NU 518 Advanced Nursing Assessment: Study Guide
Unit summaries, comparison tables, common mistakes and check-yourself questions with answers
Unit 1: Health History, Clinical Reasoning and Documentation
Key Concepts
• Comprehensive history: identifying data and source/reliability, chief complaint (CC, in the patient's
words), history of present illness (HPI), past medical/surgical history, medications and allergies,
family history, social history (tobacco, alcohol, drugs, occupation, sexual history, safety), and review
of systems (ROS).
• HPI attributes (OLDCARTS): Onset, Location, Duration, Characteristics, Aggravating/Alleviating
factors, Radiation, Timing, Severity; also associated symptoms and the patient's perspective.
• Focused (problem-oriented) assessments are used for acute complaints; comprehensive
assessments for new patients and annual exams.
• Clinical reasoning: gather cues, generate hypotheses, build a differential diagnosis, prioritize
'can't-miss' diagnoses (e.g., MI, PE, meningitis, ectopic pregnancy), test hypotheses with targeted
exam and diagnostics.
• Pertinent positives and negatives are findings that raise or lower the likelihood of diagnoses on the
differential.
• Documentation: SOAP format (Subjective, Objective, Assessment, Plan); objective data are findings,
not interpretations.
At a Glance
History component Example
Chief complaint 'Chest tightness for 2 hours'
HPI OLDCARTS details of the chest tightness
Past medical history Hypertension diagnosed 2019, appendectomy 2010
Family history Father had MI at age 50
Social history Smokes 1 pack/day for 20 years (20 pack-years), drinks 2
beers/week
Review of systems Head-to-toe symptom inventory, e.g., denies fever, cough
Common Mistakes
• Putting physical exam findings in the ROS (the ROS is subjective).
• Anchoring on the first diagnosis and failing to consider dangerous alternatives.
Check Yourself
A patient smokes 1.5 packs per day for 20 years. How many pack-years?
Answer: 1.5 x 20 = 30 pack-years.
What is a pertinent negative for suspected pneumonia?
Answer: No fever, normal breath sounds or absence of crackles (findings that would argue against
it).
, Unit 2: Exam Techniques, General Survey, Vital Signs and Nutrition
Key Concepts
• Exam sequence: inspection, palpation, percussion, auscultation (except abdomen: inspection,
auscultation, percussion, palpation).
• Palpation: fingertips for fine discrimination, dorsal hand for temperature, ulnar surface/palm for
vibration (fremitus). Percussion tones: tympany (gastric bubble), resonance (normal lung),
hyperresonance (emphysema, pneumothorax), dullness (liver, consolidation), flatness (muscle).
• Stethoscope: diaphragm for high-pitched sounds (S1, S2, breath sounds, bowel sounds); bell for
low-pitched sounds (S3, S4, mitral stenosis murmur, bruits).
• Blood pressure categories (ACC/AHA 2017): normal below 120/80; elevated 120-129 and diastolic
below 80; stage 1 130-139 or 80-89; stage 2 at least 140 or at least 90. Use correct cuff size (bladder
about 80% of arm circumference); too small a cuff gives falsely high readings.
• BMI = weight (kg) / height (m) squared: underweight below 18.5, normal 18.5-24.9, overweight
25-29.9, obese 30 and above. Waist circumference above 40 in (men) or 35 in (women) increases
cardiometabolic risk.
• Orthostatic hypotension: drop of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of
standing.
At a Glance
Percussion note Example location / condition
Tympany Gastric air bubble, distended bowel
Resonance Normal lung
Hyperresonance Emphysema, pneumothorax
Dullness Liver, pleural effusion, lobar pneumonia
Flatness Thigh muscle, large effusion
Common Mistakes
• Palpating the abdomen before auscultating it.
• Using a small cuff on a large arm, producing falsely elevated BP.
Check Yourself
A patient weighs 90 kg and is 1.80 m tall. What is the BMI?
Answer: 90 / (1.8 x 1.8) = .24, about 27.8 (overweight).
BP 134/78: which category?
Answer: Stage 1 hypertension (systolic 130-139).
Unit summaries, comparison tables, common mistakes and check-yourself questions with answers
Unit 1: Health History, Clinical Reasoning and Documentation
Key Concepts
• Comprehensive history: identifying data and source/reliability, chief complaint (CC, in the patient's
words), history of present illness (HPI), past medical/surgical history, medications and allergies,
family history, social history (tobacco, alcohol, drugs, occupation, sexual history, safety), and review
of systems (ROS).
• HPI attributes (OLDCARTS): Onset, Location, Duration, Characteristics, Aggravating/Alleviating
factors, Radiation, Timing, Severity; also associated symptoms and the patient's perspective.
• Focused (problem-oriented) assessments are used for acute complaints; comprehensive
assessments for new patients and annual exams.
• Clinical reasoning: gather cues, generate hypotheses, build a differential diagnosis, prioritize
'can't-miss' diagnoses (e.g., MI, PE, meningitis, ectopic pregnancy), test hypotheses with targeted
exam and diagnostics.
• Pertinent positives and negatives are findings that raise or lower the likelihood of diagnoses on the
differential.
• Documentation: SOAP format (Subjective, Objective, Assessment, Plan); objective data are findings,
not interpretations.
At a Glance
History component Example
Chief complaint 'Chest tightness for 2 hours'
HPI OLDCARTS details of the chest tightness
Past medical history Hypertension diagnosed 2019, appendectomy 2010
Family history Father had MI at age 50
Social history Smokes 1 pack/day for 20 years (20 pack-years), drinks 2
beers/week
Review of systems Head-to-toe symptom inventory, e.g., denies fever, cough
Common Mistakes
• Putting physical exam findings in the ROS (the ROS is subjective).
• Anchoring on the first diagnosis and failing to consider dangerous alternatives.
Check Yourself
A patient smokes 1.5 packs per day for 20 years. How many pack-years?
Answer: 1.5 x 20 = 30 pack-years.
What is a pertinent negative for suspected pneumonia?
Answer: No fever, normal breath sounds or absence of crackles (findings that would argue against
it).
, Unit 2: Exam Techniques, General Survey, Vital Signs and Nutrition
Key Concepts
• Exam sequence: inspection, palpation, percussion, auscultation (except abdomen: inspection,
auscultation, percussion, palpation).
• Palpation: fingertips for fine discrimination, dorsal hand for temperature, ulnar surface/palm for
vibration (fremitus). Percussion tones: tympany (gastric bubble), resonance (normal lung),
hyperresonance (emphysema, pneumothorax), dullness (liver, consolidation), flatness (muscle).
• Stethoscope: diaphragm for high-pitched sounds (S1, S2, breath sounds, bowel sounds); bell for
low-pitched sounds (S3, S4, mitral stenosis murmur, bruits).
• Blood pressure categories (ACC/AHA 2017): normal below 120/80; elevated 120-129 and diastolic
below 80; stage 1 130-139 or 80-89; stage 2 at least 140 or at least 90. Use correct cuff size (bladder
about 80% of arm circumference); too small a cuff gives falsely high readings.
• BMI = weight (kg) / height (m) squared: underweight below 18.5, normal 18.5-24.9, overweight
25-29.9, obese 30 and above. Waist circumference above 40 in (men) or 35 in (women) increases
cardiometabolic risk.
• Orthostatic hypotension: drop of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of
standing.
At a Glance
Percussion note Example location / condition
Tympany Gastric air bubble, distended bowel
Resonance Normal lung
Hyperresonance Emphysema, pneumothorax
Dullness Liver, pleural effusion, lobar pneumonia
Flatness Thigh muscle, large effusion
Common Mistakes
• Palpating the abdomen before auscultating it.
• Using a small cuff on a large arm, producing falsely elevated BP.
Check Yourself
A patient weighs 90 kg and is 1.80 m tall. What is the BMI?
Answer: 90 / (1.8 x 1.8) = .24, about 27.8 (overweight).
BP 134/78: which category?
Answer: Stage 1 hypertension (systolic 130-139).
