Nutrition and hydration a history of conditions that

Nutrition and Hydration
 A history of conditions that increase the
risk of malnutrition or obesity. Nausea
and vomiting. Normal daily intake.
Weight changes, noting if changes were
intentional or not, dehydration, dry skin,
fluid excess with shortness of breath, or
edema in the feet and legs. Diet
practices to promote health.
Skin
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 History of skin disease (eczema,
psoriasis), change in pigmentation,
texture or color, change in mole,
excessive dryness, sweating, pruritus,
hair growth and distribution, excessive
bruising.
Hair
 Recent loss, change in texture. Nails:
change in shape, color or brittleness
 Health promotion : amount of sun
exposure, method of self-care for skin
and hair.
Head and Neck
 Any unusually frequent or severe
headache, any head injury, dizziness,
vertigo, syncope, sinus pain.
 A history of high or low thyroid hormone
level.
 Pain in neck, limitation of motion, lumps
or swelling, enlarged or tender nodes,
goiter.
Eyes
 Difficulty with vision (decreased activity,
blurring, blind spots), eye pain, diplopia
(double vision), redness or swelling,
watering or discharge, glaucoma,
cataracts, photophobia, itching.
 Use of contact lens or glasses
 Last eye examination and any changes
at that time.
Ears
When vertigo strikes image
 A history of ear or hearing problems,
hearing loss, and ear infections. Ear
pain, change in hearing, tinnitus, and
vertigo.
 Last hearing evaluation and results and
ear protection.
Nose and Sinuses
 Discharges and its characteristics, any
unusually frequent or severe colds,
sinus pain, nasal obstruction,
nosebleeds, allergies or hay fever, pr
change in the sense of smell.
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Mouth and Throat
 Mouth pain, frequent sore throat,
bleeding gums, toothache, lesion in
mouth and tongue, dysphagia (difficulty
in swallowing), hoarseness or voice
change, tonsillectomy, altered taste.
 Health promotion : pattern of daily dental
care, use of prostheses (dentures and
bridge) and last dental check-up.
Breast
 Pain, lump. Nipple discharge, rash,
history of breast disease, any surgery on
the breasts
 Health promotion : performs breast self-
examination (BSE), including its
frequency and method used, last
mammogram.
Axilla
 Tenderness, lump or swelling, rash
Respiratory System
 History of lung diseases (asthma,
emphysema, bronchitis, pneumonia,
tuberculosis)
 Chest pain with breathing
 Wheezing or noisy breathing
 Shortness of breath, how much activity
produces SOB
 Cough, sputum (color, amount),
hemoptysis (coughing up with blood)
 Toxin or pollution exposure
 Health promotion : last chest x-ray study
Cardiovascular System
 Precordial or retrosternal pain
 Palpitations
 Cyanosis (bluish discoloration of the
skin)
 Dyspnea on exertion (e.g., shortness
when walking one flight of stairs, walking
from chair to bath, or just talking
 Orthopnea (difficulty in breathing when
lying down, relieved by upright position)
 Paroxysmal Nocturnal Dyspnea
(difficulty in breathing 2-5 hours after
going to sleep during the night)
 Edema
 History of heart murmur
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