NR 509 MIDTERM EXAM STUDY GUIDE
Basic and Advanced Interviewing Techniques
Basic maximize patient's comfort, avoid unnecessary changes in position, enhance clinical
efficiency, move head to toe, examine the patient from their right side
Active listening, empathic responses, guided questioning, nonverbal communication, validation,
reassurance, partnering, summarization, transitions, empowering the patient
Active Listening- closely attending to what the patient is communicating, connecting to the patient’s
emotional state and using verbal and nonverbal skills to encourage the patient to expand on his or her
feelings and concerns.
Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your own,
then respond in a supportive manner.
Guided Questioning- show your sustained interest in the patient’s feelings and deepest disclosures and
allows the interviewer to facilitate full communication, in the patient’s own words, without interruption.
Non-verbal- includes eye contact, facial expression, posture, head position and movement such as
shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed, neutral, or open.
Validation- helps to affirm the legitimacy of the patient’s emotional experience.
Reassurance- an appropriate way to help the patient feel that problems have been fully understood and
are being addressed.
Partnering- building rapport with patients, express your commitment to an ongoing relationship.
Summarization- giving a capsule summary of the patient’s story during the course of the interview to
communicate that you have been listening carefully.
Transitions- inform your patient when you are changing directions during the interview. Empowering the
Patient- empower the patient to ask questions, express their concerns, and probe your
recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take
medications as prescribed.
Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5
Comprehensive: Used for 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. A source
fundamental and personalized knowledge about the patient, strengthens the clinician-patient relationship.
● 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
,Flexible Focused or problem-oriented assessment: 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 problems; 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 Tangential
lighting: JVD, thyroid gland, and apical impulse of heart.
Components of the Health History Jenna/Ashley
Initial information
Identifying data and source of the history; reliability
Identifying data- age, gender, occupation, marital status
Source of history- usually patient. Can be: a family member or friend, letter of referral, or clinical record.
Reliability- Varies according to the patient’s memory, trust, and mood.
Chief Complaint
Chief Complaint- Make every attempt to quote the patient’s own 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:
Location ●
Quality ●
● Quantity or severity
Timing, onset, duration, frequency ●
Setting in which it occurs ●
Aggravating or relieving factors ●
Associated manifestations ●
-Differential diagnosis is derived from the “pertinent
positives” and “pertinent negatives” when doing Review of Systems that are relevant to the chief
complaint. A list of potential causes for the patients problems.
-Present illness should reveal patient’s responses to his or her symptoms and what effect this has on
their life.
-Each symptom needs its own paragraph and a full description.
-Medication should be documented, name, dose, route, and frequency. Home remedies,
nonprescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed
medications.
,-Allergies-foods, insects, or environmental, including specific reaction
Tobacco use, including the type. If someone has quit, note for how long
-Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness.
Past history
-Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever,
scarlet fever, and polio. Also include any chronic childhood illness -Adult
illnesses: Provide information in each of the 4 areas:
● Medical: diabetes, hypertension, hepatitis, asthma and HIV;
hospitalizations; number and gender of sexual partners; and risk
taking sexual practices.
● Surgical: dates, indications, and types of operations
● Obstetric/gynecologic: Obstetric history, menstrual history,
methods of contraception, and sexual function. ● Psychiatric:
Illness and time frame, diagnoses, hospitalizations, and treatments.
-Health Maintenance: Find out if they are up to date on immunizations and screening tests. Review Tb
tests, pap smears, mammograms, stool tests for occult blood, colonoscopy, cholesterol levels etc..
Family history
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, coronary artery
disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis,
asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, and symptoms reported by patient.
Ask about history of breast, ovarian, colon, or prostate cancer
Ask about Genetically transmitted diseases
Personal or social history
Describes educational level, occupation, family of origin, current household, personal interests, and
lifestyle
Capture the patients personality and interests, sources of support, coping style, strengths, and concerns
Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety measures,
sexual practices, and use of alcohol, drugs, and tobacco
Expanded personal and social history personalizes your relationship with the patient and builds a
rapport
Review of systems pg 11-13
Documents presence or absence of common symptoms related to each of the major body systems
Understanding and using Review of Systems questions may seem challenging at first. These
“yes-no” questions should come at the end of the inter- view. Think about asking a series of
, questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the
history may feel like a hundred questions, but it is important to make sure we have not missed
anything.”
Most Review of Systems questions pertain to symptoms , but on occasion, some clinicians
include diseases like pneumonia or tuberculosis.
Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to
system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help
clarify the diagnosis.
For example, after a full description of chest pain, you may ask, “Do you have any history of high blood
pressure . . . palpitations . . . shortness of breath . . . swelling in your ankles or feet?” or even move to
questions from the Respiratory or Gastrointestinal Review of Systems The Review of Systems questions
may uncover problems that the patient has overlooked, p
articularly in areas unrelated to the Present Illness. Significant health events, such as past
surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration.
Keep your technique flexible.
Remember that major health events discovered during the Review of Systems should be moved to the
Present Illness Past History in your write-up.
Some experienced clinicians do the Review of Systems during the physical examination, asking about the
ears, for example, as they examine them. If the patient has only a few symptoms, this combination can
be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and
examination, and necessary note taking becomes awkward
The Review of Systems: Pg. 12-13 ROS Chart Copied from online
book
General : Usual weight, recent weight change, clothing that fits more tightly or
loosely
than before; weakness, fatigue, or fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color;
changes in hair or nails; changes in size or color of moles.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness,
lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive
tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing,
tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids.
Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus
trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any,
and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.
Neck : “Swollen glands,” goiter, lumps, pain, or stiffness
in the neck.
Breasts : Lumps, pain, or discomfort, nipple discharge, self-
examination practices.
Respiratory : Cough, sputum (color, quantity; presence of blood or
hemoptysis), shortness of
breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to
include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.
Cardiovascular : “Heart Trouble”; high blood pressure; rheumatic fever; heart murmurs; chest
