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10 Cards in this Set
- Front
- Back
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What is a health history?
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It is an interview with a patient to gather subjective data about any presenting condition.
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What is subjective data?
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- Patient's verbal description of their health problems.
- includes feelings of anxiety, physical discomfort, and/or mental stress - collected from patient |
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What is objective data?
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- Observation or measurements of a patient's health status
- includes information collected from head-to-toe assessment - Collected from physical assessment, vital signs, height, weight |
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What is the purpose of the health history?
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- obtain info about pt health status
- to establish thorough database - to identify strengths/actual probs - aids in establishing an individualized plan of care - establish nurse-patient relationship |
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What is an actual or risk nursing diagnosis?
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A diagnosis that is established after the nurse gathers data and groups the significant findings into patterns of data.
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What is the biographical information of the health history?
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- aka Patient Profile
- Age - Sex - Race - Religion - Marital Status - Educational level - Primary language |
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What is the past medical history (PMH)?
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- Other known health problems
- surgeries - accidents - home medications (are they compliant with these meds) - allergies - drug/tobacco/alcohol use - significant family history |
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What is the chief complaint (CC)?
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- The sign (objective) or symptom (subjective) that caused the patient to seek health care.
- record in exact words (in quotes) - "What brings you here? What brought you to the hospital?" |
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What is the review of systems (ROS)?
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- Head-to-toe subjective data of major body organs
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What are Gordon's Functional Health Patterns?
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- role / relationships
- self-perception / self-concept - stress / coping / tolerance - value / belief - activity / exercise - sleep / rest - nutritional / metabolic - elimination / gastrointestinal - elimination / urinary - sexuality / reproductive |
