Subjective data Flashcards
1
Q
What are the components of a skin (12) subjective assessment?
A
- Previous history of skin disease
- Change in pigmentation
- Change in mole
- Excessive dryness or moisture
- Pruritus
- Excessive bruising
- Rash or lesion
- Medications
- Hair loss
- Change in nails
- Environmental or occupational hazards
- Self-care behaviours
2
Q
What are the components of a CVS (11) subjective assessment?
A
- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis or pallor
- Edema
- Nocturia
- Cardiac history
- Family cardiac history
- Personal habits (cardiac risk factors)
3
Q
What are the components of a head/face/neck (6) subjective assessment?
A
- Headache
- Head injury
- Dizziness
- Neck pain, limitation of motion
- Lumps or swelling
- History of head or neck surgery
4
Q
What are the components of a eyes (11) subjective assessment?
A
- Vision difficulty (decreased acuity, blurring, blind spots)
- Pain
- Strabismus, diplopia
- Redness, swelling
- Watering, discharge
- History of ocular problems
- Glaucoma
- Use of glasses or contact lenses
- Self-care behaviours
- Medications
- Coping with vision changes or loss
5
Q
What are the components of a ears (8) subjective assessment?
A
- Earache
- Infections
- Discharge
- Hearing loss
- Environmental noise
- Tinnitus
- Vertigo
- Self-care behaviours
6
Q
What are the components of a nose (7) subjective assessment?
A
- Discharge
- Frequent colds (upper respiratory infections)
- Sinus pain
- Trauma
- Epistaxis (nosebleeds)
- Allergies
- Altered smell
7
Q
What are the components of a mouth and throat (12) subjective assessment?
A
- Sores or lesions
- Sore throat
- Bleeding gums
- Toothache
- Sugar consumption
- Bruxism (teeth grinding)
- Hoarseness
- Dysphagia
- Altered taste
- Tobacco consumption
- Alcohol consumption
- Sleep apnea
8
Q
What are the components of a respiratory (7) subjective assessment?
A
- Cough
- Shortness of breath
- Chest pain with breathing
- History of respiratory infections
- Smoking history
- Environmental exposure
- Self-care behaviours
9
Q
What are the components of a subjective peripheral vascular (5) assessment?
A
- leg pain/cramps
- skin changes
- swelling in arms and legs
4 . node enlargement - medications
10
Q
What are the 9 components of a subjective endocrine assessment?
A
- Fatigue or lethargy
- Weight gain or loss
- Dizziness
- Feelings of depression, irritability, or anxiety
- Nausea and vomiting
- Changes in urinary or bowel habits
- Changes in vision
- Intolerance to heat or cold
- Change in appetite