Exam 1
NURS 631 - Advanced Health Assessment
HEALTH HX & GENERAL SURVEY
History Taking
- Provides sufficient info in about 75% of pts & is useful for making a dx before performing a physical
exam & additional tests
- MOST IMPORTANT step in clinical practice
Disparities in Healthcare
- Social Determinants of Health
- Neighborhood & Built Environment - access to healthy foods, crime, violence, env. Conditions,
quality of housing
- Health & Healthcare - access to healthcare, access to primary care, health literacy
- Social & Community Context - civic participation, discrimination, incarceration, social cohesion
- Education - early childhood edu & dev, enrollment in higher edu, HS grad, language & lit
- Economic Stability - employment, food insecurity, housing instability, poverty
- Medical Ethics (pg.25)
- Nonmaleficence - do no harm
- Beneficence - do good
- Respect for autonomy - accept patients choices
- Capacity - ability of pt to make own choices
- Confidentiality - duty to prevent disclosure of pts info
- Informed consent - must get permission from pt to test or tx for illness
- Truth (veracity) - telling the truth
- Justice - treated equally
Approach to the Clinical Encounter
- Clinician-Centered Approach: clinician takes charge of the interaction to meet their own need to acquire
the symptoms, details, and other data that may help them identify a disease
- Provider is leading the conversation
- Patient-Centered Approach: recognizes the importance of pt expressions of personal concerns,
feelings, and emotions, and evokes the personal context of the patient's symptoms and disease
- Patient is leading the conversation
- May have more time for eval
- The clinical interview needs to incorporate BOTH the clinician's and the patient's use of reality,
disease, and illness
Initiating the Encounter
- Set the stage
- Adjust the env. (adjust lighting etc.)
- Review clinical records (PMH etc.) → important step!
- Set the agenda (determine what to talk ab)
- Greet patient & establish rapport (introduce yourself)
- Identify pt by name/gender pronoun (if mistaken for wrong pronoun = apologize & ask what they would
like to be called)
Gathering Information
- Initiate information gathering
- Establish an agenda for encounter - “today we are going to be talking about your…”
- Invite the patient's story - “tell me about what's bringing you in today”
- Gather information about patient’s illness - obtain HPI
- Respond to patients emotional cues
, - Gather background hx - PMH, PSH, sexual hx, social hx, meds, allergies etc.
Communication
- Communication is the FIRST STEP in providing comprehensive care for the patient
- Always address the patient first THEN the other people in the room
Approach to the Patient
- First moments of encounter w/ patient can set the type of relationship & rapport you establish w/ the
patient
- Be courteous & professional
- Attentive listening - eye contact
- Greet pt by name - use formal title (unless child) “Miss. Jones”
- Shake the patient's hand - some cultures do not like this
- Greet all the visitors in the room
Talking to the Patient
- Do NOT use medical terminology (unless necessary i.e., diagnosis, test names, procedures) - most
adults have a 6th-8th grade reading level
- Look at patient when speaking to them
- Observe non-verbal cues
Asking Questions
- Direct Questions: used to ask specific information “yes/no”
- Open-ended Questions: allows patient to explain or express what they think
- Do not ask questions that seek too much info
- Be non-judgmental
- Important to convey that you respect the patient and family and what they are telling you!
- Empathetic responses - you must first recognize the patients' feelings, then actively move toward and
elicit emotional content
- Summarization - repeat what they are saying to validate them
- Transitioning
- Validation
- Empower the patient - more likely to take your advice & make lifestyle changes
- Reassurance
- Use understandable language
- Recognize non-verbal cues
- Medical interpreters
- Make your questions clear, short, and straightforward
- Speak directly to the patient
- No family members of children!
- Telephone interpreters - do not use in these situations:
- Serious diagnosis or bad news
- Pt is HOH
- Family meetings or group discussions
- Interaction requires visual elements
- Complicated or personal medical procedures or news
Disclosing Serious News
- SPIKES Protocol
- 1) set up interview - “let me take a minute ti make sure ive got what i need”
- 2) assess patients perception - “what is your understanding of the reasons we did the MRI?”
- 3) obtain the patients invitation - “if it turns out to be something serious, are you the kind of
person who likes to know exactly whats going on?”
- 4) giving knowledge & info to the pt - “unfortunately I have some bad news to tell you”
, - 5) addressing the pts emotions w/ empathetic responses - “I was also hoping for a better result”
- 6) strategy & summary - “is there anything I can do to make this a little easier?” “I want you to be
prepared for the next step. Can I explain…”
- Never let a family member know that someone has passed away on the phone - tell them there has
“been a change in status”
Health History (pg.79)
- The scope & detail of the hx depend on the pts needs and concerns, your goal for the encounter, and
clinical setting
- Focused Patient Assessment: for already established patients esp. during routine or urgent care visits
- Addresses focused concerns or symptoms
- Assesses symptoms restricted to a specific body system
- Applies exam methods relevant to assessing the concern / problem thoroughly and carefully as
possible
- Shorter apt
- Comprehensive Patient Assessment: for new patients in office or hospital
- Provides fundamental & personalized knowledge about the patient
- Includes more than 1 body system
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes r/t patient concerns
- Provides a baseline for future assessments
- Creates a platform for health promotion through education and counseling
- Develops proficiency in the essential skills of physical examination
- Longer apt
Subjective vs Objective Data***
- Subjective: symptoms that are health concerns that the patient tells you
- Objective: physical exam findings or signs you detect during the physical exam
- lab/diagnostic tests
Comprehensive Health History
- Parts of the comprehensive health history
- Identifying Data
- Includes: date, time, full name, age, DOB, sex, race, address, phone numbers, marital
status, referral source
- Occupation
- Source & reliability of information → If they have AMS = need to confirm w/ family
- Chief Complaint (CC)
- The primary symptom or concern causing the patient to see care (may be 1 or 2
concerns)
- Important to put in the patient's own words - use quotation marks
- Includes complaint + duration - “chest pain x4 days”
- Important to be specific
- History of Present Illness (HPI)
- This amplifies the chief complaint - describes the chronology of events as to how each
symptom developed. Includes pts thoughts and feelings about the illness and it
- Pertinent positives & pertinent negatives (pg.86) - helps you turn a symptom into a likely
or not likely diagnosis
- Explains when it started & the course of the concern up to this point
- Need to characterize the concern (symptom)
- Does NOT include any physical exam findings - ONLY subjective information
- Acronym = OLD CARTS or OPQRST
NURS 631 - Advanced Health Assessment
HEALTH HX & GENERAL SURVEY
History Taking
- Provides sufficient info in about 75% of pts & is useful for making a dx before performing a physical
exam & additional tests
- MOST IMPORTANT step in clinical practice
Disparities in Healthcare
- Social Determinants of Health
- Neighborhood & Built Environment - access to healthy foods, crime, violence, env. Conditions,
quality of housing
- Health & Healthcare - access to healthcare, access to primary care, health literacy
- Social & Community Context - civic participation, discrimination, incarceration, social cohesion
- Education - early childhood edu & dev, enrollment in higher edu, HS grad, language & lit
- Economic Stability - employment, food insecurity, housing instability, poverty
- Medical Ethics (pg.25)
- Nonmaleficence - do no harm
- Beneficence - do good
- Respect for autonomy - accept patients choices
- Capacity - ability of pt to make own choices
- Confidentiality - duty to prevent disclosure of pts info
- Informed consent - must get permission from pt to test or tx for illness
- Truth (veracity) - telling the truth
- Justice - treated equally
Approach to the Clinical Encounter
- Clinician-Centered Approach: clinician takes charge of the interaction to meet their own need to acquire
the symptoms, details, and other data that may help them identify a disease
- Provider is leading the conversation
- Patient-Centered Approach: recognizes the importance of pt expressions of personal concerns,
feelings, and emotions, and evokes the personal context of the patient's symptoms and disease
- Patient is leading the conversation
- May have more time for eval
- The clinical interview needs to incorporate BOTH the clinician's and the patient's use of reality,
disease, and illness
Initiating the Encounter
- Set the stage
- Adjust the env. (adjust lighting etc.)
- Review clinical records (PMH etc.) → important step!
- Set the agenda (determine what to talk ab)
- Greet patient & establish rapport (introduce yourself)
- Identify pt by name/gender pronoun (if mistaken for wrong pronoun = apologize & ask what they would
like to be called)
Gathering Information
- Initiate information gathering
- Establish an agenda for encounter - “today we are going to be talking about your…”
- Invite the patient's story - “tell me about what's bringing you in today”
- Gather information about patient’s illness - obtain HPI
- Respond to patients emotional cues
, - Gather background hx - PMH, PSH, sexual hx, social hx, meds, allergies etc.
Communication
- Communication is the FIRST STEP in providing comprehensive care for the patient
- Always address the patient first THEN the other people in the room
Approach to the Patient
- First moments of encounter w/ patient can set the type of relationship & rapport you establish w/ the
patient
- Be courteous & professional
- Attentive listening - eye contact
- Greet pt by name - use formal title (unless child) “Miss. Jones”
- Shake the patient's hand - some cultures do not like this
- Greet all the visitors in the room
Talking to the Patient
- Do NOT use medical terminology (unless necessary i.e., diagnosis, test names, procedures) - most
adults have a 6th-8th grade reading level
- Look at patient when speaking to them
- Observe non-verbal cues
Asking Questions
- Direct Questions: used to ask specific information “yes/no”
- Open-ended Questions: allows patient to explain or express what they think
- Do not ask questions that seek too much info
- Be non-judgmental
- Important to convey that you respect the patient and family and what they are telling you!
- Empathetic responses - you must first recognize the patients' feelings, then actively move toward and
elicit emotional content
- Summarization - repeat what they are saying to validate them
- Transitioning
- Validation
- Empower the patient - more likely to take your advice & make lifestyle changes
- Reassurance
- Use understandable language
- Recognize non-verbal cues
- Medical interpreters
- Make your questions clear, short, and straightforward
- Speak directly to the patient
- No family members of children!
- Telephone interpreters - do not use in these situations:
- Serious diagnosis or bad news
- Pt is HOH
- Family meetings or group discussions
- Interaction requires visual elements
- Complicated or personal medical procedures or news
Disclosing Serious News
- SPIKES Protocol
- 1) set up interview - “let me take a minute ti make sure ive got what i need”
- 2) assess patients perception - “what is your understanding of the reasons we did the MRI?”
- 3) obtain the patients invitation - “if it turns out to be something serious, are you the kind of
person who likes to know exactly whats going on?”
- 4) giving knowledge & info to the pt - “unfortunately I have some bad news to tell you”
, - 5) addressing the pts emotions w/ empathetic responses - “I was also hoping for a better result”
- 6) strategy & summary - “is there anything I can do to make this a little easier?” “I want you to be
prepared for the next step. Can I explain…”
- Never let a family member know that someone has passed away on the phone - tell them there has
“been a change in status”
Health History (pg.79)
- The scope & detail of the hx depend on the pts needs and concerns, your goal for the encounter, and
clinical setting
- Focused Patient Assessment: for already established patients esp. during routine or urgent care visits
- Addresses focused concerns or symptoms
- Assesses symptoms restricted to a specific body system
- Applies exam methods relevant to assessing the concern / problem thoroughly and carefully as
possible
- Shorter apt
- Comprehensive Patient Assessment: for new patients in office or hospital
- Provides fundamental & personalized knowledge about the patient
- Includes more than 1 body system
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes r/t patient concerns
- Provides a baseline for future assessments
- Creates a platform for health promotion through education and counseling
- Develops proficiency in the essential skills of physical examination
- Longer apt
Subjective vs Objective Data***
- Subjective: symptoms that are health concerns that the patient tells you
- Objective: physical exam findings or signs you detect during the physical exam
- lab/diagnostic tests
Comprehensive Health History
- Parts of the comprehensive health history
- Identifying Data
- Includes: date, time, full name, age, DOB, sex, race, address, phone numbers, marital
status, referral source
- Occupation
- Source & reliability of information → If they have AMS = need to confirm w/ family
- Chief Complaint (CC)
- The primary symptom or concern causing the patient to see care (may be 1 or 2
concerns)
- Important to put in the patient's own words - use quotation marks
- Includes complaint + duration - “chest pain x4 days”
- Important to be specific
- History of Present Illness (HPI)
- This amplifies the chief complaint - describes the chronology of events as to how each
symptom developed. Includes pts thoughts and feelings about the illness and it
- Pertinent positives & pertinent negatives (pg.86) - helps you turn a symptom into a likely
or not likely diagnosis
- Explains when it started & the course of the concern up to this point
- Need to characterize the concern (symptom)
- Does NOT include any physical exam findings - ONLY subjective information
- Acronym = OLD CARTS or OPQRST
