643E Midterm Exam Study Guide v n v n v n v n
1. Comprehensive Adult Assessment Sequence: *Chief Complaint vn vn vn vn vn
*Hx of present illness
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*Past medical Hx
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*Past surgical Hx
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*Family Hx vn
*Social Hx vn
*Allergies
*Medications
*Review of Symptoms of System
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*Physical Exam vn
*Assessment Steps vn
*Tx Plan
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2. Objective Data: what the health professional observes by inspecting, palpating, percussing, and auscultatin
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g during the physical examination
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3. Subjective Data: what the person says about himself or herself during history taking
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4. Normal Findings: findings that are within range
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5. Abnormal Findings: findings that are outside of normal limits
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6. Validity: The ability of a test to measure what it is intended to measure
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7. Sensitivity: indicates how likely it is to detect a condition when it is actually present in a patient. A test with low
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can be thought of as being too cautious in finding a positive result, meaning it will err on the sid
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e of failing to identify a disease in a sick person.
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8. Specificity: the percentage of true negatives out of all subjects who do not have a disease or condition. In other
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words, it is the ability of the test or instrument to obtain normal range or negative results for a person who does not
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have a disease. vn vn
9. History Taking: A step within the patient assessment process that provides detail about the patient's chief
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complaint and an account of the patient's signs and symptoms.
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*Ask open-ended questions and listen carefully to the patient's story.
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*Craft a thorough and systematic sequence to history taking and physical examination.
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*Keep an open mind toward both the patient and the clinical data.
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*Always include "the worst-
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case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely elimina
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, NUR-
643E Midterm Exam Study Guide
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ted.
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