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24 Cards in this Set
- Front
- Back
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Health history |
1. Bio graphic data /personal profile 2. Chief complaint 3. Present health history 4. Past health history 5. Family health history 6 current medications 7. Lifestyle 8. Social data 9. Psychological 10. Developmental level
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Biographical data/personal profile |
Name, address, age and birthplace, martial status, nationality, occupation |
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Chief complaint |
Concise statement describing the reason for confrontation, confinement, consultation. A. Brief spontaneous statement in the patient's own words that describe the reason for the visit. B. Reasons for seeking care C. Not a diagnostic statement - avoid translating it into terms of a medical diagnosis. |
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Present health history |
Written narrative about what Transpired regarding health of client before confinement or consultation A. For the well person, this is a short statement about general state of health. B. For the I'll person, this is a chronological record of the reason for seeking care, from the time the symptoms first started until now. C. The final summary of any symptoms should include the following |
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The final summary of any symptoms includes the following |
1. Location 2. Quality or character - specific descriptive terms. Example pinpoint, thriving, crushing, sharp? 3. Quantity or severity - passion scale ;how bad is it 4. Timing : onset, duration, frequency 5. Setting - where was the person, what s person doing? 6. Aggravating or relieving factors. 7. Associated factors - accompanying signs and symptoms. 8. Patients perspective. |
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4. Past health history |
Written narrative again. A. Childhood illness B. Accidents or injuries C. Serious or chronic disease D. Hospitilizations E. Operation F. Obstetric history G. Immunization H. Last examination date I. Allergies |
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Family health history |
A. Ages of siblings, parents, grandparents, and their current state health (1st degree only) B. If they are deceased, cause of death is obtained C. Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism and mental disorders D. Note for management done, hospitilization and other procedures done by attending physicians and at what particular year. |
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Current medications |
A. Note all meds, prescription and OTC and herbal remedies. B. Ask specifically for vitamins, birth control pills, aspirin and acids. C. For each medication, nor the name, dose and schedule and ask "how often do you take each day?" "what is it for?" & "how long have you been taking?" |
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Lifestyle |
A way of living day to day behavior and function of individuals included because lifestyle can affect health A. Personal habits B. Diet C. Sleep patterns D. Activities of daily living E. Instrumental activities of daily living F. Recreation |
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A. Personal habits |
Alcohol, coffee, cola, tea and illegal or recreational drugs type? Amount? Frequency? Duration? |
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B. Diet |
Description of a typical diet on a normal day or any special diet |
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C. Sleep patterns |
Usually daily sleep /wake times Difficulty sleeping? What remedies? Independent nursing axn advice: warm milk |
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Activities of daily living |
Any difficulties experienced in basic activities such as: eating, grooming, dressing, elimination, moving |
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E. Instrumental activities of daily living |
Difficulties experienced in food prep, transportation, house keeping, laundry, finance handling, and managing medications |
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F. Recreation |
Exercise, hobbies, vacations, anything done in your free time. Tolerance doing it? |
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8. Social data |
A. Family relationships B. Ethnic affiliation C. Educational history D. Economic status E. Home and neighborhood condition F. Occupational history |
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9. Psychological data. |
A. Major stressors B. Usual coping strategies C. Communication style D. Interaction with client support system |
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Developmental level |
Havighurst age periods and developmental tasks 1. Infancy and early childhood 2. Middle childhood 3. Adolescence 4. Early adulthood 5. Middle age 6. Later maturity |
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1. Infancy and early childhood |
Birth to 5 years old Learning to walk Learning to control bodily wastes Learning to talk Learning to form relationships with family members |
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2. Middle childhood |
6-12 years old. Learning physical skills Developing school related skills Developing conscience and values Attaining independence - eating, bathing, |
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3. Adolescence |
13-17 years old Establishing emotional independence from parents Equipping self with skills needed for productive occupation Achieving gender-based social role Establishing mature relationships with peers of both sexes |
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4. Early adulthood |
18-35 years old Choosing a partner Starting a family Managing a home Establishing a career |
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5. Middle age |
36-60 years old People settle into adult life Maintaining economic standard of living Performing civic and social responsibilities Developing adult leisure - time activities Adjusting to aging parents |
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6. Later maturity |
Over 60 year old Adjusting to deteriorating health and physical strength Adjusting to retirement Adjusting to death. |
