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Health Assessment - Lecture > Collecting Subjective and Objective Data > Flashcards

Collecting Subjective and Objective Data Flashcards

1
Q

Is the process of sharing information and meaning, and of sending and receiving messages

A

COMMUNICATION

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2
Q

Messages can be

A
  • Verbal
  • Nonverbal
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3
Q
  • More accurate than the verbal one.
  • Should coincide with the verbal data.
A

NONVERBAL MESSAGES

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4
Q

Quality of the voice and its inflections, tone, intensity, and speed when speaking

A

Vocal Cues or Paralinguistics

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5
Q

Vocal characteristics reflects:

A
  • feelings
  • Physiological or psychological problems
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6
Q

Body movements that convey a message.

A

Action Cues or Kinetics

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7
Q

May reflect feeling, mood, underlying physiologic and psychological problems.

A

Action Cues or Kinetics

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8
Q

Dress and grooming as well as furnishings or possessions.

A

Object Cues

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9
Q

Physical distance that needs to be maintained for the person to feel comfortable

A

Personal Space

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10
Q

Proxemics

A
  • Public Space
  • Social-Consultative Space
  • Personal distance
  • Intimate
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11
Q

Public Space

A

12 feet or more

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12
Q

Social-Consultative Space

A

4-12 feet

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13
Q

Personal distance

A

18 inches – 4 ft

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14
Q

Intimate

A

0-18 inches

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15
Q
  • Means of communication.
  • Interpretation is culturally prescribed.
A

Touch

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16
Q

Gaining patient’s trust:

A
  • helps obtain an accurate, comprehensive health history.
  • makes physical assessment quicker and easier for both patient and nurse.
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17
Q

Covert and not measurable.
Referred to as Symptoms

A

Subjective Data

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18
Q

Overt and measurable.
Referred to as Signs.

A

Objective Data

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19
Q

METHODS OF DATA COLLECTION

A
  • Physical Assessment
  • Observation
  • Interview
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20
Q
  • Use of IPPA.
  • Provides the objective database.
A

Physical Assessment

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21
Q
  • Deliberate use of senses to collect data.
  • Assess patient and the environment
A

Observation

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22
Q

Purposeful conversation between the nurse and the patient

A

Interview

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23
Q

Purpose of Interview:

A
  • Gather data
  • Establish rapport
  • Teach the patient
  • Health promotion
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24
Q

use of interpersonal skills with empathy, acceptance, and recognition

A

Therapeutic use of Self

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25
Q
  • Are nonverbal communication and listening skills
  • It will show full attention to what the client saying or doing
A

ATTENDING SKILLS

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26
Q

LOVERS meaning Attending Skills

A

Lean Forward
Open Stance
Verbal Output Modulated
Eye Contact
Relaxed Mode
Sit at 45 Degree Angle

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27
Q

TYPES OF QUESTIONS

A
  • Close –ended questions
  • Open-ended questions
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28
Q

Physical distance that needs to be maintained for the person to feel comfortable

A

Personal Space

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29
Q

TYPES OF INTERVIEW

A
  • Directive Interview
  • Nondirective Interview
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30
Q

structured and controlled by the nurse

A

Directive Interview

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31
Q

interview controlled by the patient

A

Nondirective Interview

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32
Q

PHASES OF INTERVIEW

A
  1. INTRODUCTORY PHASE
  2. WORKING PHASE
  3. TERMINATION PHASE
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33
Q

INTRODUCTORY PHASE

A
  • Self introduction
  • Purpose of interview
  • Time frame
  • Confidentiality
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34
Q

WORKING PHASE

A
  • Data collection
  • Longest phase
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35
Q

TERMINATION PHASE

A
  • Summary
  • Follow-up plans
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36
Q

INTERVIEW TECHNIQUES

A
  • Affirmation/Facilitation
  • Silence
  • Clarifying
  • Restating
  • Active Listening
  • Broad or General Openings
  • Reflection
  • Informing
  • Redirecting
  • Focusing
  • Sharing Perceptions
  • Sequencing Events
  • Suggesting
  • Presenting Reality
  • Summarizing
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37
Q

Acknowledging patient’s responses

A

Affirmation/Facilitation

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38
Q

Nonverbal gestures, such as nodding or sitting up and leaning forward, encourage your patient to continue

A

Affirmation/Facilitation

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39
Q

Periods of silence allow patient to collect her or his thoughts before responding and help prevent hasty responses that may be inaccurate. Silence also gives nurse more time to think and plan a response.

A

Silence

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40
Q

If nurse is unsure or confused about what the patient is saying, rephrase what she said and then ask the patient to clarify

A

Clarifying

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41
Q

Restating the patient’s main idea shows him that you are listening, allows you to acknowledge your patient’s feelings, and encourages further discussion

A

Restating

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42
Q

It also helps clarify and validate what patient has said and may help identify teaching needs

A

Restating

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43
Q

Pay attention, maintain eye contact, and really listen to what patient tells the nurse both verbally and nonverbally

A

Active Listening

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44
Q

conveys interest and acceptance. If nurse is unsure or confused about what the patient is saying, rephrase
what she said and then ask the patient to clarify.

A

Active Listening

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45
Q

This technique is effective when nurses want to hear what is important to the patient

A

Broad or General Openings

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46
Q

“What would you like to talk about?” If nurse is unsure or confused about what the patient is saying, rephrase what she said and then ask the patient to clarify

A

Broad or General Openings

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47
Q

Allows nurse to acknowledge patient’s feelings, encouraging further discussion

A

Reflection

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48
Q

When patient expresses a thought or feeling, nurses echo it back, usually in the form of a question

A

Reflection

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49
Q

Giving information allows patient to be involved in his or her healthcare decisions

A

Informing

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50
Q

Redirecting patient helps keep the communication goal-directed. It is especially useful if your patient goes off on a tangent.

A

Redirecting

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51
Q

allows you to hone in on a specific area, encouraging further discussion

A

Focusing

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52
Q

With this technique, nurse give interpretation of what has been said in order to clarify things and prevent misunderstandings

A

Sharing Perceptions

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53
Q

If patient is having trouble sequencing events, nurse may need to help patient place the events in proper order

A

Sequencing Events

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54
Q

Start at the beginning and work through the event until the conclusion

A

Sequencing Events

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55
Q

Presenting alternative ideas gives patient options

A

Suggesting

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56
Q

This is particularly helpful if the patient is having difficulty verbalizing his or her feelings

A

Suggesting

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57
Q

If patient seems to be exaggerating or contradicting the facts, help her or him reexamine what has already been said and be more realistic

A

Presenting Reality

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58
Q

is useful at the conclusion of a major section of the interview

A

Summarizing

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59
Q

It allows the patient to clarify any misconceptions you may have

A

Summarizing

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60
Q

INTERVIEWING PITFALSS

A
  • Leading
  • Letting Family Members Answer
  • Asking More Than One Question At A time
  • Not Allowing Enough Response Time
  • Using Medical Jargon
  • Assuming
  • Taking Patient’s Response Personally
  • False Reassurance
  • Persistent Questioning
  • Changing The Subject
  • Jumping to Conclusion
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61
Q
  • People will tell you what you want to hear. So don’t lead the patient.
  • Having him or her describe what is happening in his or her own words is much more helpful.
A

Leading

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62
Q

You will learn a lot more by having the patient describe things in her or his own words

A

Letting Family Members Answer

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63
Q

The patient may not know which one to answer. Or the nurse may not be sure which question is being answered

A

ASKING MORE THAN ONE QUESTION AT A TIME

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64
Q

Give the patient time to think through his or her answer. This is especially important with older patients.

A

NOT ALLOWING ENOUGH RESPONSE TIME

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65
Q

Express your questions in lay terms to make sure your patient understands you

A

USING MEDICAL JARGON

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66
Q

can lead to inaccurate interpretations and incorrect conclusions.

A

Assuming

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67
Q
  • An angry or frustrated patient may verbally attack the nurse or the healthcare facility.
  • Realize that the patient is displacing her or his feelings on you and using you as a sounding board.
A

TAKING PATIENT’S RESPONSE PERSONALLY

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68
Q

Telling the patient that everything will be fine is condescending. It may not be.

A

FALSE REASSURANCE

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69
Q
  • Persistent or probing questions make your patient uncomfortable.
  • Remember, the patient has a right to not answer a question
A

PERSISTENT QUESTIONING

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70
Q
  • Some nurses change the subject when the interview is making them uncomfortable.
  • This is not very helpful for the patient.
A

CHANGING THE SUBJECT

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71
Q
  • Make sure all the facts have been gathered before drawing conclusions.
A

JUMPING TO CONCLUSIONS

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72
Q

Provides holistic, qualitative picture of the patient

A

HEALTH HISTORY

73
Q

Purposes of Health History

A
  • Provide subjective database.
  • Identify patient strengths
  • Identify health problems
  • Identify supports
  • Identify teaching, discharge, and referral needs.
74
Q
  • Cause
  • Preexisting medical conditions. Plan for the health problem
A

Medical History

75
Q
  • Effect
  • Health and life effect. Strength and support. Coping strategies
A

Nursing History

76
Q

Health History Types

A

Focused and Comprehensive

77
Q
  • Emergency
  • Not enough time
A

Focused

78
Q
  • After stabilization of health condition
  • 30 minutes to 1 hour
A

Comprehensive

79
Q

Biographical Data

A

Name
Address and Phone Number
Age and birth date
Birthplace
Gender
Marital Status
Race
Religion
Educational Level
Occupation
Contact Person

80
Q

Reason for Seeking Healthcare

A
  • Patient’s perspective on the problem.
  • Brief and spontaneous statement in the patient’s own words.
  • The chief complaint is not a diagnostic statement. Avoid translating it into medical terms.
81
Q

The ______________________ is not a diagnostic statement. Avoid translating it into medical terms.

A

chief complaint

82
Q

Current Health Status

A
  • Usual health status
  • Any major health problems
  • Usual patterns of healthcare
  • Health concerns
83
Q

Current Health Status (PQRST)

A
  • Precipitating/Palliative Factors
  • Quality/Quantity
  • Region/Radiation/Related Symptoms
  • Severity
  • Timing
84
Q

▪What were you doing when the problem started?

A

Precipitating/ Palliative Factors

85
Q

Does anything make it better, such as medications, or certain positions?

A

Precipitating/ Palliative Factors

86
Q

Does anything make it worse, such as movement or breathing?

A

Precipitating/ Palliative Factors

87
Q

Can you describe the symptom?

A

Quality / Quantity

88
Q

To what degree does this problem affect your ability to perform your ADL?

A

Quality / Quantity

89
Q

How often are you experiencing it?

A

Quality / Quantity

90
Q

What does it feel like, look like, or sound like?

A

Quality / Quantity

91
Q

▪ Can you point where the problem is?
▪ Does it occur or spread anywhere else?
▪ Do you have any other symptoms?

A

Region / Radiation / Related Symptoms

92
Q

▪ Is the symptom, mild, moderate, or severe?
▪ Grade it on a scale of 0 to 10.

A

Severity

93
Q

▪ When did the symptom start?
▪ How often does it occur?
▪ How long does it last?

A

Timing

94
Q

Medications

A

▪ Prescriptions, OTC, herbal remedies
▪ Vitamins, birth control pills
▪ Dose and schedule
▪ Adverse reactions of medications
▪ Evaluation of medications taken

95
Q

✓ Identify health factors from the past that have a direct relationship to patient’s current health status.
✓ Identifies any chronic preexisting health problems

A

Past Health History

96
Q

Past Health History

A

▪ Childhood illnesses
▪ Hospitalizations
▪ Surgeries
▪ Serious injuries
▪ Serious/Chronic illness
▪ Immunizations
▪ Allergies
▪ Medications
▪ Recent travel

97
Q

short statement about general state of health

A

Well person

98
Q

chronological record of the reason for seeking care, from the time the symptom first started until now

A

Ill person

99
Q

Provides clues to genetically linked or familial diseases that may be risk factors for the patient.

A

Family History

100
Q

Focuses on health promotion, protective patterns, and roles and relationships

A

Psychosocial Profile

101
Q

Psychosocial Profile

A

▪ Health practices and beliefs
▪ Typical day
▪ Nutritional patterns
▪ Activity and exercise pattern
▪ Recreation, hobbies, pets
▪ Sleep/rest patterns
▪ Personal habits
▪ Occupational health problem
▪ Socioeconomic status
▪ Environmental health problems
▪ Roles, relationship, self-concept
▪ Cultural influences
▪ Religious/spiritual influences
▪ Family roles and relationships
▪ Sexuality pattern
▪ Social supports
▪ Stress and coping patterns

102
Q

Includes client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care

A

BIOGRAPHIC DATA

103
Q

The client’s answer to the question “What brought you to the hospital?” or “What is troubling you?” is expressed in the client’s own words

A

CHIEF COMPLAINT OR REASON FOR VISIT

104
Q

This includes the onset of symptoms, when the symptoms started, if its development was sudden or gradual, severity and frequency of occurrence, the site or exact location of
distress; the character of the complaint, its intensity or quality of discharge, sputum, etc.; activity of the client which may be involved in the development of the problem,
phenomena or symptoms associated with the chief complaint, and the factors that aggravate or alleviate the problem.

A

HISTORY OF PRESENT ILLNESS

105
Q

This includes childhood illnesses, immunizations, allergies to drugs, animals, or other environmental agents, accidents and injuries, hospitalizations for serious illnesses, and
medications currently used.

A

PAST HISTORY

106
Q

This is to ascertain risk factors for diseases. Particular attention should be given to disorders such as diseases of the heart, tuberculosis, cancer, diabetes, hypertension,
obesity, allergies, arthritis, bleeding, alcoholism, and any mental disorders.

A

FAMILY HISTORY OF ILLNESS

107
Q

This includes personal habits, diet, sleep/ rest patterns, activities of daily living, instrumental activities of daily living, recreation or hobbies.

A

LIFESTYLE

108
Q

This pertains to quality of family relationships/friendships, ethnic affiliation, educational background, occupational history, economic status, home and neighborhood conditions.

A

SOCIAL DATA

109
Q

These are major stressors experienced by the client and their perception of them, how they cope up with these stressors, their communication to relay appropriate emotions

A

PSYCHOLOGICAL DATA

110
Q

Includes all the health care resources that the client is currently using and has used in the past

A

PATTERNS OF HEALTH CARE

111
Q
  • Litany of questions specific to each body system.
  • Questions are about most frequently occurring symptoms related to each system.
A

Review of Systems

112
Q

▪ Perception
▪ Opinion
▪ True for the patient
▪ May or may not be true to you
▪ OPINION

A

SUBJECTIVE DATA

113
Q

▪ Reproducible findings
▪ True for the patient and for you
▪ True for you and others
▪ FACT

A

OBJECTIVE DATA

114
Q

PURPOSE OF PHYSICAL EXAMINATION

A

▪ Obtain baseline data about the client’s functional abilities
▪ Supplement, confirm, or refute data obtained in the nursing history
▪ Obtain data that will establish nursing diagnosis and plan
▪ Evaluate the physiological outcomes of healthcare
▪ Make clinical judgments about client’s health status
▪ Identify areas of health promotion and disease prevention
▪ Discover you patient’s strengths

115
Q

Types of physical assessment

A

▪ Complete
▪ Focused

116
Q

Establish or monitor health status

A

Complete Physical Examination

117
Q

Components of Complete Physical Examination

A

✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals
Anus
Lower extremities

118
Q

Focused Physical Examination
Used when:

A

▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up

119
Q

Components of Focused Physical Examination

A

▪ General survey
▪ Vital signs
▪ Assessment of the specific area or system
▪ Quick cephalocaudal scan

120
Q

Preparation

A

▪ Yourself
▪ The environment
▪ The patient

121
Q

Preparing yourself

A

▪ Identify yourself
▪ Appear calm and organized
▪ As a beginner, avoid interpreting your findings
▪ Observe standard and universal precaution

122
Q

Preparing client

A

▪ Explain where and when the examination will take place
▪ Explain what will happen during the examination
▪ Explain where and when the examination will take place
▪ Explain what will happen during the examination

123
Q

Preparing the Environment

A

▪ Temperature
▪ Lighting
▪ Privacy and noise
▪ Positioning
▪ Draping
▪ Instrumentation
▪ Methods of Examining

124
Q

Positioning
Consider:

A

▪ Client’s ability to assume a position
▪ Physical condition
▪ Energy level
▪ Age

125
Q

Different Position

A

Sitting
Supine
Dorsal recumbent
Lithotomy
Prone
Sim’s
Knee chest position

126
Q

A seated position, back unsupported and legs hanging freely

A

Sitting

127
Q

Back-lying position with legs extended; with or without pillow under the head

A

Supine

128
Q

Back-lying position with knees flexed and hips externally
rotated; small pillow under the head; soles of feet on the surface

A

Dorsal recumbent

129
Q

Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table

A

Lithotomy

130
Q

Lies on abdomen with head turned to the side, with or without a small pillow

A

Prone

131
Q

Side-lying position with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow

A

Sim’s

132
Q

knees and chest with head is turned to one side, arms
extended on the bed, and elbows flexed and resting

A

Knee chest position

133
Q
  • Provide privacy and warmth
  • Expose only the area to be assessed
A

Draping

134
Q

▪ Ensure equipment are clean, in good working condition, readily accessible
▪ Designate one area for clean/ unused and another area for dirty/ used

A

Instrumentation

135
Q

Thermometer
Types:

A

▪ Glass mercury thermometer
▪ Electronic digital thermometer
▪ Tympanic thermometer
▪ Temporal artery thermometer
▪ Disposable paper strips

136
Q

▪ Used in indirect auscultation
▪ Tubing should be 30 to 35cm long
▪ Internal diameter of 0.3cm
▪ Has a diaphragm and amplifier (bell)
▪ Have the earpieces pointing forward

A

Stethoscope

137
Q

▪ Fetal heart sounds
▪ Locate pulses

A

Doppler

138
Q

▪ Cuff width should be 40% of the arm circumference
▪ Cuff bladder encircle 80% of the arm

A

Sphygmomanometer

139
Q

▪ To assess far and near vision
▪ Far vision adult: 20 feet
▪ Far vision children: 10 feet
▪ vision: 14 inches
▪ Test each eye separately then both eyes
together
▪ Test with and without correction glasses
▪ No more than 2 mistakes

A

Visual acuity chart

140
Q

visual acuity chart (types)

A

▪ Snellen eye chart
▪ E chart
▪ STYCAR test cards
▪ Pocket vision screener

141
Q

▪ Eyes
▪ Hard-to-see places

A

Penlight

142
Q

▪ Assess the internal structures of the eyes
▪ Always use in dark room
▪ Right- to- right
▪ Left- to- left

A

Ophthalmoscope

143
Q

▪ Always palpate the tragus, helix, mastoid process for tenderness before inserting an otoscope, if tender proceed carefully
▪ Adult: pull the helix up
▪ For preschool child, pull the earlobe down

A

Otoscope/Nasoscope

144
Q

Assess hearing and vibratory sensation

A

Tuning fork

145
Q

testing vibratory sensation

A

Low frequency fork (256Hz)

146
Q

assessing hearing

A

High frequency fork (512Hz)

147
Q

▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height

A

Tape measure/ pocket ruler

148
Q

To assess range of motion exercisesr

A

Goniometer

149
Q

Used to measure body fat

A

Triceps skin fold calipers

150
Q
  • Used to measure weight
  • If obtaining daily weights, weigh the patient at the same time with the same scale
A

Scale

151
Q

▪ Better visualization of the pharynx
▪ Assessing gag reflex
▪ Break tongue depressors after use

A

Wooden tongue depressor

152
Q

▪ Used during neurological examination:
▪ Light touch
▪ Corneal reflex

A

Cotton balls

153
Q

Assess hot and cold sensation

A

Test tubes

154
Q

▪ Assess light touch and pain
▪ Discard after use

A

Safety Pin

155
Q

Use when there is risk for exposure to blood or body fluids

A

Gloves

156
Q

Techniques of Physical Examination

A

▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation

157
Q

▪ Visual examination
▪ Assessing using sense of sight
▪ Moisture
▪ Color
▪ Texture of the body surface
▪ Shape, size, position, color and symmetry of the body
▪ Also use sense of hearing and smell
▪ Use your patient as a comparative

A

Inspection

158
Q

Types of Inspection

A

▪ Direct inspection
▪ Indirect inspection

159
Q

▪ Use of sense of touch
▪ Surface characteristics, texture, consistency, temperature
▪ Masses, organs, pulsation, muscle rigidity, chest excursion
▪ Able to differentiate areas of tenderness from pain

A

Palpation

160
Q

Types of palpation

A

Light palpation
Deep palpation

161
Q
  • Temperature, texture, mobility, shape, size
  • Pulses
  • Areas of edema
  • Tenderness
A

Light palpation

162
Q
  • Organ size, masses
  • Rebound tenderness
  • Voluntary guarding
  • Ballottement
A

Deep palpation

163
Q

Striking a body surface with quick, light blows and eliciting vibrations and sounds

A

Percussion

164
Q

Percussion
Assess:

A
  • Density of underlying structure
  • Areas of tenderness
  • Deep tendon reflexes
165
Q

Types of percussion:

A
  • Direct/Immediate percussion
  • Indirect Percussion
  • Fist or blunt percussion
166
Q

Directly tapping your hand over a body surface

A

Direct/Immediate percussion

167
Q
  • Plexor, pleximeter technique
  • Percussion hammer
A

Indirect Percussion

168
Q
  • Assess organ tenderness
  • Can be direct or indirect
A

Fist or blunt percussion

169
Q

▪ Use of sense of hearing
▪ Assess heart sounds, lung sounds, bowel
sounds, vascular sounds
▪ Pitch (medium, high or low) oIntensity (soft
or loud)
▪ Duration (short or long)
▪ Quality

A

Auscultation

170
Q

Types of auscultation:

A

Direct auscultation
Indirect auscultation

171
Q

Patients with special needs

A

▪ Children
▪ Pregnant patients
▪ Elderly
▪ Disabled patients

172
Q

▪ Adopt an age appropriate approach:
▪ Infants
▪ Children 1 to 2 years old
▪ Children 2 to 3 years old
▪ Children 4 to 5 years old
▪ School- age children
▪ Adolescent
▪ Look for normal growth and developmental changes

A

Children

173
Q

▪ Assess both mother and fetus
▪ Include fundal heights and fetal heart tones
▪ Assess for physiologic changes
▪ Include nutritional assessment
▪ Remember that patients may have difficulty
changing positions
▪ Patients may have mood swings

A

Pregnant Patients

174
Q

▪ Do not rush
▪ Look for developmental changes
▪ Conserve your patient’s energy
▪ Allow enough time to respond

A

Elderly patients

175
Q

▪ Identify the disability
▪ Focus on patient’s functional ability and mental capacity
▪ Modify as necessary

A

Disabled patients

176
Q

PAST HISTORY

A

Illnesses, Immunizations, Allergies, Accidents and Injuries, Hospitalization for serious illnesses, Medications

177
Q

LIFESTYLE

A

Personal habits, Diet, Sleeping patterns, ADLs, Instrumental ADLs, Recreation/hobbies

178
Q

SOCIAL DATA

A

Family relationships/friendships
Ethnic affliation
Educational History
Occupational History
Economic status
Home and neighborhood conditions

179
Q

PSYCHOLOGICAL DATA

A

Major stessors
Usual soping patterns
Communication style

Health Assessment - Lecture (17 decks)

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