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
is a family assessment tool that identifies the needs, patterns, and relationships among family members and he environment, such as school, work, church, healthcare system
ecomap
Ask the most relevant items __ and the most sensitive ones _____
first
last
What tool is used to assess the nicotine dependence of the patient?
Fagerstrom Test for Nicotine Dependence
In Fagerstrom Test for Nicotine Dependence
7-10
4-6
less than 4
highly dependent
moderately dependent
minimally dependent
What tool is used to assess alcoholism of the patient?
CAGE Questionnaire
In Cage Questionnaire
what is
C
A
G
E
Cut
Annoyed
Guilty
Eye-opener
TRUE OR FALSE: 2 or more yes to Cage Questionnaire indicates alcoholism
TRUE
means that the patient religiously takes his/her current prescribed medications and maintenance medications, on time and without fail.
good compliance
means that the patient sometimes misses a dose of his/her medications or sometimes don’t take them on time.
fair compliance
means that the patient habitually skips medication intake. It may also mean that the patient did not
complete the therapeutic regimen or only takes the supposed maintenance medication only when signs and symptoms are experienced (e.g. taking a maintenance antihypertensive medication only when BP is elevated)
poor compliance
refer to all vaccines received by the client when he/she was ≤ 12 years of age.
childhood immunizations
BCG-this is a vaccine which helps give immunity against TB
Bacillus Calmette-Guèrin
Hep. B
Hepatitis B
DPT
Diphtheria-Pertussia-Tetanus
OPV
Oral Polio Vaccine
IPV
Inactivated Polio Vaccine
HiB
Haemophilus influenzae, Type B
AMV
Attenuated Measles Vaccine
MMR
Measles, Mumps, Rubella
RV
rotavirus vaccine
PPV/PnCV
Pneumococcal Polysaccharide Vaccine
Pneumococcal Conjugated Vaccine
Hep. A
Hepatitis A
refer to all vaccines received by the client when he/she was over 12 years of age.
adult immunizations
HP
Human Papilloma Virus
refers to the first set of doses of the said vaccine received by the client to develop immunity against a particular disease
Primary Dose
refers to the succeeding dose received by the client who has already acquired immunity against a particular disease and the said dose is given to maintain such immunity
booster dose
refers to an annual dose of a vaccine which should be given yearly to acquire short-term immunity against a particular disease
yearly dose
refers to the time period during which a person is at work.
work shift
have varied work schedules which usually change every 3 to 5 days, every week, every 2 weeks, etc..
rotating shift
is any practice, behavior or condition or combination of these that can cause injury or illness
to employees/workers.
occupational hazard
are those that lead to traumatic physical injuries
mechanical hazards
are energy forms which
could lead to illness or bodily injury
physical hazards
are chemicals (in any form) that may cause illness/injury
chemical hazards
are life forms which may cause illness/injury
biological hazards
refer to workplace conditions that pose the risk of injury to the muscles, tendons & joints of the worker
ergonomic hazards
are those which may cause emotional trauma and psychological/mental illness
psychosocial hazards
Type of Housing unit
Detached
Semi-detached
Terrace/link
Townhouse
Flat/Apartment
Condominium
Room in house or dormitory
Improvised hut or makeshift house
a separate house which does not share a common wall with another house
detached
two separate houses, which share a common wall and have separate entrances
semi-attached
houses built in rows of three or more units of which each has a common wall or walls adjoining with
the next house; have separate entrances
terrace or link
structure is similar to a two-storey terrace/link house that attaches vertically or horizontally to each
other in a block; the only difference is that each floor is occupied by different occupants and has its own separate
access to the outside.
townhouse
a multi-storey building which consists of separate housing units
flat or Apartment
a multi-storey building which is considered as an exclusive and luxurious property which has special
facilities (i.e. swimming pool, gymnasium) which could be shared by its occupants.
condominium
a boarding house could be placed in this category
room in house or dormitory
inferior living quarters generally considered temporary and unfit for living
improvised hut or makeshift house
What are the two locality?
Urban and Rural
a locality where large buildings, commercial structures, etc. mostly abound; generally densely populated
what kind of locality?
urban
a locality where most of the land area is for agricultural use; in some areas, a large portion of the area is wilderness; major sources of livelihood of people in the locality are farming, fishing, and the like
what type of locality?
rural
What are the different construction materials?
light- bamboo, nipa, coconut leaves, cardboard
strong- predominantly concrete house
mixd- refer to a combination of light materials, wood and or concrete
What is the crowding index formula?
1/2 number of children under 10 years + number of couples + all other people aged 10 year and over / no. of bedrooms
What are the different types of toilet?
Flush type
Antipolo type
Overhung latrine
Pit privy
a water-sealed, and water-reliant toilet system where waste is disposed by flushing water (either by pour flush or tank flush) through pipes into a public sewerage system or into an individual disposal system like an individual septic tank
flush type
a non-water-reliant toilet; the toilet house is elevated and the shallow pit is extended upwards to the platform (toilet floor) by means of a chute or pipe made of clay, metal, aluminum or board.
antipolo type
a non-water-reliant toilet; the toilet house is constructed over a body of water (stream, lake or
river) into which excreta are allowed to fall freely
overhung latrine
consists of a pit covered by a platform with a hole; the hole is covered (close) or not covered (open); the
platform, may, in its simplest form, consist of only two pieces of wood or bamboo; is generally considered a composting toilet and thus temporary (when the pit is full, another one is dug to serve as a pit privy)
pit privy
What are the different toilet system or ownership?
public or communal
Individual or private-owned
toilet is shared by several households; usually located outside a housing unit; sometimes a fee is required for use of said facility;
public or communal
toilet is used only by the occupants in a housing unit
private-owned
What are the three types of drainage facility?
None
Open drainage
Closed or blind drainage
waste water flows through a system of close pipes to an underground pit or covered canal.
closed or blind drainage
What are the different source of water
Distilled or purified
Electric water pump
Piped System
Open/deep well
Artesian well
generally bought from a water refilling station (usually in gallons) and placed unto a water
dispenser
distilled or purified
own freshwater supply brought from an underground water source to a tank or directly unto household pipeline through an electric pump
electric water pump
public water supply brought from an outside water source directly unto a pipeline which leads into a household; generally paid per month to a provider
piped system
water source is from a shallow hole dug in the ground; water is usually fetched using buckets tied to ropes
open or deep well
water supply is brought from an underground water source through a manual water pump (or
“bomba”/”poso”); usually located inside client’s property or shared by several households in a community
artesian well
refer to modifications made to the client’s housing unit to accommodate or consider members in the household with special needs (e.g. young children, pregnant women, elderly, those with physical disability), usually to protect them from injury or to facilitate access (i.e. a ramp installed for a family member on a wheel chair)
special adaptations
refers to general safety measures done in the home to keep children from unintentional injury; this includes installing stair gates, placing covers on electrical outlets, placing soft guards on furniture, etc.
child proofing
refers to general safety measures done in the home to keep children from unintentional injury; this
includes installing stair gates, placing covers on electrical outlets, placing soft guards on furniture, etc.
slip-proofing
refer to seasonings and sauces that add flavor or improve the taste of food.
condiments
What are the major methods of cooking food?
moist-heat cooking methods
Dry-heat cooking methods
fry-cooking methods
was designed to be a communication aid for healthcare professionals to describe stool
consistency and form.
Bristol Stool Scale
are drugs taken orally (usually in the form of a tablet or syrup) to relieve constipation; their main action is to
stimulate evacuation of the bowels
laxatives
is a solution introduced into the rectum to promote evacuation of the bowels
enema
is a solid medication for insertion usually into the rectum, where it melts and releases the active substance/medication; depending on the medication, it may act to stimulate evacuation of the bowels.
suppository
is a surgically created opening that diverts stool to the outside of the body through an opening on the abdomen called a stoma
ostomy
is a surgically created opening between the ileum (usually the terminal ileum) of the small intestine and the abdominal wall
ileostomy
is a surgically created opening between any segment of the colon and the abdominal wall to allow fecal elimination.
colostomy
is a surgically created opening between any segment of the colon and the abdominal wall to allow fecal elimination.
Colostomy
is any device that is designed, made, or adapted to assist a person perform a particular task, usually
to assist a person in ambulating.
assistive device
ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored yes/no for independence in each of the six functions.
Kantz Activity of Daily Living
