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Phys. Assess Ch. 5

What is the purpose of a health history? to collect subjective data and objective data
What is the data base used for? used to make a judgement or a diagnosis about the health status of the individual
A health record should? include pt. strengths and coping skills
What should the history do? recognize and affirm what the person is doing right, or what they are doing to stay well
What is the purpose of a history for a healthy person? assess his or her lifestyle
What is the purpose of a history for a ill person? to determine all health problems
What is a health history? a screening tool for abonormal symptoms
What is included in a history? biographical data, health history, reason for seeking care, past history, family history, review of systems, and ADL's
What is biographic data? name, adress, phone number, age and birthday, birthplace, gender, marital status, race, ethic orgin, occupation, health history
They also have to record? language and communcation needs
What do you need to do when recording history? record who gives the info., judge how reliable they are, note any special circumstances
What is a symptom? a subjective sensation that ther person feels from the disorder
What is a sign? an objective abnormality that you as the examiner could detect on examination or reports
The reason for seeking care is not? a diagnostic statement
What should you record? pt symptoms
pt will state many concerns you as a nurse should? focus on which is most important to the pt
What is health history for a ill pt? a chronologic record for seeking health care
as a person talks do not? jump to conclusions
What are the 8 critical charecteristics? location, quality, severity, timing, setting, relieving factos, associated factors, and pt's perception
With location the person should? note the percise site
How should a person describe the quality of pain? buring, sharp, dull, aching, gnawing (use similies)
How do you try to get someone to describe severity? How it impacts their ADL
How should a person decribe timing? when symtoms appear date and time
How do you describe setting? where was the person when the symptoms started
What are aggravating or relieving factors? what makes the pain worse, what makes it better
What are associated factors? is this primary symptom associated with any others?
What is PQRST? palliative, quality,region or radiation,severity scale,timing, understand pt's perception
What is palliative? What brings the pain on, what were you doing when you first noticed it
What is region? where is the pain
What is severity scale? how bad is the pain
What is understanding pt's perception? what the pt thinks it means
What does past experience help identify? how the person responds to illness
Do not refer to childhood illnesses as? "usualy childhood illnesses"
You as a nurse should know about? accident, chronic illnesses, hopitilizations, operations, and obstetric history
When asking for meds you should ask specifically about? vitamins, birth control pills, asprin, antacids
For each medication you should note? does, name, and schedule
When getting family history you should specifically ask about? heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sick cell anemia, allergies, obesity, alcoholism, mental illnes, seizure disorder, kidney disease, and TB
What is the purpose for the review of systems? To evaluate past and present health state, to double check, and to eveluate health promotion practices
How is the review of systems done? head to toe
Do not put negative when writing info you should put? present or absent
History should be limited to? pt statements or subjective data
What is in a general overall health state? present weight, fatigue, fever, weakness, chilles, sweats
Health of skin? History of skin disease
Hair? recent loss, texture change
Head? headaches, dizzy
Eyes? vision difficulty, pain, swelling, redness
Ears? infection, discharge
Nose? Discharge, colds, sinus pain, bleeding, allergies
Mouth and throat? pain, sore throat, bleeding gums..etc.
Neck? pain, lumps, swelling
Breast? pain, discharge
Respiratory? history of lung disease, chest pain, wheezing, short breath, cough, sputum
Cardiovascular? pain, cyanosis, syspnea, hypertension, anemia..etc..
Peripheral vascular? coldness, numbness, swelling, discoloration of hands and feet, varicose vein
GI? appetitie, food intolerance, dyphagia, heartburn, indigestion, pain, pyrosis, N and V
Urinary? frequency, urgency, nocturia, dysuria, polyuria etc..
Male genitals? penis pain, sores, discharge
Female genitals? menstraul history, last one, pain, discharge, sores
Sexual health? any sex?, contaceptive methods, condom
Musculoskeletal? arthritis, gout, pain, stiffness, swelling, limit of motion etc..
Neurologic system? seizures, stroke, fainting, blackouts etc..
Hematologic? bleeding of skin, bruising, lymph node swelling
Endocrine? history of diabetes, intolerance to heat and cold etc..
What does a functional assessment do? measures a person's self care ability in the areas of general physical health or absence of illness
What do you include when questioning about self esteem? education, financial status, value-belief
For activity you should record? activites and excersice program
What you should ask about sleep? sleep patterns, naps, sleep aids?
What should you ask for nutrition and elimination? recall all foods and beverages in the last 24 hrs, appetite, food allergy, and elimination etc..
What would you ask for interpersonal relationships? social roles, how you get along with ppl, time spent alone
What about spiritual resources? How spiritual things influence health
Ask how do they cope? kinds of stress in life
What personal habits should you include? smoking, alcohol, drugs
What is CAGE? (alcohol) Have you ever thought you should CUT down on drinking? have you ever been ANNOYED by critsism Have you ever felt GUILTY aobut your drinking EYE opener (do you drink in the morning)
For drugs you should ask about? pot, cocaine, crack, and barbituates
What should you ask about enviroment? surrouding, feeling safe
You should ask if they do what while driving? where seat belts
What should you ask about partener violence? start with how are things at home?
What should you ask about jobs? if they like it or not
What is HEEADSSS? Home environment education and employment eating peer related activites drugs sexuality suicide/depression safety from injury and violence
To remove stress you should? start with less threatening questions
When interviewing youth parents should be where? outside
Created by: alicia.rennaker
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