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NUR 245 Exam 1 Textbook Notes
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- NUR 245
Detailed Exam 1 Textbook Notes for Nur 245. ***An Essential Study Material??
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Chapter 4: The Complete Health History1. Purpose of Health History:
- Combines subjective data (patient's statements) and objective data (clinical observations) to
create a complete health profile.
- Essential for formulating a diagnosis and developing a health management plan.
2. **Detailed Components of Health History:
- **Biographic Data:** Detailed personal information such as name, address, phone number, age,
birth date, birthplace, gender and preferred pronoun, relationship status, race, ethnic origin,
occupation, primary language, and changes in occupation due to illness.
- **Source of History:** Identification of the information provider (patient, relative, interpreter,
etc.), their reliability, and ability to communicate effectively.
- **Reason for Seeking Care:** Direct quotations from the patient describing the reason for the
visit, including symptoms or signs and their duration.
- **Present Health or History of Present Illness:** For well individuals, a brief statement about
general health; for ill individuals, a chronological record of the reason for seeking care. Includes
eight critical characteristics: location, character/quality, quantity/severity, timing, setting,
aggravating/relieving factors, associated factors, and patient’s perception.
- **Past Health:** Detailed history including childhood illnesses, accidents or injuries, chronic
illnesses, hospitalizations, operations, obstetric history, immunizations, allergies, and medication
reconciliation.
- **Family History:** Comprehensive details about family health, highlighting diseases and
conditions that might indicate a genetic predisposition. Includes use of tools like genograms.
- **Review of Systems:** Thorough examination of each body system to gather additional
symptoms not mentioned in the Present Illness section.
3. **Special Considerations:**
- **Functional Assessment:** Includes activities of daily living, nutritional status, social
relationships, spiritual resources, coping strategies, and environmental factors.
- **Cultural and Environmental Considerations:** Understanding the patient's cultural
background, spiritual beliefs, and environmental factors that could impact health.
- **Genetics and Health:** Importance of understanding genetic predispositions and
environmental interactions.
4. **Special Populations:**
- **Children:** Incorporates prenatal, perinatal, and developmental history, along with a focus
on growth, developmental milestones, and childhood illnesses.
- **Immigrants:** Additional questions about immigration history, health perceptions, and
nutritional habits.
- **Adolescents:** The HEEADSSS assessment method focusing on home, education, eating,
activities, drugs, sexuality, suicide/depression, and safety.
5. **Health Promotion and Disease Prevention:**
- Emphasis on lifestyle choices, regular screenings, vaccinations, and early detection strategies.
6. **Pain Assessment:**
- Detailed evaluation using the pain scale and PQRSTU mnemonic (Provocative/Palliative,
Quality/Quantity, Region/Radiation, Severity Scale, Timing, Understand Patient’s Perception).
, 7. **Technological and Record-Keeping Aspects:**
- Utilization of electronic health records and technology for efficient data management, ensuring
accuracy and confidentiality.
8. **Communication Skills:**
- Effective interviewing techniques, including open-ended questions and active listening, to
gather comprehensive health information.
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