Complete health hx

Question 1

What does complete health hx include?

Answer 1

Biographical data (about patient), reason for seeking care, current health/history of current illness, past health, family hx, review of system (physical assessment), and function assessment/ADLs.

Also includes cultural and spiritual considerations.

Question 2

Developmental considerations?

Answer 2

Infants- head circumference, plot growth charts
Young kids- sit on parents lap and use toys, encourage independence and parental involvement
Adolescents- body image, potential for teaching
Older adults- accommodate for deficits (hearing loss), minimize position changes, screen for elder abuse

Question 3

When to assess patients in the hospital?

Answer 3

Assess at the start of your shift. Need consistent and focused examination at least every 8 hrs/shift.

Question 4

What do we need before starting a shift?

Answer 4

Info from previous report, signage in rooms (fall risks, allergies, isolation) and health hx.

Question 5

What finding do we stop what were are doing and call for help?

Answer 5

Temperature >38, BP (>150/90), HR (>100 or <60) RR (<10 0r >24-28), O2 saturation (>92) urine output (<30 mL/hr), altered LOC/ confusion (sudden), and sudden bleeding.

Question 6

What is reporting?

Answer 6

Includes basic info, reason for administration/medical diagnosis, changes in patient conditions.

Question 7

What is SBAR? and ISBAR

Answer 7

Situation, background, assessment, recommendation. Used when there’s a change in patient status. I-identify yourself and R is repeat.