Subjective/ Objective Data Nursing

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Subjective Data
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Client’s verbal descriptions of health problems, when the patient shares feelings, perceptions, thought and sensation,
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Objective data
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can be directly observed by the nurse
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How to Collect Subjective data
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interview the client
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health history
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helps identify nursing problems and focus for examination
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Parts of Health History
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past health history, family history, review of symptoms, lifestyle/ health practices
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Character
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discribe the sign or symptom
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Onset
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when did it begin
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Location
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where is it? Does it radiate? Does it occur anywhere else?
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Duration
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How long does it last? Does it recur
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Severity
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How bad is it? How much does it bother you?
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Pattern
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what makes it better or worse
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Associated factors
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What do you think caused it to start? Other symptoms with it? How does it affect you (ADL)?
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Supine
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uses to examine pulse, breast, abdomen, extremities, lungs, heart
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Sitting
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use to examine head/neck, back, chest, vitals, upper extremities
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Dorsal recumbent
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more comfortable for clients with back pain
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sims
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use to examine rectal and vaginal
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prone
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use to assess back/hip joints
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knee-chest
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use to examine rectum
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lithotomy
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used to examine female genitalia, rectum, reproductive organs
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standing
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used to examine gait, balance, maile genitalia
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Physical exam techniques
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inspection, palpation, percussion, auscultation
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physical exam technique used first
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inspection- least invasive, avoid changing anything when we touch it
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light palpation
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very little depression of surface
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moderate palpation
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1-2 cm depression- easily palpable masses/ structures
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deep palpation
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2.5-5 cm depression of the surface- one hand on top of other, very deep structures/ organs
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resonance
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loud, low pitch hollow sound. Normal lung tissue
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hyper-resonance
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very loud, low pitched, booming sound. Hyper inflated lung (emphysema)
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Tympany
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loud, high pitched, drumlike sound. Much of abdomen (including hair filled organs)
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dullness
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medoum pitched, thudlike sound. Solid organs (liver, kidney)
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orthostatic hypotension
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Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions
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Nursing process
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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.
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SPIRIT
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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
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cultural awareness
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being aware of ones own bias
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increases during pain
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BP, RR, PR
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decrease in response to pain
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Gastric motility, urine output, and insulin release
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cultural competence
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includes Awareness, Skill, Knowledge, Encounters, and Desire. Allows nurse to integrate a cultural assessment into health assessment of client
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Validate dehydration
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decreased BP
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Daily weights
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best measure of hydration status
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First-level priority problem
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-emergent, life threatening, and immediate -Airway problems; breathing problems; cardiac and circulation problems; Signs (vital signs concerns)
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second-level priority problem
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Next in urgency; require prompt intervention to prevent deterioration: mental status change or acute pain.
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third-level priority problem
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important to patients health, but can be addressed after more urgrant health problems are addressed.
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dullness
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percussion over diaphragm, pleural effusion, liver
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tympany
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gastric bubble, puffed cheek

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