health assessment

Question 1

Nursing health history

Answer 1

Complete health history
focused health history

Question 2

Physical Examination

Answer 2

complete assessment
exam of the body system
exam of the body area

Question 3

components of health history

Answer 3

• biographical data
• reason for seeking care: chief complaints
• current health status
• past health history
• family history
• review of systems
  *psychosocial profile

Question 4

a review of the client’s functional health patterns prior to the current contact with a health care agency.

Answer 4

health history

Question 5

biographical data

*source of the health history and his or her reliability, who referred the client,

*and whether or not the client has an advance directive

Answer 5

Complete health history

Question 6

*focused on an acute problem

*Includes all data that are found in complete health history.

*Indicated when the patient’s condition is UNSTABLE or when TIME constraints are an issue.

Answer 6

Focused health history

Question 7

provide direct information

Answer 7

biographical data

Question 8

chief complaint
document your clients direct qoute

Answer 8

reason for seeking care

Question 9

Primary level: includes
*Usual state of health
*Any major health problems
*Usual patterns of health care
*Any health concerns
Secondary or Tertiary: have an existing problem
*Perform a symptom analysis for any positive symptom that your client reports. Zero in on several key areas to evaluate your client’s symptoms
*Mnemonic: PQRST - provides key questions that will give you a thorough analysis of any presenting symptom.

Answer 9

current health status

Question 10

P = Precipitating / Palliative Factors
Ask: What were you doing when the problem started? Does anything make it better, such as medications or certain positions? Does anything make it worse, such as movement or breathing?
Q = Quality/ Quantity
Ask: Can you describe the symptom? What does it feel like, look like, or sound like? How often are you experiencing it? To what degree does this problem affect your ability to perform your usual daily activities?
R = Region/ Radiation/ Related Symptoms
*Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to lead your client.) Do you have any other symptoms? (Depending on the chief complaint, ask about related symptoms. For example, if the client has chest pain, ask if he or she has breathing problems or nausea.
*S = Severity
*Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the most severe. (Grading on a scale helps objectify the symptom)
*T = Timing
*Ask: When did the symptom start? How often does it occur? How long did it last?

Answer 10

current health status