Collecting Data Flashcards
what things do we observe during a general survey?
- behaviour (LOC, speech, facial expressions)
- physical appearance (dress, hygiene, skin, breathing)
- mobility (posture, gait, comfort level, ROM)
define anthropometric measurements
measurements of the human body, including height, weight, BMI
what red flag about weight should be noted during examination?
unintentional weight loss or gain
could prelude bigger/more severe issues
what information does the Framingham risk score provide us?
risk of heart attack within the next 10 years
what are a nurse’s objectives during the health interview?
- gain foundation of information
- start collecting subjective data
- build rapport with patient
who is our primary data source?
the patient providing subjective data
who is our secondary data source?
- family members & significant others
- charts from other practitioners
- medical alert information
- objective data we collect
when should PPE be used in a health interview?
- masks only if you or the pt is infectious
- gloves only if you anticipate coming in contact with bodily fluids
use only when necessary
what are the components of a health history?
- demographic data
- reasons for seeking care
- health history, allergies, medications
- family history
- personal/social history
- review of systems
- functional health questions
define a sign
an action or physical manifestation that can be observed through senses or obtained through examination as objective data
e.g. elevated temperature, elevated BP or HR
define symptom
a sensation or emotion perceived by the individual that is not directly observable by others (i.e. subjective data)
e.g. pain, headache, fatigue
what are the 10 attributes of a sign or symptom?
- location
- associated symptoms/signs
- timing
- environmental/exposure factors
- relieving factors
- severity/quantity
- nature/quality
- aggravating factors
- patient perspective
- significance to patient
