Ch.4: The Complete Health History Flashcards
what is the purpose of health history?
to collect subjective data
what the person says about himself/herself
subjective data
what you observe through measurements, inspection, palpation, percussion, and auscultation
objective data
the history should recognize affirm
what the person is doing right, as well as assess his or her lifestyle
Biographic data includes
name, address, phone number, age, birthdate, birthplace, gender, marital partner, status, race, ethnic origin and occupation, primary language
Source of History:
- record who furnishes the info
- reliability
- person appears well or ill
subjective sensation that the person feels from the disorder
symptom
an objective normality that you as the examiner could detect on physical examination or in laboratory reports
sign
Reason for seeking care:
try to record what the person is saying directly
list for symptoms
focus on the most pressing concern (now)
Eight Critical Characteristics Data (symptoms)
- Location
- Character
- severity
- timing
- setting
- relieving factors
- associated factors
- patient’s perception
Past health events are important because
they may have residual effects on the current health state
comparison of a list of current medications with a previous list, which is done at every hospitalizations and every clinic visit. its purpose is to reduce errors and promote patient safety
medication reconciliation
a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents and siblings
pedigree/genogram
CULTURE:
immigrants on biographical data- may evoke painful memories
spiritual resources/beliefs (Jehovah’s Witness)
past health- immunizations given in the homeland
health perception- how they describe health and illness
nutritional-foods taboo
Review of Systems:
- to evaluate the past and present health state of each body system
- to double-check in case any significant data were omitted
- to evaluate health promotion practices
ORDER OF EXAMINATION IS HEAD TO TOE
measures a person’s self-care ability in the areas of general physical health or absence of illness.
Functional Assessment
ADL’s/ functional assessment include
self esteem exercise sleep nutrition interpersonal relationships spiriritual resources coping and stress management personal habit alcohol drugs environment intimate partner violence occupation health
Perception of Health
“how do you define health?”
how do you view your sitiation
what do you expect from us as nurses?
Health history sequence:
Biographic date reason for seeking care present health or history of present illness past history medication reconciliation family history review of systems functional assessment or ADL's
CAGE TEST
use as a screening questionnaire to identify excessive or uncontrolled drinking
Cut down
Annoyed
Guilty
Eye-Opener
answer to yes to 2 of the 4 (alcohol abuse)
The Adolescent
HEEDASSS home environment eating education drugs peer-related activities sexuality suicide safety
