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Health History- Assess. CH4 > CH4 > Flashcards

CH4 Flashcards

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1
Q

What is the purpose of the health history?

A
  • to collect subjective data- what the person says about him or herself
  • It describes individual as a whole and how the person interacts with the environment
  • records strengths and coping skills
  • screening tool for abnormal symptoms, health problems, concerns, and records ways of responding to health problems
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2
Q

What does the health history recognize and affirm?

A

It should affirm what the person is doing RIGHT.

  • what he or she does to stay well.
  • For the well person, the health hx is used to assess his or her lifestyle (exercise, diet, substance use, risk reduction, health promo behaviors)
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3
Q

For an ill person, what should be included in the health hx?

A

a detailed and chronological record of the health problem

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4
Q

Health History Sequence

A
  1. Biographic Data
  2. Reason for seeking care
  3. present health or history of present illness
  4. past history
  5. Family history
  6. Review of symptoms
  7. Functional assessment of ADLs
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5
Q

What is included in Biographic Data?

A
  • Name, address, phone, age, birthday, birthplace, gender, marital status, ethnic origin, occupation.
  • note usual occupation and present occupation (illness or disability may have prompted change in occupation)
  • Record language and communication needs. Primary language and authorized representative. Joint commission requires hospitals to record language and communication needs)
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6
Q

What is included in Source of History?

A
  1. Record who gives the info- the person, relative, friend, coworker
  2. Judge how reliable the informant seems, and willingness to communicate.
  3. Note any special circumstances like an interpreted present.

*reliable person can be determined by rephrasing a question or repeating a question later, and person gives the same responses.

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7
Q

What is included in Reason for Seeking Care?

A
  • brief, spontaneous statment in persons own words.
  • states signs and symptoms
  • try to record whatever the person says is the reason for seeking care in quotation marks and record time frame
  • avoid writing the diagnosis because that is not what prompted the visit, the symptom did.
  • avoid recording a patients self-diagnosis, and instead ask what symptoms make them think they have _______.
  • If the patient lists many reasons for seeking care, ask them and only record what made them seek help NOW.
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8
Q

What is included in present health or history of present illness for the well person?

A

Short statement about the general state of health. “I feel healthy right now”

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9
Q

What is included in the history of illness for an ill person?

A
  • this section is a chronological record of the reason for seeking care, from the time the first symptom started until now.
  • isolate each reason for care identified by the person
  • If the concern started years or months ago, ask what happened in between then and now, and ask what prompted them to seek care NOW.
  • Include the 8 critical characteristics
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10
Q

What are the 8 critical characteristics of the health history?

A
  1. Location: specific, point to location, and note precise site “pain behind the eyes”.
    - is the pain localized or radiating?
    - Is the pain superficial or deep?
  2. Character or Quality: More descriptive terms to describe pain- burning, sharp, dull, aching, gnawing, throbbing, shooting. Use similes to help patient describe things (does blood in stool look sticky like tar?
  3. Quantity or severity: Quantify the sign or symptom such as “its profuse menstrual flow, needing 5 pads every hour”. Quantify pain on pain scale of 1-10.
  4. Timing: Onset, duration, frequency. When did it appear, how long did it last, was it constant, or come and go? did it resolve completely? Did it reappear?
  5. Setting: Where where you when it started? What brings it on?
  6. Aggravating factors or relieving factors: what makes it worse? What makes it better?
  7. Associated Factors: Is the primary symptom associated with any others? Review body system related to the symptom now. Review medication regimen, and alcohol and tobacco use because symptom may be a side effect.
  8. Patients Perception: Find meaning of symptom by asking how it has affected the patient. Directly ask them what they think the symptom means because it alerts you to potential anxiety if the person thinks the symptom is ominous.
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11
Q

Why are past health events important?

A
  • they have residual effects on the current health state
  • previous experience with illness may give clues as to how the person responds to illness
  • clues on the significance of illness to the patient
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12
Q

What is included in asking about childhood illnesses?

A
  • Mumps, measles, rubella, chicken pox, pertussis, strep throat.
  • Do not record “unusual childhood illnesses”
  • Ask about serious illness that may affect them in later years (rheumatic fever, scarlet fever, poliomyelitis)
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13
Q

What is included in accidents or injuries?

A

Auto accidents, fractures, penetrating wounds, head injuries*(especially if associated with unconsciousness), burns

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14
Q

What is included in serious or chronic illnesses?

A

Asthma, depression, diabetes, hypertension, heart disease, HIV, hep, sick cell anemia, cancer, seizure disorders

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15
Q

What do you ask about hospitalizations?

A

Cause of hospitalizations, name of hospital, how condition was tx, name of physician, length of stay

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16
Q

What do you ask about operations?

A

Type of surgery, date, name of surgeon, name of hospital, and how person recovered

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17
Q

What do you as about OB hx?

A
  • Number of pregnancies (gravidity)
  • number of deliveries in which fetus reached full term (term)
  • number of incomplete pregnancies (abortions)
  • number of children living ( living)
  • for each complete pregnancy, note the course of pregnancy, labor, delivery, gender, weight, and condition of each infant. Note postpartum course.
  • for incomplete pregnancies note the duration and whether the pregnancy resulted in induced abortion (I), or spontaneous abortion (S)
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18
Q

What Immunizations do you ask about?

A
  • measles-mumps-rubella
  • polio
  • diptheria-pertussis-tetanus
  • varicella
  • hep a & hep b
  • pneumococcal vaccine
  • influenza
  • note date of last tetanus, and last TB
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19
Q

What does the CDC recommend for the HPV vaccine?

A
  • Women ages 19-26

- Men ages 9-26

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20
Q

What does the CDC recommend for MMR?

A

Most adults born after 1957 don’t need a 2nd vaccination if they can document receiving at least one dose.
- health care workers, college students, international travelers, and adults exposed to measles out break need second dose.

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21
Q

What do you ask about last exam dates?

A

Dates of last:

  • physical
  • dental
  • vision
  • hearing
  • ECG
  • chest xray
  • mammogram
  • pap
  • stool occult
  • serum cholesterol
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22
Q

What do you note about allergies?

A
  • Note both allergen and the reaction

- if it is a drug, then make sure it is an actual allergy and not a side effect

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23
Q

What do you note about medications?

A
  • all Rx and all OTC meds
  • vitamins, BC pills, aspirin, antacids (always ask about these because people dont consider them medications)
  • For each medication, document the name, dose, and schedule. What is the med for? How long have you been taking it? How often do you take it each day?
  • inquire about substances (alcohol, smoking, street drugs)
  • inquire about home or herbal remedies
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24
Q

What is the best way to complete a family history?

A

Send home detailed questionnaire before the healthcare encounter because the information takes time to compile. Then use the health visit to complete it.

25
Q

What should you record about each relative?

A
  • age, cause of death, winning, tobacco use, heavy alcohol use.
  • ask specifically about coronary heart disease, high blood pressure, stroke, diabetes, obsesity, blood disorders, breast/ovarian cancer, colon cancer, sickle cell anemia, arthritis, allergies, alcohol, drug addiction, mental illness, suicide, seizure, kidney disease, TB
26
Q

What is the purpose of the Review of Systems portion of health hx?

A
  1. evaluate past and present health state of each body system
  2. double check in case any significant data was left out in the present illness section.
  3. evaluate health promotion practices
    * only ask what was not already covered in the present illnes section
27
Q

When recording information in the review of systems, what should you avoid doing?

A
  • do not write “negative” after the system heading. You need to record the “presence” or “absence” of all symptoms or the reader does not know which systems you asked about.
28
Q

What is a common mistake made by many new practitioners when doing the Review of Systems?

A
  • recording a physical finding or objective date in this section. (example- “skin was warm and dry”)
  • this section is only for subjective data stated by the patient. Factors the patients says were or were not present.
29
Q

What is reviewed in the Review of Systems?

A
  1. General overall health state: weight (gained or losses), fatigue, weakness, fever, chills, sweats.
  2. Skin: Hx of skin disease, pigment or color changes, rashes, lesions
  3. Hair: recent loss, change in texture, Nail changes.
    * health promotion= amount of sun exposure, method of self-care for skin and hair.
  4. Head: Any unusually frequent headaches, injury, dizzy
  5. Eyes: vision difficulty, eye pain, diplopia, swelling, redness, etc.
    * Health promotion= wears glasses or contacts, last vision check or glaucoma test, how they are coping with vision loss
  6. Ears: earaches, discharge and characteristics, infections, discharge, tinnitus, vertigo
    * Health Promotion: Hearing loss, hearing aid use, how loss affects them, exposure to environmental noise, method of cleaning ears
  7. Nose and sinuses: Discharge and characteristics, frequent colds, sinus pain, bleeds, allergies, change in smell
  8. Mouth and throat: Mouth pain, frequent sore throat, bleeding gums, lesions, hoarseness
    * Health promotion= pattern of daily care, use of denture, bridge, last dental check up
  9. Neck: pain with motion, lumps, swelling, enlarged or tender nodes
  10. Breast: pain, lump, nipple discharge, rash, hx of breast disease, any surgery
    * health promo= preform SBE, including its frequency and method used. date of last mammogram
  11. axilla: tenderness, lump, swelling, rash
  12. Respiratory system: History of lung disease (asthma, emphysema, etc…), wheexing, shortness of breath,
    * Health promo= last chest xray, lst tb test
30
Q

How do you eval health promo practices for the cardiovascular system?

A

Date of last ECG
Cholesterol screenings?
Other heart tests?

31
Q

How do you evaluate health promo for peripheral vascular system?

A

Does your work involve long periods of standing or long term sitting?
Avoid crossing legs at knees
wear support hose

32
Q

How do you evaluate health promotion of the GI system?

A

Use antacids?
Use laxatives?
Diet hx and substance habits can be placed here too

33
Q

How do you evaluate health promotion for urinary system?

A

Measure to avoid or treat a urinary tract infection

use of kegels after childbirth

34
Q

How do you eval health promotion for the male genital system?

A

Do you perform testicular self-exam?

how often?

35
Q

How do you eval female genital system?

A

Last OBGYN appt? Last pap test?

36
Q

What should you include when asking about sexual health?

A

Begin with “I usually ask all patients about their sexual health”

then: “are in currently in a relationship involving intercourse?”
- ask about use of condoms, and pills
- ask about dyspareunia for women, and erection or ejac changes in males.
- ask if partners has had any STD

37
Q

How do you eval health promotion for musculoskeletal system?

A

How much do you walk per day? what is the effect of limited ROM on daily activities? Do you use and mobility aids?

38
Q

How do evaluate the hematologic system?

A
  • bleeding tendency of skin or mucous membranes
  • Excessive bruising
  • lymph node swelling
  • exposure to toxic agents or radiation
  • blood transfusions and reactions
39
Q

How do you eval endocrine system?

A
  • Hx of diabetes
  • hx of diabetic symptoms (polyuria, proteinuria, polyphagia)
  • hx of thyroid disorder
  • cold or heat intolerance
  • change in skin pigmentation or texture
  • excessive sweating
  • tremors
  • relationship between appetite and weight
40
Q

What is the purpose of the functional assessment?

A
  • measures a persons self-care ability in areas of general physical health or absence of illness
  • measures ADLs (bathing, dressing, eating, walking, those needed for independent living such as housekeeping, cooking, laundry; self-concept; home and environment.
  • may measure a persons functional status and monitor changes in that status over time
  • should include F.A. questions in the health history
41
Q

When should you ask functional assessment questions?

A
  • these question are best asked later in the interview after rapport has been established because the data may feel private to the individual.
42
Q

Functional assessment questions are questions about…?

A
  1. Self-esteem, Self-concept
  2. Activity/Exercise
  3. Sleep/Rest
  4. Nutrition/Elimination
  5. Interpersonal Relationships/Resources
  6. Spiritual Resources
  7. Coping and Stress management
  8. Personal Habits
  9. Alcohol.
  10. Illicit or street drugs
  11. Evironmental/Hazards
  12. Intimate partner violence
  13. Occupational Health
43
Q

What would the nurse ask in the functional assessment to assess Self esteeem/Self concept?

A
  • Education: What was your last grade completed? Any other significant training?
  • Financial Status? Is income adequate for lifestyle/health concerns?
  • value-beliefe system: What are your religious practices? What is their perception of personal strengths?
44
Q

What would the nurse ask in the functional assessment to assess Activity and Exercise?

A
  • use a daily profile reflecting usual daily activities.
  • ask: “tell me how you spend a typical day?”
  • Note ability to do ADLs
  • Are they independent or do they need assistance?
  • Do they use any aids? (wheel chair, etc)
  • Record leisure activities enjoyed and exercise pattern )type, amount per day or week, method of warm up session, method of monitoring the bodys response to exercise
45
Q

What would the nurse ask in the functional assessment to assess sleep/rest?

A
  • what are your sleep patterns?
  • Do you nap?
  • Do you use any sleep aids?
46
Q

What would the nurse ask in the functional assessment to assess Nutrition and elimination?

A
    • do 24 hour recall of all food and bev.
  • “is this menu typical of most days?
  • describe eating habits and current appetite
  • are your finances adequate for food?
  • Who is present at meal times?
  • Indicate and food allergies or intolerances
  • Record caffeine intake
  • ask about bowel elimination, incontinence, problems with mobility
47
Q

What would the nurse ask in the functional assessment to assess interpersonal relationships/resources?

A
  • social roles: “how do you describe your role in your family?”
  • “how would you say you get along with family, friends, co-workers?”
  • Support systems: Who do you go to for support?
  • Is time spend alone pleasurable and relaxing or does it feel isolating?
48
Q

What would the nurse ask in the functional assessment to assess spiritual resources?

A
  • Many believe in a relationship between spirituality and health and may want to have spiritual matters addressed in a traditional health care setting
  • Use FICA questions = Faith, Influence, Community, Address. to incorporate the persons spiritual values into the health hx.
49
Q

How do you use FICA/what questions do you ask to incorporate spiritual values into the health history?

A
  • Faith= “does religious faith or spirituality play an important part in your life? Do you consider yourself to be religious?
  • Influence= How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?
  • Community= Are you a part of any religious or spiritual congregation?
  • Address= Would you like me to address any religious or spiritual issues or concerns with you?
50
Q

What would the nurse ask in the functional assessment to assess coping and stress management?

A
  • what kind of stress is in your life? Especially in the past year.
  • any change in lifestyle or any current stress?
  • What methods do you use to relieve stress?
  • have these been helpful?
51
Q

What would the nurse ask in the functional assessment to assess personal habits?

A
  • Tabacco, alcohol, drugs: do you smoke cigs (pipe, chew)? At what age did you start? How many packs per day (PPD)? How many years have you smoked? *always record PPD and duration (2 PPD x4years)
  • Have you ever tried to quit? How did it go? (to introduce smoking cessation plan)

-

52
Q

What would the nurse ask in the functional assessment to assess alcohol?

A
  • important because alcohol interacts adversely with meds., is a major factor in many social problems, and car accidents, etc.
  • be alert to early signs of alcohol use
  • ask them if they drink alcohol
  • if yes, ask frequency and amount –> “when was your last drink of alcohol? How much did you drink that time?
  • Out of 30 days, how many of the days do you drink alcohol?
  • Use can use a screening questionnaire to identify excessive or uncontrolled drinking ( the CAGE test)
  • if person answers “no” to drinking, ask them the reason. Any hx of alcohol treatment? Recovery activities? History of a family member drinking?
53
Q

What is the CAGE test?

A
  • used in functional assessment to ID excessive or uncontrolled drinking
  • Cut down, Annoyed, Guilty, Eye-opener (CAGE)
  • Have you ever thought you should Cut down your drinking?
  • Have you even been Annoyed by criticism of your drinking?
  • Have you ever felt Guilty about your drinking?
  • Do you drink in the morning (an Eye opener)
  • if person answers yes to 2 or more, then suspect alcohol abuse
54
Q

What would the nurse ask in the functional assessment to assess illicit or street drugs?

A
  • marijuana, cocaine, crack, amphetamine, heroin, pain killers, barbituates?
  • frequency of use and how the usage affects work and famly
55
Q

What would the nurse ask in the functional assessment to assess Environment/Hazards?

A
  • Houseing and neighborhood: do you live alone? do you know your neighbors? Safe area? transportation access?
  • note hazards, use of seatbelt, geographic or occupational exposures
  • time spent abroad, in other countries (military service, travel)
    `
56
Q

What would the nurse ask in the functional assessment to assess intimate partner violence?

A
  • Begin with open ended questions “how are things at home?” Do you feel safe?
  • If they respond to feeling unsafe, follow with closed end question, “have you ever been emotionally or physically abused by your partner or someone important to you?”, Within the past year have you been, hit, slapped, kicked, etc?
  • by whom?
  • how many times?
57
Q

What would the nurse ask in the functional assessment to assess occupational health?

A
  • ask them to describe their job
  • ever worked with any health hazard? inhalants? asbestos? chemicals? repetitive motion?
  • Do you wear protective equipment?
  • take careful smoking hx because it might be a contributing factor to occupational hazards
  • not time and reason for seeking care and whether it is related to change in work or home activities, job titles, exposure history.
  • ask what they like or dislike about their job.
58
Q

What would a nurse ask to find out the patients perception of health?

A
  • How do you define health?
  • How do you view your situation now?
  • What are your concerns?
  • What do you think will happen in the future?
  • What are your health goals?
  • What do you expect from us as nurses, physicians?

Health History- Assess. CH4 (1 decks)

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