health history Flashcards
Objective data
What you see and sense as the nurse
Subjective data
What the patient tells you, how they are feeling
IPPA
inspection, palpation, percussion, auscultation
COLDSPA (for pain)
Character, onset, location, duration, severity, pattern, associated factors
What is diaphragm used for
High pitched sounds, abdomen and heart
What is a bell used for
Low pitched sounds, heart murmurs
Initial comprehensive assessment includes
Subjective and objective data, all systems, past health history, family history, lifestyle and health practices
Ongoing or Partial assessment
Adds to comprehensive as incidents occur
Focused or problem-oriented assessment
Focus on specific problem or chief complaint
Emergency assessment
rapid, in life-threatening situation
Steps of health assessment
prep (review), collect data, validate data, document
Genogram
Family tree, documents disease process patterns in the family. can identify major health concerns or risks
Resonance
hollow sound
Hyperresonance
Booming sound
Tympany
Drum-like sound
Flatness
Flat sound
Dullness
thud-like sound
Health history components
Biographical data, reason for seeking healthcare, history of health concern, family history, past health history, review of systems, lifestyle practices, developmental level
Purpose of ROS in assessment
to know current health problems
finger pads in palpation
Fine discriminations, pulse, texture, size, consistency, shape, moisture
palmar surface in palpation
Vibrations, vocal vibration (fremitus)
dorsal surface in palpation
Temperature
finger pads in percussion
direct, tenderness or inflammation
palmar surface in percussion
blunt, tenderness of organs, size, shape, location of a mass
both hands in percussion
indirect or mediate, striking hand on patient’s skin, detecting abnormal masses or stimulating reflexes
