CH4 Complete Health History

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purpose of health history
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to collect subjective data and combined with objective data to assist the nurse in identifying “nursing diagnoses”
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biographical data
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name age/DOB race/ethnicity gender marital status occupation primary language
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chief complaint
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“title to the story” what brought you to the hospital today?
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sign
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subjective sensation that the person feels from their disorder
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symptom
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objective abnormality that you, the examiner, could detect on examination or labs
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C.L.I.T.T.A.A.A
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Character Location Intensity Timing Aggravating factors Alleviating factors Associated factors
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PMH (past medical history)
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chronic illnesses injuries surgeries/hospitalizations medications allergies
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Family History
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chronic illnesses may be genetic: diabetes hypertension coronary artery disease cancer
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Which of the following is included in documenting a history source?
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Appearance, dress, and hygiene Cognition and literacy level Documented relationship of support systems Reliability of informant
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Reliability of informant
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The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history.
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A patient seeks care for “debilitating headaches that cause excessive absences at work.” On further exploration, the nurse asks, “What makes the headaches worse?” With this question, the nurse is seeking information about:
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the patient’s perception of pain. the nature or character of the headache. aggravating factors. relieving factors.
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aggravating factors
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Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient’s perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help.
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The CAGE test is a screening questionnaire that helps to identify:
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unhealthy lifestyle behaviors. personal response to stress. excessive or uncontrollable drinking. depression.
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excessive or uncontrollable drinking
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CAGE is a screening questionnaire to identify excessive or uncontrolled drinking; C = Cut down; A = Annoyed; G = Guilty; E = Eye opener. The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults.
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The “review of systems” in the health history is:
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an evaluation of past and present health state of each body system. a documentation of the problem as perceived by the patient. a record of objective findings. a short statement of general health status.
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an evaluation of past and present health state of each body system
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The purpose of the review of systems is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person’s own words that describes the reason for the visit. This is typically known as a “chief complaint” or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement related to the patient’s general health status is typically included in the complete physical assessment record.
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When recording information for the review of systems, the interviewer must document:
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physical findings, such as skin appearance, to support historic data. “negative” under the system heading. the presence or absence of all symptoms under the system heading. objective data that support the history of present illness.
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the presence or absence of all symptoms under the system heading
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When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise it is unknown which factors were asked. Recording physical findings in the review of systems is incorrect; review of systems is limited to the patient’s statements or subjective data. Writing “negative” after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; review of systems is limited to the patient’s statements or subjective data.
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Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
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education, financial status, and value-belief system. exercise and activity, leisure activities, and level of independence. family role, interpersonal relations, social support, and time spent alone. stressors, coping mechanisms, and change in past year.
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education, financial status, and value-belief system
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Functional assessment measures a person’s self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are related to the activity and exercise section of the functional assessment. These areas are related to the interpersonal relationships and resources section of the functional assessment. These areas are related to the coping and stress management section of the functional assessment.
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PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
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severity of dementia. substance use and abuse. pain presentation. the ability to perform activities of daily living (ADLs).
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pain presentation.
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The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient’s perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person’s self-care ability including the ability to perform ADLs.
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C.L.I.T.A.A.A is equal to
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PQRSTU
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The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
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review previous medical records. rephrase the same questions later in the interview. ask the patient if there is someone who could verify information. call a family member to confirm information.
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rephrase the same questions later in the interview
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A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corrobation of information from another individual is not within the context of the present interview. This would occur outside the context of the interview.
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When taking a health history from an adolescent, the interviewer should:
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ask about violence and abuse before asking about alcohol and drug use. have at least one parent present during the interview. interview the youth alone with a parent in the waiting area. ask every youth about the use of condoms.
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interview the youth alone with a parent in the waiting area.
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The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (related to injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and situational questions.
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What information is included in greater detail when taking a health history on an infant?
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Nutritional data History of present illness Family history Environmental hazards
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Nutritional data
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The amount of nutritional information needed depends on the child’s age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother’s health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children.

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