HEALTH HISTORY Flashcards
Which of the following is a close-ended question?
“What time do you usually get up in the morning?”
Play’s the steps in the correct order to record information when using the GTPAL format
Number of pregnancies Number of term deliveries Number of preterm deliveries Number of voluntary or involuntary abortions Current number of living children
Which of the following are research validated reasons to conduct a health history using an interpreter? (Select all that apply)
To increase the accuracy of communication
To increase the client’s satisfaction with care
How many generations should you collect medical history about?
3
For which of the following diseases should you obtain family history?
Head Eyes Ears Nose Mouth Neck
A nurse is collecting data during a review of systems and ask the client how many pillows are required to sleep comfortably at night. This question involves assessment of which of the following systems?
Cardiovascular
Which of the following factors are included in health literacy? (select all that apply)
Basic reading skills
Competency using numbers
Ability to follow verbal instructions
Which aspect of life is assessed using the FICA approach?
Spirituality
Which of the following is a purpose of obtaining a health history?
To establish a baseline of the client’s health status
Drag the dialogue statement to place it in the correct interview technique category
Directive
How often do you exercise?
Did the medication help your discomfort?
Have you had an influenza vaccination this year?
When was the last time you had anything to eat or drink?
What causes you to become short of breath?
Nondirective Tell me about the voices you are hearing What questions do you have for me? How do you feel about the diagnosis? Please describe the chest pain
Match each question to its correct question type
Closed-ended
Do you have any numbness or tingling in your hand?
When was your last bowel movement?
Can you rate your pain on a scale of 0 to 10 with zero being no pain and 10 being the worst pain you can imagine?
How many flights of stairs can you climb before you become short of breath?
Open-ended What is your goal for treatment? How are you feeling today? What brings you to the clinic? Do you have questions about your scheduled surgery?
Review of Systems (ROS)
physical examination of all body systems in a systematic manner as part of the nursing assessment
Social History (SH)
information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient
Family History (FH)
The family history reviews the medical events in the patient’s family. It includes the health status or cause of death of parents, brothers and sisters, and children; specific diseases that are related to the patient’s chief complaint or the patient’s diagnosis; and the presence of any known hereditary diseases.
Past Medical History (PMH)
A listing of any illnesses the patient may have had in the past; includes treatments and procedures performed.
History of Present Illness (HPI)
the story of the patient’s problem
Chief Complaint (CC)
specific symptom or problem for which the patient is seeing the provider today
Order of Health History
Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History, FH Social History (SH), Review of System (ROS)
Gravida: # of pregnancies Term: # of term deliveries Pre-term:# of pre-term deliveries Abortions:# of abortions, elective or spontaneous Living:# of living children
what is GTPAL?
childhood illnesses, injuries, chronic illness, hospitalization, surgeries, immunizations, last medical exam, allergies, current meds, alcohol, tobacco/ nicotine use, caffeine, patterns of exercise, nutrition, sleep, recreational or prescription drug use
general data includes (14)
severity: how severe symptoms are
OLD CARTS: S means
treatment: what treatments have been tried
OLD CARTS: T means
related symptoms: other symptoms present
OLD CARTS: R means
aggravating and alleviating factors: what affects the symptoms
OLD CARTS: A means
characteristics: characteristics of symptoms
OLD CARTS: C means
duration: how long symptoms last
OLD CARTS: D means
location: where symptoms occur
OLD CARTS: L means
onset: when symptoms began
OLD CARTS: O means
Non-directive interview
An interview in which the applicant is allowed the maximum amount of freedom in determining the course of the discussion, while the interviewer carefully refrains from influencing the applicant’s remarks
open-ended questions
questions that allow respondents to answer however they want
close-ended questions
Questions that can be answered in short or single word responses.
Directive interview
a highly structured interview that uses closed questions to elicit specific information
