COLLECTING DATA Flashcards
– process of gathering
information about a client’s health
status
DATA COLLECTION
in DATA COLLECTION, It must be both _______ and ______
to prevent the omission of significant data and reflect a client’s changing health status.
SYSTEMATIC & CONTINUOUS
2 TYPES OF DATA:
SUBJECTIVE DATA & OBJECTIVE DATA
Symptoms or covert data
Includes client’s:
* Sensations
* Feelings
* Values
* Beliefs
* Attitudes
* Perception of personal health
status and life situation
EXAMPLES:
Pain, itching, worry, DOB, fear
SUBJECTIVE DATA
Signs or overt data
Detectable by an observer (seen, heard, felt, smelled)
Obtained by observation or
physical examination
EXAMPLES:
Skin discoloration, vital signs
reading, slurred speech, crackles,
cyanosis
OBJECTIVE DATA
2 SOURCES OF DATA:
PRIMARY & SECONDARY
Best source of data unless the
client is too ill, young, or
confused to communicate clearly.
CLIENT
Important source of data for a
client who is very young, too ill,
unconscious, or confused.
FAMILY MEMBERS / SUPPORT PEOPLE
Include information documented by
various health care professionals.
Types of client records: medical
records, records of therapies,
laboratory records
CLIENT RECORDS
Provide pertinent health
information and allows easy
monitoring among the healthcare
team
Laboratory and
diagnostic results
Sharing of information among
professionals is especially
important to ensure continuity
of care and a potential source
of information about a
client’s health.
HEALTH CARE PROFESSIONALS
Review of nursing and related
literature can provide
additional information for the
database.
RELEVANT LITERATURE
3 METHODS OD DATA COLLECTION
- OBSERVING
- INTERVIEWING
- EXAMINING
Gathering data by the use of senses.
Involves distinguishing data in a
meaningful manner
OBSERVING
A planned communication or a
conversation
Purpose:
* Get or give information
* Identify problems of mutual
concern
* Evaluate change
* Teach
* Provide support
* Provide counseling or therapy
INTERVIEWING
Highly structured and
elicits specific information.
The nurse establishes the
purpose of the interview
and controls the interview.
Uses closed questions
DIRECTIVE INTERVIEW
Rapport building interview.
The client is allowed to control the purpose, subject matter, and
pacing.
Uses open-ended questions
NON DIRECTIVE INTERVIEW
Restrictive and generally require only “yes” or “no” or short factual
answers that provide specific information.
Often begin with “when,” “where,” “who,” “what,” “do (did, does),” or
“is (are, was)
CLOSED QUESTIONS
Invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.
The open-ended question is useful at the beginning of an interview or to change topics and to elicit attitudes.
May begin with “what” or “how”
OPEN - ENDED QUESTIONS
An open ended question that the client can answer without direction or pressure from the nurse.
NEUTRAL QUESTION
A closed question which directs the client’s answer.
Creates problems if the client, in an effort to please the nurse, gives inaccurate responses.
LEADING QUESTION
that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
SYSTEMIC DATA COLLECTION METHOD
2 APPROACHES IN PHYSICAL ASSESSMENT/ EXAMINATION
- CEPHALOCAUDAL OR HEAD TO TOE APPROACH
- BODY SYSTEMS
Intimacy VS Isolation
YOUNG ADULT
Generativity VS Stagnation
MIDDLESCENT
Ego integrity VS Despair
OLDER ADULT
Assess client’s self-concept and self-esteem.
Sources of stress for the client and the client’s ability to cope.
Sources of support for clients in crisis, such as family, significant others, religion, or support groups.
PSYCHOSOCIAL HISTORY
WHAT ARE THE 3 PHYSICAL EXAMINATION / PHYSICAL HEALTH ASSESSMENT
PREPARATION
POSITIONING
TECHNIQUES
Permits full expansion of the
lungs and it allows the examiner to assess symmetry of upper body parts.
Areas that may be assessed:
head, neck, lungs, chest, back,
breasts, axillae, heart, vital
signs, and upper extremities.
SITTING
Allows the abdominal muscles to relax and provides easy access to
peripheral pulse sites.
If the client has trouble breathing, the head of the bed may need to be raised.
Areas that may be assessed: head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities.
SUPINE
May be more comfortable than
the supine position for clients with pain in the back or abdomen.
Areas that may be assessed:
head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.
The abdomen should not be
assessed because the abdominal
muscles are contracted in this
position.
DORSAL RECUMBENT
Client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the shoulder and elbow.
The lower leg is slightly flexed at the knee while the upper leg is flexed at a sharper angle and pulled forward.
Areas that may be assessed: rectal and vaginal areas.
SIMS
Allows the examiner to assess
posture, balance, and gait.
This position is also used for
examining the male genitalia.
STANDING
Used primarily to assess the hip joint. The back can also be assessed in this position.
Clients with cardiac and respiratory problems cannot tolerate this position.
PRONE
The weight of the body is supported by the chest and knees.
A 90-degree angle should exist between the body and the hips.
Useful for examining the rectum.
May be embarrassing and
uncomfortable for the client.
Elderly clients and those with
respiratory and cardiac problems
may be unable to tolerate this
position.
KNEE - CHEST
Client lies on the back with
the hips at the edge of the
examination table and the feet
supported by stirrups.
Used to examine the female
genitalia, reproductive tracts,
and the rectum.
Clients may feel embarrassed
and elderly clients may not be
able to assume this position
for very long or at all.
LITHOTOMY
WHAT ARE THE 4 TECHNIQUES IN PHYSICAL EXAMINATION
INSPECTION, PALPATION, PERCUSSION, AUSCULTATION
Assessing by using the sense of sight (visual examination).
In addition to visual observations,
olfactory (smell) and auditory
(hearing) cues are noted.
Frequently used to assess moisture, color, and texture of body surfaces, as well as shape, position, size, color, and symmetry of the body.
INSPECTION
Using the parts of the hand to touch
and feel for the following
characteristics:
* Texture (rough/smooth)
* Temperature (warm/cold)
* Moisture (dry/wet)
* Mobility
(fixed/movable/still/vibrating)
* Consistency (soft/hard/fluid filled)
* Strength of pulses
(strong/weak/thready/bounding)
* Size (small/medium/large)
* Shape (well defined/irregular)
* Degree of tenderness
PALPATION
Should always precede deep palpation
Skin is slightly depressed
HOW TO DO IT:
Extend the dominant hand’s fingers parallel to the skin surface and press gently while moving the hand in a circle.
To determine the details of a mass, press lightly several times rather than holding the pressure.
LIGHT/ SUPERFICIAL PALPATION
Performed with extreme caution because pressure can damage
internal organs.
Not indicated in clients who have acute abdominal pain or pain
that is not yet diagnosed.
DEEP PALPATION
extend the dominant hand as for light palpation, place the finger pads of the nondominant hand on the
dorsal surface of the distal interphalangeal joint of the middle
three fingers of the dominant hand.
BIMANUAL PALPATION
finger pad of the dominant hand presses over the area to be palpated. Often the other hand is used to support from below
USING ONE HAND
The act of striking / tapping the body surface to elicit sounds that can be heard or vibrations that can be felt.
PERCUSSION
Direct tapping of a body part with
one or two fingertips to elicit
possible tenderness (e.g., tenderness over the sinuses).
The strikes are rapid, and the
movement is from the wrist.
HOW TO DO IT:
The area to be percussed is struck
directly with the pads of two, three,
or four fingers or with the pad of
the middle finger.
DIRECT PERCUSSION
Used to detect tenderness
over organs (e.g., kidneys)
HOW TO DO IT:
One hand is placed flat on the
body surface and the fist of
the other hand is used to
strike the back of the hand
flat on the body surface.
BLUNT PERCUSSION
Tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures.
INDIRECT PERCUSSION
The process of listening to sounds produced within the body
AUSCULTATION
performed using the unaided ear
Example: listening to a respiratory wheeze or the grating of a moving joint
DIRECT AUSCULTATION
performed using a stethoscope.
Example: listening to bowel sounds, valve sounds of the heart and blood pressure
INDIRECT AUSCULTATION
Frequency of the vibrations (the number of vibrations per second)
PITCH
Loudness or softness of a
sound
INTENSITY
According to its length
DURATION
Subjective description of a
sound
QUALITY
should fit comfortably into the ears,
facing forward.
EARPIECES
Warm the ____ or ____ of the stethoscope before placing it on the client’s skin.
DIAPHRAGM & BELL
to detect high-pitched sounds
(e.g., bronchial sounds) USE THE
DIAPHRAGM
to detect low-pitched sounds (e.g.,
heart sounds) USE THE
BELL
