NSG 303 EXAM 1 STUDY GUIDE
Purpose of health assessment - Answers - - You will not only get information the
patient tells you, but you will also get the information that he/she doesn't tell you
- History obtained through the interview, combined with objective data, provides the
basis for decisions regarding the health and wellness care of a client.
Collecting subjective data - Answers - Includes what patients report to you:
- Sensations of symptoms
- Feelings
- Perceptions and desires
- Preferences
- Beliefs
- Ideas
- Values
- Personal information
4 phases of an interview - Answers - - Pre introductory Phase
- Introductory Phase
- Working Phase
- Summary and closing phase
Pre Introductory Phase - Answers - The nurse reviews the medical record which may
reveal the client's past health history and reason for seeking health care before meeting
with the client
Introductory Phase - Answers - Introduction
- Introduce self to client and client introduce themselves to you
-Explaining the purpose of the interview
-Explain what is going to happen in the interview and the examination, why you're taking
notes, why you're using a computer
-Do not want patient to to think there's a lack of interest
-Listen and look at patient
-Discussing the types of questions that will be asked
Working Phase (gathering data phase) - Answers - -Biographical data
-Reasons for seeking care
-History of present health concern
-Past health history
-Family history
-Review of body systems for current health problems
-Lifestyle and health practices and developmental level
-Listen and observe cues to interpret and validate information from the patient
Summary and Closing Phase - Answers - -Summarize information obtained during
working phase
,-Validate problems and goal with patient
-Identify and discuss possible plans to resolve the problem
-Ask patient about any other possible concerns or further questions
Open ended questions - Answers - -Ask for narrative responses
-"Tell me why you are here today"
-State topic only in general terms
Use when:
-Begin interview
-Introduce new section of questions
-Whenever the patient introduces a new topic
Closed ended questions - Answers - -Ask for specific information
-Elicit short one-or-two word answers
-Yes or no
-Forced choice
Used when:
-Fill in left out details of interview
-Need specific facts about past health problems or during review of symptoms
-Move the interview along
Complete History - Answers - When a client is having a complete, head-to-toe physical
assessment, collection of subjective data usually requires that the nurse take a
complete health history.
Focused Question - Answers - if the assessment is focused on specific areas
Effective Communication - Answers - -Begin with less threatening questions
-Use open-ended, non judgemental, unbiased questions
-Have verbal responses
Ineffective Communication - Answers - -Biased or leading questions
-"You use drugs, don't you?"
-Reading the questions
-Rushing through the interview
Past health history - Answers - - Problems at birth
- Childhood illnesses
- Immunizations to date
- Adult illness (physical, emotional, mental)
- Surgeries
- Accidents
- Prolonged pain or pain patterns
- Allergies
- Physical, emotional, social or spiritual strengths and weaknesses
- Obstetric history history (as applicable)
, - Last examination date
- Current medications
Family health history - Answers - - Age of parents (living? Date of death?)
- Health of close family members
- Parents illness and longevity
- Grandparents illnesses and longevity
- Aunts and uncles ages and illnesses and longevity
- Children's ages and illnesses or handicaps and longevity
- Family history of various conditions such as heart disease, High blood pressure,
stroke, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity,
alcoholism, mental illness, seizure disorder, kidney disease, TB
COLD SPA - Answers - 8 critical characteristics of symptoms
COLD SPA-C - Answers - C: character
How does it feel, look, smell, sound, etc
COLD SPA-O - Answers - O: onset
When did it begin, is it better or worse or the same since it began
COLD SPA-L - Answers - L: location
Where is it? Does it radiate?
COLD SPA-D - Answers - D: duration
How long does it last? Does it recur?
COLD SPA-S - Answers - S: severity
How bad is it on a scale from 1 (barely noticeable) to 10 (worst pain ever experienced)
COLD SPA-A - Answers - A: associated factors
What other symptoms do you have with it? Will you be able to continue doing your work
or other activities (leisure/exercise)?
COLD SPA-P - Answers - P: pattern
What makes it better or worse?
PQRSTU - Answers - The PQRST pain assessment method is a valuable tool
accurately describe, assess and document a patient's pain
PQRST-P - Answers - P = Provocative or palliative
PQRST-Q - Answers - Q= quality or quantity
PQRST-R - Answers - R= region or radiation
Purpose of health assessment - Answers - - You will not only get information the
patient tells you, but you will also get the information that he/she doesn't tell you
- History obtained through the interview, combined with objective data, provides the
basis for decisions regarding the health and wellness care of a client.
Collecting subjective data - Answers - Includes what patients report to you:
- Sensations of symptoms
- Feelings
- Perceptions and desires
- Preferences
- Beliefs
- Ideas
- Values
- Personal information
4 phases of an interview - Answers - - Pre introductory Phase
- Introductory Phase
- Working Phase
- Summary and closing phase
Pre Introductory Phase - Answers - The nurse reviews the medical record which may
reveal the client's past health history and reason for seeking health care before meeting
with the client
Introductory Phase - Answers - Introduction
- Introduce self to client and client introduce themselves to you
-Explaining the purpose of the interview
-Explain what is going to happen in the interview and the examination, why you're taking
notes, why you're using a computer
-Do not want patient to to think there's a lack of interest
-Listen and look at patient
-Discussing the types of questions that will be asked
Working Phase (gathering data phase) - Answers - -Biographical data
-Reasons for seeking care
-History of present health concern
-Past health history
-Family history
-Review of body systems for current health problems
-Lifestyle and health practices and developmental level
-Listen and observe cues to interpret and validate information from the patient
Summary and Closing Phase - Answers - -Summarize information obtained during
working phase
,-Validate problems and goal with patient
-Identify and discuss possible plans to resolve the problem
-Ask patient about any other possible concerns or further questions
Open ended questions - Answers - -Ask for narrative responses
-"Tell me why you are here today"
-State topic only in general terms
Use when:
-Begin interview
-Introduce new section of questions
-Whenever the patient introduces a new topic
Closed ended questions - Answers - -Ask for specific information
-Elicit short one-or-two word answers
-Yes or no
-Forced choice
Used when:
-Fill in left out details of interview
-Need specific facts about past health problems or during review of symptoms
-Move the interview along
Complete History - Answers - When a client is having a complete, head-to-toe physical
assessment, collection of subjective data usually requires that the nurse take a
complete health history.
Focused Question - Answers - if the assessment is focused on specific areas
Effective Communication - Answers - -Begin with less threatening questions
-Use open-ended, non judgemental, unbiased questions
-Have verbal responses
Ineffective Communication - Answers - -Biased or leading questions
-"You use drugs, don't you?"
-Reading the questions
-Rushing through the interview
Past health history - Answers - - Problems at birth
- Childhood illnesses
- Immunizations to date
- Adult illness (physical, emotional, mental)
- Surgeries
- Accidents
- Prolonged pain or pain patterns
- Allergies
- Physical, emotional, social or spiritual strengths and weaknesses
- Obstetric history history (as applicable)
, - Last examination date
- Current medications
Family health history - Answers - - Age of parents (living? Date of death?)
- Health of close family members
- Parents illness and longevity
- Grandparents illnesses and longevity
- Aunts and uncles ages and illnesses and longevity
- Children's ages and illnesses or handicaps and longevity
- Family history of various conditions such as heart disease, High blood pressure,
stroke, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity,
alcoholism, mental illness, seizure disorder, kidney disease, TB
COLD SPA - Answers - 8 critical characteristics of symptoms
COLD SPA-C - Answers - C: character
How does it feel, look, smell, sound, etc
COLD SPA-O - Answers - O: onset
When did it begin, is it better or worse or the same since it began
COLD SPA-L - Answers - L: location
Where is it? Does it radiate?
COLD SPA-D - Answers - D: duration
How long does it last? Does it recur?
COLD SPA-S - Answers - S: severity
How bad is it on a scale from 1 (barely noticeable) to 10 (worst pain ever experienced)
COLD SPA-A - Answers - A: associated factors
What other symptoms do you have with it? Will you be able to continue doing your work
or other activities (leisure/exercise)?
COLD SPA-P - Answers - P: pattern
What makes it better or worse?
PQRSTU - Answers - The PQRST pain assessment method is a valuable tool
accurately describe, assess and document a patient's pain
PQRST-P - Answers - P = Provocative or palliative
PQRST-Q - Answers - Q= quality or quantity
PQRST-R - Answers - R= region or radiation
