Components of Nursing Health History Flashcards
1
Q
Biographic data includes
A
Clients name
Age
Sex
Marital status
Occupation
Religious affiliation
Others
2
Q
“What brought you to the hospital?“
A
Chief of Complaint
3
Q
Chief complain should be recorded in the ______ ___ ____.
A
client’s own words.
4
Q
Use CHRONOLOGIC story
A
HISTORY OF PRESENT ILLNESS
5
Q
Exact location of distress
A
HISTORY OF PRESENT ILLNESS
6
Q
Hospitalization
A
PAST HISTORY
7
Q
Accidents and injuries
A
PAST HISTORY
8
Q
When the symptoms started
A
HISTORY OF PRESENT ILLNESS
9
Q
Childhood illness
A
PAST HISTORY
10
Q
Aggravating factors
A
HISTORY OF PRESENT ILLNESS
11
Q
Immunization
A
PAST HISTORY
12
Q
Whether the onset of symptoms was sudden or gradual
A
HISTORY OF PRESENT ILLNESS
13
Q
Medication
A
PAST HISTORY
14
Q
Activity in which the client was involved when the problem occurred
A
HISTORY OF PRESENT ILLNESS
15
Q
Allergies
A
PAST HISTORY
16
Q
Character of complaint (e.g., intensity of pain, quality of sputum)
A
HISTORY OF PRESENT ILLNESS
17
Q
Mother Father
(+) HPN (-) HPN
(-) DM (-) DM
(-) PTB (+) PTB
A
FAMILY HISTORY OF ILLNESS
18
Q
LIFESTYLE includes
A
- Personal habits-e.g. amount, frequency and duration of substance use.
- Diet – description of typical daily diet
- Sleep/Rest patterns
- Activities of Daily Living (ADL)
- Recreation / Hobbies
19
Q
How often the problem occurs
A
HISTORY OF PRESENT ILLNESS
19
Q
Family relationship
A
SOCIAL DATA
20
Q
Psychosocial history
A
PSYCHOLOGIC DATA
21
Q
Ethnic affiliation
A
SOCIAL DATA
22
Q
Coping mechanisms
A
PSYCHOLOGIC DATA
23
Q
Education history
A
SOCIAL DATA
24
Mental health history
PSYCHOLOGIC DATA
25
Occupational History
SOCIAL DATA
26
Cognitive function
PSYCHOLOGIC DATA
27
Economic status
SOCIAL DATA
28
Substance use/abuse
PSYCHOLOGIC DATA
29
Home and neighborhood conditions
SOCIAL DATA
30
Substance use/abuse
PSYCHOLOGIC DATA
31
Health care utilization
PATTERNS OF HEALTHCARE
32
Trauma history
PSYCHOLOGIC DATA
33
Medical History
PATTERNS OF HEALTHCARE
34
Risk assessment
PSYCHOLOGIC DATA
35
Medication History
PATTERNS OF HEALTHCARE
36
Sleep patterns
PSYCHOLOGIC DATA
37
Health care providers
PATTERNS OF HEALTHCARE
38
Health care preferences
PATTERNS OF HEALTHCARE
39
Current stressors
PSYCHOLOGIC DATA
40
Physical assessment has to be
- Thorough
- Systematic
- Skilled
41
Health care barriers
PATTERNS OF HEALTHCARE
42
Approaches in Physical Assessment
- Head-to-toe Assessment/Cephalocaudal
- Body System Approach
43
Health insurance coverage
PATTERNS OF HEALTHCARE
44
Purpose of Medical Review/Records
- To relate the past health care history of the patient to the present episode
- To identify what medication the patient is taking so that the assessment can include the effectiveness of the medication & the occurrence of any side effects
45
Health promotion activities
PATTERNS OF HEALTHCARE
46
DATA COLLECTION FORMAT
- Maslow's basic need frameworks
- Henderson's components of nursing care
- Gordon's functional health patterns
- Nanda's human response patterns
- Nursing theories
- Human growth & development
47
Adherence to medical advice
PATTERNS OF HEALTHCARE
48
Other term for SUBJECTIVE DATA
Symptom or Covert Data
49
Healthcare experiences
PATTERNS OF HEALTHCARE
50
SUBJECTIVE (SYMPTOMS, COVERT DATA) OR OBJECTIVE DATA (SIGNS, OVERT DATA)
Itching pain, feelings of worry includes client's sensations, feelings, values, beliefs, attitudes and
perception of personal health status and life situations.
SUBJECTIVE (SYMPTOMS, COVERT DATA)
51
SUBJECTIVE (SYMPTOMS, COVERT DATA) OR OBJECTIVE DATA (SIGNS, OVERT DATA)
Detectable by an observer or can be tested against an accepted standard
OBJECTIVE DATA
52
Other term for OBJECTIVE DATA
Signs or Overt Data
53
The subjective & objective data identified
Cues
54
How one interprets or perceive a cue
Inferences
55
GUIDELINES IN VALIDATING/ VERIFYING DATA
Data that can be measured accurately can be accepted as factual.
Data that someone else observes (indirect data) may or may not be true.
56
TECHNIQUES TO VALIDATE QUESTIONABLE INFORMTION
Double check information that's extremely abnormal or inconsistent with patient cues
Double check that your equipment is working correctly.
Recheck own data
Look for factors that may alter accuracy
Ask someone else, preferably an expert, to collect the same data
Compare subjective & objective data to see if what the person is stating is congruent with what you observe
Clarify statements and verify your inferences with the patient
Compare your impressions with those of other key members of the health care
57
Advantages; it helps one to avoid in validating/verifying data:
- Making assumptions
- Missing key information
- Misunderstanding situations
- Jumping to conclusions or focusing in the wrong direction
- Making errors in problem identification
58
What is the rule in organizing/clustering data
Cluster your data according to your purpose
59
Purpose of Organizing/Clustering Data
- To identify nursing diagnoses and problems
- To identify signs and symptoms of possible medical problems
- To set priorities
- Clustering data one way, then clustering it another way help you think critically
60
Used to set priorities
ABC (AIRWAY BREATHING CIRCULATION)
61
Used to identify signs and symptoms of possible medical problems.
Body System
62
Used to identify nursing diagnosis and problems
GORDON’S FUNCTIONAL HEALTH PROBLEMS
63
TRUE OR FALSE?
Before reporting, take a moment to be sure you have all the necessary information readily at hand.
TRUE
64
Remember _____ and _____; find it out why or how the pattern came be.
cause and effect
65
Involves deciding what’s relevant and irrelevant, making tentative decisions about what the data suggests.
Identifying patterns/testing first impression
65
Focusing assessment to gain more information to _____ _________ the situations at hand.
better understanding
66
Jot down the facts in order of _________.
importance
67
Give precise information, ______ the facts rather than how you _______ the facts.
state; interpret
68
Report abnormal findings as soon as possible.
Reporting and Recording data
69
GORDON’S FUNCTIONAL HEALTH PROBLEMS
Health perception and Health management
Nutrition and metabolism
Elimination
Activity and Exercise
Cognition and Perception
Sleep and Rest
Self- Perception and Self- Concept
Roles and Relationship
Sexuality and Reproduction
Values and Beliefs
