chp.4 health assessment

What is the purpose of the complete health history?

To collect subjective data (what the patient says) and combine it with objective data to form a health database for diagnosis.

in well patients, what is the main focus of the health history?

Assessing lifestyle and encouraging healthy behaviors, recognizing what the patient is doing right.

In ill patients, what is the main focus of the health history?

A detailed, chronological record of the health problem.

For all patients, what does the health history serve as?

A screening tool for abnormal symptoms, health problems, concerns, and health promotion behaviors.

What is the first category of the health history?

Biographic data (name, DOB, occupation, language, communication needs).

What is the second category of the health history

Source of history (usually the patient).

What is the third category of the health history?

Reason for seeking care (patient’s own words: symptoms/signs + duration).

What is the fourth category of the health history?

Present health or history of present illness.

Well person: general state of health

Ill person: detailed, chronological record of illness

What tool helps with symptom analysis?

PQRSTU:

what PQRSTU:

P = Provocative/palliative

Q = Quality/quantity

R = Region/radiation

S = Severity scale

T = Timing

U = Understand patient's perception

What is the fifth category of the health history?

Past health (childhood illnesses, injuries, hospitalizations, surgeries, immunizations, allergies, last exam, medications).

What is the sixth category of the health history?

Family history (detect risks, early screening, add questions on spiritual resources, nutrition, immigration status).

What is the seventh category of the health history?

Review of systems (past/present health of each body system, double-check data, assess health promotion).

What is the eighth category of the health history?

Functional assessment (ADLs, self-care ability, self-esteem, psychosocial aspects, substance use, IPV, occupational health).

What modifications are made for a child's health history?

Include prenatal/perinatal history, source of info, childhood illnesses/injuries, immunizations, surgeries/hospitalizations, medications, allergies, developmental milestones, nutritional history.

When assessing a child's functional abilities, what should be considered?

The child’s environment and their role in it.

What tool is used to assess an adolescent's psychosocial state?

HEEADSSS

What does HEEADSSS stand for?

H = Home environment

E = Education & employment

E = Eating

A = Activities with peers

D = Drugs

S = Sexuality

S = Suicide/depression

S = Safety (including driving)