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