NUR 3065 - Health Assess Exam 1 Study Guide (Review quizzes 1-5). Complete Solutions Guide.

NUR 3065 - Health Assess Exam 1 Study Guide (Review quizzes 1-5). Complete Solutions Guide. Subjective: What the patient tells you Includes history from chief complaint through review of symptoms ** very common error: try to avoid putting objective data into ROS area Objective: What you detect during the examination All physical examination findings ● 7 attributes of the chief complaint EXTREMELY IMPORTANT !!!!!!! OLD CART Onset: When did it start? When did it FIRST start? Duration: How long does it last? Does it come and go? Location: Where is it? Does it radiate? Characteristics: How does the pain feel? Stabbing, sharp, dull, pain scale 0-10 Associated manifestations: Have you noticed anything else that accompanies it? Relieving or exacerbating factors: is there anything that makes it better/ worse Treatment: Have you seen anyone for this problem before? How have you been treating it? ● Know all the parts of the comprehensive health history and be able to determine the information which is in each part (CC, HPI, PMH, FH, SH, ROS) Identifying data and source of the history: date and time of interview; identifying data- age, gender, occupation, marital status; source of history- usually from the pt, can be a family or friend, parent/guardian; source of referral (write thank you note if another provider sent them to you); comment on reliability of source: varies with pts memory, trust, and mood Chief Complaint(s) The one or more symptoms or concerns causing the pt to seek care, may also be a goal Quote the patient’s own words (HPI) Present Illness Amplifies and expands the chief complaint; describes how each symptom developed; chronological account. Each symptom should be addressed in sequence of occurence 7 attributes of symptom should be recorded *should be in chronological order, starting with current episode, then relevant background information Make sure you get the patient’s perspective: feelings, fears, concerns of problem; ask about ideas of the nature or cause of the problem; effect of the problem on patients life and function; expectations of the disease, clinician, of healthcare (often based on prior personal or family experiences) Include medications (name, dose, route, frequency) including OTCs, vitamins, minerals, supplements, oral contraceptives; allergies (to meds, food, insects, environmental factors and what happens when in contact with allergen); smoking habits and hx, and alcohol/drug use Past History Childhood illnesses (measles, mumps, rubella, pertussis, chicken pox, etc) List adult illnesses with dates Medical (diabetes, HTN, HIV, hospitalizations, # of sexual partners, risky sexual practices) Surgical (dates, indications, types of operations) Obstetric/Gynecological (OB hx, menstrual hx, contraceptive methods, sexual function) Psychiatric (illness, timeframe, diagnoses, hospitalizations, treatments) Health maintenance practices such as immunizations, screening tests (PPD, Pap, mammograms, occult blood, cholesterol, and dates of all)