Bates: Chapter 2 Flashcards
What the patient tells you about their history, history of present illness (HPI), and review of symptoms (ROS) is considered ______ data.
subjective
What you see during a physical exam, lab tests, radiologic findings, and vital signs are considered ______ data.
objective
In getting a history you ask about the onset, ______, and _______.
location
duration
If you had to tell me how it feels. How would you describe your headache? This is an example of ______.
characteristic symptoms
Is there anything else that happens when you experience these signs or symptoms? This is an example of ____.
associated manifestations
What helps relieve these symptoms? or What make the headache go away?
relieving factors
When did your headache start? Is an example of _____.
onset
Where is the sign or symptoms located? This is an example of _____.
location
How long has this been going on? or How long do your headaches last?
duration
What have you tried to help these symptoms go away?
treatments
How is it impacting the patient? Use a pain rating system using the appropriate pain scale.
severity
The nursing process
assessment diagnosis planning implementation evaluation
Assessment involves gathering data, _____, prioritizing your findings and is an ongoing process.
grouping together pertinent data
OLDCARTS stands for
ONSET
- When did it begin?
- When did your headache start?
LOCATION
- Where is the sign or symptom located?
- Where does your head hurt?
DURATION
- How long has this been going on?
- Is this the first time that you’ve had this type of headache?
- How long do your headaches last?
CHARACTERISTIC SYMPTOMS
- What does it feel like?
- If you had to tell me how it feels, how would you describe your headache?
ASSOCIATED MANIFESTATIONS
- Is there anything else that happens when you experience these signs or symptoms?
- Do you ever have blurry vision, double vision, feel dizzy, feel nauseous, or vomit?
- Do you see bright lights or spots around objects prior to your headaches beginning?
- Does anything seem to trigger them or make them worse once they start?
RELIEVING FACTORS
- What helps relieve these symptoms?
- What makes you feel better?
- What makes the headache go away?
TREATMENTS
- What have you tried to help these symptoms go away?
- Medications (Over the counter, prescription, or herbal)?
- Non-pharmacological pain management
SEVERITY
- How is it impacting the patient?
- Pain ratings using appropriate pain scale
- Do your headaches interfere with your ability to perform your regular activities?
Assessment data gathered needs to have (4)
reliability
validity
sensitivity
specificity
