NURS550: Advanced Health Assessment and Diagnostic Reasoning We
#1 Guided Reading
1. Chapter 1 (p 4-34) FOUNDATIONS FOR CLINICAL
PROFICIENCY
2. 1. Describe the differences between Includes all the elements of the
a. A comprehensive health histo- health history and the complete
ry/exam physical examination.
- Provides fundamental and person-
alized knowledge about the patient
- Strengthens the clinician-patient
relationship
- Helps identify or rule out physical
causes related to patient concerns
Provides a baseline for future as-
sessments
-Creates a platform for health pro-
motion through education and coun-
seling
- Develops proficiency in the essen-
tial skills of physical examination
3. b. A focused health history/exam Assesses symptoms restricted to
a specific body system (eg. sore
throat or knee pain)
Applies examination methods rele-
vant to assessing the concern or
problem as thoroughly and carefully
as possible
The patient's symptoms, age, and
health history help determine the
scope of the focused examination,
as does your knowledge of disease
pattern
4. 2. Identify examples of when you Is appropriate for new patients in the
would obtain (2 examples for each): office or hospital
a. A comprehensive health histo-
ry/exam
5. b. A focused health history/exam
, NURS550: Advanced Health Assessment and Diagnostic Reasoning We
#1 Guided Reading
Is appropriate for established pa-
tients, especially during routine or
urgent care visits
Addresses focused concerns or
symptoms
( eg. sore throat or knee pain)
6. 3. Discuss the differences between Subjective data: is what the patient
subjective and objective data tells you
Objective data: what you detect dur-
ing the examination, laboratory in-
formation and test data
7. a. Provide examples of what would The symptoms and history, from
constitute Subjective data Chief Complaint through Review of
Systems
Example: Mrs. G. is a 54-year-old
hairdresser who reports pressure
over her left chest "like an elephant
sitting there," which goes into her
left neck and arm.
8. b. Provide examples of what would All physical examination findings, or
constitute Objective data signs
Example: Mrs. G. is an older, over-
weight white female, who is pleas-
ant and cooperative. Height 52422,
weight 150 lbs, BMI 26, BP 160/80,
HR 96 and regular, respiratory rate
24, temperature 97.5 °F
9. 4. Identify what goes into each section Identifying data—such as age, gen-
of the comprehensive health history der, occupation, marital status
a. Identifying data and source of his- Source of the history—usually the
tory patient, but can be a family member
or friend, letter of referral, or the clin-
ical record
If appropriate, establish the source
#1 Guided Reading
1. Chapter 1 (p 4-34) FOUNDATIONS FOR CLINICAL
PROFICIENCY
2. 1. Describe the differences between Includes all the elements of the
a. A comprehensive health histo- health history and the complete
ry/exam physical examination.
- Provides fundamental and person-
alized knowledge about the patient
- Strengthens the clinician-patient
relationship
- Helps identify or rule out physical
causes related to patient concerns
Provides a baseline for future as-
sessments
-Creates a platform for health pro-
motion through education and coun-
seling
- Develops proficiency in the essen-
tial skills of physical examination
3. b. A focused health history/exam Assesses symptoms restricted to
a specific body system (eg. sore
throat or knee pain)
Applies examination methods rele-
vant to assessing the concern or
problem as thoroughly and carefully
as possible
The patient's symptoms, age, and
health history help determine the
scope of the focused examination,
as does your knowledge of disease
pattern
4. 2. Identify examples of when you Is appropriate for new patients in the
would obtain (2 examples for each): office or hospital
a. A comprehensive health histo-
ry/exam
5. b. A focused health history/exam
, NURS550: Advanced Health Assessment and Diagnostic Reasoning We
#1 Guided Reading
Is appropriate for established pa-
tients, especially during routine or
urgent care visits
Addresses focused concerns or
symptoms
( eg. sore throat or knee pain)
6. 3. Discuss the differences between Subjective data: is what the patient
subjective and objective data tells you
Objective data: what you detect dur-
ing the examination, laboratory in-
formation and test data
7. a. Provide examples of what would The symptoms and history, from
constitute Subjective data Chief Complaint through Review of
Systems
Example: Mrs. G. is a 54-year-old
hairdresser who reports pressure
over her left chest "like an elephant
sitting there," which goes into her
left neck and arm.
8. b. Provide examples of what would All physical examination findings, or
constitute Objective data signs
Example: Mrs. G. is an older, over-
weight white female, who is pleas-
ant and cooperative. Height 52422,
weight 150 lbs, BMI 26, BP 160/80,
HR 96 and regular, respiratory rate
24, temperature 97.5 °F
9. 4. Identify what goes into each section Identifying data—such as age, gen-
of the comprehensive health history der, occupation, marital status
a. Identifying data and source of his- Source of the history—usually the
tory patient, but can be a family member
or friend, letter of referral, or the clin-
ical record
If appropriate, establish the source
