Health History PDF

Health History Primary Source of Information: Obtained from the patient, relatives, or existing records. Demographic Data: Name, address, telephone, sex, age, civil status, religion, race. Chief Complaint (CC): Main reason for consultation, recorded in patient's own words. H...

Health History Primary Source of Information: Obtained from the patient, relatives, or existing records. Demographic Data: Name, address, telephone, sex, age, civil status, religion, race. Chief Complaint (CC): Main reason for consultation, recorded in patient's own words. History of Present Illness: Includes the "Eight Areas of Investigation": Sequence and chronology Frequency Location and radiation Character of complaint Intensity or severity Setting Associated manifestations Past History: Childhood diseases, immunizations, allergies, past hospitalizations, medications, prenatal history. Review of Systems: Subjective data from head to toe regarding the patient’s health status. Physical Assessment Is the systematic data collection method that uses observational skills to detect health problems. Preparation: Environment: Private, quiet area; good lighting. Equipment: Hand washing, proper height of examining table. Client Preparation: Psychological and physical comfort, explain procedures. Physical Preparation – Ask the client to void or if he or she needs to use the toilet prior to the examination. Positioning – during the examination, it is important for the midwife to now in what position the client should be assisted to assume in order to facilitate the examination and ensure client’s comfort Psychosocial Assessment Areas include vocation, family, social, spiritual, sexual, daily living activities, and health habits. Review of Literature Essential for obtaining additional data and maintaining up-to-date knowledge in healthcare. Order of Assessment General Survey: Appearance, behavior, vital signs. Body System Assessment: Integumentary, respiratory, cardiovascular, etc. Cephalocaudal (Head to Toe) Assessment. Tools of Physical Assessment: Inspection/Observation: Systematic observation using senses. Palpation: Light and deep palpation for texture, tenderness, etc. (involves the sense of touch as examiner feels or presses a body part) - Light palpation or touch- Use pads of finger, often to identify areas of tenderness and muscle resistance. - Deep palpation or touch- Use two hands, one hand palpates, the other supports often to press deeper into the patient’s abdominal area. Percussion: Striking body parts to elicit sounds or vibrations Auscultation: Listening to body sounds using a stethoscope. TYPES OF AUSCULTATION 1. Direct auscultation–Using an unaided ear to listen to sounds within the body. 2. Indirect auscultation–Using a stethoscope. COMMONLY USED ASSESSMENT INSTRUMENTS 1. Ophthalmoscope – lighted instrument used for examining eyes. 2. Otoscope- lighted instrument used for examining external auditory canal and eardrum. 3. Vaginal speculum–two bladed instruments used to examine the vagina and cervix. 4. Percussion hammer–used to tap body surface to test reflexes and tissue density 5. Tuning fork–used to create vibrations to test hearing 6. Tonometer–used to measure pressure within the eyes DIFFERENT POSITIONS 1. SUPINE–Back lying position with legs extended and arms at the side of the body - The best position for examination of the abdomen - To inspect for lumps and breast masses- LYING SUPINE with pillow under the shoulder 2. PRONE–Face lying position - SURGERY OF SPINE, EXAMINATION OF THE BACK AND HIP MOVEMENT  3. DORSAL RECUMBENT–If the patient is in a supine position with the knee flexed, this often used to comfort the patient with back strain - The best position for examination of the abdomen 4. LITHOTOMY–rectal or vaginal examination - Most commonly used position for delivery 5. TRENDELENBURG–To encourage drainage of secretions from the lungs of the normal newborn - SHOCK, prolapsed umbilical cord, POSTPARTUM HEMORRHAGE 6. SEMI FOWLERS–Head of bed is raised between 15° and 45°, typically at 30°. - Relief from lying position to promote lung expansion 7. SIMS–Side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow - It permits free drainage of mucus secretions especially among patients who are unconscious and unable to swallow. - Examination of vagina, rectum, ENEMA, insertion of SUPPOSITORY 8. KNEE- CHEST–Kneeling position with face flat on bed. - Best measure for severe abdominal pain 9. TRENDELENBURG–Head of bed is lowered and the foot raised in a straight incline. - To promote venous circulation in certain clients to provide postural drainage of basal lung lobes. To encourage drainage of secretions from the lungs of the normal newborn Validating Data Double-check observations, equipment, and consult with team members to confirm accuracy. After assessing the client, the client may present with actual or potential problems: a. Actual Problems or Needs – these are problems or needs which exist and manifested by signs and symptoms. b. Potential problems or Needs. – These are problems or needs which the patient has a high risk for developing. Signs and symptoms are not present. Planning Goals: Short-term: Achievable in days or weeks. Long-term: Achievable in weeks or months. Priority Setting: Immediate life-threatening issues, safety issues, patient-identified issues. GUIDELINE: S – Specific M – Measurable A –Attainable R – Realistic T – Time bounded PRIORITY SETTING -Priority setting is the process of establishing which problem requires attention first, which second and so on. General Guidelines for Setting Priorities a. Take care of immediate life-threatening issues. 1. Frist priority incudes any threat to the vital functions of breathing, heartbeat, and blood pressure. 2. Medium priority includes health threatening problems that may result in delayed development 3. Low priority includes problems that arise from normal development needs or those that require minimal support. b. Safety issues. c. Patient-identified issues. d. Midwife-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources. Intervention/Implementation Intervention is putting the care plan into action. Types of Interventions: Direct: Actions performed through client interaction. Indirect: Actions performed on behalf of clients. DIFFERENT FUNCTIONS OF Health personnel a. Independent -Actions which the health personnel carry on her without the order from persons and for which she herself is responsible. b. Dependent–Actions which the health personnel performs while following orders from a superior. c. Interdependent–Actions which the health personnel perform in collaboration with other members of the health team. Evaluation Assessing patient responses to interventions against set goals. Discharge Planning Begins on admission; involves preparing the patient for continuity of care. Reasons for Discharging: Patient returns to normal health. Transfer to another facility. Patient’s choice. Patient has died. DISCHARGE NOTE AND REFERRAL SUMMARY –These forms are completed when the patient is being transferred to another institution or to a home setting where a visit by a community health midwife is required. Discharge Against Medical Advice (DAMA) Occurs when a patient leaves without physician permission; requires special documentation.