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NCM 103 - MIDTERMS > Components of Nursing Health History > Flashcards

Components of Nursing Health History Flashcards

1
Q

Biographic data includes

A

Clients name
Age
Sex
Marital status
Occupation
Religious affiliation
Others

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2
Q

“What brought you to the hospital?“

A

Chief of Complaint

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3
Q

Chief complain should be recorded in the ______ ___ ____.

A

client’s own words.

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4
Q

Use CHRONOLOGIC story

A

HISTORY OF PRESENT ILLNESS

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5
Q

Exact location of distress

A

HISTORY OF PRESENT ILLNESS

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6
Q

Hospitalization

A

PAST HISTORY

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7
Q

Accidents and injuries

A

PAST HISTORY

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8
Q

When the symptoms started

A

HISTORY OF PRESENT ILLNESS

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9
Q

Childhood illness

A

PAST HISTORY

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10
Q

Aggravating factors

A

HISTORY OF PRESENT ILLNESS

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11
Q

Immunization

A

PAST HISTORY

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12
Q

Whether the onset of symptoms was sudden or gradual

A

HISTORY OF PRESENT ILLNESS

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13
Q

Medication

A

PAST HISTORY

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14
Q

Activity in which the client was involved when the problem occurred

A

HISTORY OF PRESENT ILLNESS

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15
Q

Allergies

A

PAST HISTORY

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16
Q

Character of complaint (e.g., intensity of pain, quality of sputum)

A

HISTORY OF PRESENT ILLNESS

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17
Q

Mother Father
(+) HPN (-) HPN
(-) DM (-) DM
(-) PTB (+) PTB

A

FAMILY HISTORY OF ILLNESS

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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
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19
Q

How often the problem occurs

A

HISTORY OF PRESENT ILLNESS

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19
Q

Family relationship

A

SOCIAL DATA

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20
Q

Psychosocial history

A

PSYCHOLOGIC DATA

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21
Q

Ethnic affiliation

A

SOCIAL DATA

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22
Q

Coping mechanisms

A

PSYCHOLOGIC DATA

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23
Q

Education history

A

SOCIAL DATA

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24
Q

Mental health history

A

PSYCHOLOGIC DATA

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25
Q

Occupational History

A

SOCIAL DATA

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26
Q

Cognitive function

A

PSYCHOLOGIC DATA

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27
Q

Economic status

A

SOCIAL DATA

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28
Q

Substance use/abuse

A

PSYCHOLOGIC DATA

29
Q

Home and neighborhood conditions

A

SOCIAL DATA

30
Q

Substance use/abuse

A

PSYCHOLOGIC DATA

31
Q

Health care utilization

A

PATTERNS OF HEALTHCARE

32
Q

Trauma history

A

PSYCHOLOGIC DATA

33
Q

Medical History

A

PATTERNS OF HEALTHCARE

34
Q

Risk assessment

A

PSYCHOLOGIC DATA

35
Q

Medication History

A

PATTERNS OF HEALTHCARE

36
Q

Sleep patterns

A

PSYCHOLOGIC DATA

37
Q

Health care providers

A

PATTERNS OF HEALTHCARE

38
Q

Health care preferences

A

PATTERNS OF HEALTHCARE

39
Q

Current stressors

A

PSYCHOLOGIC DATA

40
Q

Physical assessment has to be

A
  • Thorough
  • Systematic
  • Skilled
41
Q

Health care barriers

A

PATTERNS OF HEALTHCARE

42
Q

Approaches in Physical Assessment

A
  • Head-to-toe Assessment/Cephalocaudal
  • Body System Approach
43
Q

Health insurance coverage

A

PATTERNS OF HEALTHCARE

44
Q

Purpose of Medical Review/Records

A
  • 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
Q

Health promotion activities

A

PATTERNS OF HEALTHCARE

46
Q

DATA COLLECTION FORMAT

A
  • 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
Q

Adherence to medical advice

A

PATTERNS OF HEALTHCARE

48
Q

Other term for SUBJECTIVE DATA

A

Symptom or Covert Data

49
Q

Healthcare experiences

A

PATTERNS OF HEALTHCARE

50
Q

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.

A

SUBJECTIVE (SYMPTOMS, COVERT DATA)

51
Q

SUBJECTIVE (SYMPTOMS, COVERT DATA) OR OBJECTIVE DATA (SIGNS, OVERT DATA)

Detectable by an observer or can be tested against an accepted standard

A

OBJECTIVE DATA

52
Q

Other term for OBJECTIVE DATA

A

Signs or Overt Data

53
Q

The subjective & objective data identified

A

Cues

54
Q

How one interprets or perceive a cue

A

Inferences

55
Q

GUIDELINES IN VALIDATING/ VERIFYING DATA

A

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
Q

TECHNIQUES TO VALIDATE QUESTIONABLE INFORMTION

A

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
Q

Advantages; it helps one to avoid in validating/verifying data:

A
  • Making assumptions
  • Missing key information
  • Misunderstanding situations
  • Jumping to conclusions or focusing in the wrong direction
  • Making errors in problem identification
58
Q

What is the rule in organizing/clustering data

A

Cluster your data according to your purpose

59
Q

Purpose of Organizing/Clustering Data

A
  • 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
Q

Used to set priorities

A

ABC (AIRWAY BREATHING CIRCULATION)

61
Q

Used to identify signs and symptoms of possible medical problems.

A

Body System

62
Q

Used to identify nursing diagnosis and problems

A

GORDON’S FUNCTIONAL HEALTH PROBLEMS

63
Q

TRUE OR FALSE?

Before reporting, take a moment to be sure you have all the necessary information readily at hand.

A

TRUE

64
Q

Remember _____ and _____; find it out why or how the pattern came be.

A

cause and effect

65
Q

Involves deciding what’s relevant and irrelevant, making tentative decisions about what the data suggests.

A

Identifying patterns/testing first impression

65
Q

Focusing assessment to gain more information to _____ _________ the situations at hand.

A

better understanding

66
Q

Jot down the facts in order of _________.

A

importance

67
Q

Give precise information, ______ the facts rather than how you _______ the facts.

A

state; interpret

68
Q

Report abnormal findings as soon as possible.

A

Reporting and Recording data

69
Q

GORDON’S FUNCTIONAL HEALTH PROBLEMS

A

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

NCM 103 - MIDTERMS (7 decks)

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