NURSING > EXAM > NR 509 Midterm Study Guide Week 3 (All)

NR 509 Midterm Study Guide Week 3

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Determine scope of assessment: Focused vs. Comprehensive: Comprehensive: Used patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. Is appropriate for new patients in the office or hospital 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 Focused: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s prob- lems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. Is appropriate for established patients, especially during routine or urgent care visits Addresses focused concerns or symptoms Assesses symptoms restricted to a specific body system Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible Being aware of your reactions helps develop your clinical skills. Your success in eliciting the history from different types of patients grows with experience, but take into account your own stressors, such as fatigue, mood, and overwork. Self-care is also important in caring for others. Even if a patient is challenging, always remember the importance of listening to the patient and clarifying his or her concerns. Components of the Health History Initial information Date and time of history-time is especially important in emergent situations Identifying data-age, gender, marital status, occupation-identify source of history ie: family member, friend etc. Reliability-usually documented at end of interview ie: “patient is vague when describing symptoms”. Chief Complaint(s) Try to quote the patients words Present Illness Complete, clear and chronological description of the problem prompting the patient visit Onset, setting in which it occurred, manifestations and any treatments Should include 7 attributes of a symptom:

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