Unit Health History Flashcards
(40 cards)
What is the first step in the nursing process?
Assessment
What are the 4 parts of a nursing assesment?
1) Collect date
2) Categorize data
3) Record data
4) Systematic/ongoing process
What does collecting data include?
1) Collecting, organizing, validating, and documenting client data.
2) obersvation
3) interviews
4) nursing assessment
What is an assessment?
Collection of Data
What data is the physical assessment based off of?
- Objective data
- Your senses
- Facts
What data is health history based off of?
- Subjective data
- What the pt says
- “opinion”
- Cna verify objective data
What type of pt might not be able to give you subjective information?
1) Baby
2) Not cohearint people
3) Coma people
How can you get subjective information from a child?
Ask them questions at their word level and then verify information w/ parent.
What could make it challenging, though not impossible, for a pt to provide subjective information?
- Toddlers
- Mild cognitive impairment
- Language barrier
- Speech deficit
- Pain or severe illness
- Anxiety
- Embarrassment
- Previous negative experience w/ health care
- Cultural differences
Define medical health history.
Information obtained from the pt to aid in establishing a medical diagnosis and developing a treatment plan.
Define a nursing health history.
A written record providing data for assessing the nursing care needs of a pt.
The medical model done by the MD reviews what?
- Body systems.
Why is the nursing model different from a phycisans?
Nurses need information to provide a more holistic approach and identify both medical and nursing problesm.
Is the nursing model of health history objective or subjective information?
Subjective.
How many components are there on the nusing model of a health history?
10
What are the 10 components of a nursing model health history?
- Biographical data
- Chief complaint
- History of presenting illness
- Client’s perception of Health status and expectations for care.
- Past health history
- Family health history
- Social history
- Medication history and device use
- Complementary/ Alternative modalities
- Review of body systems and associated functional abilities
Define biographical data of a nursing model
- Name
- Address
- Age
- Gender
- Race
- Religion
- Marital status
- Occucpation
What can biographical data assess for.
- Cognitive impairment
Define the Cheif complaint of the nursing model?
The client’s perception of or reason for seeking medical or nursing advice.
What is used for a pain assessment
COLDERRA
- Characteristics (dull, achy, sharp, stabbing)
- Onset (When did the pain start?)
- Location: (Where does it actually hurt?)
- Duration: (How long does it last?)
- Exacerbations: ( What makes the pain worse)
- Radiation: ( Does it travel? To where?)
- Relief ( WHat provides relief?)
- Associated symptoms: (Nausea, anxiety)
Define the client’s preception of health status and expectations for care.
Client’s knowledge about his illness and its potential effects on his/her life.
Define the history of presenting illness in the nursing model.
An in-depth exploration of the flient’s chief conmplaint
Define past health history on the nursig model.
Includes childhood diseases and immunizations, previous hospitalization and surgeries.
Define the Family health history of the nursing model.
Data on first-degree relatives.
