Nur 212 Chapters 1-4 Summary

Chapter 1 (Foundations for Clinical Proficiency)

1. Patient Assessment: Comprehensive or Focused
a. For patients being seen for the first time, a comprehensive assessment is conducted.
i. Includes all the elements of the health history and the complete physical exam.
ii. Provides a complete picture of the overall patient and address concerns and questions
the patient may have.
iii. Comprehensive examinations are sources of personalized knowledge about the patient
and strengthens the clinical-patient relationship.
b. For patients who are more well-known to the clinical and are returning to the office for care
(or with specific “urgent care” concerns), a more flexible focused or problem-oriented
assessment is appropriate.
i. Clinician uses select methods relevant the assessment of the targeted problem
ii. Clinician uses the patient’s symptoms, age, and health history to determine the scope
of the examination
iii. The scope of history and physical examination are adjusted based on:
1. The magnitude and severity of the patient’s problem
2. Need for thoroughness
3. Clinical setting
4. Time available




2. Subjective vs. Objective Data
a. Subjective data: includes symptoms
i. What the patient tells you
1. From Chief Complaint to ROS
b. Objective data: includes signs
i. What you observe
1. What you detect during examination, laboratory and diagnostic testing
2. All physical examination findings

, 3. The Comprehensive Adult Health History

Health
History What is Included Notes and Examples
Component
 Includes age, gender, Knowing the source of referral helps assess the
occupation, marital status. quality of the information and any questions that
Identifying  Source of the history (e.g., need to be addressed in the assessment and
Data patient, family member, friend, written response.
letter of referral, or clinical
record).
 Document quality of information Examples:
 Determination made at the end  “The patient is vague when describing
Reliability
of assessment. symptoms, and the details are confusing.”
 “The patient is a reliable historian.”
 One or more symptoms or Make every attempt to quote the patient’s own
concerns causing the patient to words. Examples:
Chief
seek care.  “My stomach hurts and I feel awful.”
Complaint(s
 “I have come for my regular check-up.”
)
 “I’ve been admitted for a thorough
evaluation of my heart.”
Present  Complete, clear, and Each principal symptom should be well
Illness chronological description of the characterized and should include:
CC(s) 1. Location
 Expands on CC: Describes how 2. Quality
each symptom developed. 3. Quantity or severity
 Includes patient’s thoughts and 4. Timing (including onset, duration, and
feelings about the illness. frequency)
 Pulls in relevant portions of the 5. The setting in which it occurs
ROS (called “pertinent positives 6. Factors that aggravate or relieve the
and negatives”). symptom
 May include medications, 7. Associated manifestations
allergies, and tobacco/alcohol
use which are pertinent to
present illness.
 Other information such as risk
2

, factors and medications/home
remedies/OTC medications
should be included.
 Lists childhood illnesses. Immunizations to assess:
 Lists adult illnesses with dates  Tetanus
for events in medical, surgical,  Pertussis
OB/GYN, psychiatric.  Diphtheria
 Includes health maintenance,  Polio
such as immunizations,  Measles
screening tests, lifestyle issues,  Rubella
and home safety.  Mumps
 Influenza
 Varicella
 Hepatitis B virus
Past History  Human papilloma virus
 Meningococcal disease
 Haemophilus influenzae type B
 Pneumococci
 Herpes zoster
For screening tests, assess:
 Tuberculin tests
 Pap smears
 Mammograms
 Stool tests for occult blood
 Colonoscopy
 Cholesterol
 Outlines age and health, or age Review each condition and note whether they are
and cause of death, of siblings, present in the family: HTN, CAD, elevated
parents, and grandparents. cholesterol levels, stroke, diabetes, thyroid or
Family  Documents presence or absence renal disease, arthritis, tuberculosis, asthma or
History of specific illnesses in family, lung disease, headache, seizure disorder, mental
such as HTN, diabetes, or type illness, suicide substance abuse, allergies, history
of cancer. of breast/ovarian/colon/prostate cancer, and any
genetically transmitted diseases.
Personal and  Patient’s personality and This should include occupation, last year of
Social interests, sources of support, schooling, home situation, significant others,
History coping styles, strengths and sources of stress, important life experiences,
concerns. leisure activities, religious/spiritual beliefs,
 Describes educational level, ADLs, baseline level of function, lifestyle, sexual
orientation and practices, and alternative health
care practices.

“Yes-no” questions at the end of the interview
going from “head to toe”