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NUR1112 nursing > week 4: health history taking > Flashcards

week 4: health history taking Flashcards

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1
Q

is occupational health included in biographical data?

A

no - health & lifestyle management

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2
Q

what is included in the patients perception of present state of health?

  1. h__ p__ a__
  2. d__/n__
  3. i__
  4. h__ s__ a__
A

health promotion activities
diet/nutrition
immunisations
health screening activities

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3
Q

what are some examples of health & lifestyle management?

  1. a__ & r__ d__
  2. s__ & t__ h__
  3. s__ h__ c__
  4. e__ h__
A

alcohol & recreational drugs
smoking & tobacco history
sexual health counselling
environmental hazards

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4
Q

is marital/family status biographical data?

A

yes

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5
Q

is the nominated medical power of attorney biographical data?

A

yes

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6
Q

are interpersonal relationships/resources included in biographical data?

A

no - general health & wellbeing

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7
Q

what are the 3 mnemonics?

A

OLD CHARTS
SOCRATES
PQRSTU

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8
Q

purpose of a health history interview:

  1. a__, p__ & a__ p__ can be i__
  2. g__ of c__ can be d__ & c__
  3. i__ can be d__ & i__
  4. e__ of c__ can be e__
  5. e__ r__ with the p__
A

actual, potential & anticipated problems can be identified

goals of care can be developed & confirmed

interventions can be devised & implemented

effectiveness of care can be evaluated

establishes rapport with the patient

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9
Q

components of a health history interview:

  1. b__ d__
  2. r__ for s__ c__
  3. p__ of p__ s__ of h__
  4. p__ h__ & m__ h__
  5. f__ h__
  6. g__ o__ h__ & w__
  7. h__ & l__ m__
A 
biographical data
reason for seeking care
perception of present state of health
past health & medical history
family history
general overall health & wellbeing
health & lifestyle management
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10
Q

fill in the mnemonic for a patients perception of present state of health:

S -
O -
C -
R -
A -
T -
E - e\_\_ f\_\_
S -
A 
site
onset
character
radiation
alleviating factors
timing
exacerbating factors
severity
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11
Q

fill in the mnemonic for a patients perception of present state of health:

P - p\_\_ f\_\_
Q - q\_\_/q\_\_
R - r\_\_/r\_\_
S - 
T - t\_\_/t\_\_
U - u\_\_ p\_\_ p\_\_
A 
precipitating factor
quality/quantity
region/radiation
severity
timing/treatment
understanding patient perceptions
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12
Q

The interview should be o__ but allow room for the patient to provide the i__ they d__ i__

A

organised, information they deem important

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13
Q

is the patients occupation biographical data?

A

yes

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14
Q

fill in the mnemonic for a patients perception of present state of health:

O -
L -
D -

C -
H -
A - a\_\_& a\_\_ f\_\_
R - r\_\_ s\_\_
T -
S -
A 
onset
location
duration
characteristics
aggravating & alleviating factors
related symptoms
treatment
severity
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15
Q

should errors be obliterated in full on quality documents?

A

no

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16
Q

are current medications included in health & lifestyle management?

A

yes

17
Q

what may be useful in a family history assessment?

preparation of a g__

A

genogram

18
Q

who is the primary source of the health history interview?

A

the patient

19
Q

is culture, religion & ethnicity an example of biographical data?

A

yes

20
Q

the information obtained during the interview must be documented in a retrievable form.

true/false

A

true

21
Q

What relevant conditions are included in family history?

  1. d__
  2. h__
  3. c__
  4. d__
  5. h__
  6. h__ a__ & s__
  7. o__
A 
diabetes
hypertension
cancer
dementia
hyercholesterolaemia
heart attack & stroke
obesity
22
Q

should you translate a patients ‘chief complaint’ into the terms of a medical diagnosis?

e.g., “I have had pain in my tummy all day”

A

no

23
Q

are allergies included in past health & medical history?

A

yes

24
Q

what is the structure & process of the health history interview determined by?

the c__ & n__ of the p__

A

the conditions & needs of the patient

25
Q

what are secondary sources of data for the health history interview?

  1. s__ o__
  2. other h__ p__
  3. m__ r__
  4. l__ r__/r__
A

significant other
other healthcare professionals
medical records
laboratory reports/results

26
Q

who can access the information obtained during the interview?

o__ the t__ t__

A

only the treating team

27
Q

are values & beliefs/spiritual resources included in general overall health & wellbeing?

A

yes

28
Q

does the patient have the right to refuse to participate in the health history interview process?

A

yes

29
Q

documentation requires

  1. d__ & t__
  2. s__ & h__ w__ d__
A

date & time

signature & healthcare workforce designation

NUR1112 nursing (5 decks)

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