HWA PPx 1 Interview, Health History Flashcards
What is an assessment? What is its purpose?
Collection of data about a person’s health state.
Purpose: to make a judgement or diagnosis.
What is subjective information?
What the patient says or describes about their condition during history taking.
What is objective information?
What you as the healthcare provider can observe (think senses see, hear, touch, smell, etc) during your assessment.
What is diagnostic reasoning?
Analyzing all the data and drawing conclusions (differentials) to identify diagnoses
What is evidence based practice?
-Guide to healthcare providing patients the most current and best-practice techniques.
What are the six phases of nursing process?
- Assessment
- Diagnosis
- Outcome Identification
- Planning
- Implementation
- Evaluation
What is part of the assessment process?
-Collection of Data: review of the clinical record, health history, physical exam, functional assessment, risk assessment , review of literature.
- Use evidence-based assessment techniques.
-Document relevant data.
What are the 3 priorities? What are their characteristics?
1st Level: Highest priority, urgent, life threatening (MARCH)
2nd Level: Needs attention before decompensating to 1st level.
3rd Level: Lowest priority, long term intervention process.
What are the four databases?
- Complete
- Focused/Problem-Centered
- Follow-Up
- Emergency
What is a complete database?
Complete health history and full physical examination. Usually done in primary care settings
What is a focused database?
Collect a targeted history and the physical examination is catered to the area(s) of concern. Completed in all settings.
What is a follow-up database?
Used to check status of known issue to verify if change has occurred. Completed in all settings.
What is an emergency database?
URGENT, RAPID collection of info in conjunction with life-saving measures. Completed history is completed once the patient is stable.
What is culture?
Includes attitudes, values, beliefs, norms, and roles
* learned from birth – language acquisition and socialization
* shared by all group members
* adapted to environmental factors
* always changing
* Sub-cultures may share different beliefs, values,
attitudes, norms
What is socialization/enculturation?
Raised within a culture and acquiring the norms, values, and behaviors of that group.
What is ethnicity?
A social group that may share traits – geographic origin, religion, language, values, traditions.
What is acculturation?
Adopting culture and behaviors of the major culture.
What is race?
Reflects self-identification and construct of groups of people who share similar physical characteristics.
What is FICA? What is it used for?
FICA is a spiritual assessment tool.
F- Faith “Do you have spiritual beliefs, values or practices that help you cope with stress?”
I- Importance/Influence “Do you have specific beliefs that influence your health care decisions?”
C- Community “Are you part of a spiritual or religious community?”
A- Address/Action “How should I address these issues in your health care?”
What is an open-ended question?
One where the patient answers in descriptive terms.
Example: Can you describe your pain?
What is close-ended question?
Questions that are yes no/one or two-word answers.
Example: “Does this hurt? Can you wiggle your toes?”
What is SBAR?
S- Situation?
B- Background
A- Assessment
R- Recommendation
Means of passing down/on patient information.
What is OLDCARTS?
O- Onset
L- Location
D- Duration
C- Character
A- Aggravating Factors
R- Relieving Factors
T- Treatment
S- Severity
What is an organic mental disorder?
Caused by brain disease of known specific origin – delirium and intoxication.
