UNIT 2B Flashcards
a collection of information obtained from the patient or other sources
health history
What are the purposes of health history
Provide the subjective database.
Identify patient strengths.
Identify patient health problems, both actual and potential.
Identify supports.
Identify teaching needs.
Identify discharge needs.
Identify referral needs.
What are the components of the health history?
Biographical Data
Source of History
Present Health
a. Chief Complaint or Reason for Seeking Care
b. History of Present Illness
PTA
prior to admission
PTC
Prior to consultation
When writing the chief complaint, use the _____ terms
anatomical
What is remittent fever?
Temperature will go down but not to normal temperature
On and off fever
intermittent fever
It is a condition characterized by recurrent acute episodes of fever followed by intervening afebrile periods.
relapsing fever
38 degrees celsius
mild fever
39 degrees fever
Moderate-grade
40 degrees and beyond celsius temperature of the patient
High-grade
What are the common accompanying symptoms of fever?
chills
fatigue
weakness
pain and cough
rashes
For assessing the pain severity, you can let the patient?
rate the pain from 1-10
For the pain rating,
1-3 is
4-7 is
8-10 is
1-3 is mild
4-7 is moderate
8-10 is severe
What are the assessment tools for pain for elderly or with cognitive problems patient?
Wong-Baker Pain Scale
What are the different characters of pain?
dull
sharp
stabbing
burning
gnawing
cramping
throbbing
Deep Pain
Dull or Gnawing pain
hapdos pain
burning
squeezing pain
typically for felt by patients with dysmenorrhea
cramping
What are the different duration of pain?
constant
Rhythmic
Brief
loss of appetite
anorexia
Feeling of vomitting
nausea
lipong is
dizziness
What are the commonly used for the character of cough?
productive or non-productive
dry cough
non-productive
There is an obstruction or narrowing of airways
what is the character of the cough?
barking cough
What are the different sputum amount?
scant
moderate
copious
What are the different sputum odor?
foul-smelling
putrid
rotten odor of the sputum
putrid
What are the different sputum color?
blood-tinged
whitish
greenish
yellowish
rust-tinged
What are the different sputum consistency?
tenacious or thick
thin or water mucoid
frothy
What are the other respiratory problems?
Dyspnea
if you have a patient with TB, what do you expect the color of his or her sputum?
blood-tinged
viral infection causes what sputum color?
whitish
bacterial infection causes what sputum color?
yellowish or green
A patient has congestive heart failure or pulmonary edema, what is the sputum consistency?
frothy
difficulty of breathing
dyspnea
dysphagia
difficulty of swallowing
difficulty in urinating
dysuria
difficulty
what prefix
dys
What is COLDSPA?
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors
In writing present illness, include the ______ (especially if an accompanying symptom is anticipated but was not present with the client’s chief complaint)
pertinent negatives
Who devised the Gordon’s Functional Health Patterns?
Marjory Gordon
used by nurses to provide a more comprehensive nursing assessment of the patient
Gordon’s Functional Health Patterns
What are 11 Gordon’s Functional Health Patterns?
- Health Perception-Health Management
- Nutritional -Metabolic
- Elimination
- Activity-Exercise
- Sleep-Rest
- Cognitive-Perceptual
- Self Perception-Self Concept Pattern
- Role-Relationship
- Sexuality-Reproductive
- Coping-Stress Tolerance
11, Value-Belief
Describes perceived pattern of health and well-being and how health is managed.
health perception-health management pattern
Describes the pattern of food and fluid consumption relative to metabolic need. Also included are pattern indicators of local nutrient supply.
nutritional-metabolic pattern
What tool is used to describe the stool?
Bristol Stool Scale
Describes patterns of sleep, rest, and relaxation.
sleep-rest pattern
Describes patterns of perception and cognition.
cognitive-perceptual pattern
Describes self-concept and perception of self-worth, self-competency, body image, and mood state.
self-perception-self-concept patter
Describes pattern of role engagements and relationships.
role-relationship pattern