Advanced Practice Nursing Knowledge for Health History and Physical Examination

Advanced practice registered nurses (APRNs) are highly skilled clinicians who play a vital role in the healthcare system. APRNs are trained to provide comprehensive healthcare services to patients of all ages and populations.

An important aspect of APRN practice is collecting health history information and performing physical examinations. APRNs use this information to assess patients’ health status, identify potential health problems, and develop and implement treatment plans.

Collecting Health History Information

When collecting health history information, APRNs typically ask patients about their:

• Chief complaint: The main reason for the patient’s visit
• Past medical history: Any past illnesses, injuries, or surgeries
• Social history: Lifestyle factors such as tobacco use, alcohol consumption, and diet
• Family history: Any health conditions that run in the family
• Review of systems (ROS): Questions about specific body systems and symptoms

APRNs also ask patients about their current medications, allergies, and immunizations.

Performing Physical Examinations

The physical examination is a systematic assessment of the patient’s physical health. APRNs typically perform a head-to-toe physical examination, which includes:

• General inspection: Observing the patient’s overall appearance, including their posture, gait, and vital signs
• Skin assessment: Inspecting the patient’s skin for any abnormalities
• Head, neck, and eye examination: Assessing the patient’s head, neck, and eyes for any abnormalities
• Cardiovascular examination: Assessing the patient’s heart and blood vessels
• Respiratory examination: Assessing the patient’s lungs
• Gastrointestinal examination: Assessing the patient’s abdomen
• Musculoskeletal examination: Assessing the patient’s muscles and bones
• Neurological examination: Assessing the patient’s nervous system

Adapting Health History and Physical Examination Skills to Different Patient Populations

When collecting health history information and performing physical examinations, APRNs must adapt their skills to the developmental, gender-related, age-specific, and special population needs of the individual patient.

For example, when collecting a health history from a child, APRNs may need to ask the child’s parents or caregivers about the child’s medical history, lifestyle factors, and social history. APRNs may also need to use different physical examination techniques when examining children, such as using smaller instruments and explaining the examination process in a child-friendly way.

When collecting a health history from a pregnant woman, APRNs will need to ask about the pregnancy, such as the gestational age, any complications, and any prenatal care received. APRNs will also need to perform a physical examination that includes assessment of the fetus and the pregnant woman’s reproductive system.

Conducting Focused and Comprehensive Health Histories and Examinations

The type of health history and physical examination that an APRN conducts will depend on the patient’s individual needs. For example, a patient who is coming in for a routine checkup may need a focused health history and physical examination, while a patient who is coming in with a new medical problem may need a more comprehensive assessment.

Focused health histories and physical examinations typically focus on the patient’s chief complaint and any related areas. Comprehensive health histories and physical examinations include a more in-depth assessment of the patient’s overall health status.

Conclusion

Advanced practice nurses play a vital role in the healthcare system by collecting health history information and performing physical examinations. APRNs use this information to assess patients’ health status, identify potential health problems, and develop and implement treatment plans.

When collecting health history information and performing physical examinations, APRNs must adapt their skills to the developmental, gender-related, age-specific, and special population needs of the individual patient. APRNs may also conduct focused or comprehensive health histories and physical examinations depending on the patient’s individual needs.