Health History Flashcards
It provides holistic, qualitative picture of patient
Health History
What is the purpose of health history of a patient
- Provides subjective data
- Identify Patient Strengths
- Identify Health Problems
- Idenify Support group
- Identify teaching, discharge, and refferal needs
Medical History or Nursing History:
- Has Preexisting medical conditions
- Plan for health problem
Medical History
Medical History or Nursing History:
- has coping strategies
-idenifies strenght and support groups
Nursing History
2 types of Nursing History
Focused and Comprehensive
What data does the Nursing History have? A.M.PL.E
A - llergies
M - edications
PL- Past Illness/Pregnant
E - Events and Environment
Data we get from Current Health Status of patient (P.Q.R.S.T)
P - Precipitating / Pallliatative Factors
Q - uality/ Quantity
R - egion / Radiation / Related Symptoms
S - Severity
T - Timing
Current Health Status:
- asks question, “What were you doing when problem started?”
Precipitating / Pallitative Factors
Current Health Status:
- asks question, “can you describe symptom?”
- asks patient how much pain he or she is feeling
Quality and Quantity
Current Health Status:
- points where the problem is located
Region/ Radiation/ Symptoms
Current Health Status:
- Is the symptom mild, moderate, or severe
- Pain scale
Severity
Current Health Status:
- When did it start?
- How often does it occur?
- How long does it last?
Timing
It states the usual health status, any major health problems of the client, usual patterns of health care, and health concerns of the client
Current Health Status
History of Present illness:
- What data do u get from client that is well for their history of present illness?
Short statement about general health
History of Present illness:
- What data do u get from a patient that is ill?
Chronological record of reason for seeking care from the time symptom started until now
