NUR-643 HEALTH ASSESSMENT EXAM STUDY GUIDE NEWEST
The steps involved in conducting a health history interview include greeting the
patient, building rapport, and setting the agenda.
● Inviting the Patient's Story ● Examining the Patient's Viewpoint ●
Recognizing and Addressing the Patient's Emotional Signals ● Extending and
Explaining the Patient's Story - OPQRST
Developing and Testing Diagnostic Hypotheses ●Sharing the Treatment Plan
●Ending the Visit and Interview ●Taking Time for Self-Reflection
Subjective Information ● What the patient says you ● The history and
symptoms, starting with the chief complaint and ending with the review of
systems
As an illustration, Mrs. G., a 54-year-old hairdresser, describes pressure "like an
elephant sitting there" over her left chest that travels down her left arm and
neck.
Objective Data ● All physical examination findings or indicators ● What you
observe during the examination, laboratory data, and test data
For instance, Mrs. G. is a lovely and cooperative white woman who is
overweight and elderly. Five feet four inches, 150 pounds, BMI 26, blood
pressure of 160/80, heart rate of 96 and normal, respiration rate 24, and
temperature of 97.5 °
The Adult Health History's components include: ●Identifying information and
the history's source; dependability ●Chief complaint or complaints ● Current
illness ●Past history ●Family history ●Personal and societal history ●Systems
review
, The Patient Who Is Silent
When the patient is ready, encourage them to proceed while remaining mindful
and courteous.
Keep a watchful eye out for nonverbal clues from the patient, such as trouble
managing their emotions.
Being at ease with quiet times could be helpful, encouraging the patient to
express more intense emotions.
The Perplexed Patient
As you determine a differential diagnosis based on the symptoms of the current
illness, consider a number of potential explanations for the story's ambiguity. It
might be the patient's manner, and you can create a cohesive narrative by
applying your abilities to clarify, summarize, and ask guiding questions.
However, keep an eye out for any underlying problems that are impeding
communication.
Think of dementia in the elderly and delirium in critically ill or inebriated
patients. Dates are difficult to follow, and their histories are contradictory. Some
people could even make up stories to fill in the blanks in their recollections.
It can be exhausting and frustrating for both you and the patient to collect a
thorough history if you suspect a psychiatric or neurological issue. Proceed to
the mental status examination, emphasizing the patient's level of awareness,
orientation, memory, and comprehension ability. Asking "When was your last
appointment at the clinic? " can help ease this adjustment. Well, let's see. How
long ago was that? "Your address now is . . . ? . . . and your phone number?"
You can confirm these answers on the chart or request permission to talk to
friends or family to get their opinions.
The Individual with Modified Cognitive Function
You will have to get historical knowledge from other sources, such family
members or caregivers, in these situations. Always look for the most
knowledgeable source. Use the fundamentals of interviewing when speaking
with friends or family. Look for a quiet location to speak. Make an introduction,
explain your goal, ask them how they are feeling about the situation, and
acknowledge and acknowledge their worries. Consider the nature of their bond
with the patient when you listen to their stories and evaluate their credibility.
Describe how they are acquainted with the patient. For instance, the
accompanying adult may be the most available driver rather than the parent or
caretaker when a child is taken in for medical attention. When collecting
medical history, keep in mind that you should not provide personal information
about the patient unless the informant is the patient's health care proxy, has a
durable power of attorney for medical matters, or has the patient's consent.
The steps involved in conducting a health history interview include greeting the
patient, building rapport, and setting the agenda.
● Inviting the Patient's Story ● Examining the Patient's Viewpoint ●
Recognizing and Addressing the Patient's Emotional Signals ● Extending and
Explaining the Patient's Story - OPQRST
Developing and Testing Diagnostic Hypotheses ●Sharing the Treatment Plan
●Ending the Visit and Interview ●Taking Time for Self-Reflection
Subjective Information ● What the patient says you ● The history and
symptoms, starting with the chief complaint and ending with the review of
systems
As an illustration, Mrs. G., a 54-year-old hairdresser, describes pressure "like an
elephant sitting there" over her left chest that travels down her left arm and
neck.
Objective Data ● All physical examination findings or indicators ● What you
observe during the examination, laboratory data, and test data
For instance, Mrs. G. is a lovely and cooperative white woman who is
overweight and elderly. Five feet four inches, 150 pounds, BMI 26, blood
pressure of 160/80, heart rate of 96 and normal, respiration rate 24, and
temperature of 97.5 °
The Adult Health History's components include: ●Identifying information and
the history's source; dependability ●Chief complaint or complaints ● Current
illness ●Past history ●Family history ●Personal and societal history ●Systems
review
, The Patient Who Is Silent
When the patient is ready, encourage them to proceed while remaining mindful
and courteous.
Keep a watchful eye out for nonverbal clues from the patient, such as trouble
managing their emotions.
Being at ease with quiet times could be helpful, encouraging the patient to
express more intense emotions.
The Perplexed Patient
As you determine a differential diagnosis based on the symptoms of the current
illness, consider a number of potential explanations for the story's ambiguity. It
might be the patient's manner, and you can create a cohesive narrative by
applying your abilities to clarify, summarize, and ask guiding questions.
However, keep an eye out for any underlying problems that are impeding
communication.
Think of dementia in the elderly and delirium in critically ill or inebriated
patients. Dates are difficult to follow, and their histories are contradictory. Some
people could even make up stories to fill in the blanks in their recollections.
It can be exhausting and frustrating for both you and the patient to collect a
thorough history if you suspect a psychiatric or neurological issue. Proceed to
the mental status examination, emphasizing the patient's level of awareness,
orientation, memory, and comprehension ability. Asking "When was your last
appointment at the clinic? " can help ease this adjustment. Well, let's see. How
long ago was that? "Your address now is . . . ? . . . and your phone number?"
You can confirm these answers on the chart or request permission to talk to
friends or family to get their opinions.
The Individual with Modified Cognitive Function
You will have to get historical knowledge from other sources, such family
members or caregivers, in these situations. Always look for the most
knowledgeable source. Use the fundamentals of interviewing when speaking
with friends or family. Look for a quiet location to speak. Make an introduction,
explain your goal, ask them how they are feeling about the situation, and
acknowledge and acknowledge their worries. Consider the nature of their bond
with the patient when you listen to their stories and evaluate their credibility.
Describe how they are acquainted with the patient. For instance, the
accompanying adult may be the most available driver rather than the parent or
caretaker when a child is taken in for medical attention. When collecting
medical history, keep in mind that you should not provide personal information
about the patient unless the informant is the patient's health care proxy, has a
durable power of attorney for medical matters, or has the patient's consent.
