Fundamentals General Survey, Health History, Nursing Process – Flashcards

-What the patient tells you -The history (from chief complaint to ROS) S=Symptoms/Story

-What you detect during the examination -All physical examination findings O=Observed Ex: Lab tests, diagnostic studies, physical exam findings

Does MORE THAN assess body systems -Appropriate for new patients -Provides personalized knowledge about patient -Strengthens relationship -Helps identify/rule out physical causes (r/t patient concerns) -Provides baseline for future assessments -Creates platform for health promotion (edu/counsel) -Develops proficiency in skills

You select methods RELEVANT to thorough assessment of the TARGETED problem -Appropriate for established patients -Addresses focused concerns/symptoms -Assesses symptoms restricted to specific body system -Applies exam methods relevant to the concern

-Identifying data -Chief complaint -Present illness -Past history -Family history -Personal and social history -ROS

-Date and time -Age, gender, occupation, marital status -Source of history (patient or caregiver) -If there's a referral, then source of the referral -Note reliability (depends on patient's memory, trust, & mood)

The one or more symptoms/concerns causing the patient to seek care *Make every attempt to quote the patient's own words*

-Amplifies the chief complaint (describes how each system developed) -OLDCART -Patient's thoughts/feelings about illness -Pulls in relevant portions of ROS -Medications (why are they being used?), allergies (what happens?), habits of smoking & alcohol (how much? how often?), LNMP

-Lists childhood illnesses -Lists adult illnesses with dates (medical, surgical, accidents, obstetric/gynecologic, psychiatric) -Include health maintenance practices (immunizations, screening tests, lifestyle issues, home safety)

-Outlines/diagrams age and health, or age and cause of death (siblings, parents, grandparents) -Document presence or absence of specific illnesses in family (hypertension, CAD)

-Describe education level, family of origin, current household (violence? abuse?), personal interests, lifestyle (travel? military?)

-Document presence or absence of common symptoms related to each major body system

O: Onset (When did it start?) L: Location (Where is it?) D: Duration (How long does it last?) C: Characteristics (Quality & severity) A: Alleviating & Aggravating Factors (Does anything make it better or worse?) R: Radiating (Does the pain radiate?) T: Timing (How often does it occur? How long?)

1) Comprehensive medical history 2) Episodic medical history 3) Interval health history 4) Emergency health history

-Complete health history, usually performed at first appointment and updated every 1-2 years -Current and past health -Health promotion & screenings -Functional ability, ADLs -Complete head to toe exam

-When patient comes in with a new health problem (ex: fever/sore throat) -Combination of chief complaint and history of present illness (CC + HPI) -Smaller scope, one problem -Symptom analysis (OLDCART) -Focused exam (1-2 systems examined)

"Follow up health history" -builds on a complaint from a previous visit -may also be called a "progress note" -interval assessment -chronology: "what happened since..?" -physical exam focused on that problem

-Usually collected by emergency staff -Provides triage team with vital info for diagnosing patient's condition and prioritizing order in which patients are seen -Simultaneous history and physical exam -Trauma, bleeding, fall, etc.

-To collect data (info about client's health, including physiological, psychological, sociocultural and spiritual aspects) -To identify actual and potential problems -To establish the nurse-client relationship

-To evaluate past and present health state of each body system -Includes ONLY SUBJECTIVE data (does NOT include physical exam findings)

1) General Symptom: Fever? Fatigue? Dizziness?) [Signif: Failure to respond to treatment. Dehydration could lead to fall risk] 2) Respiratory Symptom: SOB? Cough? [Signif: Pneumonia/aspiration from bed rest/narcotics. Pulmonary embolus from bed rest, coagulopathy] 3) Cardiac Symptom: Chest pain? [Signif: Stress on myocardium from illness, fever] 4) GI Symptom: Constipation? N/V? Last BM? [Signif: Side effects of meds, impending bowel obstruction]

-Overall review or first impression that the health care provider has of a person's well being -Begins with first contact with the patient and continues throughout interview and physical exam

*Your impressions (beware of your values and beliefs)* 1) Apparent state of health (posture, gait) 2) LOC (awake, alert, responsive) 3) Facial expression 4) Distress 5) Height, build 6) Nutritional status (WD/WN, weight) 7) Skin color, obvious lesions 8) Dress, grooming, personal hygiene 9) Odors (body, breath) 10) Behavior (affect, eye contact, expressions, speech, mood, manner) 11) Mental status (orientation: person, place, time)

-Habits (tobacco, alcohol, illegal drugs) -Complementary therapies (massage, reiki, yoga) -Immunizations -Psychosocial (living arrangements, family, occupation) -Developmental-Erickson (intimacy vs isolation, generativity vs stagnation, integrity vs despair) -Travel/Military

S: Assessment/data collection Subjective information: patient interview, symptom analysis/chronology O: Assessment/data collection Objective information: physical exam A: Assessment/name the problem Diagnosis: Your synthesis of S & O P: Plan including outcomes (must be measurable), interventions & rationales, and evaluation

-Subjective -Multiple sources (patient, family, other providers, medical record) -Exchange information -Be aware of the message you send (verbal & non-verbal) -Be aware of the message you receive (culture, self-concept, past experience, emotional state, pain, age, gender, education, socioeconomic status) -Interview: go from simple to more complex, use open-ended questions, avoid yes/no questions, ask one question at a time, offer choices for answers, watch for non-verbal cues, don't DE-personalize! (the foot vs YOUR foot), be aware of judgmental comments/questions ("you don't ___, do you?") -Be aware of influence of advancing age (chronic illness, multiple meds, under-reporting, mental status, focus on ADLs)

Subjective: all the "history" information you collect Age, gender, advanced directives, PMH/CC/HPI/ROS, meds,allergies, habits, social, family, functional health, violence, abuse, functional health patterns

Objective: measurements of vital signs, general survery, physical exam (HEENT, skin, respiratory, cardiac, abdomen, neuro, musculoskeletal), lab & diagnostic tests

Assessment: your analysis of the data (subjective and objective) you collected and the priorities you identified. Give those priorities a name (pain, ineffective coping, etc.)

Identify your plan: outcomes, interventions, rationale, evaluations

Activities of Daily Living Physical: bathing, dressing, toileting, transfers, continence, feeding Instrumental: using phone, shopping, preparing food, housekeeping, laundry, transportation, taking meds

1) Health perception/health management 2) Activity/exercise 3) Elimination 4) Nutrition 5) Roles/relationships 6) Sexuality/reproductive 7) Coping/stress 8) Sleep/rest 9) Cognitive/perceptual 10) Self perception/self-concept 11) Values/beliefs