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NURSING C350 Harvey Hoya verified exam with questions and answers
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,what does the health history provide? - provides a complete picture of the person's pastand present health. The history should see what the patient is doing right to stay well
within their life syle. In other patients it might detect a health problem which reflects a
more ill person.
what is the health history sequence? - 1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)
what is Biographic Data - Biographic data include name, address, and phone number;
age and birth date; birthplace; gender; relationship status; race; ethnic origin; and
occupation.
what does Source of History mean? - The person himself or herself, although the
source may be an interpreter or caseworker. Less reliable is a relative or friend.
why is "Reason for Seeking Care" part of the health history sequence? - describes the
reason for the visit. Think of it as the "title" for the story to follow. It states one (possibly
two) symptoms or signs and their duration.
what is "Reason for Seeking Care" in the health history sequence? - brief, spontaneous
statement in the person's own words that describes the reason for the visit.
why is it important to know "Present Health or History of Present Illness" while
assessing the health history? - For the well person, this is a short statement about the
general state of health
For the ill person, this section is a chronologic record of the reason for seeking care,
from the time the symptom first started until now.
This should be in the final summary in any symptom the patient might have. 8 critical
components. - 1. Location. Be specific; ask the person to point to the location. If the
problem is pain, note the precise site. "Head pain" is vague, whereas descriptions such
as "pain behind the eyes," "jaw pain," and "occipital pain" are more precise and
diagnostically significant. Is the pain localized to one site or radiating? Is the pain
superficial or deep?
2. Character or Quality. This calls for specific descriptive terms such as burning, sharp,
dull, aching, gnawing, throbbing, shooting, viselike when describing pain. You also need
to ask about the character of other symptoms. Use similes: Blood in the stool looks like
sticky tarm whereas blood in vomitus looks like coffee grounds.
,3. Quantity or Severity. Attempt to quantify the sign or symptom, such as "profuse
menstrual flow soaking five pads per hour." Quantify the symptom of pain using the
scale shown on the right. With pain, avoid adjectives, and ask how it affects daily
activities. Then record if the person says, "I was so sick I was doubled over and couldn't
move" or "I was able to go to work, but then I came home and went to bed."
4. Timing (Onset, Duration, Frequency). When did the symptom first appear? Give the
specific date and time or state specifically how long ago the symptom started prior to
arrival (PTA). "The pain started yesterday" will not mean much when you return to read
the record in the future. The report must include answers to questions such as the
following: "How long did the symptom last (duration)?" "Was it steady (constant) or did it
come and go (intermittent)?" "Did it resolve completely and reappear days or weeks
later (cycle of remission and exacerbation)?"
5. Setting. Where was the person or what was the person doing when the symptom
started? What brings it on? For example, "Did you notice the chest pain after shoveling
snow, or did the pain
Pain scale - P: Provocative or Palliative. What brings it on? What were you doing when
you first noticed it? What makes it better? Worse?
Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it?
R: Region or Radiation. Where is it? Does it spread anywhere?
S: Severity Scale. How bad is it (on a scale of 0 to 10)? Is it getting better, worse,
staying the same?
T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last?
Frequency—How often does it occur?
U: Understand Patient's Perception of the Problem. What do you think it means?
why are past health events important? - hey may have residual effects on the current
health state.
what are some things that may be recorded when dealing with past health? - childhood
illnesses, accidents, serious or chronic diseases, hospitalizations, operation , allergies,
current medications, last examination date,
family history - highlights diseases and conditions for which a particular patient may be
at increased risk
Review of Systems - the purposes of this section are (1) to evaluate the past and
present health state of each body system, (2) to double-check in case any significant
data were omitted in the Present Illness section, and (3) to evaluate health promotion
practices.
Functional Assessment (Including Activities of Daily Living) - Functional assessment
measures a person's self-care ability in the areas of general physical health; objectively
measures the person's present functional status and monitor changes over time.
, what does perception of health mean? - how we define health, how we view a situation,
our concerns, what do we think might happen in the future.
what is biographic data through children development? - Include the child's name,
nickname, address and phone number, parents'/caregivers' names and work numbers,
child's age and birth date, birthplace, sex, race, ethnic origin, and information about
other children and family members at home.
Which is a component of the review of systems? - Health promotion
how does the review of systems include health promotion? - The review of systems
includes a patient's past and present physical health status. The patient's health
promotion is a component of the review of systems, because it helps to understand the
patient's current health-promotion practices. The nurse will perform a symptom analysis
after the assessment and review of systems. Immunizations and prenatal status
constitute the past health history of the patient.
Which information should the nurse obtain when performing a medication
reconciliation? - Over-the-counter medications
Herbal supplements
Current prescriptions
Which action by the nurse is the best way to obtain a patient's family history? - Sending
a questionnaire to the patient's house
what are some common food allergies for kids? - peanuts, fish and eggs.
Under which section would the nurse record information about hearing aid use? -
Review of systems
how many hour of sleep are recommended for teenagers? - 9 hours
While documenting a complete health history, under which section would the nurse
record a patient's activities of daily living? - functional assessment (Functional
assessment is a person's ability to perform daily activities such as housekeeping,
shopping, cooking, bathing, dressing, toileting, eating, and walking. )
Which tools in the electronic and print format can be used to collect the family history? -
my family health portrait
utah health family tree
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