NURS 306 Quiz: PA history taking

structure of a client encounter

• initiating session

• gathering information

• physical assessment

• explanation and planning

Components of assessment

• History

• Exam

History

• defining normal for the patient

• collecting info from and about patient

• identify pertinent negatives

Exam

Head to toe assessment

Primary objective of history

est database of patient’s past and present health status

Clinical value of history

• Identifies health strengths, actual risks, and potential problems

• provides subjective data to guide the physical exam

• est rapport and builds trust

• forms foundation for nurse process and care planning

4 types of hx assessments

comprehensive, focus/problem-oriented, follow-up, and emergent

Comprehensive hx

Admission of a new pt

Focus/problem-oriented history

known patient; ex.) college student seen at student health center

Follow-up hx

pt returning to have probelm evaluated ex.) pt back for worsened cough

Emergent hx

rapid assessment; life-threatening

Comprehensive history (Do’s)

• private setting

• limited distractions

• calm

• non-judgmental

• non-medical jargon

• listen actively

Comprehensive history (DONTS)

• Rely memory

• Start with delicate subject matter

• lose professionalism

• Go fast

• believe everything

types of data

primary, secondary, objective, subjective

primary

everything you learn from your patient

secondary

Data from sources other than your patient

Objective

measurable data (auscaltation, inspection, palpation, percussion)

subjective

patient’s interpretation

Components of health history

• Date and time

• Identifying data

• Chief complaint (CC)

• History of Present Illness (HPI)

Date and time

most important for rapidly changing condition

Identifying data

gender, marital status, occupation

Chief complaint (CC)

Brief “in patient’s own words”

History of Patient Illness (HPI)

OLDACARTA; attributes of a symptom

OLDACARTA

Onset, location, duration, assoc. factors, characteristics, aggravating factors, relieving factors, allergies + current medication

Allergies

swelling, rash, hives

Side effect of meds

G.I. upset (take meds with food)

components of family history

past medical and surgical history, family history, personal and social history, review of systems (ROS)

review of systems (ROS)

general pertinent negatives

Why review systems?

• evaluates current health status

• double check to see if any data omitted

• head to toe

• identifies pertinent negatives

Pertinent negatives

signs or symptoms that your client does NOT have (enlarges data base)

things to always observe

• breathing

• posture

• pain

• eye contact

• level of cognition (perception, memory, and thinking (A&Ox4)

• Speech

3 areas to use assessment (order of priority)

1. nursing care plan,

2. referral to other discipline, i

3. ndivid pt teaching