Initial Approach and History Taking
Hi, my name is Samantha. I am the registered nurse on the way to be finishing your bodily
examination. I am simply going to collect my materials after which we can get commenced.
Perform hand hygiene.
Needed supplies: gloves, alcohol swabs, cotton ball, cotton swab, tongue depressor,
ophthalmoscope, otoscope, reflex hammer, stethoscope
Initial Approach and History Taking
Obtain affected person identity facts.
Can you tell me your name and date of birth?
How vintage are you?
Gender?
Race?
Initial Approach and History Taking
What brings you in these days? Are you having any ache or different problems?
Can you tell me extra approximately the pain.
Use OPQRST
Onset: while did the signs and symptoms first begin? Was it sluggish or surprising?
Provocative or Palliative: What have been you doing whilst the signs and symptoms started?
What makes it better?
Quality and Quantity: Can yo describe the pain?
Region or Radiation: can you point to in which the pain is at? Does it radiate everywhere?
Severity: how bad is the pain right now on a scale of zero-10? What's the worst it's been?
Timing and Treatment: how long do the signs ultimate? Are they intermittent or does it come and
go? Is there whatever you are doing for the ache?
Past Medical History
Must entire by using memory!
-General Health: while became your remaining bodily exam? Do you know the date? Were there
any worries?
,-Chronic Illnesses: do you have any persistent clinical conditions? If so, while did they start and
the way were/are they being dealt with?
-Do you have got a known history of any infectious diseases? If so, what and how were/are they
dealt with?
-Do you have got any hypersensitive reactions? To medicine, meals or environmental?
-Have you ever had surgical operation? If so, what surgery? Were there complications? Did they
use anesthesia?
-Have you ever had any accidents?
-Have you ever been hospitalized? If so, for what?
-Are all of your immunizations updated? Including your formative years, Tdap, Influenza and
COVID vaccines?
-If girl, do you see a gynecologist? When changed into your remaining nicely woman
examination? When became your final PAP Smear? Do you complete month-to-month self
breast tests? When changed into your ultimate length?
-If male, do you whole monthly testicular exams?
Sexual History: The five Ps
Partners: Are you presently having intercourse? How many companions do you currently have?
Are you or your accomplice having intercourse with others?
Practices: What type of sex do you take part in? Oral, genital or anal?
Protection: Do you and your companion(s) use safety? What type? Have you received the HPV
or Hepatitis A/B vaccines? If applicable, do you use pre-exposure prophylactic medicinal drugs
or PrEp?
Past STIs: Have you ever been tested for STIs or HIV? Have you ever been identified with an
STI or HIV? If so, did you get remedy? Do your partner(s) have STIs?
Pregnancy: Do you have intentions of having pregnant? If no longer, are you using measures to
save you it?
Family History
, Can you please inform me the fitness fame, age, and if relevant the motive of loss of life for the
subsequent family contributors:
-Paternal grandparents
-Maternal grandparents
-Mother
-Father
-Siblings
-Children
Family History Disease Presence
Next, I am going to call a few diseases. Please tell me if there is a presence of the named
disorder on your grandparents, mother and father, siblings or kids.
-Cancer or Bleeding Disorders
-Neurological Disease
-Seizures
-Mental/Emotional Health Disorders
-Substance Abuse
-Endocrine Disease
-Cardiovascular Disease
-Pulmonary Disease
-Obesity
-Osteoporosis
Social History
-Where were you born?
-What is your nationality?
-What is your marital fame?
-Do you have youngsters?
-Do you sense secure at home?
-Do yo have any issues to your safety? -Are you ever uncovered to violence?
-Do you have got navy records?
-What is your occupation?
-What is your living arrangements?
-How well do you sleep at night time?
-How could your describe your present day emotional state?
Mnemonic for Social History
Brave - Born (Where had been you born)
New - Nationality/race (What is your nationality)
Mothers - Marital Status (What is your marital fame)
Carefully - Children (Do you have got kids)
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Ashley96. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.99. You're not tied to anything after your purchase.
