Ch.4: The Complete Health History

Question 1

what is the purpose of health history?

Answer 1

to collect subjective data

Question 2

what the person says about himself/herself

Answer 2

subjective data

Question 3

what you observe through measurements, inspection, palpation, percussion, and auscultation

Answer 3

objective data

Question 4

the history should recognize affirm

Answer 4

what the person is doing right, as well as assess his or her lifestyle

Question 5

Biographic data includes

Answer 5

name, address, phone number, age, birthdate, birthplace, gender, marital partner, status, race, ethnic origin and occupation, primary language

Question 6

Source of History:

Answer 6

1. record who furnishes the info
2. reliability
3. person appears well or ill

Question 7

subjective sensation that the person feels from the disorder

Answer 7

symptom

Question 8

an objective normality that you as the examiner could detect on physical examination or in laboratory reports

Answer 8

sign

Question 9

Reason for seeking care:

Answer 9

try to record what the person is saying directly
list for symptoms
focus on the most pressing concern (now)

Question 10

Eight Critical Characteristics Data (symptoms)

Answer 10

1. Location
2. Character
3. severity
4. timing
5. setting
6. relieving factors
7. associated factors
8. patient’s perception

Question 11

Past health events are important because

Answer 11

they may have residual effects on the current health state

Question 12

comparison of a list of current medications with a previous list, which is done at every hospitalizations and every clinic visit. its purpose is to reduce errors and promote patient safety

Answer 12

medication reconciliation

Question 13

a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents and siblings

Answer 13

pedigree/genogram

Question 14

CULTURE:

Answer 14

immigrants on biographical data- may evoke painful memories
spiritual resources/beliefs (Jehovah’s Witness)
past health- immunizations given in the homeland
health perception- how they describe health and illness
nutritional-foods taboo

Question 15

Review of Systems:

Answer 15

1. to evaluate the past and present health state of each body system
2. to double-check in case any significant data were omitted
3. to evaluate health promotion practices
   ORDER OF EXAMINATION IS HEAD TO TOE

Question 16

measures a person’s self-care ability in the areas of general physical health or absence of illness.

Answer 16

Functional Assessment

Question 17

ADL’s/ functional assessment include

Answer 17

self esteem
exercise
sleep
nutrition
interpersonal relationships
spiriritual resources
coping and stress management
personal habit
alcohol
drugs
environment
intimate partner violence
occupation health

Question 18

Perception of Health

Answer 18

“how do you define health?”
how do you view your sitiation
what do you expect from us as nurses?

Question 19

Health history sequence:

Answer 19

Biographic date
reason for seeking care
present health or history of present illness
past history 
medication reconciliation
family history
review of systems
functional assessment or ADL's

Question 20

CAGE TEST

Answer 20

use as a screening questionnaire to identify excessive or uncontrolled drinking
Cut down
Annoyed
Guilty
Eye-Opener
answer to yes to 2 of the 4 (alcohol abuse)

Question 21

The Adolescent

Answer 21

HEEDASSS
home environment
eating
education
drugs
peer-related activities
sexuality 
suicide
safety