Health History Flashcards

1
Q

what is the purpose of getting a health history? (5)

A

-baseline data about pt. health
-supplement, confirm, or refute previous data
-confirm and identify nursing diagnosis
-make clinical judgements r/t changes in data
-evaluate outcomes of care

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2
Q

considerations for assessment (4)

A

-cultural assessment (ex. muslims prefer women)
-infection control (clean stethoscope, etc)
-environment (keeping pt. privacy)
-equipment (take all things needed into room)

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3
Q

interview of patient
types of data

A

-subjective : pain (based off of patient)
-objective : BP (data in front of me, confirmed)

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4
Q

interview of patient
sources of data

A

-primary source : direct from patient
-secondary source : everything else (family, friends, nurse to nurse report, medical records)

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5
Q

types of diagnostic tests (5)

A

-laboratory
-radiologic studies
-skin tests
-pulmonary function tests
-endoscopy exams

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6
Q

data collection (4)

A

-interview
-nursing health history
-physical exams
-diagnostic and lab results

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7
Q

data collection (4)

A

-interview (orientation phase, working phase, termination phase)
-nursing health history (medication history, past medical history, home life - live with people, social - smoke or drink?, cheap complaint)
-physical exams
-diagnostic and lab results

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8
Q

physical assessment
comprehensive

A

looking at everything, asking questions

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9
Q

physical assessment
focused

A

ex. ) go to cough clinic - respiration, lungs

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10
Q

physical assessment
system specific

A

related to body system - ex) GI distress, look at system

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11
Q

physical assessment
ongoing

A

same every time and mark changes
ex) neuro assessment

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12
Q

physical assessment
head to toe

A

general assessment of general patient

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13
Q

elements of assessment (3)

A

-baseline history
-problem based history
-examination (vital signs, inspection, auscultation, palpation)

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14
Q

nursing process and the physical assessment (4)

A

-assessment
-nursing diagnosis
specific to us a nurse
ex) dr says generalized weakness, we do an assessment, and figure out pt is at risk for skin breakdown
-planning
-evaluation

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15
Q

techniques for assessment (5)

A

-inspection
-palpation
-percussion
-auscultation
-olfaction

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16
Q

what is included in inspection (visual) - 4

A

-visually looking and assessing patient
-good lighting
-cover parts not being examined / drape
-use additional lighting for eyes, ears, throat

17
Q

palpation (tactile) methods : (4)

A

-bimanual/manual technique
-dorsum of hand
-palm or ulnar surface of hand
-palmar surface of finger/finger pads

18
Q

light palpation is

A

1 cm or 1/2 depth

19
Q

deep palpation is

A

4 cm or 2 in deep

20
Q

what are we observing for in inspection? (4)

A

-color
-shape/symmetry
-movement
-position

21
Q

what are we assessing when we palpate? (8)

A

-texture
-resistance
-resilience
-mobility
-temperature
-thickness
-shape
-moisture

22
Q

auscultation (auditory) is listening for characteristics like : (4)

A

-frequency : # of oscillations per second
-loudness : amplitude of a sound wave
-quality : descriptive
-duration : length of sound wave

23
Q

when using stethoscope we must always _______

A

directly place on skin

24
Q

what does the bell of stethoscope do?

A

low pitched

25
Q

what does the diaphragm of stethoscope do?

A

high pitched

26
Q

what are we looking for in olfactory assessment?

A

abnormal vs normal
ex) alcohol on breath, sweet smelling mouth odor
(usually descriptive in nature)

27
Q

things to do when preparing for the assessment (GIEUWCM)

A

-Gather all necessary equipment
-Introduce yourself
-Explain procedure
-Use gloves if necessary
-Wash hands before and after ANY contact with patient
-Clean stethoscope head and blood pressure cuffs between patients
-Make patient comfortable; allow for privacy and confidentiality

28
Q

what are the special considerations for aged people?

A

-sensory and physical limitations
-recognize normal changes of aging vs abnormal

29
Q

what’s included in the general survey? (12)

A

-race/gender can’t assume
-age *ask
-body type
-posture
-signs of distress
-substance abuse
-speech
-movement/gait
-hygiene/grooming
-dress
-affect/mood
-patient abuse

30
Q

what are the signs or abuse? (4)

A

-inconsistency between injury and statement
-bruising, lacerations, burns, bites
-x - ray shows fractures in various stages of healing
-behavior issues : insomnia, anxiety, and isolation