Health History Flashcards
what is the purpose of getting a health history? (5)
-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
considerations for assessment (4)
-cultural assessment (ex. muslims prefer women)
-infection control (clean stethoscope, etc)
-environment (keeping pt. privacy)
-equipment (take all things needed into room)
interview of patient
types of data
-subjective : pain (based off of patient)
-objective : BP (data in front of me, confirmed)
interview of patient
sources of data
-primary source : direct from patient
-secondary source : everything else (family, friends, nurse to nurse report, medical records)
types of diagnostic tests (5)
-laboratory
-radiologic studies
-skin tests
-pulmonary function tests
-endoscopy exams
data collection (4)
-interview
-nursing health history
-physical exams
-diagnostic and lab results
data collection (4)
-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
physical assessment
comprehensive
looking at everything, asking questions
physical assessment
focused
ex. ) go to cough clinic - respiration, lungs
physical assessment
system specific
related to body system - ex) GI distress, look at system
physical assessment
ongoing
same every time and mark changes
ex) neuro assessment
physical assessment
head to toe
general assessment of general patient
elements of assessment (3)
-baseline history
-problem based history
-examination (vital signs, inspection, auscultation, palpation)
nursing process and the physical assessment (4)
-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
techniques for assessment (5)
-inspection
-palpation
-percussion
-auscultation
-olfaction
what is included in inspection (visual) - 4
-visually looking and assessing patient
-good lighting
-cover parts not being examined / drape
-use additional lighting for eyes, ears, throat
palpation (tactile) methods : (4)
-bimanual/manual technique
-dorsum of hand
-palm or ulnar surface of hand
-palmar surface of finger/finger pads
light palpation is
1 cm or 1/2 depth
deep palpation is
4 cm or 2 in deep
what are we observing for in inspection? (4)
-color
-shape/symmetry
-movement
-position
what are we assessing when we palpate? (8)
-texture
-resistance
-resilience
-mobility
-temperature
-thickness
-shape
-moisture
auscultation (auditory) is listening for characteristics like : (4)
-frequency : # of oscillations per second
-loudness : amplitude of a sound wave
-quality : descriptive
-duration : length of sound wave
when using stethoscope we must always _______
directly place on skin
what does the bell of stethoscope do?
low pitched
what does the diaphragm of stethoscope do?
high pitched
what are we looking for in olfactory assessment?
abnormal vs normal
ex) alcohol on breath, sweet smelling mouth odor
(usually descriptive in nature)
things to do when preparing for the assessment (GIEUWCM)
-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
what are the special considerations for aged people?
-sensory and physical limitations
-recognize normal changes of aging vs abnormal
what’s included in the general survey? (12)
-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
what are the signs or abuse? (4)
-inconsistency between injury and statement
-bruising, lacerations, burns, bites
-x - ray shows fractures in various stages of healing
-behavior issues : insomnia, anxiety, and isolation
