10/16/24, 12:10 Physical assessment exam 1 study
PM guide
Physical health assessment study guide exam 1
• Internal and external factors of communication
o Internal- liking others, empathy, self awareness, ability to listen
o External dress, note taking, ensure privacy, refuse interruptions,
physical environment
• Introducing the interview
o Introduce self/role, and reason for interview
o “ hello mrs.smith my name is siobhan and I want to ask you
some questions about previous medical history + current
complaints before your physical exam”
• Working phase of communication
o Data gathering phase
o Verbal skills to form questions
o Open ended and closed questions
o comments about major biographical data, reasons for seeking
care, history of present health concern, past health history,
family history, review of body systems (ROS) for current health
problems, lifestyle and health practices, and developmental
level. The nurse then listens, observes cues, and uses critical
thinking skills to interpret and validate information received from
the client.
• Traps of interviewing
o False assurance
o Unwanted advice
o Using authority
o Distancing – cancer on THE left side
o Using professional jargon
o Leading/biased questions
o Avoidant language
o Talking too much
o Interrupting
o Why questions
• Closing the interview
o Graceful not abrupt awkward
o Give final opportunity for pt to self-express
o “ is there anything else you would like to mention”
• Nonverbal skills
o Physical appearance
o Posture
o Gestures
o Facial expressions
about:blan 1/
k 8
, 10/16/24, 12:10 Physical assessment exam 1 study
PM guide
o Eye contact
o Voice (tone)
o touch
• Open ended vs. Closed ended questions
o Open ended questions ask for narrative info
o Closed ended ask specific information to fill in detail
• Overcoming communication barriers
o Older adults
o Hearing impaired
o Under the influence
o Sexually aggressive
o Language * certified medical interpreter
• Health history categories
o Chief concern (CC)
o History of present illness (HPI)
o Past medical history (PMH) including preexisting illnesses,
medication history, and allergies.
o Family history (FH)
o Social history (SH)
o Review of systems (ROS)
• PQRSTU
about:blan 2/
k 8
PM guide
Physical health assessment study guide exam 1
• Internal and external factors of communication
o Internal- liking others, empathy, self awareness, ability to listen
o External dress, note taking, ensure privacy, refuse interruptions,
physical environment
• Introducing the interview
o Introduce self/role, and reason for interview
o “ hello mrs.smith my name is siobhan and I want to ask you
some questions about previous medical history + current
complaints before your physical exam”
• Working phase of communication
o Data gathering phase
o Verbal skills to form questions
o Open ended and closed questions
o comments about major biographical data, reasons for seeking
care, history of present health concern, past health history,
family history, review of body systems (ROS) for current health
problems, lifestyle and health practices, and developmental
level. The nurse then listens, observes cues, and uses critical
thinking skills to interpret and validate information received from
the client.
• Traps of interviewing
o False assurance
o Unwanted advice
o Using authority
o Distancing – cancer on THE left side
o Using professional jargon
o Leading/biased questions
o Avoidant language
o Talking too much
o Interrupting
o Why questions
• Closing the interview
o Graceful not abrupt awkward
o Give final opportunity for pt to self-express
o “ is there anything else you would like to mention”
• Nonverbal skills
o Physical appearance
o Posture
o Gestures
o Facial expressions
about:blan 1/
k 8
, 10/16/24, 12:10 Physical assessment exam 1 study
PM guide
o Eye contact
o Voice (tone)
o touch
• Open ended vs. Closed ended questions
o Open ended questions ask for narrative info
o Closed ended ask specific information to fill in detail
• Overcoming communication barriers
o Older adults
o Hearing impaired
o Under the influence
o Sexually aggressive
o Language * certified medical interpreter
• Health history categories
o Chief concern (CC)
o History of present illness (HPI)
o Past medical history (PMH) including preexisting illnesses,
medication history, and allergies.
o Family history (FH)
o Social history (SH)
o Review of systems (ROS)
• PQRSTU
about:blan 2/
k 8
