Podcast
Questions and Answers
What is the primary purpose of the pre-interview phase?
What is the primary purpose of the pre-interview phase?
- To summarize important points
- To obtain patient information
- To set the stage for a smooth interview (correct)
- To establish trust with the patient
Establishing the agenda for the interview is part of the introduction phase.
Establishing the agenda for the interview is part of the introduction phase.
True (A)
What are the three categories into which a patient's information is organized?
What are the three categories into which a patient's information is organized?
Past, Present, Family history
The patient's _________ includes fears or concerns about their health problem.
The patient's _________ includes fears or concerns about their health problem.
Match the symptom attributes with their descriptions:
Match the symptom attributes with their descriptions:
Which of the following is NOT one of the seven attributes of a symptom?
Which of the following is NOT one of the seven attributes of a symptom?
The termination phase of the interview involves summarizing important points and discussing the plan of care.
The termination phase of the interview involves summarizing important points and discussing the plan of care.
The acronym FIFE stands for the ______ of the patient's perspective.
The acronym FIFE stands for the ______ of the patient's perspective.
Which of the following is NOT one of the '7 facets' of health?
Which of the following is NOT one of the '7 facets' of health?
Health is solely defined as the absence of disease.
Health is solely defined as the absence of disease.
What are the two main components of a nursing health assessment?
What are the two main components of a nursing health assessment?
The __________ involves systematic data collection to evaluate a person's health status.
The __________ involves systematic data collection to evaluate a person's health status.
What is the first step of the nursing process?
What is the first step of the nursing process?
Match each facet of health with its description:
Match each facet of health with its description:
What is the primary purpose of the nursing health assessment?
What is the primary purpose of the nursing health assessment?
The nursing diagnosis is formulated solely based on the patient's reported symptoms.
The nursing diagnosis is formulated solely based on the patient's reported symptoms.
Past medical records are not useful in collecting information during the health history.
Past medical records are not useful in collecting information during the health history.
What is the purpose of the evaluation step in the nursing process?
What is the purpose of the evaluation step in the nursing process?
A focused assessment primarily gathers information about the patient’s _______.
A focused assessment primarily gathers information about the patient’s _______.
What should be done with the information obtained during the health assessment?
What should be done with the information obtained during the health assessment?
Match the types of health assessments with their definitions:
Match the types of health assessments with their definitions:
During which step of the nursing process do nurses and patients collaborate to set goals?
During which step of the nursing process do nurses and patients collaborate to set goals?
Health history interviews serve to establish a trusting relationship with the patient.
Health history interviews serve to establish a trusting relationship with the patient.
What are the ABCs when conducting an emergency history?
What are the ABCs when conducting an emergency history?
What type of data consists of observable and measurable information?
What type of data consists of observable and measurable information?
Subjective data includes information obtained through observations and laboratory testing.
Subjective data includes information obtained through observations and laboratory testing.
What does HPI stand for in a medical history context?
What does HPI stand for in a medical history context?
The acronym OLD CART helps to remember the seven attributes of a symptom: Onset, Location, Duration, ________, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment.
The acronym OLD CART helps to remember the seven attributes of a symptom: Onset, Location, Duration, ________, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment.
Which of the following is NOT typically included in the Past History section of a medical history?
Which of the following is NOT typically included in the Past History section of a medical history?
Match the following components of medical history with their descriptions:
Match the following components of medical history with their descriptions:
The Risk factors are part of the key elements of the History of the Present Illness.
The Risk factors are part of the key elements of the History of the Present Illness.
Name one chronic childhood illness that should be included in the Past History.
Name one chronic childhood illness that should be included in the Past History.
Which immunization is NOT typically included in health maintenance assessments?
Which immunization is NOT typically included in health maintenance assessments?
Screening tests should include results and dates of tests performed.
Screening tests should include results and dates of tests performed.
What are some examples of environmental hazards that should be inquired about?
What are some examples of environmental hazards that should be inquired about?
The recommended two types of tobacco usage questions should inquire about use and _____.
The recommended two types of tobacco usage questions should inquire about use and _____.
Match the following screening tests with their purpose:
Match the following screening tests with their purpose:
What is a common symptom to ask about in a head-to-toe review of systems?
What is a common symptom to ask about in a head-to-toe review of systems?
Cultural constructs of mental illness are universally recognized and accepted.
Cultural constructs of mental illness are universally recognized and accepted.
Ask open-ended questions initially to encourage _____ from the patient.
Ask open-ended questions initially to encourage _____ from the patient.
What is the primary purpose of a physical examination?
What is the primary purpose of a physical examination?
It is appropriate to interpret your findings during a physical examination.
It is appropriate to interpret your findings during a physical examination.
List two steps you should take to make the patient comfortable during an examination.
List two steps you should take to make the patient comfortable during an examination.
Before beginning the physical examination, you should ensure that you have checked your ______.
Before beginning the physical examination, you should ensure that you have checked your ______.
Which of the following should be adjusted to create a comfortable environment for a physical examination?
Which of the following should be adjusted to create a comfortable environment for a physical examination?
Match the following actions with their purposes during a physical examination:
Match the following actions with their purposes during a physical examination:
Why is it important to inform the patient about their vital signs during the examination?
Why is it important to inform the patient about their vital signs during the examination?
Most patients view a physical examination with some anxiety.
Most patients view a physical examination with some anxiety.
Flashcards
Health Definition
Health Definition
A relative state where a person can live to their full potential, considering seven key dimensions: physical, emotional, social, cultural, spiritual, environmental, and developmental.
Nursing Health Assessment
Nursing Health Assessment
A comprehensive evaluation of a person's health, including a detailed history and physical examination.
Health History
Health History
The first part of a health assessment, focusing on gathering information about a patient's past medical history, lifestyle, and social factors.
Physical Examination
Physical Examination
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Emotional Health
Emotional Health
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Social Well-being
Social Well-being
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Cultural Influence
Cultural Influence
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Spiritual Influence
Spiritual Influence
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Nursing Process
Nursing Process
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Assessment
Assessment
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Nursing Diagnosis
Nursing Diagnosis
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Planning
Planning
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Implementation
Implementation
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Evaluation
Evaluation
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Comprehensive Health Assessment
Comprehensive Health Assessment
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Focused/Problem-Oriented Assessment
Focused/Problem-Oriented Assessment
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Pre-Interview Phase
Pre-Interview Phase
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Self-Reflection
Self-Reflection
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Introduction Phase
Introduction Phase
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Working Phase
Working Phase
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Invite the Patient's Story
Invite the Patient's Story
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FIFE (Feelings, Ideas, Function, Expectations)
FIFE (Feelings, Ideas, Function, Expectations)
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Termination Phase
Termination Phase
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Review Patient Record
Review Patient Record
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Reflect on your approach
Reflect on your approach
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Adjust the Lighting and Environment
Adjust the Lighting and Environment
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Make the Patient Comfortable
Make the Patient Comfortable
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Ensure the Patient's Privacy
Ensure the Patient's Privacy
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Wash Your Hands
Wash Your Hands
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Patient Draping
Patient Draping
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Communicate Results and Expectations
Communicate Results and Expectations
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Subjective Data
Subjective Data
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Objective Data
Objective Data
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History of Present Illness (HPI)
History of Present Illness (HPI)
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Seven Attributes of a Symptom
Seven Attributes of a Symptom
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Medications in Past History
Medications in Past History
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Childhood and Adult Illnesses in Past History
Childhood and Adult Illnesses in Past History
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Surgical History in Past History
Surgical History in Past History
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Allergies in Past History
Allergies in Past History
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What is a Health History?
What is a Health History?
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What is a Review of Systems?
What is a Review of Systems?
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What is a Genogram?
What is a Genogram?
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What is a Mental Health History?
What is a Mental Health History?
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What is Accident and Illness History?
What is Accident and Illness History?
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What is Immunization History?
What is Immunization History?
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What are Screening Tests in a Health History?
What are Screening Tests in a Health History?
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What are Risk Factors in a Health History?
What are Risk Factors in a Health History?
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Study Notes
Module 1: Definition of Health
- Health is a relative state, enabling a person to live to their full potential, encompassing seven facets.
- Physical health: how the body functions and adapts.
- Emotional health: positive outlook and healthy emotional expression.
- Social well-being: supportive relationships with family and friends.
- Cultural influence: favorable connections promoting health.
- Spiritual influence: peaceful, moral, and ethical living.
- Environmental influence: favorable conditions promoting health.
- Developmental level: cognitive abilities, problem-solving, and decision-making.
- Health isn't just the absence of disease but a combination of these factors.
Module 1: Health Assessment
- Nursing health assessment involves a comprehensive history and physical examination.
- The assessment gathers data from the patient and/or family, using past medical records if necessary.
- The assessment considers physical, psychological, social, cultural, and spiritual factors to understand their overall health status.
- A structured head-to-toe physical examination is part of the assessment to detect changes or abnormalities.
- Results assist in developing a patient care plan.
Module 1: Nursing Process
- Nurses use the nursing process (a problem-solving approach) to systematically address patient needs.
- This process involves assessing problems, setting goals, developing action plans, implementing the plan, and evaluating outcomes.
- Steps include: Assessment, Diagnosis, Planning, Implementation, and Evaluation.
- The nurse uses data collected to make diagnoses, formulate goals, and develop plans to address patient concerns.
- The process is documented in patients' medical records.
Module 2: Interviewing and Communication
- A health history interview involves building rapport, gathering information, and providing information.
- The goal is to create a trusting and supportive relationship while providing pertinent information.
- A health history format structures information into past, present, and family history categories.
- The format facilitates easy communication among healthcare providers.
- Information is gathered in a manner that allows a focused or problem-oriented approach, or a follow-up history.
- Emergency histories focus on priority needs (ABCs).
Module 2: Phases of Interview
- The interview process has pre-interview, working, and termination stages.
- In the pre-interview, the setting is prepared, and self-reflection assists professional development.
- During the working stage there is reflection, patient's story gathering, clarification of emotional clues, testing diagnostic hypotheses, agreeing on a plan for evaluation, treatment, counseling, and self-management.
- The termination phase reviews major points covered in the conversation, plans of care, and follow-up instructions.
Module 2: Seven Attributes of a Symptom
- Onset: when the symptom began.
- Location: specific area of the body where the symptom manifests.
- Duration: how long the symptom lasts each occurrence.
- Characteristics: details describing the symptom (severity, pain scale, etc.).
- Relieving/Exacerbating factors: factors that ease, worsen, or trigger symptoms.
- Explore the patient's feelings, their understanding of the problem, its impact on their life, and their expectations for care.
Module 3: Physical Examination
- Physical examinations use objective data to further assess a patient's health.
- Steps include appropriate attire, environmental adjustments that create comfort for the patient.
- Visual inspection, palpation, and auscultation are used to assess body systems.
- Observation of patient behavior and general appearance are critical parts of the examination.
- Use standard precautions in a professional manner.
- Focus on patient's comfort and privacy.
Types of Data
- Objective data includes observable and measurable information from observations, physical exams, and laboratory tests.
- Subjective data comes from the client's perspective, and includes feelings, perceptions, and concerns expressed through interviews.
History of Present Illness (HPI)
- A chronological account of the problems causing a patient to seek care.
- Covers the onset of the issue, where and how it developed, symptoms, and responses to treatment.
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