Unit Health History Flashcards
What is the first step in the nursing process?
Assessment
What are the 4 parts of a nursing assesment?
1) Collect date
2) Categorize data
3) Record data
4) Systematic/ongoing process
What does collecting data include?
1) Collecting, organizing, validating, and documenting client data.
2) obersvation
3) interviews
4) nursing assessment
What is an assessment?
Collection of Data
What data is the physical assessment based off of?
- Objective data
- Your senses
- Facts
What data is health history based off of?
- Subjective data
- What the pt says
- “opinion”
- Cna verify objective data
What type of pt might not be able to give you subjective information?
1) Baby
2) Not cohearint people
3) Coma people
How can you get subjective information from a child?
Ask them questions at their word level and then verify information w/ parent.
What could make it challenging, though not impossible, for a pt to provide subjective information?
- Toddlers
- Mild cognitive impairment
- Language barrier
- Speech deficit
- Pain or severe illness
- Anxiety
- Embarrassment
- Previous negative experience w/ health care
- Cultural differences
Define medical health history.
Information obtained from the pt to aid in establishing a medical diagnosis and developing a treatment plan.
Define a nursing health history.
A written record providing data for assessing the nursing care needs of a pt.
The medical model done by the MD reviews what?
- Body systems.
Why is the nursing model different from a phycisans?
Nurses need information to provide a more holistic approach and identify both medical and nursing problesm.
Is the nursing model of health history objective or subjective information?
Subjective.
How many components are there on the nusing model of a health history?
10
What are the 10 components of a nursing model health history?
- Biographical data
- Chief complaint
- History of presenting illness
- Client’s perception of Health status and expectations for care.
- Past health history
- Family health history
- Social history
- Medication history and device use
- Complementary/ Alternative modalities
- Review of body systems and associated functional abilities
Define biographical data of a nursing model
- Name
- Address
- Age
- Gender
- Race
- Religion
- Marital status
- Occucpation
What can biographical data assess for.
- Cognitive impairment
Define the Cheif complaint of the nursing model?
The client’s perception of or reason for seeking medical or nursing advice.
What is used for a pain assessment
COLDERRA
- Characteristics (dull, achy, sharp, stabbing)
- Onset (When did the pain start?)
- Location: (Where does it actually hurt?)
- Duration: (How long does it last?)
- Exacerbations: ( What makes the pain worse)
- Radiation: ( Does it travel? To where?)
- Relief ( WHat provides relief?)
- Associated symptoms: (Nausea, anxiety)
Define the client’s preception of health status and expectations for care.
Client’s knowledge about his illness and its potential effects on his/her life.
Define the history of presenting illness in the nursing model.
An in-depth exploration of the flient’s chief conmplaint
Define past health history on the nursig model.
Includes childhood diseases and immunizations, previous hospitalization and surgeries.
Define the Family health history of the nursing model.
Data on first-degree relatives.
Define social history w/ how it relates to nursing model.
Information about family and other relationships, economic status, occupations, exposure to toxic materials, home and neighborhood conditions, and ethnicity.
Define the medicaion history and device used on a nursing model.
Past and current medications and any devices they might use. (oxygen)
Define complementary/alternative modalities (CAM) w/ how it relates to nursing model.
Therapies used instead of or in addition to MD ordered therapies (acupuncture).
Define “review of body systems and associated functional abilities” w/ how it relates to the nursing model.
-Subjective data
- Includes questions such as do you have a cough/chest pain?
- Functional abilities such as needing assistance
The nursing interview is to gather _____ data w/ _____ communication and in a _____ way.
- Subjective data
- Structured
- Purposeful
What are the 3 parts to a pt interview?
1) Prepare yourself
2) Prepare the space
3) Prepare the pt.
How does a nurse prepare herself for a nursing interview?
1) Know your purpose
2) Read the pt’s chart
3) Form some goals
4) Think of some opening questions
5) Schedule some uninterrupted time
6) Gather the necessary assessment forms and equipment
7) Take a deep breath and compose your self
How does a nurse prepare the space?
1) Provide privacy
2) Keep the focus on the client
3) Remove distractions
4) Sit down. Do not hover over the bed.
How does a nurse prepare the pt?
1) Introduce yourself
2) Call the pt by name
3) Tell the pt what youw ill be doing and why
4) Assess and provide comfort
5) Assess for anxiey
6) Assess readiness to discuss helath issues
7) Interviews
When does the nurse establish RAPPORT?
During the “prepare the pt” stage
When conducting a nursing interview, how does she show, w/ her body, that she is listening?
1) Face the pt.
2) Learn toward the pt.
3) open and relaxed posture
4) Keep eye contact (when culturally correct).
What are somethings that create barriers?
- Asking why..
- Expressing disapproval
- Offering advice
- Using patronizing language
Describe a non-directive interview.
- Pt controls the subject matter
- Encourages the pt to share more information
- Who, what, when, where, did/does, is/are.
- Use open ended questions
- Avoid asking why
When would you use a Directive interview?
- In an emergency
- Obtain factual, easily categorized information.
Define a directive interivew.
- Specific
- Can be answered w/ a yes/no
- Nurse controls the interview
Uses mostly closed questions
When would you use nondirective interviews?
- Promote communication
- Facilitate thought.
- Build rapport
- Help pt to express feelings.
