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16 Cards in this Set
- Front
- Back
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Give 5 reasons to perform a health assessment.
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1. To obtain info about health status
2. To establish a database 3. To identify strengths and actual problems 4.Aids in establishing an individualized care plan 5. To establish a N-C relationship |
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List 6 compoonents of a nursing health history.
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1. Biographical data
2. Chief complaint (CC) 3. History of Present Illness (HPI) 4. Past medical History (PH) 5. Health Patterns 6. Review Of Systems (ROS) |
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T/F Using only probing questions to determine the specific problem during the initial interview is correct.
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FALSE: A combination of directive and nondirective approaches is usually appropriate during the info gathering interview.
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DEF: Subjective or objective data that can be directly observed by the nurse
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DEF: Cues
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DEF: The nurse’s interpretation or conclusions made based on cues
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DEF: Inferences
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DEF: Information that are apparent only to the person affected; can be described or verified only by that person
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DEF: Subjective Data
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DEF: Information that is detectable by an observer or can be tested against an accepted standard; can be seen; heard; felt; or smelled
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DEF: Objective Data
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DEF: A highly structured interview that uses closed questions to elicit specific information
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DEF: Directive Interview
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DEF: The answer given to the question; 'What is troubling you?' or 'Can you tell me the reason you came to the hospital or clinic today?'
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DEF: Chief Complaint (CC)
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What is special about the recording process for the CC?
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The chief complaint should be recorded in the client’s own words
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DEF: A head-to-toe subjective data of major body systems
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DEF: Review of Systems (ROS)
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DEF: Includes when symptoms started; acuity; frequency; location of distress; character of complaint; aggravating factors; etc.
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DEF: History of Present Illness (HPI)
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DEF: Includes childhood illnesses; allergies; past injuries; previous surgeries; medications; etc.
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DEF: Past medical History (PH); includes family history
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DEF: Includes role/relationship; self-perception; activity; nutrition; sexuality; etc.
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DEF: Functional Health Patterns
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DEF: Any piece of information that influences decisions
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DEF: Cues
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DEF: The determination that the diagnosis accurately reflects the problem of the client; that the methods used for data gathering were appropriate; and that the conclusion or diagnosis is justified by the data
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DEF: Validation
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