What is the purpose of the complete health history
to collect subjective data. Combine subjective and objective data to create a database in order to make a diagnosis or judgment about patient
What is the purpose of the complete health history for ill patients?
health history includes detailed, chronological record of the problem at hand
What is the purpose of the complete health history for all patients?
used as a screening tool for abnormal sx, health problems and concerns. Also records health promotion behaviors and coping skills
How many categories should one gather data in?
8
What is biographical data?
patients name, DOB, occupation, primary language, and communication needs
Why is it important to record source of history in a health history assessment
to show who you received the data from, to judge reliability of the information, and in order to get the best communication out of the patient for accuracy
Why is it important to record present health or history of present illness?
for a well person, note the general state of health... for an ill person, chronologically record reason for seeking care... Pay close attention to the mention of Sx then preform a sx analysis (OLDCARTS)
What are the categories in a complete health assessment
biographical data, source of info, reason for seeking care, present health or history of present illness, past health events, family history, review of systems, and functional assessment
Why is it important to do a review of symptoms?
evaluate past and present health state of each system, double check in case any information was overlooked or omitted, evaluate health promotion practices.
what is important to do when taking an older adults health history
ask additional questions such as exploring changes in activities of daily living that may result from the aging process or chronic illness. Recognize positive health measures
What is activities of daily living (ADLs) and how do you assess them
Functional measurements of how much independence a person has such as baithing, dressing, toileting, eating, walking, laundry, cooking, shopping, housekeeping etc. observe and ask questions about self esteem, activity, sleep, nutrition, relationships, religion, coping, habits, alcohol, drugs, environment, partner violence and occupational health
Describe Maslow's hierarchy of needs
1. physiological (breathing, food, water, sex, sleep, maintaining homeostasis)
2. Safety (security of body, employment, mortality, family health, property and resources)
3. Love/belonging (friendship, family, sexual intimacy)
4. Esteem (self esteem, confidence, achievement, respect of others, respect by others)
5. Self-actualization (mortality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts)
