Subjective data Flashcards

1
Q

What are the components of a skin (12) subjective assessment?

A
  1. Previous history of skin disease
  2. Change in pigmentation
  3. Change in mole
  4. Excessive dryness or moisture
  5. Pruritus
  6. Excessive bruising
  7. Rash or lesion
  8. Medications
  9. Hair loss
  10. Change in nails
  11. Environmental or occupational hazards
  12. Self-care behaviours
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2
Q

What are the components of a CVS (11) subjective assessment?

A
  1. Chest pain
  2. Dyspnea
  3. Orthopnea
  4. Cough
  5. Fatigue
  6. Cyanosis or pallor
  7. Edema
  8. Nocturia
  9. Cardiac history
  10. Family cardiac history
  11. Personal habits (cardiac risk factors)
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3
Q

What are the components of a head/face/neck (6) subjective assessment?

A
  1. Headache
  2. Head injury
  3. Dizziness
  4. Neck pain, limitation of motion
  5. Lumps or swelling
  6. History of head or neck surgery
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4
Q

What are the components of a eyes (11) subjective assessment?

A
  1. Vision difficulty (decreased acuity, blurring, blind spots)
  2. Pain
  3. Strabismus, diplopia
  4. Redness, swelling
  5. Watering, discharge
  6. History of ocular problems
  7. Glaucoma
  8. Use of glasses or contact lenses
  9. Self-care behaviours
  10. Medications
  11. Coping with vision changes or loss
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5
Q

What are the components of a ears (8) subjective assessment?

A
  1. Earache
  2. Infections
  3. Discharge
  4. Hearing loss
  5. Environmental noise
  6. Tinnitus
  7. Vertigo
  8. Self-care behaviours
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6
Q

What are the components of a nose (7) subjective assessment?

A
  1. Discharge
  2. Frequent colds (upper respiratory infections)
  3. Sinus pain
  4. Trauma
  5. Epistaxis (nosebleeds)
  6. Allergies
  7. Altered smell
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7
Q

What are the components of a mouth and throat (12) subjective assessment?

A
  1. Sores or lesions
  2. Sore throat
  3. Bleeding gums
  4. Toothache
  5. Sugar consumption
  6. Bruxism (teeth grinding)
  7. Hoarseness
  8. Dysphagia
  9. Altered taste
  10. Tobacco consumption
  11. Alcohol consumption
  12. Sleep apnea
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8
Q

What are the components of a respiratory (7) subjective assessment?

A
  1. Cough
  2. Shortness of breath
  3. Chest pain with breathing
  4. History of respiratory infections
  5. Smoking history
  6. Environmental exposure
  7. Self-care behaviours
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9
Q

What are the components of a subjective peripheral vascular (5) assessment?

A
  1. leg pain/cramps
  2. skin changes
  3. swelling in arms and legs
    4 . node enlargement
  4. medications
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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
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