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204 Exam 1 > The Complete Health History > Flashcards

The Complete Health History Flashcards

1
Q

A brief, spontaneous statement in the persons own words that describes the reason for the visit

A

Chief Complaint (CC)

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2
Q

What do you do with the CC?

A

put it in quotations

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3
Q

The chief complaint is always what?

A

subjective

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4
Q

Characteristics of a Symptom pt 1

A

Location
Character or quality
Quantity or severity
Timing (onset, duration, frequency)

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5
Q

What 7 things are in a Health History?

A 
Biographical Data
Reason for seeking care (CC)
Current health/history of current illness
Past health
Family history
Review of systems
Functional assessment or ADLs
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6
Q

What are the levels of prevention?

A

Primary, Secondary, Tertiary

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7
Q

Health protection & promotion against illness/injury
Prevent incidence of disease
Promote self-responsibility

A

Primary prevention

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8
Q

Examples of primary prevention

A 
Immunizations
Accident prevention (wearing helmet)
Dental care & teaching care
Poison control & prevention
Family planning
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9
Q

Limit the spread of disease
Prevention of complication or disabilities
Health maintenance

A

Secondary prevention

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10
Q

Examples of secondary prevention for nursing interventions for hospitalized pts

A 
care
treatments
ROM exercises
Medications
Growth & development
Mammogram
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11
Q

Secondary prevention individuals have

A

health problems currently but at risk for further illness

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12
Q

Limit the unnecessary disability
Irreversible damage has occurred
Rehab
TEACH PT & FAMILY TO ADAPT

A

Tertiary prevention

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13
Q

Examples of tertiary prevention

A

Strokes
Cancers
AIDS
Spinal cord injuries

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14
Q

What does SBAR stand for?

A

Situation
Background
Assessment
Recommendation

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15
Q

Before calling physical you:

A

Asess pt
Review chart of what physician to call
Know diagnosis
Read most recent progress note & assessment

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16
Q

What should you have available when speaking with physician?

A 
Chart
Allergies
Meds
IV Fluids
Labs/Results
17
Q

What is said in the background portion of SBAR? 3 things

A

State admission diagnosis & date of admission
State pertinent med history
Brief synopsis of treatment to date

18
Q

More characteristics of symptoms pt 2

A

Setting
Aggravating or relieving
Associated factors
PT perception (mentally)

19
Q

PQRSTU

A 
Provocative or palliative
Quality or quantity
Region or radiation
Severity time
Timing
Understand pt perception
20
Q

What does provocative/palliative mean?

A

Pro=what makes it better

pall=what makes it worse

204 Exam 1 (7 decks)

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