208 Concept: Comm and Clinical judgment: Topics: General Survey and Health History (special considerations) Flashcards
Define symptom.
A subjective sensation that the patient feels from the disorder.
Define sign.
An objective abnormality that you as the examiner could detect on physical examination or in lab reports.
T or F: The purpose of a health history is to collect objective data about the health of an individual.
False. The purpose of the health history is to collect subjective data.
T or F: A health database is formed by combining data from the health history, the physical exam, and laboratory studies.
True
T or F: A complete health history provides a picture of the patient’s past and current health.
True
T or F: The health history is a screening tool for abnormal symptoms, health problems, and concerns.
True
T or F: A person’s routine remedies for health problems should not be included in the health history.
False. Note all prescription and over-the-counter medications in the health history. Ask specifically about vitamins and other supplements, birth control pills, Aspirin, and antacids; note use of complementary therapies, such as homeopathic or herbal remedies.
T or F: The health history informant should always be the person who is seeking treatment.
False. The informant is usually the patient, but it may be a parent or, in some cases, a relative or friend.
What is the sequence of the health history?
- Biographical date
- Reason for seeking care
- History of current illness
- Past health history
- Family health history
- Review of systems
- Functional assessment
What four elements do you look at during the General Survey?
- Physical appearance
- Body structure
- Mobility
- Behaviour
During the General Survey, when assessing physical appearance, what are you paying attention to?
- age
- sex
- level of consciousness
- skin colour
- facial features
What is objective data?
What you get out of the patients records
Use of your 5 senses
What is subjective data?
What the patient tells you or a family member
Can use italics or quotes
What are some common interviewer traps?
Using authority Talking too much False Reassurance Giving unwanted advice Using leading/biased questions Using medical jargon Avoidance language
What are developmental considerations for communication with infants and children?
Parents/caregivers source of information; allow children opportunity to answer (ie. Pain assessments)
What are developmental considerations for communication with adolescents?
Want to be adults, but don’t necessarily have the cognitive ability; may or may not be capable of mature actions.
What are developmental considerations for communication with older adults?
Address by last name (Mr Smith); interviews may take longer or may need to break up due to storytelling or physical limitations
What are you assessing for physical appearance during the General Survey?
Age Gender Level of consciousness Skin colour Facial features
What are you assessing for body structure during the General Survey?
Stature Nutrition Symmetry Posture Position Body build, contour Physical deformity
What are you assessing for mobility during the General Survey?
Gait
Range of motion
Mobility aids
What are you assessing for behaviour during the General Survey?
Facial expression Mood and affect Speech Dress Personal hygiene
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
A)To provide an opportunity for interaction between the patient and the nurse
B) To provide a form for obtaining the patient’s biographic information
C) To document the normal and abnormal findings of a physical assessment
D)To provide a database of information about the patient’s past and current health
D) To provide a database of information about the patient’s past and current health
What information does biographical data cover?
Name Address and phone number Age and birth date Birthplace Gender Marital status Ethnocultural background Occupation (usual and present) Source of information (Including primary language and authorized representative)
What information does the reason for seeking care cover?
- A brief statement in patient’s words, using quotation marks; Includes health maintenance, health promotion, or wellness needs
- Symptom: Subjective sensation
- Sign: Objective abnormality. Detectable on physical examination or in laboratory reports
What information does the reason for seeking care cover?
Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetrical history Immunizations Most recent examination date Allergies Current medications
What information does the reason for seeking care cover?
Age and health or cause of death of blood relatives
Health of close family members (spouse, children)
Family history of various conditions, such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental health issues, and others
Family tree (genogram) (not today)
What developmental/special considerations exist for a health history for infants and children?
Developmental history - milestones Nutritional history Family history Review of systems Elimination Immunization Any chronic illnesses Social aspects
What developmental/special considerations exist for a health history for adolescents?
HEEADSSS method of interviewing Home environment Education and employment Eating Activities, peer-related Drug (substance) use Sexuality Suicide or depression Safety from injury and violence
What developmental/special considerations exist for a health history for older adults?
ADLs impacted by aging
- senses
- mobility
- sexuality
- safety
- medications/chronic conditions
What is the purpose of the review of systems section?
a) evaluate the past and current health state of each body system
b) double-check in case any significant data were omitted in the Current Illness section
c) to evaluate health promotion practices
What is the order of examination in the Review of Systems section?
approximately head to toe
