Chapter 4 Health history Flashcards
What is the purpose of a health history ?
collect subjective data to go along with objective data from physical exam to form the data base
- gives a full image of pts past and present health, also can be used as a screening tool for abnormalities
- opportunitity for health promotion recommendations
What areas are included in the health assessment ?
Biographic data
Source of history
Reason for seeking care
Present health or history of present illness
Past health
Family history
Review of systems
Functional assessment including activities of daily living (ADLs)
biographic data to be included ?
Name, address, and phone number
Age, birth date, and birthplace
Gender (identification) and relationship status
Race and ethnic origin
Occupation: usual and present
Primary language
Language-concordant provider or medical interpreter
what is the reason for seeking care ? what do you document here ?
Brief spontaneous statement in person’s own words describing reason for visit
-symptoms ( subjective
- signs (objective)
what are the 8 critical characteristics
Location—be specific and precise
Character or quality—provide descriptive terms
Quantity or severity—use scales to identify intensity
Timing—onset, duration, and frequency
Setting—location and/or associated activity
Aggravating or relieving factors—what makes it worse or better
Associated factors—is the concern r/t any other symptom?
Patient’s perception—how does it affect you?
Question sequence should answer the following questions :
PQRSTU memonic =
P = Provocative or palliative
Q = Quality or quantity
R = Region or radiation
S = Severity scale: 1 to 10
T = Timing or onset
U = Understand patient’s perception of problem
past health history should include :
- Childhood illnesses
Experienced or exposed to presence or absence of complications - Accidents or injuries
Type and nature of event, acute and/or residual deficit noted
Serious or chronic illnesses
Presence of comorbidities has pronounced effect. - Hospitalizations
Types based on clinical indications, interventions used as therapy, and length of stay along with dates of occurrences - Operations
Facility, name of health care provider, and date of procedures - Obstetric History
Relevant data r/t childbearing inclusive of GPAL, labor/delivery experience, condition of infant, and postpartum course - Immunizations
Correlate with CDC Guidelines. - Last Examination Date
Obtain last data set for commonly occurring labs/diagnostics (blood work, ECG, chest x-ray, occult blood and gender-specific testing—PAP/PSA).
-Allergies
Note allergen and reaction. - Current Medications
why is it important to ask about family history
Highlights diseases or conditions that an individual may be at risk for as a result of genetics
Provides age and health or cause of death of relatives
Pedigree or genogram used as standardized tool to organize data
Results may lead to early screening, lifestyle adjustments, and/or undergo periodic surveillance
What is the purpose of the review of systems ?
Evaluate past and present state of each body system
Assess that all pertinent data relative to each body system have been noted
Evaluate health promotion practices
What are ADL’S
Self-care activities of daily living as they relate to general health status
ADLS should include
Self-esteem, self-concept
Activity and exercise
Sleep and rest
Nutrition and elimination
Interpersonal relationships and resources
Spiritual resources
Coping and stress management
Personal habits
Illicit or street drugs
Environment and work hazards
Intimate partner violence
Occupational health
what should be included when asking about perception of health ?
How do you define health?
How do you view your situation now?
What are your concerns?
What are your health goals?
What do you expect from us as nurses, physicians, or other health care providers?
how does a health history for a child differ ?
Addresses sections identified previously with regard to health history of the adult
Health history adapted to include information specific for age and developmental stage of child
Past health history for a child should contain ?
Prenatal, perinatal, and postnatal status
Developmental History- developmental milestones
Roles of caregivers and parental roles
Nutritional history
functional assessment for child ?
childs position in family unit, More focus on ADLs and how they relate to the family and child.
Interpersonal relationships
Activity and rest
Home environment
Environmental hazards
Coping and stress management
Habits
Health promotion
