 4cm organs, masses |
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Term
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Definition
General appearance
BMI
Body fat distribution: waist in cm, hips in cm divide waist and hip >8 indicates central fat: DM, HTN, Stroke, HD |
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