FULL ANSWERS
◉ biographic information. Answer: Factual demographic data; age;
address; occupation; working status; marital status; source of health
care; and types of insurance
◉ Chief concern of reason for seeking health care. Answer: this is the
information you gather when you initially set an agenda during a
patient centered interview
you learn a patient chief concerns or problems
◉ Patient Expectations. Answer: Patient's understanding of why he
or she is seeking health care. The assessment of patient expectations
is not the same as the reason for seeking medical care, although they
are often related. Failure to identify a patient's expectations of
health care providers results in poor patient satisfaction.
◉ Present illness of health concerns. Answer: Essential and relevant
data about the nature and onset of symptoms.
PQRST
Provokes
Quality
Radiates
,Severity
Time
◉ Health History. Answer: provides a holistic view of a patient's
health care experiences and current health habits
Medical history
surgical history
medication history
Allergies
Social History
◉ Family History. Answer: history that includes data about
immediate and blood relatives. This also reveals info about the
family structure, interaction, support, and function
◉ Psychosocial History. Answer: provides information about a
patient's support system, which often includes a spouse or partner,
children, other family members, and close friends.
Also includes how the patient typically copes with stress
◉ Spiritual History. Answer: review with patients their beliefs about
life, their source of guidance in acting on beliefs, and the relationship
they have with family in the exercising their faith
,◉ Review of Systems (ROS). Answer: A systematic approach for
collecting the patient's self-reported data on all body systems.
◉ Observation of Patient Behavior. Answer: - It is important to
closely observe a patient's verbal and nonverbal behaviors.
- Adds depth to objective database
- Observations direct you to gather additional objective information
to form accurate conclusions about the patient's condition.
- An important aspect of observation includes a patient's level of
function: the physical, developmental, psychological, and social
aspects of everyday living.
◉ diagnostic and laboratory data. Answer: Results provide further
explanation of alterations or problems identified during the health
history and physical examination
Compare laboratory data with the established norms for a particular
test, age, group, and gender
◉ Interpreting and validating assessment data. Answer: the
successful ongoing interrelation and validation of assessment data
ensure that you have collected a complete database.
, ◉ interpretation. Answer: this is clinical reasoning
you are determine the presence of abnormal findings, recognizing
that further observations are needed to clarify information, and
beginning to identify a patients health problems
◉ Data Validation. Answer: validate the information you have
collected to avoid making incorrect inferences
Validation of assessment is the comparison of data with another
source to determine data accuracy
Gives you the opportunity to clarify vague or unclear data
◉ data documentation. Answer: record the results of the nursing
health history and physical examination in a clear, concise manner
using appropriate terminology. this information becomes the
baseline to identify patient health problems, plan and implement
care, and evaluate a patient's response to interventions.
◉ Concept Mapping. Answer: Visual representation that allows you
to graphically show the connections among a patient's many health
problems
◉ Nursing Diagnosis. Answer: is a clinical judgement concerning a
human response by a patient that a nurse is competent to treat