NURS HEALTH ASS SH total health history
Chief Complaint
•
Finding:
Established chief complaint
•
Finding:
Reports pain
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to
express their reason for seeking care, primary concerns, or condition they
are presenting with.
Example Question:
Do you have any pain?
•
Finding:
Reports foot wound
(Found)
Pro Tip: If a patient mentions pain, it's important to determine what
specifically is causing her pain, if she knows.
Example Question:
What's causing your pain?
History of Presenting Illness
•
Finding:
Asked to rate current pain level on a scale
,NURS HEALTH ASS SH total health history
•
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is
important to gauge how it ebbs and flows while she is in your care.
Example Question:
Can you rate the pain on a scale of 0 to 10?
•
Finding:
Asked for details about the
pain
•
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the
pain can be important data to support the cause of the pain.
Example Question:
Can you please describe the pain?
•
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Determining what physical activities and movements exacerbate
the patient's pain can help you better understand the problems and assess
treatment needs. This can also alert you if a patient's activities of daily
living are hindered.
,NURS HEALTH ASS SH total health history
Example Question:
What is the pain like when you stand on your foot?
•
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Finding out how the patient's pain has changed will give you
insight into the acceleration of infection.
Example Question:
How has the pain changed over time?
•
Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking about where else the patient's pain radiates can help
determine the progression of infection.
Example Question:
Does the pain radiate anywhere else?
•
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is
important to determine their risk for falls while in your care.
Example Question:
, NURS HEALTH ASS SH total health history
Can you bear weight on your foot?
•
Finding:
Asked location of wound
•
Finding:
Reports right foot is injured
(Found)
Pro Tip: Confirming which extremity an injury is located is a best practice for
your patient's safety.
Example Question:
Which foot is in pain?
•
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Confirming where a wound is located ensures you are aware of your
patient's biggest complaint.
Example Question:
Where is the wound?
•
Finding:
Asked details of the injury
•
Finding:
Chief Complaint
•
Finding:
Established chief complaint
•
Finding:
Reports pain
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to
express their reason for seeking care, primary concerns, or condition they
are presenting with.
Example Question:
Do you have any pain?
•
Finding:
Reports foot wound
(Found)
Pro Tip: If a patient mentions pain, it's important to determine what
specifically is causing her pain, if she knows.
Example Question:
What's causing your pain?
History of Presenting Illness
•
Finding:
Asked to rate current pain level on a scale
,NURS HEALTH ASS SH total health history
•
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is
important to gauge how it ebbs and flows while she is in your care.
Example Question:
Can you rate the pain on a scale of 0 to 10?
•
Finding:
Asked for details about the
pain
•
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the
pain can be important data to support the cause of the pain.
Example Question:
Can you please describe the pain?
•
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Determining what physical activities and movements exacerbate
the patient's pain can help you better understand the problems and assess
treatment needs. This can also alert you if a patient's activities of daily
living are hindered.
,NURS HEALTH ASS SH total health history
Example Question:
What is the pain like when you stand on your foot?
•
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Finding out how the patient's pain has changed will give you
insight into the acceleration of infection.
Example Question:
How has the pain changed over time?
•
Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking about where else the patient's pain radiates can help
determine the progression of infection.
Example Question:
Does the pain radiate anywhere else?
•
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is
important to determine their risk for falls while in your care.
Example Question:
, NURS HEALTH ASS SH total health history
Can you bear weight on your foot?
•
Finding:
Asked location of wound
•
Finding:
Reports right foot is injured
(Found)
Pro Tip: Confirming which extremity an injury is located is a best practice for
your patient's safety.
Example Question:
Which foot is in pain?
•
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Confirming where a wound is located ensures you are aware of your
patient's biggest complaint.
Example Question:
Where is the wound?
•
Finding:
Asked details of the injury
•
Finding:
