Collecting Subjective and Objective Data Flashcards
1
Q
Is the process of sharing information and meaning, and of sending and receiving messages
A
COMMUNICATION
2
Q
Messages can be
A
- Verbal
- Nonverbal
3
Q
- More accurate than the verbal one.
- Should coincide with the verbal data.
A
NONVERBAL MESSAGES
4
Q
Quality of the voice and its inflections, tone, intensity, and speed when speaking
A
Vocal Cues or Paralinguistics
5
Q
Vocal characteristics reflects:
A
- feelings
- Physiological or psychological problems
6
Q
Body movements that convey a message.
A
Action Cues or Kinetics
7
Q
May reflect feeling, mood, underlying physiologic and psychological problems.
A
Action Cues or Kinetics
8
Q
Dress and grooming as well as furnishings or possessions.
A
Object Cues
9
Q
Physical distance that needs to be maintained for the person to feel comfortable
A
Personal Space
10
Q
Proxemics
A
- Public Space
- Social-Consultative Space
- Personal distance
- Intimate
11
Q
Public Space
A
12 feet or more
12
Q
Social-Consultative Space
A
4-12 feet
13
Q
Personal distance
A
18 inches – 4 ft
14
Q
Intimate
A
0-18 inches
15
Q
- Means of communication.
- Interpretation is culturally prescribed.
A
Touch
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.
17
Q
Covert and not measurable.
Referred to as Symptoms
A
Subjective Data
18
Q
Overt and measurable.
Referred to as Signs.
A
Objective Data
19
Q
METHODS OF DATA COLLECTION
A
- Physical Assessment
- Observation
- Interview
20
Q
- Use of IPPA.
- Provides the objective database.
A
Physical Assessment
21
Q
- Deliberate use of senses to collect data.
- Assess patient and the environment
A
Observation
22
Q
Purposeful conversation between the nurse and the patient
A
Interview
23
Q
Purpose of Interview:
A
- Gather data
- Establish rapport
- Teach the patient
- Health promotion
24
Q
use of interpersonal skills with empathy, acceptance, and recognition
A
Therapeutic use of Self
25
- Are nonverbal communication and listening skills
- It will show full attention to what the client saying or doing
ATTENDING SKILLS
26
LOVERS meaning Attending Skills
Lean Forward
Open Stance
Verbal Output Modulated
Eye Contact
Relaxed Mode
Sit at 45 Degree Angle
27
TYPES OF QUESTIONS
- Close –ended questions
- Open-ended questions
28
Physical distance that needs to be maintained for the person to feel comfortable
Personal Space
29
TYPES OF INTERVIEW
- Directive Interview
- Nondirective Interview
30
structured and controlled by the nurse
Directive Interview
31
interview controlled by the patient
Nondirective Interview
32
PHASES OF INTERVIEW
1. INTRODUCTORY PHASE
2. WORKING PHASE
3. TERMINATION PHASE
33
INTRODUCTORY PHASE
- Self introduction
- Purpose of interview
- Time frame
- Confidentiality
34
WORKING PHASE
- Data collection
- Longest phase
35
TERMINATION PHASE
- Summary
- Follow-up plans
36
INTERVIEW TECHNIQUES
- Affirmation/Facilitation
- Silence
- Clarifying
- Restating
- Active Listening
- Broad or General Openings
- Reflection
- Informing
- Redirecting
- Focusing
- Sharing Perceptions
- Sequencing Events
- Suggesting
- Presenting Reality
- Summarizing
37
Acknowledging patient’s responses
Affirmation/Facilitation
38
Nonverbal gestures, such as nodding or sitting up and leaning forward, encourage your patient to continue
Affirmation/Facilitation
39
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.
Silence
40
If nurse is unsure or confused about what the patient is saying, rephrase what she said and then ask the patient to clarify
Clarifying
41
Restating the patient’s main idea shows him that you are listening, allows you to acknowledge your patient’s feelings, and encourages further discussion
Restating
42
It also helps clarify and validate what patient has said and may help identify teaching needs
Restating
43
Pay attention, maintain eye contact, and really listen to what patient tells the nurse both verbally and nonverbally
Active Listening
44
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.
Active Listening
45
This technique is effective when nurses want to hear what is important to the patient
Broad or General Openings
46
“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
Broad or General Openings
47
Allows nurse to acknowledge patient’s feelings, encouraging further discussion
Reflection
48
When patient expresses a thought or feeling, nurses echo it back, usually in the form of a question
Reflection
49
Giving information allows patient to be involved in his or her healthcare decisions
Informing
50
Redirecting patient helps keep the communication goal-directed. It is especially useful if your patient goes off on a tangent.
Redirecting
51
allows you to hone in on a specific area, encouraging further discussion
Focusing
52
With this technique, nurse give interpretation of what has been said in order to clarify things and prevent misunderstandings
Sharing Perceptions
53
If patient is having trouble sequencing events, nurse may need to help patient place the events in proper order
Sequencing Events
54
Start at the beginning and work through the event until the conclusion
Sequencing Events
55
Presenting alternative ideas gives patient options
Suggesting
56
This is particularly helpful if the patient is having difficulty verbalizing his or her feelings
Suggesting
57
If patient seems to be exaggerating or contradicting the facts, help her or him reexamine what has already been said and be more realistic
Presenting Reality
58
is useful at the conclusion of a major section of the interview
Summarizing
59
It allows the patient to clarify any misconceptions you may have
Summarizing
60
INTERVIEWING PITFALSS
- 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
61
- 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.
Leading
62
You will learn a lot more by having the patient describe things in her or his own words
Letting Family Members Answer
63
The patient may not know which one to answer. Or the nurse may not be sure which question is being answered
ASKING MORE THAN ONE QUESTION AT A TIME
64
Give the patient time to think through his or her answer. This is especially important with older patients.
NOT ALLOWING ENOUGH RESPONSE TIME
65
Express your questions in lay terms to make sure your patient understands you
USING MEDICAL JARGON
66
can lead to inaccurate interpretations and incorrect conclusions.
Assuming
67
- 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.
TAKING PATIENT’S RESPONSE PERSONALLY
68
Telling the patient that everything will be fine is condescending. It may not be.
FALSE REASSURANCE
69
- Persistent or probing questions make your patient uncomfortable.
- Remember, the patient has a right to not answer a question
PERSISTENT QUESTIONING
70
- Some nurses change the subject when the interview is making them uncomfortable.
- This is not very helpful for the patient.
CHANGING THE SUBJECT
71
- Make sure all the facts have been gathered before drawing conclusions.
JUMPING TO CONCLUSIONS
72
Provides holistic, qualitative picture of the patient
HEALTH HISTORY
73
Purposes of Health History
- Provide subjective database.
- Identify patient strengths
- Identify health problems
- Identify supports
- Identify teaching, discharge, and referral needs.
74
- Cause
- Preexisting medical conditions. Plan for the health problem
Medical History
75
- Effect
- Health and life effect. Strength and support. Coping strategies
Nursing History
76
Health History Types
Focused and Comprehensive
77
- Emergency
- Not enough time
Focused
78
- After stabilization of health condition
- 30 minutes to 1 hour
Comprehensive
79
Biographical Data
Name
Address and Phone Number
Age and birth date
Birthplace
Gender
Marital Status
Race
Religion
Educational Level
Occupation
Contact Person
80
Reason for Seeking Healthcare
- 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
The ______________________ is not a diagnostic statement. Avoid translating it into medical terms.
chief complaint
82
Current Health Status
- Usual health status
- Any major health problems
- Usual patterns of healthcare
- Health concerns
83
Current Health Status (PQRST)
- Precipitating/Palliative Factors
- Quality/Quantity
- Region/Radiation/Related Symptoms
- Severity
- Timing
84
▪What were you doing when the problem started?
Precipitating/ Palliative Factors
85
Does anything make it better, such as medications, or certain positions?
Precipitating/ Palliative Factors
86
Does anything make it worse, such as movement or breathing?
Precipitating/ Palliative Factors
87
Can you describe the symptom?
Quality / Quantity
88
To what degree does this problem affect your ability to perform your ADL?
Quality / Quantity
89
How often are you experiencing it?
Quality / Quantity
90
What does it feel like, look like, or sound like?
Quality / Quantity
91
▪ Can you point where the problem is?
▪ Does it occur or spread anywhere else?
▪ Do you have any other symptoms?
Region / Radiation / Related Symptoms
92
▪ Is the symptom, mild, moderate, or severe?
▪ Grade it on a scale of 0 to 10.
Severity
93
▪ When did the symptom start?
▪ How often does it occur?
▪ How long does it last?
Timing
94
Medications
▪ Prescriptions, OTC, herbal remedies
▪ Vitamins, birth control pills
▪ Dose and schedule
▪ Adverse reactions of medications
▪ Evaluation of medications taken
95
✓ Identify health factors from the past that have a direct relationship to patient’s current health status.
✓ Identifies any chronic preexisting health problems
Past Health History
96
Past Health History
▪ Childhood illnesses
▪ Hospitalizations
▪ Surgeries
▪ Serious injuries
▪ Serious/Chronic illness
▪ Immunizations
▪ Allergies
▪ Medications
▪ Recent travel
97
short statement about general state of health
Well person
98
chronological record of the reason for seeking care, from the time the symptom first started until now
Ill person
99
Provides clues to genetically linked or familial diseases that may be risk factors for the patient.
Family History
100
Focuses on health promotion, protective patterns, and roles and relationships
Psychosocial Profile
101
Psychosocial Profile
▪ 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
Includes client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care
BIOGRAPHIC DATA
103
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
CHIEF COMPLAINT OR REASON FOR VISIT
104
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.
HISTORY OF PRESENT ILLNESS
105
This includes childhood illnesses, immunizations, allergies to drugs, animals, or other environmental agents, accidents and injuries, hospitalizations for serious illnesses, and
medications currently used.
PAST HISTORY
106
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.
FAMILY HISTORY OF ILLNESS
107
This includes personal habits, diet, sleep/ rest patterns, activities of daily living, instrumental activities of daily living, recreation or hobbies.
LIFESTYLE
108
This pertains to quality of family relationships/friendships, ethnic affiliation, educational background, occupational history, economic status, home and neighborhood conditions.
SOCIAL DATA
109
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
PSYCHOLOGICAL DATA
110
Includes all the health care resources that the client is currently using and has used in the past
PATTERNS OF HEALTH CARE
111
- Litany of questions specific to each body system.
- Questions are about most frequently occurring symptoms related to each system.
Review of Systems
112
▪ Perception
▪ Opinion
▪ True for the patient
▪ May or may not be true to you
▪ OPINION
SUBJECTIVE DATA
113
▪ Reproducible findings
▪ True for the patient and for you
▪ True for you and others
▪ FACT
OBJECTIVE DATA
114
PURPOSE OF PHYSICAL EXAMINATION
▪ 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
Types of physical assessment
▪ Complete
▪ Focused
116
Establish or monitor health status
Complete Physical Examination
117
Components of Complete Physical Examination
✓ General survey
✓ Vital signs
✓ Head
✓ Neck
✓ Upper extremities
✓ Chest and back
✓ Abdomen
✓ External genitals
Anus
Lower extremities
118
Focused Physical Examination
Used when:
▪ patient is unstable
▪ Time constraints exist
▪ Episodic follow-up
119
Components of Focused Physical Examination
▪ General survey
▪ Vital signs
▪ Assessment of the specific area or system
▪ Quick cephalocaudal scan
120
Preparation
▪ Yourself
▪ The environment
▪ The patient
121
Preparing yourself
▪ Identify yourself
▪ Appear calm and organized
▪ As a beginner, avoid interpreting your findings
▪ Observe standard and universal precaution
122
Preparing client
▪ 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
Preparing the Environment
▪ Temperature
▪ Lighting
▪ Privacy and noise
▪ Positioning
▪ Draping
▪ Instrumentation
▪ Methods of Examining
124
Positioning
Consider:
▪ Client’s ability to assume a position
▪ Physical condition
▪ Energy level
▪ Age
125
Different Position
Sitting
Supine
Dorsal recumbent
Lithotomy
Prone
Sim’s
Knee chest position
126
A seated position, back unsupported and legs hanging freely
Sitting
127
Back-lying position with legs extended; with or without pillow under the head
Supine
128
Back-lying position with knees flexed and hips externally
rotated; small pillow under the head; soles of feet on the surface
Dorsal recumbent
129
Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
Lithotomy
130
Lies on abdomen with head turned to the side, with or without a small pillow
Prone
131
Side-lying position with lowermost arm behind the body,
uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
Sim’s
132
knees and chest with head is turned to one side, arms
extended on the bed, and elbows flexed and resting
Knee chest position
133
- Provide privacy and warmth
- Expose only the area to be assessed
Draping
134
▪ Ensure equipment are clean, in good working condition, readily accessible
▪ Designate one area for clean/ unused and another area for dirty/ used
Instrumentation
135
Thermometer
Types:
▪ Glass mercury thermometer
▪ Electronic digital thermometer
▪ Tympanic thermometer
▪ Temporal artery thermometer
▪ Disposable paper strips
136
▪ 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
Stethoscope
137
▪ Fetal heart sounds
▪ Locate pulses
Doppler
138
▪ Cuff width should be 40% of the arm circumference
▪ Cuff bladder encircle 80% of the arm
Sphygmomanometer
139
▪ 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
Visual acuity chart
140
visual acuity chart (types)
▪ Snellen eye chart
▪ E chart
▪ STYCAR test cards
▪ Pocket vision screener
141
▪ Eyes
▪ Hard-to-see places
Penlight
142
▪ Assess the internal structures of the eyes
▪ Always use in dark room
▪ Right- to- right
▪ Left- to- left
Ophthalmoscope
143
▪ 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
Otoscope/Nasoscope
144
Assess hearing and vibratory sensation
Tuning fork
145
testing vibratory sensation
Low frequency fork (256Hz)
146
assessing hearing
High frequency fork (512Hz)
147
▪ Lengths and circumferences
▪ Abdominal girth
▪ Fundal height
Tape measure/ pocket ruler
148
To assess range of motion exercisesr
Goniometer
149
Used to measure body fat
Triceps skin fold calipers
150
- Used to measure weight
- If obtaining daily weights, weigh the patient at the same time with the same scale
Scale
151
▪ Better visualization of the pharynx
▪ Assessing gag reflex
▪ Break tongue depressors after use
Wooden tongue depressor
152
▪ Used during neurological examination:
▪ Light touch
▪ Corneal reflex
Cotton balls
153
Assess hot and cold sensation
Test tubes
154
▪ Assess light touch and pain
▪ Discard after use
Safety Pin
155
Use when there is risk for exposure to blood or body fluids
Gloves
156
Techniques of Physical Examination
▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation
157
▪ 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
Inspection
158
Types of Inspection
▪ Direct inspection
▪ Indirect inspection
159
▪ 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
Palpation
160
Types of palpation
Light palpation
Deep palpation
161
- Temperature, texture, mobility, shape, size
- Pulses
- Areas of edema
- Tenderness
Light palpation
162
- Organ size, masses
- Rebound tenderness
- Voluntary guarding
- Ballottement
Deep palpation
163
Striking a body surface with quick, light blows and eliciting vibrations and sounds
Percussion
164
Percussion
Assess:
- Density of underlying structure
- Areas of tenderness
- Deep tendon reflexes
165
Types of percussion:
- Direct/Immediate percussion
- Indirect Percussion
- Fist or blunt percussion
166
Directly tapping your hand over a body surface
Direct/Immediate percussion
167
- Plexor, pleximeter technique
- Percussion hammer
Indirect Percussion
168
- Assess organ tenderness
- Can be direct or indirect
Fist or blunt percussion
169
▪ 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
Auscultation
170
Types of auscultation:
Direct auscultation
Indirect auscultation
171
Patients with special needs
▪ Children
▪ Pregnant patients
▪ Elderly
▪ Disabled patients
172
▪ 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
Children
173
▪ 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
Pregnant Patients
174
▪ Do not rush
▪ Look for developmental changes
▪ Conserve your patient’s energy
▪ Allow enough time to respond
Elderly patients
175
▪ Identify the disability
▪ Focus on patient’s functional ability and mental capacity
▪ Modify as necessary
Disabled patients
176
PAST HISTORY
Illnesses, Immunizations, Allergies, Accidents and Injuries, Hospitalization for serious illnesses, Medications
177
LIFESTYLE
Personal habits, Diet, Sleeping patterns, ADLs, Instrumental ADLs, Recreation/hobbies
178
SOCIAL DATA
Family relationships/friendships
Ethnic affliation
Educational History
Occupational History
Economic status
Home and neighborhood conditions
179
PSYCHOLOGICAL DATA
Major stessors
Usual soping patterns
Communication style
