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NURS 02 - HEALTH ASSESSMENT (LEC) > Collection of Subjective Data: The interview and health history taking > Flashcards

Collection of Subjective Data: The interview and health history taking Flashcards

1
Q

Integral part of interviewing the clients to obtain health history

A
  • Sensation
  • Feelings
  • Perception
  • Preferences
  • Desire
  • Values
  • Beliefs
  • Ideas
  • Personal Information
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2
Q

Why health history taking is important?

A
  • Provides clues for possible problems
  • Provides information that may reveal a client’s risk for a problem as well as areas for strength & weakness
  • Obtained through interviewing
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3
Q

Vital for accurate and thorough data

A

Interviewing skills

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4
Q
  • Through this, Clients developmental, physiological, psychological, sociocultural, and spiritual status to identify deviations
  • Establishes rapport and trusting relationship
A

Interviewing

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5
Q

What nurses do during pre introductory phase?

A
  • Nurse review the medical record of the patient
  • take note of different consideration prior to the interview
  • Consider the client’s past health history
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6
Q

Special Considerations During the Interview

Gerontologic Variations in Communication

A
  • Assess hearing acuity
  • Don’t yell, speak slowly
  • Position yourself in the side with better hearing
  • Position in front to allow the client to read your lips
  • Remember that older patients may feel vulnerable and scared
  • Speak clearly and use straight forward language
  • Show respect
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7
Q

Special Considerations During the Interview

Cultural Variations in Communication

A
  • Reluctance to reveal personal info
  • Variations in ability to receive info
  • Variations in meaning conveyed by language
  • Variations in use and meaning of nonverbal cues
  • Variations in past, present, and future time orientation
  • Variation in disease perception
  • Variations in family’s role
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8
Q

Special Considerations During the Interview

Emotional Variation in Communication

A
  • May be anxious and scared
  • May be depressed due to life events
  • May be sensitive to some issues
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9
Q

This is an excellent way to begin assessment process

Provides foundation in identifying problems

A

Complete Health Assessment

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10
Q

What are the demographic data?

A
  • Name
  • Address
  • Phone number
  • Gender
  • Birthday
  • Religion
  • Occupation
  • Nationality
  • Educational Attainment
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11
Q
A
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12
Q

History of Present Health Concern

A
  1. Problem at birth
  2. Childhood illnesses
  3. Immunization to date
  4. Adult illnesses
  5. Surgeries
  6. Accidents
  7. Pain patterns
  8. Allergies
  9. Physical, emotional, or spiritual weaknesses
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13
Q

PQRST stands for?

A

Precipitating (What brought the pain?; What do you do to be relived?)
Quality (What does the pain feels like? Piercing, stabbing, throbbing, pulsating, burning, shooting, tingling)
Region/Radiation (Where do you feel the pain?)
Severity (Use rating scale 1-10)
Time/Duration (How long it lasts?)

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14
Q

COLDSPA stands for?

A

Characteristics
On set
Location
Duration
Severity
Patterns
Additional associating factors

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15
Q

Series of questions about all the body systems used to evaluate the past and present health state

A

Review of System (ROS)

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16
Q

ROS - Subjective Data
Physical Examination -Objective Data

A

.

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17
Q

ROS
- Identify the problem not covered yet
- from cephalic to caudal
- Clients are instructed that they will be asked a number of questions
- Need checklist
- Obtains info about the pt. health promotion practices
- Begin to more gen ques progress to specific ques
- Document presence of findings and absence of symptoms
- Ask only ques that has not been covered
- Explain the importance of ROS even if it is lengthy, as it is an opportunity to double check completeness
- Direct convo in a way that it is comfortable
- Use cmmon language

A

.

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18
Q

ROS
1. General Health State

A

Weight gain/loss, malaise, fatigue

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19
Q

ROS
2. Nutrition and Hydration

A
  • History of conditions that increase the risk of malnutrition
  • Diet practices to promote health
  • Ascites - build up fluids in the stomach
  • Weight change, dehydration, edema
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20
Q

ROS
3. Skin, Hair, and Nails

A
  • History of skin, hair, and nail distress
  • Electrolytes found in sweat and urine
  • Hair loss, brittle nails : Malnutrition
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21
Q

ROS
4. Head and Neck

A
  • History of high or low thyroid hormones
  • Headache, syncope (passing out), dizziness, sinus (Swollen tissue lining)
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22
Q

ROS
5. Eyes

A
  • History of poor vision, glaucoma, cataracts
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23
Q

ROS
6. Ears

A
  • Hearing problems, loss, and infections
  • Tinnitus (ringing sound) and vertigo
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24
Q

ROS
7. Nose, mouth, and throat

A
  • History of mouth/throat cancer
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ROS 8. Thorax and lungs
- History of emphysema, asthma, or lung cancer - Green mucus: infected
26
ROS 9. Heart and blood vessel
- Congenital heart problems, myocardial infarctions, heart surgery/failure, arrhythmia, and murmur (low, irregular sound) - Stress test: threadmill
27
ROS 10. Peripheral vascular
- Inspecting skin color, temperature, and presence of edema or ulcers, palpating pulses,
28
ROS 11. Breast
- breast cancer or cystic breast condition
29
ROS 12. Abdominal - gastrointestinal
- History of colon cancer, cholelithiasis (gallstone), liver failure etc. - Black stool: Upper bleeding - Red stool : Lower bleeding
30
ROS 13. Abdominal - urinary
- Renal failure, urinary tract infection - Nocturia - too much pee at night (diabetes)
31
ROS 14. Musculoskeletal
- History of injury and arthritis - Change in gait (how person walks) and restricted ROM
32
ROS 15. Neurological
- History of head/brain injury - Tremors, memory loss, numbness
33
ROS 16. Male genitalia
- History of undescended testicle, hernia (luslos) and testicular cancer
34
ROS 17. Female Genitalia
- pcos
35
ROS 18. Anus, rectum, and prostate
- History of hemorrhoids (almoranas)
36
ROS 19. Endocrine and hematological System
- Anemia - Diaphoresis (excessive sweating)
37
It is the 2nd step of physical exam
Collection of Objective Data
38
PHYSICAL EXAMINATION PREPARATION
Preparing the Physical Setting Preparing Oneself Approaching and Preparing the Client
39
40
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Positioning Techniques (8)
1. Sitting position 2. Supine position 3. Dorsal Recumbent Position 4. Sim's position 5. Standing position 6. Prone position 7. Knee Chest position 8. Lithotomy position
42
1. Sitting position
- Neck - Head - Lungs - Chest - Back - Breast - Axillae - Heart - Vital signs - Upper extremities
43
2. Supine position
- Abdominal muscle relax - peripheral pulse site
44
3. Dorsal Recumbent Position
- More comfortable than supine position - Abdomen should not be assessed since it's contracted
45
4. Sims position
- Rectal and vaginal
46
5. Standing position
- Male genitalia
47
6. Prone position
- back and hips - cardiac and respiratory patients should not do this
48
7. Knee Chest position
- Rectum - May be embarrassing so it must be done quickly - Couldn't done by elderly
49
8. Lithotomy position
- Genitalia - Rectum - Keep the client well draped
50
Why do we validate data?
- to avoid errors in assessment - to ensure accuracy
51
Data Requiring Validation
- Discrepancies between subj and obj data - Discrepancies between the client's statement
52
Methods of validation
- Rechecking through repeat assessment - Asking additional question to the client - With another professional - Obj will support subj data
53
Documentation of Data
54
Guidelines for documentation of data
55
Diagnosis - process Diagnosing - basis for selection of nursing intervention Etiology - cause
.
56
Cluster of existing signs and symptoms
defining characteristics
57
What is the basic three part statement?
PES format Problem Etiology Signs and symptoms
58
- Start with "readiness" or enhanced - Involved health promotion and health teaching - seven syndrome diagnoses - Unknown etiology
One part statement
59
Enumerate the 7 status of nursing diagnoses
1. Actual Diagnosis 2. Health Promotion Diagnosis 3. Risk Nursing Diagnosis 4. Syndrome Diagnosis 5. Problem (Diagnostic label) and definition 6. Ineffective 7. Compromise
60
Actual Diagnosis
61
Health Promotion Diagnosis
62
Risk Nursing Diagnosis
63
Syndrome Diagnosis
64
Problem (Diagnostic label) and definition
65
Ineffective
66
Compromise

NURS 02 - HEALTH ASSESSMENT (LEC) (2 decks)

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