HISTORY TAKING - HA

11問 • 1年前

問題一覧

COLLECTING SUBJECTIVE DATA Exploring the Patient’s Perspective (F-I-F-E) - The patient's ____, including fears or concerns, about the problem - The patient's ____ about the nature and the cause of the problem - The effect of the problem on the patient's life and _____ - The patient's ______ of the disease, of the clinician, or of health care, often based on prior personal or family experiences

FEELINGS, IDEA, FUNCTION, EXPECTATIONS

reason for seeking health care

CHIEFS COMPLAINT

- amplifies the chief complaint; describes how each symptom developed - includes patient’s thoughts and feelings about the illness - pulls in relevant portions of the review of systems, called “pertinent positives and negatives” - may include medications, allergies, and tobacco used and alcohol, which are frequently pertinent to the present illness

PRESENT ILLNESS

1. C - _____ = how does it feel, look, smell, sound 2. O - ____ = when did it begin; is it better, worse, or the same since it began 3. L - ______ = where is it? does it radiate? 4. D - ______ = how long does it last? does it recur? 5. S - ______ = how bad is it on a scale of 1-10 6. P - _______ = what makes it better? what makes it worse? 7. A - ________ = other symptoms, can you do ADL’s

CHARACTER, ONSET, LOCATION, DURATION, SEVERITY, PATTERN, ASSOCIATED FACTORS

- list childhood illnesses - list adult illnesses with dates for events in at least four categories: medical, surgical, obstetric/gynecologic, and psychiatric - includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety

PAST HISTORY

- any childhood illnesses - immunizations - adult illness (physical, emotional, mental) - surgeries - accident - allergies - prolonged pain or pain patterns

PAST MEDICAL HISTORY

-outlines or diagrams age and health, or age and cause of death of siblings, parents, and grandparents - documents presence or absence of specific illnesses in family, such as hypertension, diabetes, or type of cancer

FAMILY HISTORY

describes educational level, family of origin, current household, personal interests, and lifestyle

PERSONAL AND SOCIAL HISTORY

-nutrition and diet - sleep patterns - use of medications and other substances: caffeine, nicotine, alcohol, recreational drugs - lifestyle - exercise

SOCIAL HISTORY

- age of menarche - dysmenorrhea - how many pregnancies - 1 - delivery - NSD (Normal Spontaneous Delivery) / CS (Cesarean Section) - any miscarriage or abortion - pregnancy terminated below 20 weeks

OB HISTORY

- Client is asked specific questions to elicit further details of current health problems or problems from the recent past that may still affect the client or that are recurring - Problems that are not related to the chief complaint - Just include the patient’s subjective information and not the examiner’s observations - nurses helps in the ROS by asking questions that may elicit answers from the patient - Done per body system

REVIEW OF SYSTEMS

HCI

JHAYS · 5問 · 1年前

HCI