NUR 505 Advanced Health
Assessment Module 1
Foundational Principles
Study Guide
Chapter 1
• What is the difference between subjective and objective data? What is included under
each of these when obtaining a history and physical exam?
1. Subjective Data- Symptoms, what the patient is c/o or describing as
occurring.
1. Patient Identifiers
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past medical history (PMH)
5. Social history (SH)
6. Allergies
7. Medications
8. Review of Symptoms (ROS)
2. Objective Data- Physical exam findings.
1. Physical exam (PE)
2. Labs and diagnostics
3. Problem list
4. Assessment (Diagnosis)
5. Plan
o What is the ROS? What purpose does it serve? What do you document in each
body system included in the ROS?
1. ROS-inventory of specific body systems designed to document any
current or past symptoms the patient might be experiencing. This is
documented as positive or negative symptoms. If positive, may need to
explore further as part of HPI. Identify a time frame for the history of
symptoms (for the past 14 months…)
2. 14 Systems to review per CMS guidelines:
1. Constitutional
2. Eyes
3. Ears, Nose, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
, 8. Musculoskeletal
9. Integumentary
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic
14. Allergic/Immunologic
• Review specialty populations (Peds, Pregnancy, and elderly). What are some specific
differences when taking histories and performing physical exams in these populations?
o What approaches are different with a pediatric child exam?
o How do you earn the child’s trust and make them comfortable? What about
considering the developmental stages of pediatric patients?
1. Establish a rapport.
2. Use age-appropriate communication.
3. Engage in play.
4. Use visual aids.
5. Ask permission.
6. Offer choices. (Which ear should I look in first?)
7. Involve parents.
8. Use distraction.
9. Praise and encouragement.
10. Respect boundaries.
11. Maintain professionalism.
12. Follow through and maintain promises.
13. Get down on the floor and play with the child.
14. At age 7 children can be dependable historians.
15. Family dynamics will become evident in the history taking.
16. CC: the relationship of the person providing information should be
recorded.
Infants:
• The organizational structure for recording the history and physical
examination of newborns and infants is similar to adults.
• Add to history:
• Birth history
• Growth trajectory
• Developmental milestones (past and current)
• Diet
• Breast-fed or formula-fed infants.
• Solid foods
• Sleep
• Injury prevention
• Add to physical examination.
, • Head circumference, fontanels, molding
• Quality of cry
• Primitive reflexes
• Sucking
• Moro
• Current development
• Gross motor
• Fine motor
• Speech / language
• Cognitive
• Social / emotional
Children and adolescents:
• Adapt recorded history based on age and development.
• Add to history:
• Major neonatal problems until school-age
• Growth and development
• Behavior
• School performance
• ROS: eczema, seborrhea, otitis media, snoring, mouth
breathing, allergies, dental care, bedwetting.
• Add to physical examination:
• Puberty changes
• Tanner Stage
• Parent might need to step out of the room.
• Don’t force conversation.
• Ask about peer group.
• School performance
• Extracurricular activities
• Risky behaviors start at this age.
• Maintain confidentiality, but there are limits when safety is a
concern.
Assessment Module 1
Foundational Principles
Study Guide
Chapter 1
• What is the difference between subjective and objective data? What is included under
each of these when obtaining a history and physical exam?
1. Subjective Data- Symptoms, what the patient is c/o or describing as
occurring.
1. Patient Identifiers
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past medical history (PMH)
5. Social history (SH)
6. Allergies
7. Medications
8. Review of Symptoms (ROS)
2. Objective Data- Physical exam findings.
1. Physical exam (PE)
2. Labs and diagnostics
3. Problem list
4. Assessment (Diagnosis)
5. Plan
o What is the ROS? What purpose does it serve? What do you document in each
body system included in the ROS?
1. ROS-inventory of specific body systems designed to document any
current or past symptoms the patient might be experiencing. This is
documented as positive or negative symptoms. If positive, may need to
explore further as part of HPI. Identify a time frame for the history of
symptoms (for the past 14 months…)
2. 14 Systems to review per CMS guidelines:
1. Constitutional
2. Eyes
3. Ears, Nose, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
, 8. Musculoskeletal
9. Integumentary
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic
14. Allergic/Immunologic
• Review specialty populations (Peds, Pregnancy, and elderly). What are some specific
differences when taking histories and performing physical exams in these populations?
o What approaches are different with a pediatric child exam?
o How do you earn the child’s trust and make them comfortable? What about
considering the developmental stages of pediatric patients?
1. Establish a rapport.
2. Use age-appropriate communication.
3. Engage in play.
4. Use visual aids.
5. Ask permission.
6. Offer choices. (Which ear should I look in first?)
7. Involve parents.
8. Use distraction.
9. Praise and encouragement.
10. Respect boundaries.
11. Maintain professionalism.
12. Follow through and maintain promises.
13. Get down on the floor and play with the child.
14. At age 7 children can be dependable historians.
15. Family dynamics will become evident in the history taking.
16. CC: the relationship of the person providing information should be
recorded.
Infants:
• The organizational structure for recording the history and physical
examination of newborns and infants is similar to adults.
• Add to history:
• Birth history
• Growth trajectory
• Developmental milestones (past and current)
• Diet
• Breast-fed or formula-fed infants.
• Solid foods
• Sleep
• Injury prevention
• Add to physical examination.
, • Head circumference, fontanels, molding
• Quality of cry
• Primitive reflexes
• Sucking
• Moro
• Current development
• Gross motor
• Fine motor
• Speech / language
• Cognitive
• Social / emotional
Children and adolescents:
• Adapt recorded history based on age and development.
• Add to history:
• Major neonatal problems until school-age
• Growth and development
• Behavior
• School performance
• ROS: eczema, seborrhea, otitis media, snoring, mouth
breathing, allergies, dental care, bedwetting.
• Add to physical examination:
• Puberty changes
• Tanner Stage
• Parent might need to step out of the room.
• Don’t force conversation.
• Ask about peer group.
• School performance
• Extracurricular activities
• Risky behaviors start at this age.
• Maintain confidentiality, but there are limits when safety is a
concern.
