NUR 2092 Final Exam Study Guide
What is included in a health history?
Biographic data [Name, address, DOB, occupation, gender, martital status,
primary language, ethnicity]
Reason for seeking care: Subjective from pt
Present health status
Medications, Immunizations, What improves it, What makes it worse,
Past medical history
Surgical history, OB /GYN Nutritional Hx
Family history
First generation
Personal and psychosocial history
Support, living environment, Substances, Safety
Review of body systems: PQRSTU
Define subjective and objective.
Subjective: What pt says about themself
Objective: what is observed during assessment
Give an example of an open ended question.
Tell me about , how are you doing today
Now a closed question
Do you have pain?
What is redirecting, silence, restating?
Communication that client has time to think; silence can be uncomfortable;
provides you w/ chance to observe client and note nonverbal cues
What should be included in social history?
where do they live, are they safe, do they have clean water, head, air
conditioning, do you work, do you feel safe, smoke, alcohol, recreational
drugs, safety devices, do you exercise, safety equipment, sun screen
Why is this information necessary?
, When do you screen for intimate partner violence?
Always
Barriers to communication: Name 3
-Lack of interest or attention/lack of respect
-Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature
-The patient’s inability to hear you, hearing deficit, or language barrier
-Language/ use of jargon, or speaking above someone’s educational level
-Safety: fear
-Psychological barriers: embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility
• What questions do you need to ask each time you enter a
patient’s room? (2 of them)
-Name and DOB
• Pain assessment: what scale do you use?
0-10
• How often do you do a pain assessment?
Every Assessment
• Non pharmacological and pharmacological pain management.
Describe 2 methods.
Deep or patterned breathing
Relaxation techniques
Warm or cool compresses
Compression/elevation
Quiet dark room
Position change
Pillows/clean linens
Bathing
Music
distraction
• What questions do you ask regarding pain?
What kind of pain? When did it start? Where? Worse
or better?
• PQRST
Proactive/Palliation:Quality:Region:Severity:Timing
What is included in a health history?
Biographic data [Name, address, DOB, occupation, gender, martital status,
primary language, ethnicity]
Reason for seeking care: Subjective from pt
Present health status
Medications, Immunizations, What improves it, What makes it worse,
Past medical history
Surgical history, OB /GYN Nutritional Hx
Family history
First generation
Personal and psychosocial history
Support, living environment, Substances, Safety
Review of body systems: PQRSTU
Define subjective and objective.
Subjective: What pt says about themself
Objective: what is observed during assessment
Give an example of an open ended question.
Tell me about , how are you doing today
Now a closed question
Do you have pain?
What is redirecting, silence, restating?
Communication that client has time to think; silence can be uncomfortable;
provides you w/ chance to observe client and note nonverbal cues
What should be included in social history?
where do they live, are they safe, do they have clean water, head, air
conditioning, do you work, do you feel safe, smoke, alcohol, recreational
drugs, safety devices, do you exercise, safety equipment, sun screen
Why is this information necessary?
, When do you screen for intimate partner violence?
Always
Barriers to communication: Name 3
-Lack of interest or attention/lack of respect
-Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature
-The patient’s inability to hear you, hearing deficit, or language barrier
-Language/ use of jargon, or speaking above someone’s educational level
-Safety: fear
-Psychological barriers: embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility
• What questions do you need to ask each time you enter a
patient’s room? (2 of them)
-Name and DOB
• Pain assessment: what scale do you use?
0-10
• How often do you do a pain assessment?
Every Assessment
• Non pharmacological and pharmacological pain management.
Describe 2 methods.
Deep or patterned breathing
Relaxation techniques
Warm or cool compresses
Compression/elevation
Quiet dark room
Position change
Pillows/clean linens
Bathing
Music
distraction
• What questions do you ask regarding pain?
What kind of pain? When did it start? Where? Worse
or better?
• PQRST
Proactive/Palliation:Quality:Region:Severity:Timing
