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NURS 307 > Chapter 4: Complete Health History > Flashcards

Chapter 4: Complete Health History Flashcards

1
Q

What is the purpose of a complete health history?

A

Is to collect subjective data and build rapport.

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2
Q

What are the two types of data?

A

Subjective vs. objective

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3
Q

Subjective data

A

What the person says about himself or herself

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4
Q

Objective data

A

What you observe through measurement, inspection, palpation, percussion and auscultation.

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5
Q

Adult Health History Sequence

A
  1. Biographical Data
  2. Source of history/Reliability
  3. Chief complaint/Reason for seeking care
  4. History of Present Illness
  5. Past Health
  6. Family History
  7. Functional Assessment (ADL)
  8. Review of Systems
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6
Q

Biographic Data

A

Includes name, address, phone number, date of birth, age, birthplace, gender, marital partner status, race, ethnic origin and occupation.

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7
Q

Source of History/Reliability

A
  1. Record who furnishes the information
  2. Judge how reliable the informant seems and how willing they are to communicate
  3. Note if the person appears well or Ill
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8
Q

Reason for Seeking Care/Chief Complaint

A

A. Brief spontaneous statement in client’s own words, should be in quotations
B. Usually just one symptom, concern, sign.

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9
Q

***History of Present Illness (HPI/Symptomanalysis)

A 
A. Location
B. Quality/Character
C. Quantity/Severity
D. Timing (onset, duration, frequency)
E. Setting
F. Aggravating and Relieving Factors
G. Associated Factors
H. Patient's Perception
I. (Radiation)
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10
Q

Past Health

A 
A. Childhood Illnesses
B. Accidents or injuries
C. Serious or chronic illnesses 
D. Hospitalizations
E. Operations
F. Obstetric History
G. Immunization a
H. Last Exam
I. Allergies
J. Medications
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11
Q

Family History

A

Disease processes that run in the family, think about genetic diseases.

A. Genogram - minimum of 3 generations, include ages, diseases, ages at death, cause of death, etc.

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12
Q

Functional Assessment (ADL)

A 
A. Education
B. Activities/Exercise
C. Sleep/rest
D. Nutrition
E. Roles/relationships/responsibilities/resources
F. Spiritual resources
G. Coping & Stress management
H. Personal Habits
I. Environment Hazards
J. Occupation Hazards
K. Safety
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13
Q

Review of Systems

A 
(Ask a minimum of 3 symptoms for each system)
A. General
B. Skin/hair
C. Head/neck
D. Eyes
E. Ears, nose, throat (mouth)
F. Breasts
G. Respiratory
H. Cardiovascular
I. Peripheral vascular
J. Gastrointestinal
K. Genitourinary/sexual health
L. Musculoskeletal
M. Neurological
N. Hematologist
O. Endocrine
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14
Q

History of Present Illness: Location

A

Ask the person to point to the location. If the problem is pain, note the precise site.

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15
Q

History of Present Illness: Character or Quality

A

Descriptive terms such as burning, sharp, dull, aching, etc.

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16
Q

History of Present Illness: Quantity/Severity

A

Quantify the symptom of pain using a scale.

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17
Q

History of Present Illness: Timing

A

Onset, Duration and Frequency. Ex) When did the symptom first appear? How often does it occur? How long does it last?

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18
Q

History of Present Illness: Setting

A

Where was the person or what were they doing when the symptom started? What brings it on?

19
Q

History of Present Illness: Aggravating and Relieving Factors

A

What makes the pain worse?What is the effect of any treatment? (What makes it better/What makes it worse?)

20
Q

History of Present Illness: Associated Factors

A

Is this primary symptom associated with any others?

21
Q

History of Present Illness: Patient’s Perception

A

Find out he meaning of the symptom by asking how it affects daily activities. Also ask directly, “What do you think it means?”

22
Q

History of Present Illness: Radiotion

A

Where is it? Does it spread anywhere?

23
Q

Past Health: Childhood Illnesses

A

Measles, mumps, rubella, chickenpox, pertussis, polio, strep throat (rheumatic fever/scarlet fever)

24
Q

Past Health: Accidents or Injuries

A

Auto accidents, fractures, etc.

25
Q

Past Health: Serious or Chronic Illnesses

A

Diabetes, asthma, hypertension, depression, etc.

26
Q

Past Health: Hospitalizations

A

Cause, name of hospital, treatment, duration, complications, etc.

27
Q

Past Health: Operations

A

Type of surgery, date, MD, hospital, complications, etc.

28
Q

Past Health: Obstetric History

A

G__ : Number of Pregnancies
T__ : Number of Deliveries in which the fetus reached full term.
PT__ : Number of Preterm pregnancies
Ab__ : Number of incomplete pregnancies (miscarriages or abortions)
L__ : Number of children living

29
Q

Past Health: Immunizations

A

Includes tetanus, influenza, TB, Hep A & B, zoster, pneumococcal, meningococcal, HPV

30
Q

Past Health: Last Examination

A

Type, date, results

31
Q

Past Health: Allergies

A

Note allergen and reaction

32
Q

Past Health: Medications

A

Name, dose/amount, frequency, duration, reason for use. Include prescription and over the counter, supplements, etc.

33
Q

Functional Assessment (ADL): Education

A
  • Last grade completed, other significant training
34
Q

Functional Assessment (ADL): Sleep/Rest

A

Sleep patterns, daytime naps, any sleep aids used

35
Q

Functional Assessment (ADL): Nutrition

A

Record the diet by a recall of all food and beverages taken over the past 24 hours.

36
Q

Functional Assessment (ADL): roles/relationships/responsibilities/resources

A

Ask about social roles, support systems, include contact with spouse, sibling, parents, children, friends, organizations, workplace.

37
Q

Functional Assessment (ADL): Spiritual Resources

A

Use FICA (Faith Influence Community and Address) questions to incorporate the person’s spiritual values in the health history.

38
Q

Functional Assessment (ADL): Coping and Stress Management

A

Types of stresses in life, especially in the past year. Any changes in lifestyle or an current stress methods tried to relieve stress and whether they worked.

39
Q

Functional Assessment (ADL): Personal Habits

A

Tobacco: Record number of packs smoked per day and duration. Ask if they tried to quit.
Alcohol: Ask whether person drinks. Ask specific question about the amount and frequency of alcohol use.
Street Drugs: Ask about prescription painkillers such as OxyContin, Vicodin,cocaine, etc. Indicate frequency use and how it has affected work and family.

40
Q

Functional Assessment (ADL): Environmental Hazards

A

Housing and Neighborhood.
Safe area?
Adequate heat and utilities, access to transportation and involvement in community services.
Note environmental health.

41
Q

Functional Assessment (ADL): Occupational Hazards

A

Ask the person to describe his or her job.
Ever work with any health hazards such as inhalants, chemicals, etc.
Wear any protective equipment? …

42
Q

Functional Assessment (ADL): Safety (domestic /intimate partner violence)

A

Has the patient ever been physically or emotionally abused? Feel safe?

43
Q

Review of Symptoms

A

needs to ask a minimum of 3 symptoms for each system.
general, skin/hair, head/neck, eyes, ear/nose/throat(mouth), breasts, respiratory, cardiovascular, peripheral vascular, gastrointestinal, genitourinary/sexual health, musculoskeletal, neurologic, hematologic, endocrine

44
Q

The purposes of the review of systems are to:

A

(1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices

NURS 307 (29 decks)

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