Health History/POC Flashcards
The First 6 standards are based on the nursing process
Assessment
Diagnosis
outcome identification
Planning
Implementation
Evaluation
Assessment
Collection of “pertinent data and information relative to the healthcare consumer’s health or the situation
5 core competencies identified by Institute of Medicine
1) Provide patient-centered care
2)Work in interdisciplinary teams
3) Use evidenced-based practice
4) Apply quality improvements
5) Use informatics
ADOPIE
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Assessment
Collects pertinent data & information relative to pt’s health or the situation
Diagnosis
Analyzes the assessment data to determine actual or potential diagnosis, problems, or issues
Outcome Identification
Identifies expected outcomes for plan individualized to the pt or situation
Planning
Develops a plan that prescribes strategies to attain expected, measurable outcomes
Implementation
Implements the identified plan
* Coordination of Care- Coordinates care delivery
** Health teaching and Health Promotion- Uses strategies ot promote health and a safe environment
Evaluation
Evaluates progress toward attainment of goals and outcomes
Types of Health Assessments
Comprehensive assessment
Problem-based/focused assessment
Episodic/follow up assessment
Shift assessment
Screening assessment/examination
Comprehensive Assessment
Detailed history and physical exam performed at the onset of care in a primary care setting or on admission to a hospital or LTC facility.
Includes health problems experienced by the patient, health promotion, disease prevention and assessment for problems associated with known risk factors or assessment for age and gender specific health problems
Problem-Based/focused assessment
H & P examination, that is limited to a specific problem or complaint. Commonly used in a walk in clinic/ER, may slo be applied in other outpatient setting.
Collecting data on a specific problem, the nurse also considers the potential impact of the patient’s underlying health status
Episodic/Follow up assessment
usually done when a patient is following up with a health are profider for a previously identified problem
Shift Assessment
When individuals are hospitalized nurse conduct assessment each shift. The purpose of the shift assessment identify changes to a patients condition from the baseline-Focus based on the condition or problem the patient is experiencing
Screening assessment/examination
Short examination focused on disease detection. Maybe performed in a health care providers office as part of the comprehensive exam
or at a health fair
Examples include B/P screening, glucose screening, cholesterol screening, and colorectal screening
Health History
Subjective data collected during interview involving nurse & patient
Purpose to obtain important information from patient for a plan to:
Promote Health
Prevent Disease
Resolve acute health problems
Minimize limitation r/t chronic health problems can be developed
Health History Components
Biographic data
Reason for seeking care
H/x of presenting illness
Present health status
Past health h/x
Family h/x
Personal/Psychosocial h/x
Review of systems
Health History Biographic Data
Name/preferred name
Gender/gender identity
Address/telephone/e/email address
Birth date
Birthplace
Race/ethnicity
Religion
Marital status
Occupation
Contact person
Source of data
OLD CARTS
Onset
Location
Duration
Characteristics
Aggravating factors
Related symptoms
Treatment
Severity
Onset
When did symptoms begin
Location
Where are the symptoms
Duration
How long does the symptoms last?
Characteristics
Describe the symptom
Aggravating factors
What makes the symptoms worse
Related Symptoms
Are other symptoms present
Treatment
What factors alleviate the symptoms
Severity
Describe the intensity of the symptoms
Review of Systems
General symptoms
Integumentary system
Head and neck
Breasts
Respiratory system
Cardiovascular system
Gastrointestinal system
Urinary system
Neurologic system
Health H/X-Heart/Peripheral Vascular System
Ask about Chronic illnesses r/t to CV System
Ask about medications and OTC drugs/supplements
Ask about congenital heart issues
Ask about cholesterol levels
Ask about prior cardiac procedures, surgeries, EKG’s, stress test, etc
Ask about family h/x
Ask about stress control, alcohol, and caffeine usage, & smoking
Health H/X- Nutritional Assessment
Do you have any chronic illnesses? Special diets or restrictions?
Do you take vitamins or supplements?
Do you have any food allergies or intolerances?
What is your activity level/exercise pattern?
Do you have a specific diet based on preferences or culture/spiritual practices?
Health H/X-Reproductive/Perineum
Chronic illnesses/medications/supplements?
Past reproductive problems??
Prior sexually transmitted infections? STI’s?
Any surgeries on reproductive organs or rectum?
H/X of cancer or family h/x of cancer?
Sexual h/x(sex type, frequency, #of sexual partners, STI protection? birth control?)
Menstrual h/x?
pregnancy h/x?
Health H/X-ABD/Gastrointestinal System
Chronic diseases?/ Medications?
Frequency, color and consistency of BM?
Urination pattern? Color of urine? any difficulty urinating?
Any abd or urinary problems in past including incontinency?
Any surgeries?
Family h/x of GERD/PUD/Crohn’s/Ulcerative colitis/ or colitis/or colon cancer?
Family h/x of kidney stones or kidney/bladder cancer?
Alcohol usage or smoking?
Health H/X- Musculoskeletal System
Chronic Diseases?
Accidents? Trauma? Surgeries?
Family h/x of arthritis, spinal curvature? Back problems?
Exercise/sports?
Pain?
Problems w/movements? Joints?
Problems w/ADL’s?
Prenatal Health H/X (Pregnant woman)/OB/GYN
Chronic illness?
General info re: reproductive system, problems w/menstruation, infections, painful intercourse, and sexual patterns should be included
(includes info regarding current/past pregnancies-Determine exact date of LMP to estimate delivery date)
Obstetric H/X:
# of pregnancies(including current) (G)
# of full term births (T)
# of preterm births (P)
# of abortions (A)
# of living children (L)
Document following for each pregnancy:
Course of pregnancy (duration gestation/date of delivery/any problems?)
Process of labor (manner labor started/spontaneous/induced/length/complications
Delivery method (pain management)
Condition of infant at birth (including wt)
Postpartum (mother/infant)
Health H/X Older Adult
Shift focus: Reflects changes in their roles and perceptions during retirement years
General statement of feelings about self
Family/social relationships
Functional ability/ Ability to perform BADL’s/IADL’s
Sleep?
Mental Health?
Assessment of the Infant/Child/Adolescent
Pediatric nursing-birth through adolescence
Nurse considers: Differences in A&P w/growth, developmental milestones specific to age/psychosocial issues unique to infants/toddles/preschoolers/school-age/adolescents
Adding to complexity if the fact that children are assessed in context of their families
(nurse must be skilled at interviewing/observing both families/children)
Physical exam-nurse adjusts exam components & techniques to meet unique needs of each age group
Health H/X Infant/Child/Adolescent
Pediatric Health h/x adapted to age & developmental status of child
*Age specific data in areas of perinatal h/x, growth, development, & behavioral status
* Observe interaction between parent & child throughout h/x & exam
Complete h/x obtained during well child visits
Focused h/x when child presents w/illness
H/x obtained from parent/adult accompanying child
After parent’s concerns explored-addition questions can be asked directly to school-age child & adolescents using language and concepts appropriate to age
Important to give adolescents opportunity to talk w/o parent present/given opportunity to discuss issues privately
AMA/GAPS questionnaire to be completed by younger/middle/older adolescents/parent
These forms provide valuable first step in data collection for these age groups
Mental Health Assessment
General Health H/X
Do you have any chronic illness?
Medications? OTC? Supplements?
Describe your feelings/mood
Do you consider your present feelings to be a problem in your daily life?
Mental Health
Past Health H/X
Have you been treated for mental health problems?
Have you experienced any behaviors that could indicate mental health problems?
How have you coped w/these behaviors ?
How well are these coping strategies working for you?
Mental Health
Family H/X
Do you have any blood relatives who have behaviors that could indicate a mental health problem, such as mental illness, alcoholism, or drug abuse? Describe?
Personal/Psychosocial H/X
*Self-Concept
How would you describe yourself to others? What do you like about yourself?
* Interpersonal Relationships
How satisfied are you w/your relationships w/people?
Are there people you can talk w/about your feelings & problems?
* Stressors
Have there been any recent changes in your life?
How have these changes affected your stress level?
What are the major stressors in your life now?
How do you deal w/stress? Are these methods of stress relief currently effective for you?
*Anger
How do you react when you are angry? Do you react when you are angry? Do you react verbally or physically, or do you keep your anger inside? Can you talk about what has caused this anger?
* Alcohol Use
How often do you drink alcohol, including beer, wine or liquor?
* Recreational Drug Use
Some people use recreational drugs. Do you ever use them? If yes, tell me about your drug use
Problem Based H/X
Depression
During the past 2 weeks have you felt down, depressed, or hopeless?
During the past month have you often had little interest or pleasure in doing things?
Are you able to fall asleep and stay asleep without difficulty?
Have you noticed any marked changes in your eating habits?
Gained/lost weight w/o trying?
Lack of energy?
Experienced feelings of elations, increased activity levels, agitation, irritability, or like your thoughts are going very fast?
Do you have friends that you can trust? Are they available for when you need them?
Have you had depressive feelings like this before? What did you do about them?
Have you thought about hurting yourself or taking your own life? Do you have a plan? Do you have the means of carrying out your plan? Is there anything that would prevent you from carrying out your plan?
What has kept you from hurting yourself in the past?
Problem Based H/X
Anxiety
Do you feel anxious?
How long have you been experiencing this feeling?
Have you noticed a change in your feelings? describe
What do you think initiated them? How did you cope?
Have you had difficulty concentrating or making decisions?
Have you been preoccupied/forgetful?
Are you able to fall asleep & stay asleep w/o difficulty?
Have you noticed a change in amount of energy that you have? fatigue? Have you been more irritable than normal?
So your muscles seem tense?
Do you feel a tightening in your throat?
ANXIETY/Over the last 2 weeks have you had the following experiences?
Patients are asked how often they experience these feelings
on a scale from “not at all” to “nearly every day”
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Having difficulty sitting still
Being easily annoyed or irritated
Feeling afraid, as if something awful might happen
Risk Factors
ANXIETY
Psychosocial Environment
Genetics
Unrelieved Stress
Other mental health disorders
Substance Abuse
