HEALTH 12i Topic 1: Assessing Health History PDF
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Uploaded by EffectualErudition4369
University of Negros Occidental-Recoletos
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This document provides an overview of assessing a patient's health history and data collection, including methods like clinical interviews and medical records review. It covers essential aspects of healthcare such as collecting vital signs and lab results. Key topics covered include assessing health, along with vital signs.
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HEALTH 12i TOPIC 1: ASSESSING HEALTH HISTORY AND DATA COLLECT Assessing a patient's health history and collecting relevant data is a crucial step in providing effective healthcare Methods of Data Collection: Clinical Interviews: Conducting structured or semi-structured interv...
HEALTH 12i TOPIC 1: ASSESSING HEALTH HISTORY AND DATA COLLECT Assessing a patient's health history and collecting relevant data is a crucial step in providing effective healthcare Methods of Data Collection: Clinical Interviews: Conducting structured or semi-structured interviews with patients to obtain detailed information about medical histories, symptoms, or treatment experiences Medical Records Review: Analysing patient medical records and electronic health records (EHRs) to extract relevant data, such as diagnoses, treatments, outcomes, and lab results. Observations: Directly observing patient interactions, healthcare procedures, or clinical settings to collect quantitative and qualitative data Biological Sampling: Collecting blood, tissue, urine, or saliva samples for laboratory analysis, genetic studies, or biomarker identification Effective Communication Techniques: Active Listening: Paying full attention to the patient and showing empathy. Clarification and Summarization: Repeating or summarizing information to ensure accuracy. Clarification and Summarization: Repeating or summarizing information to ensure accuracy. Nonverbal Communication: Using body language and facial expressions to convey understanding and support. Objective and Subjective cues Objective cues are measurable and observable signs that can be seen, heard, or felt by the healthcare provider. These cues are factual and can be verified by others. They often involve quantitative data and are not influenced by personal feelings or opinions. 1. Vital Signs: Blood pressure, heart rate, respiratory rate, and temperature. 2. Lab Results: Blood tests, urinalysis, and imaging results. 3. Physical Examination: Observations like skin color, swelling, or abnormal sounds heard through a stethoscope. 4. Behavioral Observations: Actions such as limping, coughing, or difficulty breathing Examples: Vital Signs:  Blood Pressure: 130/80 mmHg (normal blood pressure).Pulse: 72 beats per minute (normal pulse).  Respiratory Rate: 18 breaths per minute (normal breathing rate).  Temperature: 37°C (normal body temperature). Lab Results:  Blood Sugar: 90 mg/dL (normal blood sugar level).  Cholesterol Level: 180 mg/dL (normal cholesterol level).  Hemoglobin: 13 g/dL (normal hemoglobin level).  Subjective cues are based on the patient's personal experiences, feelings, and perceptions. These cues are not directly measurable and rely on the patient's self-report. They often involve qualitative data and can vary from person to person. 1. Symptoms: Pain, dizziness, fatigue, or nausea. 2. Emotions: Feelings of anxiety, depression, or fear. 3. Personal Experiences: Descriptions of how a condition affects daily life, such as difficulty sleeping or decreased appetite. 4. Perceptions: Patient's belief about their health status or the effectiveness of a treatment. Example: Feelings: "Gaantos ko sang grabeng sakit sa tyan.“ "Nagakalipong ko kada aga.“ "Permi ko gid nga gapakapoy bisan wala ko masyado nagahimo sang mabug-at nga buluhaton.“ Emotion: "Gakabalaka ako sa akon balatian.“ "Gakabatyag ko nga masubo ko permi." "Ginahadlokan ko ang operasyon." Personal experience: "Lisod ko gid magkatulog kada gab-i.“ "Wala ko ganahan magkaon kay ginakapoy ko.“ "Lisod ang pagginhawa ko kada adlaw.“ Perception: "Gabatyag ko nga mas magluya pa ako sa nabatyagan ko subong.“ "Indi ko sigurado kon epektibo gid man ang pagbulong nga ginhatag sa akon." Importance in Healthcare: Both objective and subjective cues are crucial in the assessment and diagnosis of a patient's condition. Objective cues provide concrete evidence of health status, while subjective cues offer insight into the patient's experience and perspective. Together, they help healthcare providers develop a comprehensive understanding of the patient's health and tailor treatment plans accordingly. Vital Signs: Blood Pressure: 130/80 mmHg (normal blood pressure).Pulse: 72 beats per minute (normal pulse). Respiratory Rate: 18 breaths per minute (normal breathing rate). Temperature: 37°C (normal body temperature). Lab Results: Blood Sugar: 90 mg/dL (normal blood sugar level). Cholesterol Level: 180 mg/dL (normal cholesterol level). Hemoglobin: 13 g/dL (normal hemoglobin level).
