NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
● Chapter 1
Basic and Advanced Interviewing Techniques
Basic maximize patient's comfort, avoid unnecessary changes in
position, enhance clinical efficiency, move head to toe, examine the
patient from their right side
Active listening, empathic responses, guided questioning, nonverbal
communication, validation, reassurance, partnering, summarization,
transitions, empowering the patient
Active Listening- closely attending to what the patient is communicating,
connecting to the patient’s emotional state and using verbal and nonverbal
skills to encourage the patient to expand on his or her feelings and concerns.
Empathic Responses-the capacity to identify with the patient and feel the
patient’s pain as your own, then respond in a supportive manner.
Guided Questioning- show your sustained interest in the patient’s feelings and
deepest disclosures and allows the interviewer to facilitate full communication,
in the patient’s own words, without interruption.
Non-verbal- includes eye contact, facial expression, posture, head position and
movement such as shaking or nodding, interpersonal distance, and placement
of the arms or legs-crossed, neutral, or open.
Validation- helps to affirm the legitimacy of the patient’s emotional
experience. Reassurance- an appropriate way to help the patient feel that
problems have been fully understood and are being addressed.
Partnering- building rapport with patients, express your commitment to an
ongoing relationship. Summarization- giving a capsule summary of the patient’s
story during the course of the interview to communicate that you have been
listening carefully.
Transitions- inform your patient when you are changing directions during the
interview. Empowering the Patient- empower the patient to ask questions,
express their concerns, and probe your recommendations in order to
encourage them to adopt your advice, make lifestyle changes, or take
medications as prescribed.
Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5
Comprehensive: Used for patients you are seeing for the first time in the office or
hospital. Includes all the elements of the health history and complete physical
examination. fundamental and personalized knowledge about the patient,
A
strengthens the clinician-patient relationship.
● Is appropriate for new patients in the office or hospital
● Provides fundamental and personalized
knowledge about the patient
● Strengthens the clinician–patient relationship
● Helps identify or rule out physical causes related
to patient concerns
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
● Provides a baseline for future assessment
● Creates a platform for health promotion
through education and counseling
● Develops proficiency in the essential skills
of physical examination
Flexible Focused or problem-oriented assessment: For patients you know well
returning for routine care, or those with specific “urgent care” concerns like
sore throat or knee pain. You will adjust the scope of your history and physical
examination to the situation at hand, keeping several factors in mind: the
magnitude and severity of the patient’s problems; the need for thoroughness;
the clinical setting—inpatient or outpatient, primary or subspecialty care; and
the time available.
● Is appropriate for established patients,
especially during routine or urgent care
visits
● Addresses focused concerns or symptoms
● Assesses symptoms restricted to a specific body system
● Applies examination methods relevant to
assessing the concern or problem as
thoroughly and carefully as possible
Tangential lighting: JVD, thyroid gland, and apical impulse of heart.
Components of the Health History Jenna/Ashley
Initial information
Identifying data and source of the history; reliability
Identifying data- age, gender, occupation, marital
status
Source of history- usually patient. Can be: a family member or friend, letter of
referral, or clinical record.
Reliability- Varies according to the patient’s memory, trust,
and mood. Chief Complaint
Chief Complaint- Make every attempt to quote the patient’s
own words. Present Illness
Complete, clear and chronological description of the problem prompting
the patient visit Onset, setting in which it occurred, manifestations and
any treatments
Should include 7 attributes of a symptom:
● Location
● Quality
● Quantity or severity
● Timing, onset, duration, frequency
● Setting in which it occurs
● Aggravating or relieving factors
● Associated manifestations
-Differential diagnosis is derived from the “pertinent positives” and “pertinent
negatives” when doing Review of Systems that are relevant to the chief
complaint. A list of potential causes for the patients problems.
-Present illness should reveal patient’s responses to his or her symptoms
and what effect this has on their life.
-Each symptom needs its own paragraph and a full description.
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
-Medication should be documented, name, dose, route, and frequency. Home
remedies, non- prescriptions drugs, vitamins, minerals or herbal supplements,
oral contraceptives, or borrowed medications.
-Allergies-foods, insects, or environmental, including specific
reaction Tobacco use, including the type. If someone has quit,
note for how long
-Alcohol and drug use should always be investigated and is often pertinent to
the Presenting Illness.
Past history
-Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox,
rheumatic fever, scarlet fever, and polio. Also include any chronic childhood
illness
-Adult illnesses: Provide information in each of the 4 areas:
● Medical: diabetes, hypertension, hepatitis, asthma
and HIV; hospitalizations; number and gender of
sexual partners; and risk taking sexual practices.
● Surgical: dates, indications, and types of operations
● Obstetric/gynecologic: Obstetric history,
menstrual history, methods of contraception, and
sexual function.
● Psychiatric: Illness and time frame,
diagnoses, hospitalizations, and
treatments.
-Health Maintenance: Find out if they are up to date on immunizations and
screening tests. Review Tb tests, pap smears, mammograms, stool tests for
occult blood, colonoscopy, cholesterol levels etc..
Family history
Outlines or diagrams age and health, or age and cause of death, of siblings,
parents, and grandparents
Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, elevated cholesterol levels, stroke,
diabetes, thyroid or ren tuberculosis, asthma or lung disease,
al disease,
headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, and symptoms reported by patient.
Ask about history of breast, ovarian, colon, or
prostate cancer Ask about Genetically transmitted
diseases
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
Personal or social history
Describes educational level, occupation, family of origin, current household,
personal interests, and lifestyle
Capture the patients personality and interests, sources of support, coping
style, strengths, and concerns
Includes lifestyle habits that promote health or create risk, such as exercise
and diet, safety measures, sexual practices, and use of alcohol, drugs, and
tobacco Expanded personal and social history personalizes your relationship
with the patient and builds a rapport
Review of systems pg 11-13
Documents presence or absence of common symptoms related to each of
the major body systems
Understanding and using Review of Systems questions may seem challenging at
first. These“yes-no” questions should come at the end of the inter- Think
about askin questions going from “head to toe.” It is helpful to
prepare the g a series
of the history may feel like a
patient by
hundred questions, butsaying, “The next
it is important to make sure we have not missed
anything.”
Most Review of Systems questions pertain to symptoms, but on occasion, some
clinicians include diseases like pneumonia or tuberculosis.
Note that as you elicit the Present Illness, you may also draw on Review of
Systems questions related to system(s) relevant to the Chief Complaint to
establish “pertinent positives and negatives” that help clarify the
diagnosis.
For example, after a full description of chest pain, you may ask, “Do you have
any history of high blood pressure . . . palpitations . . . shortness of breath . . .
swelling in your ankles or feet?” or even move to questions from the
Respiratory or Gastrointestinal Review of Systems
The Review of Systems questions may uncover problems that the patient has
overlooked, particularly in areas unrelated to the Present Illness. Significant
health events, such as past surgery, hospitalization for a major prior illness, or
a parent’s death, require full exploration. Keep your technique flexible.
Remember that major health events discovered during the Review of Systems
should be moved to the Present Illness Past History in your write-up.
Some experienced clinicians do the Review of Systems during the physical
examination, asking about the ears, for example, as they examine them. If the
patient has only a combination can be efficient. If there are
fe multiple w symptoms,
symptoms, however, this can disrupt the of both the history and
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
College of Nursing satisfactory guaranteed
● Chapter 1
Basic and Advanced Interviewing Techniques
Basic maximize patient's comfort, avoid unnecessary changes in
position, enhance clinical efficiency, move head to toe, examine the
patient from their right side
Active listening, empathic responses, guided questioning, nonverbal
communication, validation, reassurance, partnering, summarization,
transitions, empowering the patient
Active Listening- closely attending to what the patient is communicating,
connecting to the patient’s emotional state and using verbal and nonverbal
skills to encourage the patient to expand on his or her feelings and concerns.
Empathic Responses-the capacity to identify with the patient and feel the
patient’s pain as your own, then respond in a supportive manner.
Guided Questioning- show your sustained interest in the patient’s feelings and
deepest disclosures and allows the interviewer to facilitate full communication,
in the patient’s own words, without interruption.
Non-verbal- includes eye contact, facial expression, posture, head position and
movement such as shaking or nodding, interpersonal distance, and placement
of the arms or legs-crossed, neutral, or open.
Validation- helps to affirm the legitimacy of the patient’s emotional
experience. Reassurance- an appropriate way to help the patient feel that
problems have been fully understood and are being addressed.
Partnering- building rapport with patients, express your commitment to an
ongoing relationship. Summarization- giving a capsule summary of the patient’s
story during the course of the interview to communicate that you have been
listening carefully.
Transitions- inform your patient when you are changing directions during the
interview. Empowering the Patient- empower the patient to ask questions,
express their concerns, and probe your recommendations in order to
encourage them to adopt your advice, make lifestyle changes, or take
medications as prescribed.
Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5
Comprehensive: Used for patients you are seeing for the first time in the office or
hospital. Includes all the elements of the health history and complete physical
examination. fundamental and personalized knowledge about the patient,
A
strengthens the clinician-patient relationship.
● Is appropriate for new patients in the office or hospital
● Provides fundamental and personalized
knowledge about the patient
● Strengthens the clinician–patient relationship
● Helps identify or rule out physical causes related
to patient concerns
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
● Provides a baseline for future assessment
● Creates a platform for health promotion
through education and counseling
● Develops proficiency in the essential skills
of physical examination
Flexible Focused or problem-oriented assessment: For patients you know well
returning for routine care, or those with specific “urgent care” concerns like
sore throat or knee pain. You will adjust the scope of your history and physical
examination to the situation at hand, keeping several factors in mind: the
magnitude and severity of the patient’s problems; the need for thoroughness;
the clinical setting—inpatient or outpatient, primary or subspecialty care; and
the time available.
● Is appropriate for established patients,
especially during routine or urgent care
visits
● Addresses focused concerns or symptoms
● Assesses symptoms restricted to a specific body system
● Applies examination methods relevant to
assessing the concern or problem as
thoroughly and carefully as possible
Tangential lighting: JVD, thyroid gland, and apical impulse of heart.
Components of the Health History Jenna/Ashley
Initial information
Identifying data and source of the history; reliability
Identifying data- age, gender, occupation, marital
status
Source of history- usually patient. Can be: a family member or friend, letter of
referral, or clinical record.
Reliability- Varies according to the patient’s memory, trust,
and mood. Chief Complaint
Chief Complaint- Make every attempt to quote the patient’s
own words. Present Illness
Complete, clear and chronological description of the problem prompting
the patient visit Onset, setting in which it occurred, manifestations and
any treatments
Should include 7 attributes of a symptom:
● Location
● Quality
● Quantity or severity
● Timing, onset, duration, frequency
● Setting in which it occurs
● Aggravating or relieving factors
● Associated manifestations
-Differential diagnosis is derived from the “pertinent positives” and “pertinent
negatives” when doing Review of Systems that are relevant to the chief
complaint. A list of potential causes for the patients problems.
-Present illness should reveal patient’s responses to his or her symptoms
and what effect this has on their life.
-Each symptom needs its own paragraph and a full description.
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
-Medication should be documented, name, dose, route, and frequency. Home
remedies, non- prescriptions drugs, vitamins, minerals or herbal supplements,
oral contraceptives, or borrowed medications.
-Allergies-foods, insects, or environmental, including specific
reaction Tobacco use, including the type. If someone has quit,
note for how long
-Alcohol and drug use should always be investigated and is often pertinent to
the Presenting Illness.
Past history
-Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox,
rheumatic fever, scarlet fever, and polio. Also include any chronic childhood
illness
-Adult illnesses: Provide information in each of the 4 areas:
● Medical: diabetes, hypertension, hepatitis, asthma
and HIV; hospitalizations; number and gender of
sexual partners; and risk taking sexual practices.
● Surgical: dates, indications, and types of operations
● Obstetric/gynecologic: Obstetric history,
menstrual history, methods of contraception, and
sexual function.
● Psychiatric: Illness and time frame,
diagnoses, hospitalizations, and
treatments.
-Health Maintenance: Find out if they are up to date on immunizations and
screening tests. Review Tb tests, pap smears, mammograms, stool tests for
occult blood, colonoscopy, cholesterol levels etc..
Family history
Outlines or diagrams age and health, or age and cause of death, of siblings,
parents, and grandparents
Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, elevated cholesterol levels, stroke,
diabetes, thyroid or ren tuberculosis, asthma or lung disease,
al disease,
headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, and symptoms reported by patient.
Ask about history of breast, ovarian, colon, or
prostate cancer Ask about Genetically transmitted
diseases
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
, NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
Personal or social history
Describes educational level, occupation, family of origin, current household,
personal interests, and lifestyle
Capture the patients personality and interests, sources of support, coping
style, strengths, and concerns
Includes lifestyle habits that promote health or create risk, such as exercise
and diet, safety measures, sexual practices, and use of alcohol, drugs, and
tobacco Expanded personal and social history personalizes your relationship
with the patient and builds a rapport
Review of systems pg 11-13
Documents presence or absence of common symptoms related to each of
the major body systems
Understanding and using Review of Systems questions may seem challenging at
first. These“yes-no” questions should come at the end of the inter- Think
about askin questions going from “head to toe.” It is helpful to
prepare the g a series
of the history may feel like a
patient by
hundred questions, butsaying, “The next
it is important to make sure we have not missed
anything.”
Most Review of Systems questions pertain to symptoms, but on occasion, some
clinicians include diseases like pneumonia or tuberculosis.
Note that as you elicit the Present Illness, you may also draw on Review of
Systems questions related to system(s) relevant to the Chief Complaint to
establish “pertinent positives and negatives” that help clarify the
diagnosis.
For example, after a full description of chest pain, you may ask, “Do you have
any history of high blood pressure . . . palpitations . . . shortness of breath . . .
swelling in your ankles or feet?” or even move to questions from the
Respiratory or Gastrointestinal Review of Systems
The Review of Systems questions may uncover problems that the patient has
overlooked, particularly in areas unrelated to the Present Illness. Significant
health events, such as past surgery, hospitalization for a major prior illness, or
a parent’s death, require full exploration. Keep your technique flexible.
Remember that major health events discovered during the Review of Systems
should be moved to the Present Illness Past History in your write-up.
Some experienced clinicians do the Review of Systems during the physical
examination, asking about the ears, for example, as they examine them. If the
patient has only a combination can be efficient. If there are
fe multiple w symptoms,
symptoms, however, this can disrupt the of both the history and
NR 509 Mid-Term Study Guide-Review Week 4 Chamberlain
College of Nursing satisfactory guaranteed
