Subjective/ Objective Data Nursing

First-level priority problem

-emergent, life threatening, and immediate -Airway problems; breathing problems; cardiac and circulation problems; Signs (vital signs concerns)

Nursing process

1) Assessment - Collects information. 2) Nursing Diagnosis - Describes health problems. 3) Planning - Setting priorities and goals. 4) Implementation - Carries out the plan (goals). 5) Evaluation - Measures if the goals of the planning step were met.

moderate palpation

1-2 cm depression- easily palpable masses/ structures

deep palpation

2.5-5 cm depression of the surface- one hand on top of other, very deep structures/ organs

increases during pain

BP, RR, PR

Subjective Data

Client's verbal descriptions of health problems, when the patient shares feelings, perceptions, thought and sensation,

orthostatic hypotension

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

decrease in response to pain

Gastric motility, urine output, and insulin release

Severity

How bad is it? How much does it bother you?

Duration

How long does it last? Does it recur

second-level priority problem

Next in urgency; require prompt intervention to prevent deterioration: mental status change or acute pain.

SPIRIT

S- Spiritual belief P- personal spirituality I- integration with spiritual community R- ritualized practices and restritions I- implications for medical care T- terminal events planning * nonformal technique

cultural awareness

being aware of ones own bias

Objective data

can be directly observed by the nurse

Validate dehydration

decreased BP

tympany

gastric bubble, puffed cheek

health history

helps identify nursing problems and focus for examination

third-level priority problem

important to patients health, but can be addressed after more urgrant health problems are addressed.

cultural competence

includes Awareness, Skill, Knowledge, Encounters, and Desire. Allows nurse to integrate a cultural assessment into health assessment of client

Physical exam techniques

inspection, palpation, percussion, auscultation

physical exam technique used first

inspection- least invasive, avoid changing anything when we touch it

How to Collect Subjective data

interview the client

Tympany

loud, high pitched, drumlike sound. Much of abdomen (including hair filled organs)

resonance

loud, low pitch hollow sound. Normal lung tissue

dullness

medoum pitched, thudlike sound. Solid organs (liver, kidney)

Dorsal recumbent

more comfortable for clients with back pain

Parts of Health History

past health history, family history, review of symptoms, lifestyle/ health practices

dullness

percussion over diaphragm, pleural effusion, liver

prone

use to assess back/hip joints

Sitting

use to examine head/neck, back, chest, vitals, upper extremities

sims

use to examine rectal and vaginal

knee-chest

use to examine rectum

lithotomy

used to examine female genitalia, rectum, reproductive organs

standing

used to examine gait, balance, maile genitalia

Supine

uses to examine pulse, breast, abdomen, extremities, lungs, heart

light palpation

very little depression of surface

hyper-resonance

very loud, low pitched, booming sound. Hyper inflated lung (emphysema)

Pattern

what makes it better or worse

Onset

when did it begin

Location

where is it? Does it radiate? Does it occur anywhere else?

Character

discribe the sign or symptom

Daily weights

best measure of hydration status

Associated factors

What do you think caused it to start? Other symptoms with it? How does it affect you (ADL)?