Phys. Assess Ch. 5
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| What is the purpose of a health history? | to collect subjective data and objective data
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| What is the data base used for? | used to make a judgement or a diagnosis about the health status of the individual
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| A health record should? | include pt. strengths and coping skills
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| What should the history do? | recognize and affirm what the person is doing right, or what they are doing to stay well
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| What is the purpose of a history for a healthy person? | assess his or her lifestyle
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| What is the purpose of a history for a ill person? | to determine all health problems
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| What is a health history? | a screening tool for abonormal symptoms
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| What is included in a history? | biographical data, health history, reason for seeking care, past history, family history, review of systems, and ADL's
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| What is biographic data? | name, adress, phone number, age and birthday, birthplace, gender, marital status, race, ethic orgin, occupation, health history
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| They also have to record? | language and communcation needs
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| What do you need to do when recording history? | record who gives the info., judge how reliable they are, note any special circumstances
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| What is a symptom? | a subjective sensation that ther person feels from the disorder
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| What is a sign? | an objective abnormality that you as the examiner could detect on examination or reports
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| The reason for seeking care is not? | a diagnostic statement
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| What should you record? | pt symptoms
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| pt will state many concerns you as a nurse should? | focus on which is most important to the pt
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| What is health history for a ill pt? | a chronologic record for seeking health care
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| as a person talks do not? | jump to conclusions
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| What are the 8 critical charecteristics? | location, quality, severity, timing, setting, relieving factos, associated factors, and pt's perception
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| With location the person should? | note the percise site
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| How should a person describe the quality of pain? | buring, sharp, dull, aching, gnawing (use similies)
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| How do you try to get someone to describe severity? | How it impacts their ADL
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| How should a person decribe timing? | when symtoms appear date and time
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| How do you describe setting? | where was the person when the symptoms started
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| What are aggravating or relieving factors? | what makes the pain worse, what makes it better
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| What are associated factors? | is this primary symptom associated with any others?
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| What is PQRST? | palliative, quality,region or radiation,severity scale,timing, understand pt's perception
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| What is palliative? | What brings the pain on, what were you doing when you first noticed it
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| What is region? | where is the pain
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| What is severity scale? | how bad is the pain
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| What is understanding pt's perception? | what the pt thinks it means
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| What does past experience help identify? | how the person responds to illness
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| Do not refer to childhood illnesses as? | "usualy childhood illnesses"
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| You as a nurse should know about? | accident, chronic illnesses, hopitilizations, operations, and obstetric history
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| When asking for meds you should ask specifically about? | vitamins, birth control pills, asprin, antacids
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| For each medication you should note? | does, name, and schedule
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| 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
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| 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
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| How is the review of systems done? | head to toe
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| Do not put negative when writing info you should put? | present or absent
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| History should be limited to? | pt statements or subjective data
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| What is in a general overall health state? | present weight, fatigue, fever, weakness, chilles, sweats
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| Health of skin? | History of skin disease
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| Hair? | recent loss, texture change
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| Head? | headaches, dizzy
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| Eyes? | vision difficulty, pain, swelling, redness
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| Ears? | infection, discharge
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| Nose? | Discharge, colds, sinus pain, bleeding, allergies
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| Mouth and throat? | pain, sore throat, bleeding gums..etc.
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| Neck? | pain, lumps, swelling
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| Breast? | pain, discharge
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| Respiratory? | history of lung disease, chest pain, wheezing, short breath, cough, sputum
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| Cardiovascular? | pain, cyanosis, syspnea, hypertension, anemia..etc..
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| Peripheral vascular? | coldness, numbness, swelling, discoloration of hands and feet, varicose vein
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| GI? | appetitie, food intolerance, dyphagia, heartburn, indigestion, pain, pyrosis, N and V
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| Urinary? | frequency, urgency, nocturia, dysuria, polyuria etc..
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| Male genitals? | penis pain, sores, discharge
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| Female genitals? | menstraul history, last one, pain, discharge, sores
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| Sexual health? | any sex?, contaceptive methods, condom
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| Musculoskeletal? | arthritis, gout, pain, stiffness, swelling, limit of motion etc..
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| Neurologic system? | seizures, stroke, fainting, blackouts etc..
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| Hematologic? | bleeding of skin, bruising, lymph node swelling
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| Endocrine? | history of diabetes, intolerance to heat and cold etc..
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| What does a functional assessment do? | measures a person's self care ability in the areas of general physical health or absence of illness
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| What do you include when questioning about self esteem? | education, financial status, value-belief
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| For activity you should record? | activites and excersice program
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| What you should ask about sleep? | sleep patterns, naps, sleep aids?
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| What should you ask for nutrition and elimination? | recall all foods and beverages in the last 24 hrs, appetite, food allergy, and elimination etc..
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| What would you ask for interpersonal relationships? | social roles, how you get along with ppl, time spent alone
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| What about spiritual resources? | How spiritual things influence health
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| Ask how do they cope? | kinds of stress in life
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| What personal habits should you include? | smoking, alcohol, drugs
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| 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)
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| For drugs you should ask about? | pot, cocaine, crack, and barbituates
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| What should you ask about enviroment? | surrouding, feeling safe
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| You should ask if they do what while driving? | where seat belts
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| What should you ask about partener violence? | start with how are things at home?
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| What should you ask about jobs? | if they like it or not
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| What is HEEADSSS? | Home environment education and employment eating peer related activites drugs sexuality suicide/depression safety from injury and violence
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| To remove stress you should? | start with less threatening questions
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| When interviewing youth parents should be where? | outside
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Created by:
alicia.rennaker
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