Components of Nursing Health History Flashcards
Biographic data includes
Clients name
Age
Sex
Marital status
Occupation
Religious affiliation
Others
“What brought you to the hospital?“
Chief of Complaint
Chief complain should be recorded in the ______ ___ ____.
client’s own words.
Use CHRONOLOGIC story
HISTORY OF PRESENT ILLNESS
Exact location of distress
HISTORY OF PRESENT ILLNESS
Hospitalization
PAST HISTORY
Accidents and injuries
PAST HISTORY
When the symptoms started
HISTORY OF PRESENT ILLNESS
Childhood illness
PAST HISTORY
Aggravating factors
HISTORY OF PRESENT ILLNESS
Immunization
PAST HISTORY
Whether the onset of symptoms was sudden or gradual
HISTORY OF PRESENT ILLNESS
Medication
PAST HISTORY
Activity in which the client was involved when the problem occurred
HISTORY OF PRESENT ILLNESS
Allergies
PAST HISTORY
Character of complaint (e.g., intensity of pain, quality of sputum)
HISTORY OF PRESENT ILLNESS
Mother Father
(+) HPN (-) HPN
(-) DM (-) DM
(-) PTB (+) PTB
FAMILY HISTORY OF ILLNESS
LIFESTYLE includes
- 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
How often the problem occurs
HISTORY OF PRESENT ILLNESS
Family relationship
SOCIAL DATA
Psychosocial history
PSYCHOLOGIC DATA
Ethnic affiliation
SOCIAL DATA
Coping mechanisms
PSYCHOLOGIC DATA
Education history
SOCIAL DATA
Mental health history
PSYCHOLOGIC DATA
Occupational History
SOCIAL DATA
Cognitive function
PSYCHOLOGIC DATA
Economic status
SOCIAL DATA
Substance use/abuse
PSYCHOLOGIC DATA
Home and neighborhood conditions
SOCIAL DATA
Substance use/abuse
PSYCHOLOGIC DATA
Health care utilization
PATTERNS OF HEALTHCARE
Trauma history
PSYCHOLOGIC DATA
Medical History
PATTERNS OF HEALTHCARE
Risk assessment
PSYCHOLOGIC DATA
Medication History
PATTERNS OF HEALTHCARE
Sleep patterns
PSYCHOLOGIC DATA
Health care providers
PATTERNS OF HEALTHCARE
Health care preferences
PATTERNS OF HEALTHCARE
Current stressors
PSYCHOLOGIC DATA
Physical assessment has to be
- Thorough
- Systematic
- Skilled
Health care barriers
PATTERNS OF HEALTHCARE
Approaches in Physical Assessment
- Head-to-toe Assessment/Cephalocaudal
- Body System Approach
Health insurance coverage
PATTERNS OF HEALTHCARE
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
Health promotion activities
PATTERNS OF HEALTHCARE
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
Adherence to medical advice
PATTERNS OF HEALTHCARE
Other term for SUBJECTIVE DATA
Symptom or Covert Data
Healthcare experiences
PATTERNS OF HEALTHCARE
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)
SUBJECTIVE (SYMPTOMS, COVERT DATA) OR OBJECTIVE DATA (SIGNS, OVERT DATA)
Detectable by an observer or can be tested against an accepted standard
OBJECTIVE DATA
Other term for OBJECTIVE DATA
Signs or Overt Data
The subjective & objective data identified
Cues
How one interprets or perceive a cue
Inferences
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.
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
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
What is the rule in organizing/clustering data
Cluster your data according to your purpose
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
Used to set priorities
ABC (AIRWAY BREATHING CIRCULATION)
Used to identify signs and symptoms of possible medical problems.
Body System
Used to identify nursing diagnosis and problems
GORDON’S FUNCTIONAL HEALTH PROBLEMS
TRUE OR FALSE?
Before reporting, take a moment to be sure you have all the necessary information readily at hand.
TRUE
Remember _____ and _____; find it out why or how the pattern came be.
cause and effect
Involves deciding what’s relevant and irrelevant, making tentative decisions about what the data suggests.
Identifying patterns/testing first impression
Focusing assessment to gain more information to _____ _________ the situations at hand.
better understanding
Jot down the facts in order of _________.
importance
Give precise information, ______ the facts rather than how you _______ the facts.
state; interpret
Report abnormal findings as soon as possible.
Reporting and Recording data
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
