title: History taking and physical assessment in holistic palliative care.
abstract: In carrying out a holistic palliative care assessment the palliative care clinical nurse specialist needs to develop the knowledge and skill of history taking and health assessment to make safe and competent decisions with patients regarding the future management of their care. This article examines this process in making a differential diagnosis with particular reference to the respiratory physical examination of a patient with a history of lung cancer using the Calgary-Cambridge Model. The model gives structure to the preparation, history taking, and physical examination (inspection, palpation, percussion and auscultation) before explaining, planning and closing the consultation, while considering the palliative patient's and family's individual wishes and goals.
authors.affiliation: Macmillan Palliative Care Clinical Nurse Specialist, palliative care team, South West Acute Hospital, Enniskillen, Northern Ireland.
authors.forename: Marie
authors.initials: M
authors.lastname: Donnelly
authors.affiliation: Nurse Lecturer/Pathway Leader Specialist Practice in Anaesthetic Nursing and Examination Liaison Officer, School of Nursing and Midwifery, Queen's University Belfast.
authors.forename: Daphne
authors.initials: D
authors.lastname: Martin
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000451:nursing*; D002983:Clinical Competence; D018939:Holistic Nursing; D064946:Hospice and Palliative Care Nursing; D006801:Humans; D008175:Lung Neoplasms / Q000451:nursing*; D008487:Medical History Taking; D009720:Nurse Clinicians; D009730:Nursing Assessment; D010808:Physical Examination; D012017:Referral and Consultation
keywords: Clinical examination skills; Clinical nurse specialist; History taking; Palliative care; Person-centred assessment