The Complete Health History Flashcards
A brief, spontaneous statement in the persons own words that describes the reason for the visit
Chief Complaint (CC)
What do you do with the CC?
put it in quotations
The chief complaint is always what?
subjective
Characteristics of a Symptom pt 1
Location
Character or quality
Quantity or severity
Timing (onset, duration, frequency)
What 7 things are in a Health History?
Biographical Data Reason for seeking care (CC) Current health/history of current illness Past health Family history Review of systems Functional assessment or ADLs
What are the levels of prevention?
Primary, Secondary, Tertiary
Health protection & promotion against illness/injury
Prevent incidence of disease
Promote self-responsibility
Primary prevention
Examples of primary prevention
Immunizations Accident prevention (wearing helmet) Dental care & teaching care Poison control & prevention Family planning
Limit the spread of disease
Prevention of complication or disabilities
Health maintenance
Secondary prevention
Examples of secondary prevention for nursing interventions for hospitalized pts
care treatments ROM exercises Medications Growth & development Mammogram
Secondary prevention individuals have
health problems currently but at risk for further illness
Limit the unnecessary disability
Irreversible damage has occurred
Rehab
TEACH PT & FAMILY TO ADAPT
Tertiary prevention
Examples of tertiary prevention
Strokes
Cancers
AIDS
Spinal cord injuries
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
Before calling physical you:
Asess pt
Review chart of what physician to call
Know diagnosis
Read most recent progress note & assessment
What should you have available when speaking with physician?
Chart Allergies Meds IV Fluids Labs/Results
What is said in the background portion of SBAR? 3 things
State admission diagnosis & date of admission
State pertinent med history
Brief synopsis of treatment to date
More characteristics of symptoms pt 2
Setting
Aggravating or relieving
Associated factors
PT perception (mentally)
PQRSTU
Provocative or palliative Quality or quantity Region or radiation Severity time Timing Understand pt perception
What does provocative/palliative mean?
Pro=what makes it better
pall=what makes it worse
