History Taking, Vital Signs, and Monitoring Devices Flashcards
What is the chief complaint?
A chief complaint is a concise statement of the symptoms that caused a patient to seek medical care. The patient history will generally begin by determining the chief complaint.
What is the history of present illness (HPI)?
A history of present illness is a description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. The HPI includes: onset, location, duration, characteristic, alleviating and aggravating factors, radiating or relieving factors, timing, and severity.
Why are open-ended questions preferred for history taking?
Open-ended questions are preferred when you want the patient to describe things in his or her own words.
Examples include:
* “Why did you call for help today?”
* “How would you describe the pain?”
* “What were you doing when this started?”
When are close-ended questions appropriate?
Close-ended questions may be preferred when time is critical. Close-ended questions can also be useful if the patient is only able to speak short sentences due to severe pain or respiratory distress.
Describe proper active listening techniques.
- It is more effective to have one provider take responsibility for obtaining the patient history.
- Facilitate communication with you patient by maintaining eye contact, and providing verbal or non-verbal cues that you are listening.
- Avoid interrupting the patient.
- Attempt to clarify non-specific statements.
Define pertinent negatives.
Pertinent negatives are symptoms that are important to consider but are not present.
What does the accronym OPQRST stand for?
- Onset: “What were you doing when the symptoms began?”
- Provocation: “Does anything make your symptoms better or worse?”
- Quality: “How would you describe the pain?”
- Radiation: “Does the pain go anywhere?”
- Severity: “How would you rate the pain on a scale from 1 to 10, with 10 being the most severe?”
- Time: “When did the symptom start?” Note: this is especially important with potential heart attack and stroke patients.
What is SAMPLE history?
- Signs and symptoms are findings you can objectively see, feel, hear, or smell.
- Allergies, especially to prescription or over-the-counter medications.
- Medications the patient takes regularly, including prescription, non-prescription medications, vitamins, and supplements.
- Past pertinent history, any relevant past medical history, cardiac, respiratory, diabetic, seizure, and stroke history.
- Last oral intake, most recent food and fluid intake.
- Events leading to incident.
Most vital signs provide a combination of quantitative (numerical) and qualitative (non-numerical) data. Every patient encounter should include at least two sets of vital signs. If unable to obtain at least two sets of vital signs, your patient care report should indicate why.
What are the standard vital signs?
Respirations, pulse, blood pressure, pupils, skin, pulse oximetry (the “sixth” vital sign).
How are respirations assessed?
Respirations are usually assessed by observing the patient’s chest rise and fall. Sometimes easier to feel or auscultate respirations by placing a hand on the chest, or listening with a stethoscope.
How is the respiratory rate determined?
The respiratory rate is determined by counting the number of breaths (inhalations or exhalations, not both) for 30 seconds and doubling.
Describe the different types of respiratory rhythms and tidal volume of breathing.
- Normal: regular rhythm and adequate chest rise and fall.
- Shallow: minimal chest rise and fall.
- Labored: increased work of breathing.
- Irregular: abnormal breathing pattern.
Explain the difference between normal lung sounds and abnormal lung sounds.
Normal lung sounds are “clear and equal bilaterally” and abnormal lung sounds include absent, diminished, or unequal sounds, or wheezes or rales. Sample documentation of respirations: “16 normal.” Always document both the quality and quantity of respirations.
Location for pulse check for conscious patients.
For adults and children, check their radial pulse and for infants, check their brachial pulse.
What does blood pressure measure?
Blood pressure measures the pressure exerted against the walls of the arteries during contraction of the left ventricle and in between contractions.
How is blood pressure measured?
Blood pressure is measured in millimeters of mercury (mmHg) with a sphygmomanometer (blood pressure cuff) and a stethoscope, or an automated noninvasive blood pressure monitoring device.
What is systolic blood pressure?
Systolic blood pressure is the top number. Systole is the pressure exerted against the walls of the arteries during contraction.
What is diastolic blood pressure?
Diastolic blood pressure is the bottom number. Diastole is the pressure exerted against the walls of the arteries while the left ventricle is at rest.
