NUFT 204 Exam 1 7 parts of health history answer 1 Biographical data 2 Reason for seeking care C C 3 Current health or history of current illness HPI history of present illness Examples of Biographical data in health hstory answer Name 4 Past health 5 Family history 6 Review of systems Head to toe 7 Functional assessment or ADLs Address and phone number Age and birth date Birthplace Sex Marital status Race Ethnic origin Occupation usual and present Source of information Reason for seeking care in health history C C answer a brief spontaneous statement in the person s own words that describes the reason for the visit formerly called Chief Complaint or CC Example I couldn t eat for two days because I was throwing up objective answer something that can be observed example vomiting subjective answer something the patient says to me I can debate that Ex Nauseas Present Health or History of Present Illness HPI in health history answer PQRSTU mnemonic P Provocative or palliative Q Quality or quantity R Region or radiation S Severity scale T Timing U Understand patient s perception PQRSTU answer P Provocative or palliative Q Quality or quantity R Region or radiation S Severity scale T Timing U Understand patient s perception Past health in health history answer Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last examination date Allergies Current medications Family History in Health History answer Age and health or cause of death of blood relatives Health of close family members spouse children Family history of various conditions such as heart disease high blood pressure stroke diabetes blood disorders cancer obesity mental illness and others Family tree genogram The review of systems in the health history is A an evaluation of past and present health state of each body system B a documentation of the problem as perceived by the patient C a record of objective findings D a short statement of general health status answer Head to toe assessment A Functional Assessment Including ADLs Activities of Daily Living in Health history answer Self esteem self concept Activity exercise Sleep rest Nutrition elimination Interpersonal relationships resources Spiritual resources Coping and stress management Personal habits Tobacco Alcohol Street drugs Environment hazards Occupational health Intimate partner violence Perception of Health answer How do you define health How do you view your situation now What are your concerns goals What do you think will happen in the future What do you expect from your health care providers Why should we have scientific knowledge during hygeine answer Before we provide hygiene care we need to identify any diseases the patient may have that may affect their skin or their mouth Take note of any skin abnormalities for allergies in order to prevent injury describe a Normal Nail answer normal nail is transparent smooth and convex with a pink nail bed and a translucent white tip Why pay attention to feet hands and nails answer to prevent infection odor and injury Specially for diabetics and those with circulation issues Mucous membranes answer mouth eyes nose ears vaginal and rectal areas Xerostomia answer Dry mouth can be caused my drugs like pyschiatric drugs Oral cavity is lined with answer Mucous membranes All mucuous membranes should be smooth without lesions Normal oral mucosa answer light pink soft moist smooth and without lesions Things that impair salivary secretion answer Medications exposure to radiation mouth breathing alcohol based products gingivitis answer inflammation of the gums things that affect hair characteristics answer hormonal changes nutrition emotional stress physical stress aging infection and other illnesses alopecia answer hair loss During hygiene assess answer emotional status health promotion practices health care education needs Factors influencing hygiene answer Social practices personal preferences body image socioeconomic status health beliefs and motivation cultural variables developmental stage physical condition critical thinking during hygiene answer Integrate nursing knowledge Consider developmental and cultural influences Think creatively Be nonjudgmental and confident Draw on your own experiences Rely on professional standards Nursing Process answer five step systematic method for giving patient care involves assessing diagnosing planning implementing and evaluating ADPIE Hygiene Assessment answer Ability to perform self care skin feet and nails oral cavity use of sensory aids normal cultural hygiene care Hygiene and diagnosis answer Activity intolerance Bathing self care deficit Dressing self care deficit Impaired physical mobility Impaired oral mucous membrane Ineffective health maintenance Risk for infection Patient at risk for hygiene issues answer homeless low socioeconomic status those with chronic illnesses mentally ill and extreme ages hygiene planning answer Set goals and outcomes Partner with the patient and family Set priorities based on assistance required extent of problems nature of diagnoses Hygiene Implementation answer Use caring to reduce anxiety promote comfort Assist and prepare patients to perform hygiene as independently as possible Teamwork and collaboration Health care team members Family Community agencies Administer meds for symptoms before hygiene Be alert for patient s anxiety or fear Discuss signs and symptoms of problems Inform patients about community resources Bathing guidelines answer Provide privacy Maintain safety Maintain warmth Promote independence Anticipate needs denture care guidelines answer Keep dentures covered in water when they are not worn Store in an enclosed labeled cup with the cup placed on patient s bedside stand Brush dentures with soft toothbrush and rinse with tepid water QSEN answer Quality and Safety Education for Nurses Hygiene Safety Guidelines answer Identify the patient with two identifiers Move from the cleanest to less clean areas Use clean gloves for contact with nonintact skin mucous membranes secretions excretions or blood Test the temperature of water or solutions Use principles of body mechanics and safe patient handling Give proper direction to NAP when delegating EHR answer electronic health record NCQA National Committee for Quality Assurance answer not for profit organization dedicated to assessing and reporting on quality and performance of health care plans TJC The Joint