Assessment and Health History

27問 • 2年前

問題一覧

Match the definition to to word: The systematic continuous collection, validation and communication of data.

Assessment

Select the 4 parts included in assessment

Observtion, Interviewing, Physical Examination, Intuition

Match the type of assessment with the definition. The assessment performed with in a certain time after admission. The purpose is to establish a complete database for problem identification, reference, and future comparison. Example: Nursing admission assessment.

Initial assessment (comprehensive assessment)

Match the type of assessment with the definition. An ongoing process integrated with nursing care. Used to determine the status of a particular problem identified in an earlier assessment.

Problem- Focused Assessment

Match the type of assessment with the definition. Performed during a physical or psychological crisis of patient and is used to identify life threatening problems or to identify new or overlooked problem.

Emergency assessment

Match the type of assessment with the definition. Can be performed several month after the initial assessment to compare the current status to baseline data obtained previously. Example: reassessment of a patients health status outpatient or home care or a shift assessment in the hospital.

Time- Lapsed Assessment

SOAP/ SOAPIE(R) (Select 7, and in order)

Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, Revision

(S) subjective data example:

Patient feels light headed

(O) objective data example:

BP = 82/47, HR = 85

(A) example of the assessment (what was found)

Patient is hypotensive

(P) plan, an example of a plan:

Patient is instructed not to get out of bed, notify the provider

(I) example of an intervention:

0.9 NS (normal saline) 500cc bonus IV x 1 given per order

(E), example of the evaluation:

BP = 110/62, patient denies dizziness and light headedness

What is the (R) revision part of the SOAPIER

If the intervention did not work now what are you doing to do?

Phases of the interview

Introduction, Discussion, Summary

Select 3 types of health histories:

Comprehensive, Problem based/ problem focused, Episodic/ follow up

Select the type of health history that matches the definition. Performed on new patients in any setting, takes more time.

Comprehensive

Match the type of health history with the definition. Information limited to the current problem.

Problem based/ problem focused

Match the the health history with the definition. Focuses on a specific problem and patient has already gotten treatment for.

Episodic/ follow up

What are the components of comprehensive health history.

Biographic data, Reason for seeking care, History of presenting illness, Present health status, Past health history, Family history, Personal and psychosocial history, Review of symptoms

What are the items on the following list examples of? Name, DOB, gender, address, phone, birth place, race/ethnicity, religion, marital status, occupation, contact person, source of data.

Biographic data

Select the example of Reason for seeking care (chief complaint)

Patient says “My right knee has been hurting for 2 weeks now.”

POLDCARTS

Previous history, Onset, Location, Duration, Characteristics, Aggrevating/ allieviating factors, Related symptoms, Treatment, Severity

Past health status

Current health conditions, Medications, Allergies

Past health history

Chilhood illnesses, Surgeries, Hospitalizations, Accidents or injuries, Immunizations, Last exams/ diagnostic tests, Obstretic history

BIG NO NO when asking questions?

Starting sentence with “why?”

What is a good tool for question asking?

Silence

Health assessment questions

ユーザ名非公開 · 15問 · 2年前

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