Collection of Subjective Data

Question 1

Systematic collection of subjective data which is stated by the client, and objective data which is observed by the nurse.

Answer 1

Health History

Question 2

Phases of Taking Health History

Answer 2

Interview Phase, Recording Phase

Question 3

Purpose of Health History

Answer 3

1. To elicit info
2. To obtain data
3. To initiate relationship

Question 4

Types of Nursing Health History

Answer 4

1. Complete Health History
2. Interval Health History
3. Problem-focused Health History

Question 5

Component of health history that contains basic information such as name, sex, age, etc.

Answer 5

Biographical Data

Question 6

A component of health history that is the reason for hospitalization.

Answer 6

Chief Complaint

Question 7

A component of health history that gathers information relevant to the chief complaint and the client’s problem, including essential and relevant data, and self medical treatment

Answer 7

History of Present Illness

Question 8

Component of Present Illness

Answer 8

Introduction
Investigation of Symptoms
Negative Information
Relevant Family Information
Disability

Question 9

Four Parts of Present Illness

Answer 9

Usual Health Status
Chronological Story
Relevant Family History
Disability Assessment

Question 10

COLDSPA

Answer 10

Character, Onset, Location, Duration, Severity, Pattern, Associated Factors

Question 11

(COLDSPA) Describe the sign or symptom (feeling, appearance, sound, smell, or taste if applicable)

Answer 11

Character

Question 12

(COLDSPA) When did it begin?

Answer 12

Onset

Question 13

(COLDSPA) Where is it? Does it radiate? Does it occur anywhere else?

Answer 13

Location

Question 14

(COLDSPA) How long does it last? Does it recur?

Answer 14

Duration

Question 15

(COLDSPA) How bad is it? How much does it bother you?

Answer 15

Severity

Question 16

(COLDPSA) What makes it better or worse?

Answer 16

Pattern

Question 17

(COLDSPA) What other symptoms occur with it? How does it affect you?

Answer 17

Associated Factors

Question 18

Component of Health History to identify all major past health problems of the client

Answer 18

Past Health History

Question 19

Component of Health History to learn about the general health of the client’s blood relatives, spouse, and children and to identify any illness of environmental genetic, or familiar nature that might have implications for the client’s health problems.

Answer 19

Family History

Question 20

Component of Health history that gather information about
surroundings of the client including physical, psychological,
social environment, and presence of hazards, pollutants and safety measures

Answer 20

Environmental History

Question 21

Component of Health History in which the purpose is to record major, current, health related information.

Answer 21

Current Health Information/Lifestyle

Question 22

Current Health Information/Lifestyle include:

Answer 22

Allergies
Habits
Medications
Exercise
Sleep
Pattern of Life

Question 23

Component of Health History that includes how the client and his family cope with disease or stress, and how
they respond to illness and health.

Answer 23

Psychosocial History

Question 24

Components of Psychosocial History

Answer 24

Major Stressor
Communication
Self concept
Mood
Usual Coping Mechanism

Question 25

Component of Health History that collect data about the past and the present of each of the client systems.

Answer 25

Review of Systems (ROS)

Question 26

Component of Health History that collects data about eating habits and pattern, quality and quantity of food, sources of food.

Answer 26

Nutritional Health History

Question 27

Component of Health History that collects data about culture.

Answer 27

Assessment of Intercultural Factors