15 Questions
Which method of data collection involves listening to heart, lung, and gastrointestinal sounds?
Auscultation
What type of data can only be verified by the patient?
Subjective Data
Which step in the nursing process involves recognizing cues and symptoms?
Assessment
In Maslow's Hierarchy of Needs, which level focuses on prioritizing life-threatening cues?
Physiological Needs
Which type of assessment data can be measured against an accepted standard and verified by another observer?
Objective Data
What type of data is characterized by sensations, feelings, values, beliefs, attitudes, and perceptions?
Subjective data
Which method of data collection involves using the senses like vision, hearing, touch, and smell?
Observing
When is it appropriate to use a secondary resource for gathering data according to Taylor et al.?
When the patient is too ill or unconscious
Which type of data is detectable by an observer and can be measured or tested against an accepted standard?
Objective data
Which aspect of data collection involves obtaining information through vision, hearing, touch, and smell?
Observation techniques
What is the primary purpose of a patient interview according to the text?
To identify problems
Which of the following is a common communication error to avoid during an interview?
Ignoring cultural considerations
In nursing physical assessment, what is the main focus according to the provided text?
Appraisal of health status and functional abilities
Which type of questioning technique yields yes or no answers according to the text?
Closed-ended questions
What is the importance of using an interpreter or translator during a patient interview?
To communicate effectively with non-English speaking patients
Study Notes
Collecting Data
- Subjective Data (Symptoms): apparent only to the person affected, can be described/verified only by the person affected, includes sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status and life situations
- Example of Subjective Data: "I feel like my heart is racing" or "I have pain"
Objective Data (Signs)
- Characteristics: detectable by an observer, can be measured or tested against an accepted standard, can be seen, heard, felt, or smelled
- Example of Objective Data: Apical HR 150, regular & strong
Sources of Data
- Primary Sources: the client, family, and support persons
- Secondary Sources: health professionals, medical records (used when the client is unable to communicate, e.g., too ill, unconscious, child, confused, or on request)
Methods of Data Collection
- Observing: gathering data using senses (vision, hearing, touch, and/or smell) to obtain data, such as skin color, body or breath odors, lung or heart sounds, skin temperature
- Interviewing: planned, purposeful communication to obtain or give information, identify problems, evaluate change, teach, and provide support and counseling
- Interview Setting Preparation: time, place, seating arrangements, respectful distance, language, and consideration of interpreters, translators, or family members
- Interview Tips: terminating the interview and assessment, summarizing, and avoiding common communication errors
- Questioning Techniques: closed-ended questions (yielding yes or no answers) and open-ended questions (yielding explanations)
Nursing Physical Assessment
- Focus: client's functional abilities
- Purposes: appraisal of health status, identification of health problems, and establishment of a database for nursing interventions
- Physical Assessment Techniques: observation, inspection, auscultation, palpation, and percussion
- Data obtained: BP, HR, heart, lung, and GI sounds, skin color, temperature, moisture, muscle strength, and more
AAPIE – Assessment
- Assessment: recognize cues, identify priority patient problems, and cluster abnormal cues
- Analysis: analyze cues, prioritize, and identify priority patient problems
- Planning: generate solutions, take action, and evaluate outcome
- Implementation: independent nursing interventions and teaching
Learn about the differences between subjective data (symptoms) and objective data (signs) in healthcare. Understand how subjective data are personal experiences and feelings reported by the patient, while objective data are measurable and observable by healthcare providers.
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