WEEK 1- HEALTH HISTORY Flashcards
Differentiate between subjective & objective data.
subjective- what the patient says, we can use “..” for things they say, pain, describes reason for seeking care
objective data- things we can measure, height, weight, BMI
Outline components of the distinct health history types: Complete, focused, follow up & emergency.
Complete: everything
Episodic/Problem-Centred/Focused- focused on specifics
Follow-Up- updates on past
Emergency- immediate and focused
Describe how the complete history incorporate psychosocial, developmental, sexual, cultural & spiritual components
what to avoid in interview
developmental considerations
techniques in communication
Sending
Receiving
Attending to power differentials
Communication skills
Unconditional positive regard
Empathy
Active listening
health assessment
health history (objective/subjective data)
physical exam
documentation
Health History
biographical data
reason for seeking care
current illnesses
Past Health
Family History
Review of Systems
Functional Assessment
Perception of Health
biographical data
Name
Address & phone number
Age and birth date
Birthplace
Gender
Marital Status
Ethnocultural background
Occupation
Primary Language
source of history
Record who furnishes the information
Reliability of informant
Special circumstances (e.g., interpreter)
reason for seeking care
Ask patient what prompted them to seek care
Symptom/sign
Use of quotation marks
current health
O Onset
P Provocative or palliative
Q Quality or quantity
R Region or radiation
S Severity scale
T Timing
U Understand patient’s perception
the working phase
Introducing the interview
The working phase
Open-ended and closed questions
communication
Responses: assisting the narrative
Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
nonverbal skills
Nonverbal skills
Physical appearance
Posture
Gestures
Facial expression
Eye contact
Voice
Touch
challenging situations
Hearing-impaired patients
Acutely ill patients
Patients under the influence of alcohol or drugs
Personal questions asked of the clinician
Dealing with sexual advances
Patients who are crying
Angry patients
Patients who threaten violence
Anxious patients
The nurse is required to do a health history and physical assessment on a client who does not speak English. What is the best strategy?
- get a staff member to translate
The nurse has completed the initial assessment on the client. The nurse documents some of the assessment findings: Temp 36.9◦C, P 68, Bp 123/75, and Respirations 14. This data is best described as:
objective data
The nurse is conducting an environmental assessment on a 52 year old male client who works in a chemical processing plant. What would this environmental assessment include?
type of exposure
The nurse is admitting is assessing a new client. What would be the best type of assessment to perform?
comprehensive assessment
The nurse is taking a comprehensive health history on a new client. The nurse knows that a complete description of the present illness is necessary:
to obtain primary data
