health history Flashcards
role of the nurse
- to listen
- to promote health
- prevent illness
- treat responses to illness
- advocate
- educate
NOT DIAGNOSE
health assessment (def)
gathering information about the health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on the findings and evaluating patient care outcomes
purpose of health history
- collect subjective and objective data
- provides complete picture of patient’s past and present health history
- can be used as a screening tool for detection of abnormalities
- sequence may vary in terms of obtained information
- focus may differ in terms of clinical practice and/or nature of complaint
subjective data
what the patient says, history taking
objective data
information that is seen, heard, felt, or smelled by an observer; physical finding
health history sequence
- biographic data
- source of history
- reason for seeking care
- present health history or HPI
- past health history
- family history
- review of systems
- functional assessment
biographic data
name, contact info, DOB, gender, race/ethnicity, occupation, language spoken
source of history
who is giving information
judge reliability of informant and how willing he or she is to communicate
reason for seeking care
- brief spontaneous statement in person’s own words describing for visit
- list symptoms
HPI
- collect all provided data and identify eight critical characteristics
- make sure collected data are precise and accurate
- use standardized indicators to document findings
eight critical characteristics of HPI
location, character(quality), severity, timing, setting, aggravating/relieving factors, associated factors and patient’s perception
OLD CARTS
onset, location, duration, chracteristics, aggravating/alleviating factors, review of systems, timing, severity
past medical history
childhood illness, accidents or injuries, serious/chronic illness, hospitalization, surgical operations, obstetric history, immunizations, last exam date, allergies, current medications
accidents/injuries
type and nature of event, acute and/or residual deficit noted
serious/chronic illness
presence of comorbidities has pronounced effect
hospitalizations
types based on clinical indications, length of stay along with dates of occurrences
surgical operations
facility, name of healthcare provider, date of procedures
obstetric history
pregnancy, relevant data r/t childbearing, labor/delivery experience, state of infant, postpartum course
immunizations
correlate with CDC guidelines
last exam date
obtain last data test for commonly occurring labs/diagnostics
allergies
note allergen reaction
current medications
perform medication reconciliation (up to date), include prescribed and OTC medication and/or herbal therapy
family history
- highlights diseases or conditions that an individual may be at risk for as a result of genetics
- provides age and health/cause of death of relatives
- based on results ability to seek early screening, make possible lifestyle adjustments
- pedigree/genogram used as standardized tool
purpose of ROS
- evaluate past and present state of each body system
- assess all pertinent data relating is noted
- evaluate health promotion practices
- organized manner proceeding in a logical sequence
ROS
- use language to facilitate communication
- do not include objective data
- include all relevant body systems, pertinent document relatice to individual patient
functional assessment
- ADLS
- objectively measure functional status (monitor/assess)
- relevant data r/t lifestyle and type of living environment
- substance/alcohol
functional assessment examples
- activity/exercise
- sleep/rest
- nutrition
- personal habits
- intimate partner violence
