Quiz 1 Flashcards
Subjective data
aka review of systems
info pt says
Health history
info based on client’s perception
demographics
hx of illness
family hx
review of systems
social hx
Focused interview
starts with open ended Qs and ends with focused Qs
helps determine differential dx
Differential diagnosis
correct dx out of all possible dx
Objective data
what you observe by examination
How should subjective and objective data be kept?
separate in documentation
What are the methods for validating data?
repeat an assessment
consult w/ another clinician to review data
talk to family
ask clarifying Qs
compara objective vs subjective
What is the order of assessment?
inspect
palpation
percussion
auscultation
depends on system
abdomen:
inspection
auscultation
palpation
percussion
What is important to do with assessment findings?
label
be cautious with abbreviations
What are different types of pain rating scales?
numeric rating scale 0-10
Wong-Baker FACES
PAINAD (pain assessment in advanced dementia)
FLACC (face, legs, activity, cry, consolability)
POLDCART
Previous hx
Onset
Location
Duration
Characteristic
Aggravating factors
Relieving factors
Time
PQRST
Provoking factors
Quality
Radiates to (or Region)
Severity
Time
When inspecting, what should be assessed for each body system?
color
size
shape
contour
symmetry
movement
drainage
color
When palpating, what should be assessed?
size
mobility
position
temperature
texture
tenderness
How is light palpation done?
one handed
with finger pads of dominant hand circular motion
1 cm depth
How is deep palpation done?
extended fingers of non dominant hand
downward
2-4 cm depth