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NR 509 Midterm Study Guide (Version 4), NR 509 Advanced physical assessment, Chamberlain
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NR 509 Midterm Study Guide (Version 4), NR 509 Advanced physical assessment, Chamberlain
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NR 509 Mid Term Exam StudyGuide
NR 509: Advanced Physical
Assessment - Chamberlain
, NR 509 Mid-term study guide
Ch. 1
• Basic and Advanced Interviewing Techniques
• Basic
o Gather a sensitive and nuanced hx.
o Perform thorough and accurate exam
o Improve pt. rapport
o Focus your assessment
o Sent guideposts that direct clinical decision making
o Avoid interpreting your findings- may be premature.
o Warn pt. that your assessment may take longer but that
doesn’t mean negative findings
• Advanced
o With time and practice- able to integrate:
o Empathetic listening
o Ability to interview pts of all ages, genders, races, ethnicities, etc.
o Improved techniques to examine different body systems
o Differentiate level of sick vs. not sick
o Improved process of clinical reasoning leading to diagnosis and
plan
o Will grow and begin clinical reasoning from first impression of
meeting pt.
o ID Sx. And abnormal findings, linking underlying pa xtho
o Establish and test explanatory hypotheses
• Components of the Health History
• Identifying data – age, gender, marital status, occupation
o Source of hx. - usually pt. but could be family or friend, letter of
referral or clinical record
o Establish the source of referral is necessary
• Reliability- pt. memory, trust, mood
• Chief Complaint- one or more symptoms or concerns causing pt. to seek
care
o Try and keep this in patients own words “my stomach feels awful”
• Present illness- amplifies CC
o **Complete, clear and chronologic description of the problems
prompting the pts. Visit including onset, setting it developed
how it manifests and tx.
To date
, o Includes pt. thoughts and feelings about illness
o *pertinent positives and pertinent negatives*
o May include meds, allergies, tobacco, ETOH…
o Seven attributes of a symptom 1. Location 2. Quality 3.
Quantity or severity 4. Timing (onset, duration, frequency)
5. Setting it occurs 6.
Factors that aggravate or relieve 7. Associated manifestations
o Consider placing PMHx in this area to support potential
problem (hx. Of CAD with pt. presenting with CP)
o How these sx are affecting ADLs
o Medications taking to help or than may exacerbate
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