Answers
Health History - ANSWER-Information about a patients health in his or her own words
and based on the patients own perception. Includes biographic data, perceptions about
health, past and present history of illness or injury, Family History, a review of systems,
and health.
Primary Souce - ANSWER-The patient is the best source because he or she can
describe personal symptoms, experiences, and factors leading to the current concerns.
Secondary Source - ANSWER-A person or record that beyond the patient that provides
additional information about the patient.
The interview - ANSWER-Subjective data gathering, including the health history and
focused interview, that include primary and secondary sources
Focused Interview - ANSWER-An interview that enables the nurse to clarify points, to
obtain missing information, and to follow up on verbal and nonverbal cues identified in
the health history
Components of Health History - ANSWER-Biographic Data
History of Present Illness
Past Medical History
Family Medical History
Psychosocial History
Review of Body Systems
Biographic Data - ANSWER-Name, DOB, Birthplace, Sex, Marital Status, Gender
Identity, Sexual Orientation, Race, Religion, Occupation, Health Insurance, Source of
information/ Reliability.
History of Present Illness - ANSWER-Reason for Seeking Care
Health Beliefs and Practices
Health Patterns: Lifestyle, Nutrition, and Activity
Medications: Prescription and OTC meds
,Past Medical History - ANSWER-Medical
Surgical
Hospitalization
Outpatient Care
Childhood Illness
Immunizations
Mental and Emotional Health
Allergies
Substance Use
Family Medical History - ANSWER-Immediate Family
Extended Family
Genogram and Pedigree
Nursing Process - ANSWER-A rational and dynamic process used by the nurse to plan
for and provide patient care
Assessment
Diagnosis
Planning
Implementation
Evaluation
Psychosocial History - ANSWER-Occupational History
Education
Financial Background
Roles and Relationships
Family
Social Structures/ Emotional Concerns
,Self-Concept
Review of Body Systems - ANSWER-Skin, Nail, and Hair
Head, Neck, and Lymphatics
Eyes
Ears, Mouth, Nose and Throat
Respiratory
Breasts and Axillae
Cardiovascular
Peripheral Vascular
Abdomen
Male/Female Reproductive
Urinary
Musculoskeletal
Neurological
SBAR - ANSWER-S(Situation)B(Background)A(Assessment)R(Recommendation)
Commonly used guide of communication between team members in Health
Situation - ANSWER-Concern for Patient
Vital Signs
Code Status
Background - ANSWER-Patient Mental Status
Skin
On Oxygen or Not
Assessment in SBAR - ANSWER-What do I think the problem is?
Recommendation - ANSWER-Suggestion of Level of Care
Tests
, Treatment
Components of Wellness - ANSWER-physical, emotional, intellectual, spiritual, social,
environmental
Stages of Wellness - ANSWER-Primary
Secondary
Tertiary
Primary Stage of Prevention - ANSWER-interventions that occur to promote health and
well being before a problem occurs
Immunizations, etc
Diverstiy - ANSWER-The state of being different.
HIPAA - ANSWER-Health Insurance Portability and Accountability Act of 1996
only individuals involved in direct patient care are allowed to access the patients health
record
Why is Culture/diversity important in Nursing? - ANSWER-When Nurses understand
diversity, apply cultural and spiritual knowledge, and act in cultural and spiritually
competent ways, the can be more effective in assessing patients, developing culturally
and spiritually sensitive interventions, and influencing healthcare Policy and Practice.
Pain - ANSWER-A Highly unpleasant sensation that affects a person's senses and
emotion and is associated with real or potential tissue damage
Acute Pain - ANSWER-Pain that only lasts through the expected recovery of an illness,
injury or surgery, whether it has a sudden or slow onset and regardless of intensity.
Chronic Pain - ANSWER-Prolonged , usually reoccurring and persisting over 6 months
or longer.
Pain Rating Intensity Scale - ANSWER-Pain Scale from 0 to 10.
OLDCART & ICE - ANSWER-Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment
&