nurse 252 complete health history Flashcards
what is the purpose of a complete health history?
To collect subjective and objective data
for an ill pt, the health history includes a detailed and chronological record of the health problem
what is important to remember about the source and recording of a pts history?
record who provides the information, notes any special circumstances such as an interpreter
- record reason for seeking care
- as pt talks, dont jump to conclusions or bias the story by adding your opinion
what is included in a pts past health?
Childhood illness accidental injuries serious or chronic illnesses hospitalizations operations obststrical history immunizations allergies current medications family history
For hair skin and nails what history should u ask about?
History of eczema, psoriasis, change in mole
What should a nurse ask for health promotion about hair, skin and nails?
ask what the pt is doing to stay healthy and for prevention (eg, amount of sun exposure and use of sunscreen)
What should you ask for assessment of the head? What kind of health promotion could you tell the pt?
ask whether the pt has had any unusual headaches, injury, or dizziness
HP: the use of protective gear during sports
what should a nurse ask for assessment of the eyes?
ask if they have diabetes- may have diabetic retinopathy- which means that every 1-2 years they need to get their eyes checked
what should a nurse document about a pts eye? and that health promotion questions to ask?
document difficulty with vision, blurring, diplopia (double vision) - ask about most recent eye exam
what should a nurse take note of when assessing the ear? what health promotion?
presense of ear aches, infections, vertigo
HP: use of earplugs, method of cleaning the ears (can lead to impaction if cleaned wrong)
what should a nurse take note of then assessing nose, sinus, mouth and throat? what should nurse ask about?
record discharge, nosebleeds, sore throats and toothache, nurse should ask about pts pattern of dental care
what does having poor oral care increase the risk of?
Coronary artery disease
what should a nurse document about breasts?
if there is any pain, lumps, or discharge (in men and women)
what should a nurse ask about regarding breasts?
when was last mammogram (ages 50-74) every 2-3 years
what should a nurse document about respiratory system?
document history of lung disease (asthma, emphysema, tuberculosis)
what should a nurse ask regarding a pts respiratory system?
ask when pt had last X-ray
what should a nurse ask about and health promote with cardiac system?
Pain, palpation, cyanosis, dyspnea on excertion
hp: ask the pt the date of most recent ECG (for pts with chest pain)
what is important to remember about some ECG abnormalities?
lots of them are completely non life-threatening and can live with
what should a nurse ask a pt about gastrointestial system?
if the pt has any food intolerances, nausea, or vomiting
what should the nurse document about regarding GI system
document the pts use of laxatives and antacids
what is nippissing district developmental screening?
a parent-report screening tool to see if there is potential for thier child to have development delay
what is racialization?
a process by whcih ethno-racial groups are categorized, stigmatized, inferiorized, and marginalized by “others” - can be conscious or unconscious
what is cultural safety?
“defined as both a process an an outcome whose goal is to promote greater equity” by focusing on the root cause of “pwer imbalances and inequitable social relationships in health care”
what is an importatn question to ask regarding religion and spirituality?
Do you have any religious beleifs or practices that you would like me to know about in realtion to your health? Dietary restrictions? Medications vs fasting?
how many layers does the skin have?
Two , the epidermis and the dermis
charactertiscs of the epidermis?
Is thin but tough
melanocytes produce pigment, melanin, which gives the skin and hair brown tones
All people have the same amoug of melanocyes, however, the amount of malanin they produce varies with genes (more= darker)
what is the dermis?
the inner supportive later consisting mosly of connective tissue or collagen
- tough, fibrous protein that enables the skin to resist tearing
- nerves, sensory receptors, and blood vessles lie in the dermis
what is the subcutaneous layer?
is adipose tissue, which is made up of fat cells
-stores fat for energy, provides insulation for temp control and aids in protection by its cushioning effect
whats different about skin in older adults?
- elastin, collagen, and subcutaneous fat are lost as in muscle tone
- sweat glands and sebeceous glands decrease in bumber and function, leaving skin dry and frail = skin breakdown
- decreased response of sweat glands to thermoregulation also puts older adults at risk for sun stroke
- this is also why elderly have lower body temp
what are the two types of hair?
- vellus hair; fine, faint, covers most of body
- Terminal hair: darker and thicker, grows on scalp and eyebrows, pubes
what are sebaceous / sweat glands?
- produce lipid substances, sebum which is secreted through hair follicles
- sebum oils lubricate the skin and hair
- eccrine glans are coiled tubules that open directly onto the skin surface and produce sweat
- as sweat evaportates it reduces the body temp
what is it called when the body loses it ability to thermoregulate?
heat stroke
what is the cause of dandruff and hair loss?
poor sebaceous glands
what is subjective data for skin conditions? (reported by patient)
- previous history of skin disease (allergies, hives, psoriasis, eczema)
- change in pigmentation
- changes in mole
- excessive dryness or moisture
- pruritus
- excessive bruising
- rash or lesion
- medications
- hair loss
- change in nails
- environmental or occupational hazards
- self-care behaviours
what is vitiligo?
an aquired condition -genetic
- complete absesne of melanin pigment in patchy areas
- dark skinned ppl are more severly affected
- minimal treatment
- can reduce spread by keeping areas out of the sun
what treatment is availbe for vitiligo?
-minimal, but UV light therapy, corticosteriod cream, blue light treatment- but no covered
what is erythema?
intense redness of the skin from excess blood in the dialted superficial capillaries -excpeted with fever, local inflammation or with emotional reactions such as blushing
-from fever and allergies
what is cyanosis?
bluish, mottle discoloration that signifies decreased perfusion; the tissues are not adequatley perfused with oxygenated blood
- Cyanodid indicated hypoxemia (low o2 in blood) and occurs with shock, heart failure, chronic bronchitis, and congential heart disease.
- poor circulation, lack of 02
- blue lips, finger, chest is concerning, means internal organs arent getting 02
what is jaundice?
is a yellow, discoloration indicating rising amounts of bilirubin (RBC’s that die and accumulate in blood, changes skin color) in the blood
- exept for physiological jaundice in the newborn, does not normally occur
- first noted in sclera
- as levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body
what situations may jaudice be present?
- substance users- check eyes, if yellow in skin- heaeded to liver failure
-hepatitis (inflammation of liver)
anything to do with liver
-toxicity with drugs /medication
-self resolves within about 10 days
what is hypothermia used for in a hospital setting ?
Generalized coolness may be induced, such as in hypothermia for surgery or high fever
-some pts are cooled to 32 degrees, which protects the brain and spinal cord function for surgery
in what situation will localized hypothermia be expected?
-localized coolness is expected with an immobalized extremity, as when a limb is in a cast or with IV fluid, since there is a decrease in perfusion (passage of fluid through the circulatory system)
in what situation will hyperthermia occur?
generalised hyperthermia occurs with an increase in metabloic rate as in fever after heavy excersise
-can be dangerous, can burn body from inside out
what is diaphoresis
profuse perspiration (sweating) comes with increased metabolic rate and occurs with strenuous activity or fever
what is dehydration?
assess the oral mucous membrane
-with dehydration, mucous membranes look dry and lips look parched and cracked
what is edema
-fluid that accumulates in the intercellular space
-pitting edema is graded on a four-point scale (skin stays down where person is touched)
stage 4 will stay down for a couple mins
what is a 1+ for edema
mild pitting, sligh indentaion, no percepitalbe swelling of leg
what is a 2+ for edema
moderate pitting, indentation subsides rapidly
what is a 3+ edema
Deep pitting, indentation remains for a short time, leg looks swollen
what is a 4+ edema
very deep pitting, indentation lasts a long time, leg is very swollen
what is bilateral edema or edema that is generalized over the whole body (anasrca) is considered to be what?
a central probelm such as heart or kidney failure
how do you do the turgor test?
pinch up a large fold of skin on the anterior aspect of the chest under the clavicle
- mobility = the skins ease of rising
- turgor = its ability to return to the place when released
what does poor turgor indicate?
severe dehydration, the pinches skin “tents” or stand by itself
what does immobalization do?
impedes delivery of blood which carries oxygen and nutrients to the skin, and impedes venous drainage, which carries metabolic waste away from the skin
what part of the skin in damaged in a stage 2 pressure ulcer?
partical thickness: Damage to the dermis and epidermis, looks like an open blister
what does a stage 3 ulcer do damage to?
extends to the subcutanous tissue, looks like a crater
-but no bone, muscle, or tendoms are visible
what is psorisis ????
- scaly erythematous patch, with silvery scales on top
- usually on scalp, outside of elbows, low back and anogential area
- treatment is heavy immunosuppressents
- sad disease, psychologically devistating
what is toxic alopecia?
- absense of hair
- patchy, asymmetrical balding that accompanies sever illness or use of chemo, growing hairs are lost and resting hairs are spared
- regrowth occurs after illness ends or after discontinuation of toxin
