Chapter 9: Nursing Process; Basic Components for a Nursing Health History Flashcards
Reasons for Seeking Health Care
Goals of care, expectation of the services and care delivered, and expectations of the health care system
Present Illness or Health Concern
Onset, symptoms, nature of symptoms, duration, precipitating factors, relief measures, and weight loss or gain
Health History
Prior illnesses throughout development; injuries and hospitalizations, surgeries, blood transfusions, allergies, immunizations, habits, prescribed and self-prescribed medications, work habits, relaxation activities, sleep schedule, exercise, eating or nutritional patterns
Family History
Health status of immediate family and living relatives, cause of death of relatives, risk factor analyses for cancer, heart disease, diabetes mellitus, kidney disease, hypertension, or mental disorders
Environmental History
Hazards, pollutants, and physical safety
Psycho-social and Cultural History
Primary language, cultural group, community resources, mood, attention span, and developmental stage
Review of Systems
Head-to-toe review of all major body systems and patient’s knowledge of and compliance with health care
