NR509 physical assessment Save
Terms in this set (130)
The nurse practitioner (NP) is occasionally running out of food, being discriminated against in
completing a comprehensive the workplace, has a great amount of smog in their community,
assessment of Anita, a new client having difficulty making the rent payment
in a primary care facility. Which
assessment finding(s) reported
by Anita are related to social
determinants of health? Select all
that apply.
- addresses focused concerns or symptoms
-used for established clients during routine or urgent care visits
Focused assessment: - health history and physical exams are focused on the problem
-Includes: brief history of present illness, only the system related
to the problem in the ROS
, - used for new clients
-provides personalized information about the client
-strengthens the clinician-client relationship
-provides a baseline for future assessments
comprehensive assessment:
-provides an opportunity for health promotion education and
counseling
includes: extended history of the present illness, at least two area
of PMhx, family hx, social hx, at least 10 ROS
Subjective data includes symptoms that the client describes such
subjective data as a sore throat, headache, or pain. It also includes the client's
feelings, perceptions, and concerns
Objective data includes the physical examination findings or signs
observed. Information obtained from the client during any part of
objective data the health history is considered subjective data. All physical
examinations, laboratory information, and test data are considered
objective data
-review the clinical record
-ensure the client is comfortable
-clarify the goals/agenda for the encounter
-establish rapport
-identify client's preferred title, name, and gender pronouns
-use "people first" language (i.e. hearing loss, wheelchair)
initial encounter -identify the c/o
-open-ended approach for client's story
-gather information about the client's perspective of the illness
using the FIFE (feelings, ideas, function, expectations)
-conduct health history interview
-gather information about PMHx, meds, allergies, family, personal
and social, ROS
"How would you describe your
sexual identity?"
"How would you describe your
gender identity?"
"What is the sex on your original
birth certificate?"
, -active listening-closely attending to what the pt is communicating,
connect to pt's emotional state, use verbal and nonverbal skills
-empathy- the capacity to identify with the pt and feel the pt's pain
as your own
-guided questioning- allows for interviewer to facilitate full
communications
-validating- affirm legitimacy of pt's emotional experience
-empowerment; encourage pt to ask questions
Basic Interviewing Skills
-partnering; express your commitment to ongoing relationship
-transitioning; inform your pt when you are changing directions
-reassuring; help the pt feel that their problems have been heard
- summarizing; giving a summary of the pt's story to communicate
that you have been carefully listening
-nonverbal communication
-people first language --> ex. patient with diabetes instead of
diabetic
The history of the present illness is a concise, clear, and
chronological description of the chief complaint which prompted
the client's visit. A symptom analysis guided by the mnemonic OLD
CARTS will reveal information regarding the onset, location,
history of present illness
duration, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms. There are other
mnemonics and variations of OLD CARTS that may also be used to
guide in gathering information about the chief complaint.
The Five P's:
-partners
-practices
-protection from STIs
personal and social history
-Past hx of STIs
-Pregnancy plans
-Plus-- assess for trauma, violence, sexual health concerns,
provide support for sexual orientation and gender identity
assessment questions with the onset, location, duration, characteristics, aggravating factors,
related symptom attribute relieving factors, treatments, severity of symptoms
Terms in this set (130)
The nurse practitioner (NP) is occasionally running out of food, being discriminated against in
completing a comprehensive the workplace, has a great amount of smog in their community,
assessment of Anita, a new client having difficulty making the rent payment
in a primary care facility. Which
assessment finding(s) reported
by Anita are related to social
determinants of health? Select all
that apply.
- addresses focused concerns or symptoms
-used for established clients during routine or urgent care visits
Focused assessment: - health history and physical exams are focused on the problem
-Includes: brief history of present illness, only the system related
to the problem in the ROS
, - used for new clients
-provides personalized information about the client
-strengthens the clinician-client relationship
-provides a baseline for future assessments
comprehensive assessment:
-provides an opportunity for health promotion education and
counseling
includes: extended history of the present illness, at least two area
of PMhx, family hx, social hx, at least 10 ROS
Subjective data includes symptoms that the client describes such
subjective data as a sore throat, headache, or pain. It also includes the client's
feelings, perceptions, and concerns
Objective data includes the physical examination findings or signs
observed. Information obtained from the client during any part of
objective data the health history is considered subjective data. All physical
examinations, laboratory information, and test data are considered
objective data
-review the clinical record
-ensure the client is comfortable
-clarify the goals/agenda for the encounter
-establish rapport
-identify client's preferred title, name, and gender pronouns
-use "people first" language (i.e. hearing loss, wheelchair)
initial encounter -identify the c/o
-open-ended approach for client's story
-gather information about the client's perspective of the illness
using the FIFE (feelings, ideas, function, expectations)
-conduct health history interview
-gather information about PMHx, meds, allergies, family, personal
and social, ROS
"How would you describe your
sexual identity?"
"How would you describe your
gender identity?"
"What is the sex on your original
birth certificate?"
, -active listening-closely attending to what the pt is communicating,
connect to pt's emotional state, use verbal and nonverbal skills
-empathy- the capacity to identify with the pt and feel the pt's pain
as your own
-guided questioning- allows for interviewer to facilitate full
communications
-validating- affirm legitimacy of pt's emotional experience
-empowerment; encourage pt to ask questions
Basic Interviewing Skills
-partnering; express your commitment to ongoing relationship
-transitioning; inform your pt when you are changing directions
-reassuring; help the pt feel that their problems have been heard
- summarizing; giving a summary of the pt's story to communicate
that you have been carefully listening
-nonverbal communication
-people first language --> ex. patient with diabetes instead of
diabetic
The history of the present illness is a concise, clear, and
chronological description of the chief complaint which prompted
the client's visit. A symptom analysis guided by the mnemonic OLD
CARTS will reveal information regarding the onset, location,
history of present illness
duration, characteristics, aggravating factors, relieving factors,
treatments, and severity of the symptoms. There are other
mnemonics and variations of OLD CARTS that may also be used to
guide in gathering information about the chief complaint.
The Five P's:
-partners
-practices
-protection from STIs
personal and social history
-Past hx of STIs
-Pregnancy plans
-Plus-- assess for trauma, violence, sexual health concerns,
provide support for sexual orientation and gender identity
assessment questions with the onset, location, duration, characteristics, aggravating factors,
related symptom attribute relieving factors, treatments, severity of symptoms
