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NURS550: ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING WEEK #1 GUIDED READING
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NURS550: ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING WEEK #1 GUIDED READING
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NURS550: ADVANCED HEALTH ASSESSMENT ANDDIAGNOSTIC REASONING WEEK #1 GUIDED READING
Chapter 1 (p 4-34) - FOUNDATIONS FOR CLINICAL PROFICIENCY
1. Describe the differences between
a. A comprehensive health history/exam - Answers -Includes all the elements of the
health history and the complete physical examination.
- Provides fundamental and personalized knowledge about the patient
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes related to patient concerns
Provides a baseline for future assessments
-Creates a platform for health promotion through education and counseling
- Develops proficiency in the essential skills of physical examination
b. A focused health history/exam - Answers -Assesses symptoms restricted to a specific
body system (eg. sore throat or knee pain)
Applies examination methods relevant to assessing the concern or problem as
thoroughly and carefully as possible
The patient's symptoms, age, and health history help determine the scope of the
focused examination, as does your knowledge of disease pattern
2. Identify examples of when you would obtain (2 examples for each):
a. A comprehensive health history/exam - Answers -Is appropriate for new patients in
the office or hospital
b. A focused health history/exam - Answers -Is appropriate for established patients,
especially during routine or urgent care visits
Addresses focused concerns or symptoms
( eg. sore throat or knee pain)
3. Discuss the differences between subjective and objective data - Answers -Subjective
data: is what the patient tells you
Objective data: what you detect during the examination, laboratory information and test
data
a. Provide examples of what would constitute Subjective data - Answers -The
symptoms and history, from Chief Complaint through Review of Systems
Example: Mrs. G. is a 54-year-old hairdresser who reports pressure over her left chest
"like an elephant sitting there," which goes into her left neck and arm.
b. Provide examples of what would constitute Objective data - Answers -All physical
examination findings, or signs
Example: Mrs. G. is an older, overweight white female, who is pleasant and
cooperative. Height 5′4′′, weight 150 lbs, BMI 26, BP 160/80, HR 96 and regular,
respiratory rate 24, temperature 97.5 °F
, 4. Identify what goes into each section of the comprehensive health history
a. Identifying data and source of history - Answers -Identifying data—such as age,
gender, occupation, marital status
Source of the history—usually the patient, but can be a family member or friend, letter of
referral, or the clinical record
If appropriate, establish the source of referral, because a written report may be needed
b. Chief complaint - Answers -The one or more symptoms or concerns causing the
patient to seek care.
Note: make every attempt to quote the pt's own words. Eg. "my stomach hurts and I feel
awful"
c. History of present illness - Answers -Is a complete, clear, and chronologic description
of the problems prompting the patient's visit, including the onset of the problem, the
setting in which it developed, its manifestations, and any treatments to date.
Pulls in relevant portions of the Review of Systems, called "pertinent positives and
negatives" (see p. 11)
May include medications, allergies, and tobacco use and alcohol, which are frequently
pertinent to the present illness
d Past history - Answers -Lists childhood illnesses
Lists adult illnesses with dates for events in at least four categories: medical, surgical,
ob/gyn, & psychiatric Includes health maintenance practices such as immunizations,
screening tests, lifestyle issues, and home safety
e. Family history - Answers -Outlines or diagrams age and health, or age and cause of
death, of siblings, parents, and grandparents
Documents presence or absence of specific illnesses in family, such as hypertension,
diabetes, or type of cancer
f. Personal and social history - Answers -- Describes educational level, family of origin,
current household, personal interests, and lifestyle.
- occupation & health promotion
- hx of tobacco, drug & alcohol use.
(Health Promotion/Maintenance Activities: screenings, immunizations, sleep, exercise
Tobacco Use: (never, quit, or current; amount) [Type - ie. cigarette, e-cigarette,
smokeless tobacco, etc.)
Alcohol and Drug use: (never, quit, current; type)).
g. Review of systems - Answers -Documents presence or absence of common
symptoms related to each of the major body systems
Bonus : Cardinal techniques of Examination - Answers -1. Inspection
2. Palpation
3. Percussion
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