Health History

Question 1

what is the purpose of getting a health history? (5)

Answer 1

-baseline data about pt. health
-supplement, confirm, or refute previous data
-confirm and identify nursing diagnosis
-make clinical judgements r/t changes in data
-evaluate outcomes of care

Question 2

considerations for assessment (4)

Answer 2

-cultural assessment (ex. muslims prefer women)
-infection control (clean stethoscope, etc)
-environment (keeping pt. privacy)
-equipment (take all things needed into room)

Question 3

interview of patient
types of data

Answer 3

-subjective : pain (based off of patient)
-objective : BP (data in front of me, confirmed)

Question 4

interview of patient
sources of data

Answer 4

-primary source : direct from patient
-secondary source : everything else (family, friends, nurse to nurse report, medical records)

Question 5

types of diagnostic tests (5)

Answer 5

-laboratory
-radiologic studies
-skin tests
-pulmonary function tests
-endoscopy exams

Question 6

data collection (4)

Answer 6

-interview
-nursing health history
-physical exams
-diagnostic and lab results

Question 7

data collection (4)

Answer 7

-interview (orientation phase, working phase, termination phase)
-nursing health history (medication history, past medical history, home life - live with people, social - smoke or drink?, cheap complaint)
-physical exams
-diagnostic and lab results

Question 8

physical assessment
comprehensive

Answer 8

looking at everything, asking questions

Question 9

physical assessment
focused

Answer 9

ex. ) go to cough clinic - respiration, lungs

Question 10

physical assessment
system specific

Answer 10

related to body system - ex) GI distress, look at system

Question 11

physical assessment
ongoing

Answer 11

same every time and mark changes
ex) neuro assessment

Question 12

physical assessment
head to toe

Answer 12

general assessment of general patient

Question 13

elements of assessment (3)

Answer 13

-baseline history
-problem based history
-examination (vital signs, inspection, auscultation, palpation)

Question 14

nursing process and the physical assessment (4)

Answer 14

-assessment
-nursing diagnosis
specific to us a nurse
ex) dr says generalized weakness, we do an assessment, and figure out pt is at risk for skin breakdown
-planning
-evaluation

Question 15

techniques for assessment (5)

Answer 15

-inspection
-palpation
-percussion
-auscultation
-olfaction

Question 16

what is included in inspection (visual) - 4

Answer 16

-visually looking and assessing patient
-good lighting
-cover parts not being examined / drape
-use additional lighting for eyes, ears, throat

Question 17

palpation (tactile) methods : (4)

Answer 17

-bimanual/manual technique
-dorsum of hand
-palm or ulnar surface of hand
-palmar surface of finger/finger pads

Question 18

light palpation is

Answer 18

1 cm or 1/2 depth

Question 19

deep palpation is

Answer 19

4 cm or 2 in deep

Question 20

what are we observing for in inspection? (4)

Answer 20

-color
-shape/symmetry
-movement
-position

Question 21

what are we assessing when we palpate? (8)

Answer 21

-texture
-resistance
-resilience
-mobility
-temperature
-thickness
-shape
-moisture

Question 22

auscultation (auditory) is listening for characteristics like : (4)

Answer 22

-frequency : # of oscillations per second
-loudness : amplitude of a sound wave
-quality : descriptive
-duration : length of sound wave

Question 23

when using stethoscope we must always _______

Answer 23

directly place on skin

Question 24

what does the bell of stethoscope do?

Answer 24

low pitched

Question 25

what does the diaphragm of stethoscope do?

Answer 25

high pitched

Question 26

what are we looking for in olfactory assessment?

Answer 26

abnormal vs normal ex) alcohol on breath, sweet smelling mouth odor (usually descriptive in nature)

Question 27

things to do when preparing for the assessment (GIEUWCM)

Answer 27

-Gather all necessary equipment -Introduce yourself -Explain procedure -Use gloves if necessary -Wash hands before and after ANY contact with patient -Clean stethoscope head and blood pressure cuffs between patients -Make patient comfortable; allow for privacy and confidentiality

Question 28

what are the special considerations for aged people?

Answer 28

-sensory and physical limitations -recognize normal changes of aging vs abnormal

Question 29

what's included in the general survey? (12)

Answer 29

-race/gender *can't assume* -age *ask -body type -posture -signs of distress -substance abuse -speech -movement/gait -hygiene/grooming -dress -affect/mood -patient abuse

Question 30

what are the signs or abuse? (4)

Answer 30

-inconsistency between injury and statement -bruising, lacerations, burns, bites -x - ray shows fractures in various stages of healing -behavior issues : insomnia, anxiety, and isolation