subjective/objective Flashcards by Chelle Ace

this is the integral part of interviewing to obtain a nursing history

collecting subjective data

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this is obtained thru interviewing

information

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establishing rapport and trusting relationship that gathers info on development, psychological, physiological. sociocultural status to identify deviations that can be treated

interviewing

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these are problems in the mind that manifest physically

somatic

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what are the 4 phases of interview?

preintroductory phase
introductory phase
working phase
summary and closing phase

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this phase includes introducing yourself to the patient, purpose of the interview and providing privacy or confidentiality

introductory phase

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this phase considers the client’s past health history and may compare it to the new findings acquired

preintroductory phase

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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

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nurse summarizes information obtained during the working phase and validates problems and goals with the client

summary and closing phase

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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

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three communication variations in interview

gerontologic
emotional
cultural

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nonverbal communication (6) in interview

appearance- (professional)
demeanor- (professional poise)
facial expression (neutral nd friendly)
attitude- (nonjudgmental attitude)
silence
listening

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COLDSPA

C-haracter
O-nset
L-ocation/radiation
Duration
Severity
Pattern
Associated factors

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this is abou tall body systems that help to reveal concerns as part of the comprehensive health assessment

review of systems

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state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

health

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get to know the status, professional clinical judgment to formulate diagnosis. this is a continuous collection/documentation of data

Assessment

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2 components of health assessment in nursing

health history
physical exam

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thisis when the cause of a disease is unknown

idiopathic

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this is the chance of recovery

prognosis

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this is the systematic client-centered method for studying the delivery of nursig care. prvides structure for nursing practice

Nursing process

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what are the purpose of nursing process?

identify status, need or problems and establish plans to meet needs.

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determines whether it should be terminated, continued or changed

evaluation

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this includes evaluation of health status and how those specific needs will be addressed

health assessment in nursing

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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

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2 types of data

1. subjective data 2. 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

1. initial comprehensive assessment 2. problem-focused 3. partial ongoing assessement 4. emergency assessment 5. 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

1. prepare self 2. 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

1. problem focused diagnosis 2. health promotion diagnosis 3. risk nursing diagnosis 4. 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

Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns,

nursing diagnosis