Objective and Subjective data

What are the 6 types of subjective data?

1. Chief complaint 2. History of Present illness 3. Past medical history 4. Family History 5. Personal and Social History 6. Review of Systems

Name the history & Physical diagnosis plan of care

1. Collect subjective data 2. collect objective data 3. establish a differential diagnosis 4. establish a diagnosis 5. establish a plan of care

Name the physical examination techniques

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

What are the three categories of objective data?

1. Physical Examination 2. Laboratory Studies 3. Imaging and Diagnostic Studies

stethoscope diaphragm

Auscultate breath sounds

Pressure Ulcer Scale for Healing (PUSH)

Determine the degree of healing of a pressure ulcer

fingerpads

Fine discriminations: pulses, texture, size, consistency, shape, crepitus

Bubble of blood under skin- collection of blood- squishy

Hematoma

4 types of assessment

Initial comprehensive ongoing or partial focused or problem orientated emergency assessment

sphygomanometer and stethoscope

Measure diastolic and systolic blood pressure. Stethoscope to auscultate blood sounds when measuring blood pressure

metric ruler

Measure size of skin lesions

skinfold calipers

Measure skinfold thickness of subcutaneous tissue

Nursing- holistic and focused on care Medical- could be from a specific problem

Nursing diagnosis vs medical diagnosis

Nursing diagnosis

Nursing diagnosis+ related to factors + as evidenced by (data from health assessment-subjective and/or objective)

objective data

Physical characteristics (e.g., skin color, posture) Body functions (e.g., heart rate, respiratory rate) Appearance (e.g., dress and hygiene) Behavior (e.g., mood, affect) Measurements (e.g., blood pressure, temperature, height, weight) Results of laboratory testing (e.g., platelet count, x-ray findings) This type of data is obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation. Another source of objective data is the client's medical/health record, which is the document that contains information about what other health care professionals (i.e., nurses, physicians, physical therapists, dietitians, social workers) observed about the client.

Alternation in normal skin

Primary lesion

gloves and gown

Protect examiner in any part of the examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items, or when disease-causing agents could be transmitted to or from the client

Ulcer formed in alternation of normal skin

Secondary lesion

emergency assessment

a very rapid assessment performed in life-threatening situations In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment. An example of an emergency assessment is the evaluation of the client's airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected. The major and only concern during this type of assessment is to determine the status of the client's life-sustaining physical functions.

Bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

ongoing or partial assessment

consists of data collection that occurs after the comprehensive database is established. This consists of a minioverview of the client's body systems and holistic health patterns as a follow up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data

Focused or Problem Oriented Assessment

does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not address areas not related to the problem.

initial comprehensive assessment

involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client's overall functioning) as well as objective data gathered during a step-by-step physical examination.

thermometer

measures temperature

down back

move the ear ____ and ____ when taking tympanic temperature of child

up back

move the ear ____ and _______ when taking tympanic temperature of an adult

30

take pulse and respiration rate for ________ sec when regular

1 min

take pulse and respiration rate for __________ when irregular

dorsal of hand

temperature

tuning fork

test for bone and air conduction of sound

Watch with second hand

time heart rate, fetal pulse, or bowel sounds when counting

stethoscope bell

Auscultate the thyroid

Braden Scale for predicting Pressure sore risk

Predict one's risk to develop pressure sore

subjective data

sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client (Fig. 1-7). To elicit accurate subjective data, learn to use effective interviewing skills with a variety of clients in different settings. The major areas of subjective data include: Biographical information (name, age, religion, occupation) History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) Personal health history Family history Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment) Review of systems

snellen e chart

Test distant vision

woods light

Test for fungus

opaque card

Test for strabismus

penlight

Test pupillary constriction

ulnar or palmar surface

Vibrations, thrills, fremitus

otoscope

View the ear canal and tympanic membrane

opthalmoscope

View the red reflex and to examine the retina of the eye