Chapter Outline
Introduction
The comprehensive health history and physical examination help the nurse devise a plan of care for the patient. To complete the health history and physical exam successfully, the nurse must use effective communication, critical thinking, and clinical judgment skills. The development of these skills arms the nurse with a solid foundation for practice. The concept of clinical judgment is the basis for decision-making and requires the nurse to integrate all data they have on the patient, including subjective and objective information.
The nurse’s ability to communicate effectively is essential to gathering complete and accurate data from and about a patient, collaborating with other providers to coordinate care, and facilitating open, empathetic conversations with patients. The nurse will rely on their critical thinking skills to analyze patient data and piece together the “puzzle” of how to approach care. They must be able to identify patterns and establish priorities for their patients based on the data they have gathered and analyzed. The nurse will use each of these skills when taking a history and performing an exam on a patient. For example, the nurse will use their communication skills to explain what will happen during the exam to ease a patient’s anxiety, critical thinking to adjust their questions according to a patient’s needs, and clinical judgment to recognize and assess the data they gather during the patient encounter.