Health Assessment Ch 4 – Flashcards

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The purpose of the complete health history
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to collect subjective data
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Critical characteristics used to explore each symptom the patient identifies.
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1. location- ask the pt. to point to the location 2. character or quality- specific descriptive terms 3.Quantity or severity- qualify the sign or symptom 4.Timing- onset, duration, frequency 5. Setting- where were you 6. Aggravating or relieving factors- what makes it worse, brings it on, or makes it better. 7.Associated factors- primary symptom associated with any others. 8. Patient's perception- meaning of the symptom to the patient
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Elements of the health history:
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1. Reason for seeking care- brief, spontaneous statement in pt.'s own words. 2.Present health state- statement about the general state of health 3. Past history- important b/c they may have residual effects on the current health state. 4. Review of systems- evaluate past & present health state of each body system. 5. Functional patterns of living- measures a persons self care ability.
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Rational for obtaining a family history
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to highlight those diseases and conditions for which a particular pt. may be at increased risk for.
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Pedigree or genogram
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a graphic family tree in at least 3 generations such as parents, grandparents, and siblings.
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Rationale for obtaining a systems review
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1. evaluate the past and present health state of each body system 2. double check incase any significant data were omitted in the present illness section. 3. evaluate health promotion practices.
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Items included in a functional assessment
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spiritual resources, activity/ exercise, sleep/rest, nutrition/ elimination, coping/ stress management, self esteem, self concept, interpersonal relationships, personal habits, occupational health, environmental hazard, and alcohol or illicit street drugs.
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One way to verify the reliability within the context of the interview is to:
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rephrase the same question later in the interview.
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During an initial interview, the examiner says, "Mrs. J' tell me what you do when your headaches occur." With this question the examiner is seeking information about:
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aggravating or relieving factors
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Which of the following of an appropriate recording of a patent's reason for seeking health care?
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"grabbing" chest pain for 2 hr
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Select the best description of "review of systems" as part of the health history.
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the evaluation of the past and present health state of each body system
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Which of the following is considered to be subjective?
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pain lasting 2 hours
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