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13 Cards in this Set

  • Front
  • Back
what are the reasons for performing a health history?
obtain information about status- to establish a data base-to identify strengths&possible problems--aids in planning care-to start nurse client role
what are the components of the nursing health history? (10)
biographic data(age,occupation)--chief complaint--present illness--past history--family history-- lifestyle--social information-- psychological info--body systems--pattern of healthcare--
what are some communication techniques in data collection?
-therapeutic communication
-don't be judgemental--consider their culture--use various questions--provide privacy--use pencil to take notes..
this is any piece of information or data that influences decisions?
cues.
this is the interpretation or conclusion made based on cues and observed data? this is called
inferences
determination that the diagnosis accurately reflects the clients problem, and that the methods used were appropriate and justified? this is called
validation
this type of interview is highly structured and elicits specific information?
direct interview
this is what the client states brought him to the hospital ?
chief complaint (cc)
this is the review of all health problems by body system. its purpose is to prevent the omssion of data related to illness & discover other problems?
review of systems (ROS)
this involves usual health status, chronologic story, relevant family history, & disability assessment?
history to prevent illness (HPI)
this is all the previous immunizations & experiences with illness?
past medical history (PH)
this is all the previous immunizations & experiences with illness?
past medical history (PH)
this is bases on health perception/management, nutritional, metabolic, elimination, cognitive/perceptual, roles,and relationships,and coping with stress?
functional health patterns