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U of R SCHOOL OF NURSING > CLASS 2 - HEALTH HISTORY > Flashcards

CLASS 2 - HEALTH HISTORY Flashcards

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1
Q

PURPOSE OF HEALTH HISTORY

A
  • Gather information to establish database
  • Documentation of health status/problems
  • Identify/prioritize needs of a client
  • Permanet legal record of care
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2
Q

CATEGORIES OF HEALTH HISTORY

A
  • Comprehensive
  • Interval or ongoing
  • Focused or episodic
  • Emergency
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3
Q

COMPREHENSIVE HEALTH HISTORY ASSESSMENT

A
  • Identifying biographical data
  • Age, sex, race, ethinicity
  • Marital status
  • Occupation
  • Date, time, setting
  • Date of last exam
  • Example: RS, 51 y/o female of dutch descent, married, works as assistant professor at U of R SON
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4
Q

SOURCE OF HEALTH ASSESSMENT

A
  • Information can be coming from different sources (medical records, friend if patient is unconscious)
  • Primary: coming directly from the patient
  • Secondary: coming from a friend or family member
  • Always note if you have a translator - sometimes info doesn’t get back to you or get to patient because of unsure terms
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5
Q

RELIABILITY OF HEALTH ASSESSMENT

A
  • Want to have reliable patient
  • If patient is confused they can give false information
  • Through conversation you can realize if they are giving good, consistent information
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6
Q

REASONS FOR SEEKING CARE

A
  • Chief complaint: the sign (objective) or symptom (subjective) finding that causes the patient to seek health care
  • Record as quotes
  • Example: “I’m here because I fell off my bike yesterday and hurt my ankle”
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7
Q

HISTORY OF PRESENT ILLNESS - 8 DIMENSIONS FACTORS

A
  • Bodily location
  • Quality
  • Quantity
  • Chronology
  • Setting
  • Aggravating, neutral, and alleviating factors
  • Associated manifestations
  • Client’s perception
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8
Q

BODILY LOCATION ASSESSMENT

A
  • The client’s placement of the problem on or within
  • Have them point to location
  • Example: “Pain behind the eyes” instead of “head pain”
  • Pain localized to site or radiating?
  • Superficial or deep?
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9
Q

QUALITY ASSESSMENT

A
  • The client’s perception of the extent of the problem, including effect on daily activities
  • What is it like?
  • What does it feel like?
  • Intensity?
  • Does it affect work, sleep, exercise, eating?
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10
Q

QUANTITY ASSESSMENT

A
  • The client’s quantification of the problem
  • What is its size?
  • Number?
  • Configuration?
  • Frequency?
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11
Q

CHRONOLOGY (TIMING) ASSESSMENT

A
  • The client’s description of the timing of the problem
  • When did (does) it start?
  • Duration
  • Cycle of remission
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12
Q

SETTING ASSESSMENT

A
  • The client’s perception of the environment’s influence on the problem
  • What are the circumstances when it occurs?
  • What were you doing when this happened?
  • Physical environment location?
  • Emotional reactions trigger?
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13
Q

AGGRAVATING, NEUTRAL, AND ALLEVIATING FACTORS ASSESSMENT

A
  • The client’s interpretation of factors that influence the problem
  • What makes it better/worse?
  • Medications?
  • Position?
  • What seems to help?
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14
Q

ASSOCIATED MANIFESTATIONS ASSESSMENT

A
  • The client’s indication of signs and symptoms that exist concurrently with the problem
  • Concurrent symptoms (fever, pain, stiffness, etc)
  • Concurrent social conditions?
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15
Q

CLIENT’S PERCEPTION ASSESSMENT

A
  • The meaning of the symptom for the client and how it affects his/her life
  • What do you think this means?
  • How has this affected your daily life?
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16
Q

CURRENT HEALTH STATUS FACTORS

A
  • Medications (prescribed, OTC, herbal)

- Allergies (environmental, food, animal, response to allergens)

17
Q

PAST MEDICAL HISTORY ASSESSMENT FACTORS

A
  • General health status
  • Childhood illness
  • Medical illness
  • Accidents or injuries
  • Surgeries or hospitalizations
  • Obstetric/gynecologic
  • Psychiatric
  • Immunizations
  • Screening exams
18
Q

CHILDHOOD ILLNESS ASSESSMENT

A
  • Measles, mumps, rubella, chickenpox, pertussis, strep throat
  • Serious illnesses that may affect persons for later years (scarlet fever, poliomyelitis)
19
Q

MEDICAL ILLNESS ASSESSMENT

A
  • Chronic or episodic

- Hypertension, diabetes, high cholesterol

20
Q

ACCIDENTS OR INJURIES ASSESSMENT

A
  • Auto accidents
  • Fractures
  • Penetrating wounds
  • Head injuries
  • Burns
21
Q

SURGERIES ASSESSMENT

A
  • Type of surgery
  • Date
  • Name of surgeon
  • Name of hospital
  • How person recovered
22
Q

HOSPITALIZATIONS ASSESSMENT

A
  • Cause
  • Name of hospital
  • How condition was treated
  • How long the person was hospitalized
  • Name of physician
23
Q

OBSTETRIC/GYNECOLOGIC ASSESSMENT

A
  • Number of pregnancies
  • Number of deliveries in which fetus reached full term
  • Number of preterm pregnancies
  • Number of incomplete pregnancies (miscarriage, abortion)
  • Number of children living
  • For each pregnancy note course, labor and delivery, sex, weight, and condition of each infant
24
Q

PSYCHIATRIC ASSESSMENT

A
  • Any treatment or counseling received
25
Q

IMMUNIZATIONS ASSESSMENT

A
  • Assess vaccination history and urge recommended vaccines
  • Check if immunizations are up to date
  • Use CDC recommendations for adults (beware of occupation, travel, contraindications, etc)
26
Q

SCREENING EXAMS ASSESSMENT

A
  • Physical
  • Dental
  • Vision
  • Hearing
  • ECG
  • X-ray
  • Mammogram
  • Pap test
27
Q

FAMILY HISTORY ASSESSMENT

A
  • Records the health status of immediate blood relatives to assess risk for possible genetic or communicable diseases
  • Includes age, gender, cause of death
28
Q

FACTORS OF FAMILY HISTORY ASSESSMENT

A
  • Ask specifically about : coronary heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB
29
Q

GENOGRAM ASSESSMENT

A
  • Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations
30
Q

PERSONAL/SOCIAL ASSESSMENT FACTORS

A
  • Education
  • Spiritual practices
  • Occupational health
  • Home environment
  • Domestic violence
  • Functional status
31
Q

EDUCATIONAL ASSESSMENT

A
  • Highest grade completed
  • Other significant training
  • Financial status
32
Q

SPIRITUAL PRACTICES ASSESSMENT

A
  • FICA questions to incorporate person’s spiritual values into health history
  • Faith: “Does religious faith play an important part in your life?”
  • Influence: “How does your religious faith influence the way you think about your health?”
  • Community: “Are you part of any religious or spiritual communities?”
  • Address: “Would you like me to address any religious concerns?”
33
Q

OCCUPATIONAL HEALTH ASSESSMENT

A
  • Ask the person to describe their job
  • Worked with health hazards: chemicals, asbestos
  • Wear protective equipment
  • Aware of any problems now from work exposure
34
Q

HOME ENVIRONMENT ASSESSMENT

A
  • Housing and neighborhood (lives alone, knowledge of neighbors)
  • Safety of area
  • Adequate heat and utilities
  • Access to transportation
  • Traveling to other countries or abroad during military service
35
Q

DOMESTIC VIOLENCE ASSESSMENT

A
  • Begin with open-ended questions
  • “How are things at home?”
  • “Do you feel safe?”
  • If concern with anything, ask close-ended questions
  • “Have you ever been emotionally or physically abused by your partner?”
36
Q

FUNCTIONAL STATUS ASSESSMENT

A
  • C: Have you ever thought you should CUT down your drinking?
  • A: Have you ever been ANNOYED by criticism of your drinking?
  • G: Have you ever felt GUILTY about your drinking?
  • E: Do you drink in the morning (EYE opener?)
  • Yes to two or more, suspect alcohol abuse
37
Q

LIFESTYLE CHOICES ASSESSMENT

A
  • Smoking or tobacco use (type & amount)
  • Street drugs (Vicodin, cocaine, heroin, marijuana)
  • Alcohol (frequency, type & amount)
  • Nutrition
  • Exercise (frequency, type & amount)

U of R SCHOOL OF NURSING (12 decks)

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