Term
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Definition
| elicited from the pt or other sources in an emergency situation. only info required to treat the emergency need of the pt is gathered. after the life threatening condition is no longer present, the nurse can elicit a more comprehensive history |
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Term
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Definition
a comprehensive history of the pt's past and present health status. it is usually gathered during a pt's initial visit to a health care facility on a nonemergency basis and on admission to a hospital
*30-60 min (inform pt of amt of time)
if not completed, it may be best to continue later to avoid fatiguing pt |
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Term
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Definition
| shorter and specific to pt's current reason for seeking health care |
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Term
| interval or follow-up health history |
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Definition
| builds on a preceding visit to a health care facility |
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Term
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Definition
| the sign (objective finding) or sympton (Subjective) that causes the pt to seek Health care. reasons for seeking health care should be recorded as direct quotes from the pt. they should not be direct quotes from either the health care provider or the nurse. |
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Term
| associated manifestations |
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Definition
| one of ten characteristics of chief complaint and refer to signs and symptoms that accompany the CC |
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Term
| history of the present illness (HPI) |
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Definition
a chronological account of the patient's CC and the events surrounding it. the chronology can be taken one of two ways:
from the current state or the problem back to its origin (reverse chronology)
or from the origin of the symptom leading to current status (forward chronology) |
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Term
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Definition
| describes the way it feels to the pt. use the pt's own terms to describe the quality of the CC. |
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Term
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Definition
| depicts severity, volume, number, or extent of CC. one mechanism that can be used to assess quantity of pain is a numerical scale, known as the visual analog scale, which 0 is no pain, and 10 is worst pain possible. subjective terms are difficult to quantify. if the pt consistently uses the same terms, then a relative scale can be used to assess whether the chief complaint is improving or becoming worse. |
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Term
| negative findings (pertinent negatives) |
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Definition
| manifestations expected in the pt with a suspected pathology, but which are denied by the pt. if the pt does not mention specific signs and symptoms that might be present with a given illness, ask whether they are present. lack of pertinent negatives may lead to a different diagnosis. document both positive findings and pertinent negatives because both give clues to the pt's condition |
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Term
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Definition
| factors that worsen severity of CC |
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Term
| Appendicitis signs/symptoms |
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Definition
| nausea, vomiting, anorexia, low-grade fever |
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Term
| timing used to describe CC |
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Definition
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Term
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Definition
indicates amt of time in which the CC is present.
continuous and intermittent are terms used to describe duration
when possible, the duration of the CC should be stated in specific times such as minutes, hours, days. |
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Term
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Definition
| terms that depict quantity of CC |
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Term
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Definition
| refers to time at which the CC begins and is usually described as gradual or sudden |
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Term
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Definition
| region (location) and radiation. ex. tingling in left arm |
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