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Advanced Health Assessment Week One
The first part of the health assessment is the __________. physical examination __________ is a continuing process and determines if the goals/outcomes have been attained. evaluation __________ indicates how closely a given observation agrees with the best possible measure of reality. Validity __________ is charting the best course to achieve the patient's optimal wellness and comfort. Planning Symptoms are also known as __________ data. subjective __________ is also known as precision. reliability
__________ data is information gathered from the physical assessment and the laboratory tests. objective The health __________ entails both a comprehensive health history and a complete physical examination, which are used to evaluate the health status of a person. assessment Health assessment is the __________ of nursing practice. foundation The __________ is the symptom(s) or concern(s) causing the patient to seek care. chief complaint __________ varies according to the patient's memory, trust, and mood. Reliability The phase of the interviewing process that helps put the patient at ease and establish trust is called the __________ phase. introduction A health history that concentrates on acute problems is called a(n) Problem (or focused) history
T/F
Recording information for infants differs from adults because it includes immunization status. False T/F A problem may be defined as anything that will need further evaluation and/or attention. True A 34-year-old male with a history of complex social medical needs (including current substance abuse) presents to a primary care teaching clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The NP desires to utilize the approaches to this patient that are most likely to lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the NP to use? Following the patient's lead to understand their thoughts, ideas, concerns, and requests 3 multiple choice options A 30-year-old female professional athlete presents to a new primary care provider with chronic menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a dismissal of her complaints because of her high level of physical fitness and conditioning. She is seeking a care provider who will explore the issue in more detail and work with her particular concerns. Validating and empathetic with open-ended questions 3 multiple choice options A 16-year-old male presents to an STD clinic, at the request of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his
sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The NP receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique? Using nonverbal communication to encourage the patient to expand their narrative 3 multiple choice options A 36-year-old female air traffic controller presents to the NP's office for a routine visit three months after losing her spouse to a lengthy battle with a neurodegenerative disease. The patient denies any psychiatric symptoms on review of systems and states that she has slept better in the last month than she had in the previous years. She endorses a healthy support system. She becomes briefly tearful when speaking of the plans that they had when they first married that were never fulfilled; she then changes the subject rapidly to whether her Pap smear is due. Which of the following is an example of an empathetic response to this patient? Recognizing the patient's emotions by asking or confirming how she feels about the event 3 multiple choice options A 13-year-old male presents to the NP's office after his family relocates to a state. The patient underwent treatment for sarcoma when he was 10 years old, which included an above-the-knee amputation. He has learned to successfully navigate with a prosthetic leg and even engage in competitive athletics at school. He does not like to speak of his experience with cancer and often makes up humorous stories to tell new acquaintances about his amputation. Although he is very well engaged in most of the visits with the NP, when the topic of cancer arises, he tries to avoid the question or quickly change the subject. Which of the following statements is most likely to be helpful in cementing the patient's trust of the NP? That sounds like a frightening experience that you are recovering well from. 3 multiple choice options What are the two types of exams that are performed? Comprehensive and focused (problem oriented)
- Onset:
- Remitting or exacerbating factors:
- Associated manifestations: OLDCART Onset Location Duration Characteristics Aggravating factors Relieving factors Treatment OPQRST Onset Provocation Quality Region/Radiation Severity Timing Location questioning Where is it? Where does it radiate to?
Quality questioning What does it feel like? Quantity/ Severity questioning How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) Timing questioning When did (does) it start? How long does it last? How often does it come? Onset questioning (setting in which symptom occurs). Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. Remitting or exacerbating factors questioning Is there anything that makes it better or worse? Associated manifestations questioning Have you noticed anything else that accompanies it? Two mnemonics to help pursue 7 attributes of a symptom OLDCART OPQRST
Present Illness Includes ○Expands upon the person's chief complaint ○Includes individual's thoughts and feelings about the illness ○Contains pertinent positives and negatives from the ROS ○May include medications, allergies, alcohol and tobacco use if pertinent to the present illness Past Illness Includes ○Childhood illnesses ○Adult illnesses with dates (medical, surgical, OBGYN, psych) ○Health maintenance (immunizations, screening tests, lifestyle issues, home and safety) Family History Includes ○Age and health or age and cause of death ○Siblings, parents, and grandparents (occasionally will extend to other family members) *May ask specifically about certain diseases (HTN, diabetes, cancer) Personal and Social History Includes ○Educational level ○Family of origin ○Current household ○Interests ○Lifestyle
Review of Systems Includes ○Presences of absence of symptoms specific to body systems Objective data Secondary data not from patient, rather observable/measurable information by healthcare provider ●Signs ●Vital signs ●Physical exam findings ●Diagnostic tests Differential Diagnosis (DDx) A rule out, or an attempt to determine which one of the several diseases can be causing the signs and symptoms that are present How is a differential diagnosis formed? The presence or absence of additional symptoms helps generate the differential diagnosis, which includes the most likely and, at times, the most serious diagnoses, even if less likely, which could explain the patient's condition. HPI History of Present Illness Components of HPI ●Summary: Onset, setting, manifestations and treatments to date
●Patients may use periods of silence to collect their thoughts, remember details, or decide if they can trust the provider with certain information ●Being comfortable with periods of silence may be therapeutic, prompting the patient to reveal deeper feelings How should the confusing patient be approached? In these patients gathering a detailed history can tire and frustrate the patient and the provider. Shift to the mental status examination, focusing on level of consciousness, orientation, memory, and capacity to understand. What should be considered as part of your DDx for the confusing patient? ●Mental status change: psychosis ●Mental illness: schizophrenia, or a neurologic disorder ●Delirium: acutely ill or intoxicated patients and dementia in the elderly Capacity a clinical designation and can be assessed by clinicians Competence a legal designation and can only be decided by a court What must a patient be able to do in order to make decisions? (4)
- Understand the relevant information
- Appreciate their situation
- Use reason to make a decision
- Communicate their choice The ability to make decisions.... is "temporal and situational" (it can fluctuate) What are some questions the depressed patient should be asked? ○"Over the past 2 weeks, have you felt down, depressed, or hopeless?" ○"Over the past 2 weeks, have you felt little interest or pleasure in doing things?" ○If s/s of depression, always ask about suicide ○Assess the severity of depression What questions should be asked when taking a sexual history? ●Determine risks for pregnancy, STIs, and human immunodeficiency virus (HIV) ●Also ask about satisfaction with sexual activity ●"Do you have sex with men, women, or both?" ●"How many sexual partners have you had in the last 6 months? In the last 5 years? In your lifetime?" ●"Have you had any new partners in the past 6 months?" ●"How often do you use condoms?" ●"Do you have any concerns about HIV infection or AIDS?" Tolerance
○If localized can be related to neuropathy or myopathy weight loss a loss of 5% or more of usual body weight over a 6-month period Review of Childhood Illnesses includes ●measles, ●mumps ●rubella ●varicella ●pertussis ●rheumatic fever ●scarlet fever ●polio ●any chronic illness Review of medical history should include ●DM, HTN, HIV, hepatitis, asthma, ○Include hospitalizations ○Number and gender of sexual partners ○Risk-taking sexual practices Review of surgical history should include ● dates ● indications
● type of operation Obstetric history should include menstrual history methods of contraception sexual function Psychiatric history should include Illness and time frame diagnoses hospitalizations treatments
