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
