A health history provides a holistic view of a patient's health care experiences and current health habits
Assess whether a patient has ever been hospitalized or injured or has had surgery.
Has any illness or injury limited the patient's ability to function?
Include a complete medication history Review the use of any prescription medications, herbal supplements, and over-the-counter drugs.
Also essential are descriptions of allergies, including allergic
reactions to food, latex, drugs, or contact agents includes a description of a patient's habits, emotional status, and lifestyle patterns.
Assessing for the use of alcohol, tobacco, caffeine, or recreational drugs determines a patient's risk for diseases involving the liver, lungs, heart, or nervous system.
Assessing Patterns of coping exercise and nutrition
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
The Human Body in Health and Disease
7th EditionGary A. Thibodeau, Kevin T. Patton
1,505 solutions
Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
Law and Ethics for Health Professions
9th EditionCarlene Harrison, Karen Judson
836 solutions
an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan.
a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A data base is established by collecting information from all available sources, including interviews with the client and the client's family, a review of any existing records of the client's health, observation of the client's response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client's care. The data base is continually updated. The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the data base by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem.
Students also viewed Recommended textbook solutions
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
Medical Language Accelerated
2nd EditionAndrew Cavanagh, Steven Jones
568 solutions
Essentials of Medical Language
4th EditionDavid M Allan, Rachel Basco
404 solutions