NR 509 Advanced physical assessment -Final
examination with complete solution (100%
guaranteed A
Clinical Encounters
should be both provider-centered and client-centered.
provider-centered approach
the NP guides the interaction to ensure that all data needed is acquired to
help identify a problem and determine a treatment plan.
Shared Decision Making (SDM)
has been called the pinnacle of patient-centered care.
Experts recommend a three-step process: introducing choices and
describing options using patient decision support tools when available;
exploring patient preferences; and moving to a decision, checking that the
patient is ready to make a decision and offering more time, if needed.
client-centered approach
the client's concerns, feelings, requests, and perspectives are prioritized,
which does not incorporate the provider's perspective and expertise.
two types of client assessments
comprehensive assessment
focused or problem-oriented assessment
Fostering the ________-__________ relationship is critical because
without a good relationship none of the other goals of the clinical
encounter can be pursued in an optimal manner.
Clinician; Patient
Focused Assessment
Addresses focused concerns or symptoms
Used for established clients during routine or urgent care visits
Health history and physical exams are focused on the problem
Includes:
,brief history of the present illness
only the system related to the problem in the review of systems
Comprehensive Assessment
Used for new clients
Provides personalized information about the client
Strengthens the clinician-client relationship
Provides a baseline for future assessments
Provides an opportunity for health promotion education and counseling
Includes:
extended history of the present illness
at least two areas of past medical history, family history, and social
history
at least 10 systems in the review of systems
Elements of a Standard Comprehensive Health History;
Chief Complaint
History of Present Illness
Past Medical History
Medications and Allergies
Family History
Personal and Social History
Review of Systems
Chief Complaint (CC)
the primary problem that prompted the client to schedule a visit with the
provider and is a starting point to begin information gathering.
When documenting the CC, make every attempt to:
quote the patient's own words especially if it is descriptive, unusual, or
unique.
OLD CARTS
Mnemonic for seven attributes of a patient's principal symptoms;
onset; location; duration; characteristic; alleviating and aggravating
factors; radiation or relieving factors; timing; and severity.
Pertinent positives
,symptoms that are expected with a potential diagnosis related to the chief
complaint.
Pertinent negatives
symptoms the client does not have that are expected with a potential
diagnosis related to the chief complaint.
Differential Diagnosis (DDx)
a list of possible causes to explain the patient's problem or condition. This
list will include the most likely and, at times, the most serious causes,
even if less likely.
Subjective data
includes symptoms that the client describes such as a sore throat,
headache, or pain. It also includes the client's feelings, perceptions, and
concerns. Information obtained from the client during any part of the
health history
Examples of subjective data
Lower back pain
Fatigue
Stomach cramps
Immunization history
Objective data
includes the physical examination findings or signs observed. All physical
examinations, laboratory information, and test data
Examples of Objective Data
Heart rate
Blood pressure
Lung sounds
Wound appearance
Ambulation description
Weight
subjective information; objective information
The clinical record from the Chief Complaint (CC) through the Review of
Systems is considered ___________ ________, whereas all physical
, examination, laboratory information and test data are ___________
____________.
Clinical Encounter Sequence
Initiate Encounter
Gather Information
Perform Physical Exam
Explain and Plan
Close the Encounter
Initiate the Encounter
Set the stage for the interview
Review the clinical record
Ensure the client is comfortable
Clarify the goals/agenda for the encounter; balance provider and client
goals
Establish rapport
Identify the client's preferred title, name, and gender pronouns
Use "people first" language (i.e., a person with hearing loss, a person who
uses a wheelchair)
Setting the Stage
Prepare for the interview.
Check your appearance.
Make sure the patient is comfortable and the environment is conducive to
the very personal information soon to be shared.
Reflect on any biases you have that color your reactions to the patient and
the therapeutic alliance you need to create.
Gather Information
Identify the client's chief complaint or reason for seeking care
Invite the client's story using an open-ended approach
Gather information about the client's perspective of the illness using the
mnemonic FIFE
Conduct the health history interview
Gather information about past medical history, medications and allergies,
family history, personal and social history, and review of systems
examination with complete solution (100%
guaranteed A
Clinical Encounters
should be both provider-centered and client-centered.
provider-centered approach
the NP guides the interaction to ensure that all data needed is acquired to
help identify a problem and determine a treatment plan.
Shared Decision Making (SDM)
has been called the pinnacle of patient-centered care.
Experts recommend a three-step process: introducing choices and
describing options using patient decision support tools when available;
exploring patient preferences; and moving to a decision, checking that the
patient is ready to make a decision and offering more time, if needed.
client-centered approach
the client's concerns, feelings, requests, and perspectives are prioritized,
which does not incorporate the provider's perspective and expertise.
two types of client assessments
comprehensive assessment
focused or problem-oriented assessment
Fostering the ________-__________ relationship is critical because
without a good relationship none of the other goals of the clinical
encounter can be pursued in an optimal manner.
Clinician; Patient
Focused Assessment
Addresses focused concerns or symptoms
Used for established clients during routine or urgent care visits
Health history and physical exams are focused on the problem
Includes:
,brief history of the present illness
only the system related to the problem in the review of systems
Comprehensive Assessment
Used for new clients
Provides personalized information about the client
Strengthens the clinician-client relationship
Provides a baseline for future assessments
Provides an opportunity for health promotion education and counseling
Includes:
extended history of the present illness
at least two areas of past medical history, family history, and social
history
at least 10 systems in the review of systems
Elements of a Standard Comprehensive Health History;
Chief Complaint
History of Present Illness
Past Medical History
Medications and Allergies
Family History
Personal and Social History
Review of Systems
Chief Complaint (CC)
the primary problem that prompted the client to schedule a visit with the
provider and is a starting point to begin information gathering.
When documenting the CC, make every attempt to:
quote the patient's own words especially if it is descriptive, unusual, or
unique.
OLD CARTS
Mnemonic for seven attributes of a patient's principal symptoms;
onset; location; duration; characteristic; alleviating and aggravating
factors; radiation or relieving factors; timing; and severity.
Pertinent positives
,symptoms that are expected with a potential diagnosis related to the chief
complaint.
Pertinent negatives
symptoms the client does not have that are expected with a potential
diagnosis related to the chief complaint.
Differential Diagnosis (DDx)
a list of possible causes to explain the patient's problem or condition. This
list will include the most likely and, at times, the most serious causes,
even if less likely.
Subjective data
includes symptoms that the client describes such as a sore throat,
headache, or pain. It also includes the client's feelings, perceptions, and
concerns. Information obtained from the client during any part of the
health history
Examples of subjective data
Lower back pain
Fatigue
Stomach cramps
Immunization history
Objective data
includes the physical examination findings or signs observed. All physical
examinations, laboratory information, and test data
Examples of Objective Data
Heart rate
Blood pressure
Lung sounds
Wound appearance
Ambulation description
Weight
subjective information; objective information
The clinical record from the Chief Complaint (CC) through the Review of
Systems is considered ___________ ________, whereas all physical
, examination, laboratory information and test data are ___________
____________.
Clinical Encounter Sequence
Initiate Encounter
Gather Information
Perform Physical Exam
Explain and Plan
Close the Encounter
Initiate the Encounter
Set the stage for the interview
Review the clinical record
Ensure the client is comfortable
Clarify the goals/agenda for the encounter; balance provider and client
goals
Establish rapport
Identify the client's preferred title, name, and gender pronouns
Use "people first" language (i.e., a person with hearing loss, a person who
uses a wheelchair)
Setting the Stage
Prepare for the interview.
Check your appearance.
Make sure the patient is comfortable and the environment is conducive to
the very personal information soon to be shared.
Reflect on any biases you have that color your reactions to the patient and
the therapeutic alliance you need to create.
Gather Information
Identify the client's chief complaint or reason for seeking care
Invite the client's story using an open-ended approach
Gather information about the client's perspective of the illness using the
mnemonic FIFE
Conduct the health history interview
Gather information about past medical history, medications and allergies,
family history, personal and social history, and review of systems
