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Health Assessment - Health History
Terms in this set (21)
The 7 attributes of a symptom
comprehensive, focused, follow-up, emergency
The 4 types of health histories
Identifying data and source
Component of a comprehensive adult health hx which can include demographic data collection and can be given by the patient, family, or referral source.
Component of a comprehensive adult health hx that provides the patient's version of their symptoms. No medical dx is written for this.
Report goals of the visit
What can a nurse do if there are no chief complaints?
Hx of present illness (HPI)
Component of a comprehensive adult health hx where a chronological account is given. OLD CART can be used to collect this information.
pertinent positives, negatives
HPI key elements can include _______ _______ and/or ______ from the review of systems.
Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations, Exacerbations/Relieving Factors, and Treatments
What does the acronym OLD CART stand for
Asking a patient to rate their pain on a scale is an example of a what symptom attribute?
Treatments; things that naturally happen to make the symptom better or worse (e.g., bending at the knees)
Relieving/Exacerbation factors are not _____. They are ______. Give one example.
If a patient says, "I have noticed a rash with my symptoms," this is considered a/an _________ __________.
Component of the comprehensive adult health hx that includes allergies, medications, childhood/adult illness, health maintenance, and/or alcohol or illicit drug use.
Follow up with a clarifying question such as, "What happens?"
If a patient states they have an allergy, what is the next step a nurse should take?
Past Hx: Health maintenance
Immunizations, screening tests, risk factors, and safety measures are all examples of ______ _____ measures that can be related to a patient's past hx.
Family Hx (FHX)
Component of the comprehensive adult health hx that includes information about genetic risk factors.
The nurse must be nonjudgemental
The single most important guideline for sensitive topics
C - Ever felt the need to CUT DOWN
A - ANNOYED by criticism of drinking/use
G - Felt GUILTY about drinking/use
E - Drink/use first thing in the morning (EYE OPENER) to help calm nerves
Screening tool used for alcohol and illicit drug use
Review of Systems
Component of the comprehensive adult health hx where problems the patient may have overlooked can be uncovered
Medications; Misinformation/Disease Process
Sexual dysfunction can be a result of ______ and/or _____.
Use open-ended questions then move on to more specific.
What is the best questioning approach for capturing a patient's mental health history?
- unexplained/inconsistent injuries
- delay in getting treatment for trauma
- past history of repeated injuries
- hx of alcohol/drug abuse
- dominating partner who doesn't want to leave the room
Physical abuse should be considered under what circumstances?
Sets found in the same folder
Health Assessment - Integumentary System
Health Assessment - Nutrition
Health Assessment - Musculoskeletal System & Pain
Sets with similar terms
prepU Chapter Two Health History and Interview
Jensen Prep U Chapter 2
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