Health History and Physical Assessment – Video Lecture

Flashcards covering the health history interview, data types, documentation practices, and components of the health history and physical assessment as discussed in the video lecture.

What are the two major components of an assessment in nursing, and why are they both important?

Health history (thorough qualitative interview) and physical examination (objective, quantitative data); both are equally important and provide context for the exam.

What type of data does the health history primarily collect?

Qualitative data from the patient through an interview.

What type of data does the physical examination primarily collect?

Objective, quantitative data such as vital signs and observable findings.

What is the class’s ideal goal regarding normals for a health assessment?

To establish what a normal healthy adult sounds, looks, listens to, and feels like.

Why is it important to know what is normal in patient assessment?

So you can recognize when something is not normal and investigate further.

How does the health history help in building the patient–nurse relationship?

It helps build trust, enabling more honest communication and better treatment planning.

What communication approach is emphasized for health history interviews?

Therapeutic communication with active listening and nonjudgmental responding.

What is a key best practice when documenting during a patient interview?

Face the patient and document key information as you listen rather than staring at the computer the whole time.

When should the focus of the assessment be narrowed to a specific area?

When the patient reports a symptom (eg, headache or abdominal pain) that requires targeted questioning and examination.

What are biographical data in the health history?

Basic identifiers (name, birth, address), emergency contact, primary care source, and the patient’s chief concern.

How should the patient’s chief concern be recorded?

Record exactly what the patient says, ideally in the patient’s own words.

What does History of Present Illness (HPI) include?

Detailed description of the current symptoms with onset, location, duration, quality, aggravating/relieving factors, timing, and severity.

What components are commonly used to describe pain history?

Onset, location, duration, quality, aggravating factors, relief measures, timing, severity, and patient’s goal.

How is pain severity typically quantified?

Using a 0 to 10 scale, with questions about current, worst, best, and goal pain levels.

What is included in past medical history?

Childhood illnesses, immunizations (record year/month of last dose), adult illnesses (eg, MI, stroke, diabetes, HTN, cancer, asthma), communicable diseases, surgeries/injuries, medications (current, OTC, supplements), allergies, disabilities.

Why is documenting immunizations and allergies important?

Immunization history helps determine protection status; documenting allergies (and reactions) guides safe prescribing and avoidance.

What should be recorded about allergies to distinguish true allergies from intolerances?

Note the reaction type (eg, anaphylaxis vs GI distress) to determine the safety of medications.

How is family history structured in the health history?

Two generations are typically reviewed for hereditary risks; include patient’s parents and grandparents, and note any genetic conditions.

What topics are covered in the personal and social history?

Lifestyle, occupation/exposure, alcohol/drug/caffeine use, smoking, sleep, exercise, diet, sexual activity and protection, travel, religious practices, stress, coping, and support systems.

What is the purpose of the review of systems (ROS)?

To relate the chief complaint to other body systems and assess multi-system involvement.

What documentation tips are emphasized for clarity and future reference?

Include specific dates, avoid vague terms like last year, and quote patients when their words capture important meaning.