EXAM 3- Health Hx Flashcards
1
Q
why do we perform a pt health hx
A
- gather baseline data
- supplement, confirm, or refute previous data
- confirm/identify nursing diagnosis
- make clinical judgements r/t changes in data
- evaluate physiological outcomes of care
2
Q
what should you consider when completing a pt hx?
A
- cultural sensitivity- match the pt’s culture, use professional translators
- infection control- clean equip., PPE, hygiene
- environment- privacy (visitors/door)
- equipment- be prepared
3
Q
primary source of data
A
comes from pt
4
Q
secondary source of data
A
comes from family/friends, EMR, healthcare professionals
5
Q
diagnostic tests
A
- laboratory- ABg, CBC, sputum
- radiologic studies- X-Ray, CT, V/Q Scan, PET scan
- skin tests
- pulmonary function tests
- endoscopy exam
6
Q
interview method of data collection
A
- orientation phase
- working phase
- termination phase
7
Q
methods of data collection
A
- interview
- nursing health hx
- physical examination
- diagnostic & laboratory results
8
Q
types of physical assessment
A
- comprehensive
- focused- focused on the cc/problem
- system specific- focused on a system
- ongoing- same routine assessment, looking for changes
- all assessments are considered head to toe
all include assessing & asking questions
9
Q
elements of an assessment
A
- history- baseline & problem-based
- examination- vitals, inspection, auscultation, palpation
10
Q
assessment process & physical
A
- assessment- interview, physical assessment
- nursing diagnosis- identiy the risk
- planning- based on assessment data, plan care to prevent problems/ avoid the risk
- evaluation- establishes nursing accountability, evaluate, take responsibility
11
Q
in what stage of the nursing process does the nurse establish accountability & responsibility?
A
evaluation
12
Q
techniques for assessment
A
- inspection
- palpation
- percussion
- auscultation
- olfaction
included all senses except taste
13
Q
inspection process
visual
A
- good lighting, use additional lighting/devices if needed
- expose all of the body part to be examined, respect privacy
- observe for: color (sclera, skin), shape/symmetry, movement (gait), position (anatomically, midline)
14
Q
palpation process
tactile
A
- bimanual/manual technique
- dorsum of hand- assess temp
- palm/ulnar surface of hand- shape, texture
- palmar surface/ finger pads- radial pulse
- assess for: texture, resisitance (ROM), resilience (duration), mobility, temp, thickness (skin integrity), shape (breast), moisture (clammy)
- light palpation: 1/2 in depth (radial pulse)
- deep palpation: 2 in depth (abd. assessment)
15
Q
percussion process
auditory & tactile
A
- direct- applied directly to body
- indirect- applied through another surface
