Chapter 4 (The Complete Health History) Flashcards
Interpersonal relationships and resources such as support systems are assessed during the __________ assessment of the complete health history.
functional
Cognition and literacy level is part of the ________ status assessment.
mental
Appearance, dress, and hygiene are observations included in the _________ survey.
general
The _________ of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate.
source
The _______________ will assess lifestyle, including such factors as exercise, diet, risk reduction, and health promotion behaviors.
health history
Coping and stress management are assessed during the _______________ of the complete health history.
functional assessment
CAGE is a screening questionnaire to identify _________ or uncontrolled __________ .
What does it stand for?
excessive, drinking
(e.g., C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).
The purposes of the review of systems are to evaluate the _________ and ________ health state of each body system, to ___________ in case any significant data were omitted in the present illness section, and to _________ health promotion practices.
past and present
double-check
evaluate
Review of systems is limited to the patient _________ or ________ data.
statements
subjective
When recording information for the review of systems, the interviewer must document the presence or absence of all symptoms under the _____________.
system heading
Assessment of self-esteem and self-concept is part of the _________ assessment. Areas covered under self-esteem and self-concept include _________, ___________, and _________.
functional
education, financial status, and value-belief system.
Stressors, coping mechanisms, and change in the past year are all related to the coping and stress management section of the ______________.
functional assessment
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
What does the mnemonic mean?
Symptoms
P = provocative or palliative Q = quality or quantity R = region or radiation S = severity scale T = timing U = understand patient’s perception.
When taking a health history from an adolescent, the interviewer should interview the adolescent (alone w/ parent in waiting room) or (w/ parent in examination room)
interview the youth alone with a parent in the waiting area
Review of Systems. The purposes of this section are:
(1) to evaluate the past and present health state of each body system,
(2) to double-check in case any significant data were omitted in the Present Illness section, and
(3) to evaluate health promotion practices
Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness
ADLs, such as bathing, dressing, toileting, eating, walking; instrumental activities of daily living (IADLs), or those needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.
Explain F.I.C.A.
Faith: “Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?”
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 community or congregation?”
Address: “Would you like me to address any religious or spiritual issues or concerns with you?”
Explain C.A.G.E.
Have you ever thought you should CUT down your drinking?
Have you ever been ANNOYED by criticism of your drinking?
Have you ever felt GUILTY about your drinking?
Do you drink in the morning? (i.e., an EYE opener?)
What test is used to screen excessive intake of alcohol?
AUDIT
What supplemental information is added to the comprehensive history evaluation format when taking the health history of an infant?
Prenatal and natal history, pattern of growth and development, detailed review of immunizations
