lOMoAR cPSD| 47061011
Exam 1 NRSG 3323:
Exam 1 covers modules 1-5, there are 50 questions and you will have 1 hour.
YES there is math!
Module 1:
• Discuss goals of obtaining a patient health history (why do we do this??)
Health History Goals
• Gather information o Provides the subjective database o Primary source vs secondary
Primary – patient; best source of information
Secondary – when patient unable or unwilling to provide information; family member,
caregiver, records, etc; parent of small children prime example; used to augment and
verify previously obtained data--validates
Stroke patient that may be unable to communicate may need a secondary source to
advocate on their behalf Identify actual and potential health problems o
When used with physical assessment, lab data, etc
• Identify teaching and referral needs
• Formal, planned, goal-oriented interaction
• Done to determine self care, wellness concerns, teaching needs, referral needs, ADLs, etc
• Used to develop nursing diagnosis and develop plan
• Essential to develop a strong rapport o First impressions key
o If we give up an impression of not being trustworthy or being uninterested they may not open up
and prevent us from getting an appropriate history
• Negotiate management
o Patients may not be willing to negotiate lifestyle changes if you have a poor attitude o
Example: Pt has HTN---------- needs to quit smoking
But have them go from 2packs to 1 ect o
Non-verbal’s are important
• Contract for:
o Positive behavioral change--do not expect a major change (a person who smokes 2 packs a
day..ask them to go to 1)
o Disease prevention
• Support emotional and spiritual needs
• Allow them time to talk, and listen
• Keep in mind that what is not said is just as important (body language)
• Nonverbal communication is key
• Come in the patient's room and explain what you are going to be doing and then LISTEN to the patient. Do
not interrupt just let them talk
• Describe content relevant to categories in a traditional health history
Traditional Health History
• Always starts with a general survey
, lOMoAR cPSD| 47061011
o Overall general understanding of health status
• CC - Chief Complaint: in pt’s own words (it is the pt’s story) o Problem in their own words-- it is the
reason why they are seeking care (usually related to specific symptoms) other times they are healthy and
just want to get screened which relates to the pt’s concerns!
When documenting Brief statement documented in the patient's own words Reason
for this visit, hospitalization etc.
What problem brought you here today?
Typically related to a single symptom
Frame questions that maintains the pt as the primary focus
Can alter providers interpretation if not documented in patients own words
Be aware of the patients misuse of medical terminology related to increased access from
the internet
• May need to ask additional questions to verify that the medical terminology they are using is consistent
with what they are actually experiencing
o Duration of problems o How long has this problem been present? o When did the symptoms
begin?
• HPC/HPI - History of Present Concern/illness
o Details of the current problem
Typically give you a chronologic sequence of events--what brought it on (let the pt tell
you the story)
Use open ended questions, listen actively, don’t interrupt
Symptoms evaluation: COLDERA; PQRST etc.
• Characteristics, onset, location, duration, exacerbation, relieved by, associated S & S
o Previous treatment for problem--things that worked and things that didn’t Surgery,
hospitalizations, medications, alternative therapies Were they successful? Were they happy
with results?
o Impact of problem on lifestyle--How was their health before the problem occurred??
Does it interfere with ADLs, can they work, does it affect relationships, does it affect
their daily life
o State of health before problem
• PMH - Past Medical History o Documents any historical incidences of patients health that may influence
their overall current health status o Concerned with:
General health and strength
Emotional status
Allergies
Medications (OTC, Rx, BCP, Herbs, Vit)
Childhood illnesses
Major adult illnesses
Immunizations
Surgery
Serious injury and resulting disability
Pregnancies/deliveries
Transfusions
Recent screening tests
• FH - Family History o Incidence of specific illness in the immediate and extended family
, lOMoAR cPSD| 47061011
o Concerned with genetic risk/predisposition or the interaction of genetic and environmental
factors (alcoholism, diabetes, cancers, stroke, cardiovascular diseases, allergies, renal,
hemophilia)
o Responds to questions such as:
Am I at risk for the same condition as….?
Why was my child born with or developed….?
Why did several people in my family have….?
I want to understand the risk will I pass on if I have children.
family history--this is genetic information only
• Discuss the importance of a genogram to developing a patient plan of
care Interpret symbols and drawing conventions used in genogram
What data goes where???
Know how to read a genogram ( basic symbols covered in lecture) – yes there will be one on
the exam.
Exam 1 NRSG 3323:
Exam 1 covers modules 1-5, there are 50 questions and you will have 1 hour.
YES there is math!
Module 1:
• Discuss goals of obtaining a patient health history (why do we do this??)
Health History Goals
• Gather information o Provides the subjective database o Primary source vs secondary
Primary – patient; best source of information
Secondary – when patient unable or unwilling to provide information; family member,
caregiver, records, etc; parent of small children prime example; used to augment and
verify previously obtained data--validates
Stroke patient that may be unable to communicate may need a secondary source to
advocate on their behalf Identify actual and potential health problems o
When used with physical assessment, lab data, etc
• Identify teaching and referral needs
• Formal, planned, goal-oriented interaction
• Done to determine self care, wellness concerns, teaching needs, referral needs, ADLs, etc
• Used to develop nursing diagnosis and develop plan
• Essential to develop a strong rapport o First impressions key
o If we give up an impression of not being trustworthy or being uninterested they may not open up
and prevent us from getting an appropriate history
• Negotiate management
o Patients may not be willing to negotiate lifestyle changes if you have a poor attitude o
Example: Pt has HTN---------- needs to quit smoking
But have them go from 2packs to 1 ect o
Non-verbal’s are important
• Contract for:
o Positive behavioral change--do not expect a major change (a person who smokes 2 packs a
day..ask them to go to 1)
o Disease prevention
• Support emotional and spiritual needs
• Allow them time to talk, and listen
• Keep in mind that what is not said is just as important (body language)
• Nonverbal communication is key
• Come in the patient's room and explain what you are going to be doing and then LISTEN to the patient. Do
not interrupt just let them talk
• Describe content relevant to categories in a traditional health history
Traditional Health History
• Always starts with a general survey
, lOMoAR cPSD| 47061011
o Overall general understanding of health status
• CC - Chief Complaint: in pt’s own words (it is the pt’s story) o Problem in their own words-- it is the
reason why they are seeking care (usually related to specific symptoms) other times they are healthy and
just want to get screened which relates to the pt’s concerns!
When documenting Brief statement documented in the patient's own words Reason
for this visit, hospitalization etc.
What problem brought you here today?
Typically related to a single symptom
Frame questions that maintains the pt as the primary focus
Can alter providers interpretation if not documented in patients own words
Be aware of the patients misuse of medical terminology related to increased access from
the internet
• May need to ask additional questions to verify that the medical terminology they are using is consistent
with what they are actually experiencing
o Duration of problems o How long has this problem been present? o When did the symptoms
begin?
• HPC/HPI - History of Present Concern/illness
o Details of the current problem
Typically give you a chronologic sequence of events--what brought it on (let the pt tell
you the story)
Use open ended questions, listen actively, don’t interrupt
Symptoms evaluation: COLDERA; PQRST etc.
• Characteristics, onset, location, duration, exacerbation, relieved by, associated S & S
o Previous treatment for problem--things that worked and things that didn’t Surgery,
hospitalizations, medications, alternative therapies Were they successful? Were they happy
with results?
o Impact of problem on lifestyle--How was their health before the problem occurred??
Does it interfere with ADLs, can they work, does it affect relationships, does it affect
their daily life
o State of health before problem
• PMH - Past Medical History o Documents any historical incidences of patients health that may influence
their overall current health status o Concerned with:
General health and strength
Emotional status
Allergies
Medications (OTC, Rx, BCP, Herbs, Vit)
Childhood illnesses
Major adult illnesses
Immunizations
Surgery
Serious injury and resulting disability
Pregnancies/deliveries
Transfusions
Recent screening tests
• FH - Family History o Incidence of specific illness in the immediate and extended family
, lOMoAR cPSD| 47061011
o Concerned with genetic risk/predisposition or the interaction of genetic and environmental
factors (alcoholism, diabetes, cancers, stroke, cardiovascular diseases, allergies, renal,
hemophilia)
o Responds to questions such as:
Am I at risk for the same condition as….?
Why was my child born with or developed….?
Why did several people in my family have….?
I want to understand the risk will I pass on if I have children.
family history--this is genetic information only
• Discuss the importance of a genogram to developing a patient plan of
care Interpret symbols and drawing conventions used in genogram
What data goes where???
Know how to read a genogram ( basic symbols covered in lecture) – yes there will be one on
the exam.
