Assess Your Skills

Study Notes

The purpose of a health history is to collect subjective data to combine with objective data from physical exams and lab studies to form a database.
Biographic data such as name, age, gender, race, and occupation should be recorded.
The reason for seeking care should be documented in the patient's own words, along with reported symptoms and signs.
The source of history should be recorded and the reliability of the informant judged.
The history of present illness should identify eight critical characteristics.
Past medical history should include childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, and operations.
Family history can highlight diseases or conditions that an individual may be at risk for as a result of genetics.
A review of systems should evaluate past and present state of each body system, assess that all pertinent data relative to each body system have been noted, and evaluate health promotion practices.
Functional assessment should include self-care activities of daily living, activity and exercise, sleep and rest, nutrition and elimination, interpersonal relationships and resources, spiritual resources, coping and stress management, personal habits, illicit or street drugs, environment and work hazards, intimate partner violence, and occupational health.
The general survey is a study of the whole person, including physical appearance, body structure, mobility, and behavior.

Body mass index (BMI) is a practical marker of optimal weight for height and an indicator of obesity or malnutrition.
Waist circumference is an indicator of excess abdominal fat, which is an independent risk factor for disease.
Malnutrition can result from inadequate intake of protein and calories or prolonged starvation.
Pain is a highly complex and subjective experience originating from the central nervous system and/or the peripheral nervous system.
Pain can be acute or chronic, and can be classified by its duration.
Accurate pain assessment involves distinguishing sensations and different responses to analgesics.
Pain assessment is influenced by culture, social, emotional, and spiritual concerns.
Nociceptive pain develops when functioning and intact nerve fibers in the periphery and CNS are stimulated.
Pain can be classified by its duration, providing information regarding underlying mechanisms and treatment decisions.
The initial pain assessment involves questions about onset, intensity, quality, duration, frequency, location, aggravating factors, and relieving factors.