CLASS 2 - HEALTH HISTORY Flashcards
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
2
Q
CATEGORIES OF HEALTH HISTORY
A
- Comprehensive
- Interval or ongoing
- Focused or episodic
- Emergency
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
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
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
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”
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
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?
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?
10
Q
QUANTITY ASSESSMENT
A
- The client’s quantification of the problem
- What is its size?
- Number?
- Configuration?
- Frequency?
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
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?
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?
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?
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?
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)
