subjective/objective Flashcards
this is the integral part of interviewing to obtain a nursing history
collecting subjective data
this is obtained thru interviewing
information
establishing rapport and trusting relationship that gathers info on development, psychological, physiological. sociocultural status to identify deviations that can be treated
interviewing
these are problems in the mind that manifest physically
somatic
what are the 4 phases of interview?
- preintroductory phase
- introductory phase
- working phase
- summary and closing phase
this phase includes introducing yourself to the patient, purpose of the interview and providing privacy or confidentiality
introductory phase
this phase considers the client’s past health history and may compare it to the new findings acquired
preintroductory phase
this is the phase of taking notes/ documentation about major biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems (ROS) for current health problems, lifestyle and health practices, and developmental level.
working phase
nurse summarizes information obtained during the working phase and validates problems and goals with the client
summary and closing phase
elements in the working phase
- major biographical data,
- reasons for seeking care,
- history of present health concern, 4. past health history,
- family history,
- review of body systems (ROS)
- lifestyle and health practices, and 8. developmental level
three communication variations in interview
- gerontologic
- emotional
- cultural
nonverbal communication (6) in interview
- appearance- (professional)
- demeanor- (professional poise)
- facial expression (neutral nd friendly)
- attitude- (nonjudgmental attitude)
- silence
- listening
COLDSPA
C-haracter
O-nset
L-ocation/radiation
Duration
Severity
Pattern
Associated factors
this is abou tall body systems that help to reveal concerns as part of the comprehensive health assessment
review of systems
state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
health
get to know the status, professional clinical judgment to formulate diagnosis. this is a continuous collection/documentation of data
Assessment
2 components of health assessment in nursing
- health history
- physical exam
thisis when the cause of a disease is unknown
idiopathic
this is the chance of recovery
prognosis
this is the systematic client-centered method for studying the delivery of nursig care. prvides structure for nursing practice
Nursing process
what are the purpose of nursing process?
identify status, need or problems and establish plans to meet needs.
determines whether it should be terminated, continued or changed
evaluation
this includes evaluation of health status and how those specific needs will be addressed
health assessment in nursing
what is the purpose of health assessment in nursing?
to collect data that will identify problems in every stages t oprevent rootcause and extent of disease
2 types of data
- subjective data
- objective data
this is the info that a healthcare professional gathers thru physical examination and observation of nurse
objective data
what are the 5 different types of assessment
- initial comprehensive assessment
- problem-focused
- partial ongoing assessement
- emergency assessment
- time lapsed reassessment
time performed for initial comprehensive assessment
during admission
time performed for problem focused
ongoing process
time performed for partial on going assessment
whenever the nurse encounters the patient
this type of assessment assesses the input and output of the patient or the “GENITO URINARY SYSTEM”
partial ongoing process
time performed for emergency assessment
rapid/psychological crisis
time performed for time-lapsed reassessment
several months after initial assessment
how do you prepare for physical examination
- prepare self
- prepare client
this is a positioning technique to expose upper extremities, allow full expansion of lungs
sitting postion
this is a positioning technique where all extremities, and peripheral sites are accessible. this also allows ABDOMINAL MUSCLES TO RELAX
supine position
this is a positioning technique where there is less pressure on the back/abdomen because abdominal muscles are CONTRACTED. ideal for clients with back pain
dorsal recumbent postion
this is a positioning technique allow VAGINAL ACCESS
sim’s positon
this is a positioning technique where posture, balance and gait can be assessed. ideal for examining male genitalia
standing position
this is a positioning technique where hip and back is assessed. however not for cardiac/ respiratory problems
prone position
this is a positioning technique where RECTUM can be assessed however not ideal for elderly, respiratory and cardiac problems
knee chest position
this is a positioning technique where genitalia, rectum, reproductive tracts are being assessed. this is assisted w feet stirrups
lithotomy position
confirming or validating data. discrepancies bet. collected subjective and objective data
validating data
promotes communication, endorsement, formulate diagnoses and plan immediate and ongoing interventions
documentation of data
2 sources of data
primary (client)
secondary (relative/fam/patient records)
a clinical judgment about indiv, fam or community responses to actual and potential health problems/life processes
Diagnosis
4 categories of nursing diagnosis
- problem focused diagnosis
- health promotion diagnosis
- risk nursing diagnosis
- syndrome diagnosis
this is the actual diagnosis, problem present at the time of assessment
problem focused diagnosis
preparedness to implement behavior to improve their health condition
health promotion diagnosis
problem does not exists. presense of RISK factors
risk nursing diagnosis
cluster of nursing diagnosis
syndrom diagnosis
what is the PES format?
problem-etiology-signs and symptoms
physical assessment techniques P.A.P.I
percussion
auscultation
palpation
inspection
this is an emotional/mental pain
psychological pain
this is a process of somatization when psychological pain becomes physical pain
psychosomatic pain
this is a pain caused by nerve receptors detecting harmful stimuli.
skin, muscles, bones, connective tissue
nociceptive pain
this is a damage of any level of the NERVOUS SYSTEM (peripheral nerves, spinal brain)
Neuropathic pain
responses both causing nociceptive and neurologic pain
inflammatory pain
2 aspects of inflammatory pain
inflammatory pain
immune pain
pain originating from the skin or superficial tissues
cutaneous pain
pain describes pain emanating from the internal thoracic, pelvic, or abdominal organs.
visceral pain
pain in the ligament, blood vessels
deep somatic pain
pain in the body areas AWAY from the pain force
referred pain
pain in removed/amputated body
phantom pain
associated w recent injury
acute
non malignant pain, constant pain for more than 6 months
chronic
damage caused by surgery, CHEMO
cancer pain
the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature. temperature returns to acceptable value atleast once in 24 hours
intermittent fever
a wide range of temperature fluctuation (more than 2 ° c) occurs over the 24 hr period, all of which are above normal
fever spikes and falls without a return to the normal temperature levels, fluctuating but doesn’t return to normal
Remittent fever
short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
period of febrile periods interspersed with acceptable temperature values
Relapsing fever
the body temperature fluctuates minimally but always remains above normal
temperature remains continuously elevated above 38 degrees celsius and demonstrates little fluctuation
Sustained/ Constant fever
> 40.5C
hyperpyrexia
37.1 -38.2
low grade fever
is scored on a 0-2 scale, which results in a total pain score between 0 and 10. The child should be observed briefly and then scored each category based on the description supplied.
FLACC SCALE
TYPES Of INTERVIEW (6) TECHNIQUES
1 open minded questions
2. close ended questions - specific type
3. laundry list approach- diff types of pain
4. making observations
5. restate/rephrasing- based on client statement
6. encourage verbalizing
instructions to help patient achieve the health care goal
nursing interventions
established in a nursing care plan in terms of observable client responses–hopes to achieve by implementing nursing orders
goal
Collecting subjective and objective data
assessment
Generating solutions, developing a plan, and determining which outcomes need to be met first
planning
