patient history and physical examination report choose the best answer.

What data does the nurse collect during the patient history interview?

RATIONALE: During the patient history interview and physical examination, the nurse collects the necessary data to support the identification of nursing diagnoses and collaborative problems. The nurse would place information about the patient's concern that his illness is threatening his job security in which function health pattern?

What does the nurse ask during a health history?

During the health history, the nurse asks the patient about any alcohol or substance abuse. What functional health pattern is being assessed? RATIONALE: Health perception-health management pattern focuses on pt. perceived level of health & well-being and personal practices for maintaining health.

Which situation would the nurse most likely conduct a comprehensive assessment?

In which situation would the nurse most likely conduct a comprehensive assessment? RATIONALE: Comprehensive assessment most often at beginning of pt. course of care [C) newly admitted to unit or facility]. Emergency assessment during immediate management of trauma or resuscitation (A).

What is history and physical examination report?

The History and Physical Exam, often called the "H&P" is the starting point of the patient's "story" as to why they sought medical attention or are now receiving medical attention.

What should be included in a history and physical?

Contents of a History and Physical Examination (H&P) 2. The H&P shall consist of chief complaint, history of present illness, allergies and medications, relevant social and family history, past medical history, review of systems and physical examination, appropriate to the patient's age.

What is physical examination of a patient?

Definition. Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.

What 3 things are measured in a physical examination?

Measurements may include vital signs (blood pressure, pulse, respiration) as well as other clinical measures (such as expiratory flow rate and size of lesion). Physical exam includes psychiatric examinations.

How do you write a patient history report?

At a minimum it should include the following, but be prepared to take down any information the patient gives you that might be relevant:Allergies and drug reactions.Current medications, including over-the-counter drugs.Current and past medical or psychiatric illnesses or conditions.Past hospitalizations.More items...

How do you take patient history?

Following a StructureGreet the patient by name and introduce yourself.Ask, “What brings you in today?” and get information about the presenting complaint.Collect past medical and surgical history, including any allergies and any medications they're currently taking.Ask the patient about their family history.More items...•

Why is physical examination important?

A physical examination can be helpful because it can help determine the status of your health. This can give way to early intervention and prevention of any health issues that you are currently at risk for.

What is the purpose of physical examination?

A physical examination helps your PCP to determine the general status of your health. The exam also gives you a chance to talk to them about any ongoing pain or symptoms that you're experiencing or any other health concerns that you might have.

What are the types of physical examination?

Physical examination Inspection. Palpation. Auscultation. Percussion.

What is a physical exam quizlet?

an examination of the entire body and all body systems.

What are the 4 techniques used in a physical exam?

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.

What is physical assessment in nursing?

Physical assessment: A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required.