NUR 3065 Health Assess Exam 1 Study Guide (Review quizzes 1-5) Review quizzes 1-5
(Critical thinking, interviewing, health history)
● Differentiate
... [Show More] between subjective vs. objective data
Subjective:
What the patient tells you
Includes history from chief complaint through review of symptoms
** very common error: try to avoid putting objective data into ROS area
Objective:
What you detect during the examination
All physical examination findings
● 7 attributes of the chief complaint EXTREMELY IMPORTANT !!!!!!!
OLD CART
Onset: When did it start? When did it FIRST start?
Duration: How long does it last? Does it come and go?
Location: Where is it? Does it radiate?
Characteristics: How does the pain feel? Stabbing, sharp, dull, pain scale 0-10
Associated manifestations: Have you noticed anything else that accompanies it?
Relieving or exacerbating factors: is there anything that makes it better/ worse
Treatment: Have you seen anyone for this problem before? How have you been treating it?
● Know all the parts of the comprehensive health history and be able to determine the
information which is in each part (CC, HPI, PMH, FH, SH, ROS)
Identifying data and source of the history:
date and time of interview; identifying data- age, gender, occupation, marital status;
source of history- usually from the pt, can be a family or friend, parent/guardian; source
of referral (write thank you note if another provider sent them to you); comment on
reliability of source: varies with pts memory, trust, and mood
Chief Complaint(s)
The one or more symptoms or concerns causing the pt to seek care, may also be a goal
Quote the patient’s own words
(HPI) Present Illness
Amplifies and expands the chief complaint; describes how each symptom developed;
chronological account. Each symptom should be addressed in sequence of occurence
7 attributes of symptom should be recorded
*should be in chronological order, starting with current episode, then relevant
background information
Make sure you get the patient’s perspective: feelings, fears, concerns of problem; ask about
ideas of the nature or cause of the problem; effect of the problem on patients life and function;
expectations of the disease, clinician, of healthcare (often based on prior personal or family
experiences)
Include medications (name, dose, route, frequency) including OTCs, vitamins, minerals,
supplements, oral contraceptives; allergies (to meds, food, insects, environmental factors and
what happens when in contact with allergen); smoking habits and hx, and alcohol/drug use
Past History
Childhood illnesses (measles, mumps, rubella, pertussis, chicken pox, etc)
List adult illnesses with dates
Medical (diabetes, HTN, HIV, hospitalizations, # of sexual partners, risky sexual
practices)
Surgical (dates, indications, types of operations)
Obstetric/Gynecological (OB hx, menstrual hx, contraceptive methods, sexual
function)
Psychiatric (illness, timeframe, diagnoses, hospitalizations, treatments)
Health maintenance practices such as immunizations, screening tests (PPD,
Pap, mammograms, occult blood, cholesterol, and dates of all)
Family History
Ages and health/cause of death for 3 generations: siblings, parents, and grandparents,
children, grandchildren
Document presence or absence of specific illness in family ex: HTN, diabetes,
TB, arthritis, asthma, COPD, seizures, genetically transmitted diseases
Personal & Social History
Describes educational level, family of origin, current household, personal interests,
lifestyle
Occupation, last year of schooling, home situation, significant others, stressors and
stress relief methods, job hx, financial situation, retirement, hobbies, religious
and spiritual beliefs, ADLs
Exercise, diet, dietary supplements, caffeine intake, safety measures (seat belt, helmet,
guns, smoke detectors, sunblock), alternative health care practices
Smoking> how many per day for how many years. If they quit, when? Document pack hx
Review of Systems
Documents presence or absence of common symptoms related to each major body
system, series of questions going from “head to toe”
Record pertinent positives and negatives > move the ones that explain the CC up
to HPI area
- ROS General: weight changes, weakness, fatigue, fever
- ROS Skin: rashes, lumps, sores, itching, dryness, changes in hair, skin, nails, moles
- ROS HEENT:
- Head: headache
- Eyes: vision changes, contacts/glasses, pain/redness, hx of glaucoma or
cataracts
- Ears: hearing, tinnitus, hearing aid, discharge
- Nose/sinuses: frequent colds, nasal stiffness, nosebleeds, sinus trouble
- Throat, mouth, pharynx: condition of teeth/gums, dentures/how do they fit, sore
tongue, frequent dry mouths, hoarseness, last dental exam
- Neck: swollen “glands”, goiter, pain/stiffness
- ROS Breasts: lumps, pain/discomfort
- ROS Respirator: cough, sputum, dyspnea, wheezing, hx of asthma, bronchitis,
emphysema, pneumonia, TB
- ROS Cardiovascular: heart trouble, high BP, heart murmurs, palpitations, chest
pain/discomfort, edema, results of past EEGs
- ROS Gastrointestinal: trouble swallowing, heartburn, nausea, bowel movements, pain,
abdominal pain, jaundice, liver problems, gallbladder problems, hepatitis
- ROS Peripheral Vascular: leg cramps, varicose veins, past clots in veins, swelling in
calves, legs, or feet, color change in fingertips or toes during cold weather, swelling with
redness or tenderness
- ROS Urinary: frequency of urination, urgency, burning or pain, urinary infections,
kidney/flank/suprapubic pain, kidney stones, incontinence in males, reduced force of
urinary stream, hesitancy/dribbling
- ROS Genital- Males: hernias, discharge from or sores on penis, testicular pain or
masses, scrotal pain/swelling, hx of STI and treatments, sexual
habits/interests/function/satisfaction, birth control methods, problems
- ROS Genital- Females: age of menarche, regularity/frequency/duration of menses,
amount of bleeding, last normal menstrual period, dysmenorrhea (menstrual cramping),
age at menopause, menopausal symptoms, postmenopausal bleeding (if have not bled
for more than a year and then all the sudden bleed again = RED flag) exposure to DES
from maternal use (if patient was born prior to 1971) > linked to cervical CA, vaginal
discharge/sores/lumps/itching, STIs and treatments, number of pregnancies, # of type of
deliveries, # of abortions (spontaneous and induced), complications of pregnancy, birth
control methods, sexual habits/interests/function/satisfaction [Show Less]