NCM 101 A Quiz 3

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Created by
Jarrel Sam

Cards (36)

  • NURSING HEALTH HISTORY
    • Data collected about the client’s current level of wellness
    • It is the primary focus of the interview process
    • A review of client’s functional health patterns before the current contact with the healthcare agency
    • Used in developing plan of care and formulating nursing interventions
  • BASIC COMPONENTS OF THE NURSING HEALTH HISTORY
    • Personal Profile
    • Functional Assessment
    • Functional Assessment Tests
    • Review of Systems
    • Assessment in Pregnancy
    • Pediatric Additions to Health History
  • Biographic Data
    • Factual demographic data about the client
  • Biographic Data Includes:
    Name
    Address
    Date of Birth
    Gender
    Marital Status
    Religion
    Race
    Ethnic origin
    Occupation
    Source of Health Care
  • To present a more direct and clearer picture of the patient’s condition, it is recommended that the actual verbalization of the patient is documented in a subjective data format
  • PERSONAL PROFILE
    • Biographic Data
    • Reason for Seeking Health Care
    • History of Present Illness
    • Past Medical History
    • Family History
  • History of Present Illness
    • Usual health status
    • Elaboration of the chief complaint in chronological sequence
    • Additional Interview Spiels
    • For clients interviewed during their hospital admission, this portion shall recall the present condition in succession from symptoms encountered before hospitalization up to the day of the interview.
  • Past Medical History
    • Childhood illnesses
    • Childhood immunizations
    • Allergies
    • Accidents and injuries
    • Hospitalizations
    • Medications
  • Hospitalizations
    • this must include any surgical procedures encountered or previous hospitalization admissions related to the case being presented. Preferably, the date or year the patient was hospitalized should be noted.
  • Medications
    • Medications the patient has been prescribed oftentimes (e.g. maintenance drugs) and/or any OTC drugs commonly taken for illnesses.
  • Family History
    • Presented in GENOGRAM
    • Ages of siblings, parents and grandparents
    • Their current state of health
    • Cause of death
    • It reveals risk factors for certain illnesses of a genetic or familial like DM, HPN, CA, Obesity, etc.
  • GENOGRAM
    • A 3rd level generation outlining is the least/minimum requirement for presentation.
    • Reference for the diagram presented has to be cited.
  • FUNCTIONAL ASSESSMENT
    • Gordon’s Functional Health Assessment
    • Activities of Daily Living
  • BASIC COMPONENTS OF THE NURSING HEALTH HISTORY
    1. PERSONAL PROFILE
    2. FUNCTIONAL ASSESSMENT
    3. FUNCTIONAL ASSESSMENT TESTS
    4. REVIEW OF SYSTEMS
    5. ASSESSMENT IN PREGNANCY
    6. PEDIATRIC ADDITIONS TO HEALTH HISTORY
  • Gordon’s Functional Health Assessment
    • Health Perception-Health Maintenance Pattern
    • Nutrition-metabolic pattern
    • Elimination Pattern
    • Activity- Exercise Pattern
    • Sleep-Rest Pattern
    • Cognitive Perceptual Pattern
    • Self Perception Self Concept Pattern
    • Role Relationship Pattern
    • Sexuality-Reproductive Pattern
    • Coping-Stress Tolerance Pattern
    • Value-Belief Pattern
  • Activities of Daily Living
    • The things we normally do in daily living including any daily activity we perform for self-care
  • FUNCTIONAL ASSESSMENT TESTS
    1. Newborns (APGAR SCORING)
    2. Adult (Katz Index of Independence in ADL and Barthel index)
  • APGAR SCORING
    • Developed by Dr. Virginia Apgar
    • A method of assessing the newborn’s adjustment to extrauterine life
    • Taken 1 minute and 5 minutes after birth
    • 1 minute score indicates need for resuscitation
    • 5-minute score is more reliable in predicting mortality and neurologic deficits
  • SCORE
    7- 10
    • Good Adjustment, Vigorous
    • Normal
    7-4
    • Moderately depressed infant
    • Needs airway clearance
    3 & below
    • Severely depressed infant
    • In need of resuscitation
  • Katz Index of Independence in ADL
    • It is based on an evaluation of the functional independence or dependence of patients in:
    • Bathing, Dressing, Toileting, Transferring, Continence, and Feeding.
  • Barthel index
    • The index should be used as a record of what a patient does, not as a record of what a patient could do.
    • The main aim is to establish the degree of independence from any help, physical or verbal, however minor and for whatever reason.
    • The need for supervision renders the patient not independent.
  • REVIEW OF SYSTEMS
    • Review of all health problems by body systems
    • The normal function of each body system is assessed and any noted changes
    • Such changes are usually subjective
    • Findings in the ROS help the nurse to direct assessment during physical examination
  • ASSESSMENT IN PREGNANCY
    • LMP
    o Last Menstrual Period; the 1st day of the Last Menstruation
    • AOG
    o Age of Gestation; the age of the uterus
    • EDC
    o Expected date of confinement
  • OB Score
    • Pregnancy information; TPAL
    1. T – full-term babies
    2. P – premature babies
    3. A – Abortion
    4. L – Living children
  • Head
    • Measured at the level of the eyebrows
    • Range: 33 to 35 cm, average is 35 cm
    • Less than 32 cm is indicative of Microcephaly in term infants
    • 4cm and more, greater than the chest circumference indicates Hydrocephalus
  • Chest
    • Measured at the level of the nipple
    • Ranges from 30-32 cm
    • Less than 30 indicates prematurity
    • Head and Chest Circumference
    • Head > chest at birth
    • Head = chest 9-10 mo.
    • Head < chest after 1 yr.
  • Abdomen
    • Measured just below the umbilicus
    • Approximately the same as chest circumference
  • Length
    • Measure newborn length from top of the head to heel
    • Length
    • Gains 13.75 cm (5.5 in.) by 6 months
    • Additional 7.5 cm (3 in.) by 12 months
    • Average of 45 – 55 cm or 18 to 22 inches
    • Male – 20 inches or 50 cm
    • Female 19.6 inches or 49 cm
  • Weight
    • Weight
    • Doubles by 5 months
    • Triples by 12 months
    • Ranges from 6 to 8.5 lbs or 2500 to 4000 grams
    • Male infant – 7.5 lbs
    • Female infant – 7 lbs
    • Less than 2,500 grams – Small for Gestational Age (SGA)
    • More than 4000 grams – Large for Gestational Age (LGA)
  • HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERNS
    1. How has general health been?
    2. Any colds in the past year? When appropriate: absences from work?
    3. Most important things you do to keep healthy? Think these things make a difference in health? Use of cigarettes, alcohol, drugs? Breast self-examination?
    4. Accidents?
    5. In the past, been easy to find ways to follow suggestions from physicians or nurses?
    6. When appropriate: what do you think caused this illness? Actions taken when symptoms are perceived? Results of action?
    7. When appropriate: things important to you in your health care? How can we be most helpful?
  • NUTRITIONAL-METABOLIC PATTERN
    1. Typical daily food intake? (Describe.) Supplements (vitamins, type of snacks)?
    2. Typical daily fluid intake? (Describe.)
    3. Weight loss or gain? (Amount.) Height loss or gain? (Amount.)
    4. Appetite?
    5. Food or eating: Discomfort? Swallowing? Diet restrictions?
    6. Heal well or poorly?
    7. Skin problems: Lesions? Dryness?
    8. Dental problems?
  • ELIMINATION PATTERN
    1. Bowel elimination pattern? (Describe.) Frequency? Character? Discomfort? The problem in control? Laxatives?
    2. Urinary elimination pattern? (Describe.) Frequency? The problem in control?
    3. Excessive perspiration? Odor problems?
    4. Body cavity drainage, suction, and so on? (Specify.)
  • ACTIVITY-EXERCISE PATTERN
    1. Sufficient energy for desired or required activities?
    2. Exercise pattern? Type? Regularity?
    3. Spare-time (leisure) activities? Child: play activities?
    4. Perceived ability
  • Functional Level Codes:
    Level 0: full self-care
    Level I: requires the use of equipment or device
    Level II: requires assistance or supervision from another person
    Level III: requires assistance or supervision from another person and
    equipment or device
    Level IV: is dependent and does not participate
  • SLEEP-REST PATTERN
    1. Generally rested and ready for daily activities after sleep?
    2. Sleep onset problems? Aids? Dreams (nightmares)? Early awakening?
    3. Rest-relaxation periods?
  • COGNITIVE-PERCEPTUAL PATTERN
    1. Hearing difficulty? Hearing aid?
    2. Vision? Wear glasses? Last checked? When last changed?
    3. Any change in memory lately?
    4. Important decision easy or difficult to make?
    5. Easiest way for you to learn things? Any difficulty?
    6. Any discomfort? Pain? When appropriate: How do you manage it?