Health Assessment and Data Collection

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Questions and Answers

What type of data includes information such as vital signs and laboratory results?

Primary Data

Biographical Data

Objective Data (correct)

Subjective Data

Which statement best describes subjective data?

It is collected solely through physical examinations.

It can be perceived and verified only by the client. (correct)

It typically represents data obtained from family members.

It includes observable and measurable findings.

How often should pain assessments be completed according to the established guidelines?

Once a day

Every shift

Every 2 hours

Every 4 hours (correct)

What is a primary source of data collection in health assessments?

Direct interview with the client Signup and view all the answers

Which of the following is NOT included in the components of subjective data?

Body measurements Signup and view all the answers

Which of these is a characteristic of objective data?

It can be directly observed or measured. Signup and view all the answers

Which of the following responsibilities does a nurse have during a pain assessment?

Evaluating the impact of pain on the patient's daily life. Signup and view all the answers

What does the term 'pain' encompasses according to the provided content?

A subjective sensory and emotional experience. Signup and view all the answers

What pain scale is suitable for children ages 3 and older?

Wong-Baker Faces Pain Scale Signup and view all the answers

What is the maximum score possible on the CRIES pain scale?

10 Signup and view all the answers

Which pain scale is specifically recommended for non-verbal patients?

CPOT Signup and view all the answers

Which pain assessment tool is appropriate for infants under 6 months?

CRIES Signup and view all the answers

How is the FLACC scale scored?

0-10, categorized with face, legs, activity, cry, and consolability Signup and view all the answers

What does the acronym CPOT stand for?

Critical Care Pain Observation Tool Signup and view all the answers

Which pain scale ranges from 0 to 10 based on a numeric system?

Numeric Pain Intensity Scale Signup and view all the answers

For which age group is the FLACC scale not valid?

Children with developmental delay Signup and view all the answers

Study Notes

Data Collection and Pain Assessment

Health assessment is a systematic method for gathering and analyzing data to plan patient-centered care.
Physical examination uses techniques to collect objective data from head to toe.
Data collection must be systematic and continuous to prevent omitting significant information and reflect a client's changing health status.

Types of Collected Data

Subjective Data (Stated): Refers to symptoms or covert data; verbal statements from the patient during an interview. It can only be described or verified by the patient.
- Includes biographical data, reasons for seeking care, history of current health concerns, past health history, family health history, lifestyle/health practices profile, and developmental level.
Objective Data (Observed): Refers to signs or overt data; evident, measurable observations such as vital signs, odors, redness, hostile behaviors, and findings from lab tests or medical imaging. It can be seen, heard, felt, or smelled and obtained by observation or physical exam.
- Includes physical characteristics, body functions, appearance, behavior, measurements, and results of lab tests.

Pain Assessment

Pain is a subjective, unpleasant sensory and emotional experience.
Pain assessments should be completed every 4 hours, and vital signs should be taken.
Pain assessment on admission includes: previous pain experiences, effects on the patient, methods used (helpful or not), a history of substance abuse, and how the patient describes/shows pain. Patient's medications (including OTC and herbal remedies) should also be considered. Establish an acceptable pain level with the patient.

Nurse Responsibility

Upon admission, all patients will be assessed for pain using one of the following scales:
- Numeric Pain Intensity Scale
- Wong-Baker Faces Pain Scale
- FLACC (Faces, Legs, Activity, Cries, CONSOL ability)
- CRIES (Crying, Requires oxygen, Increased Vital Signs, Expression, Sleeplessness)
- CPOT (Critical Care Pain Observation Tool)

Pain Scales

Numeric Pain Intensity Scale: Commonly used for hospitalized and nursing home patients, even those with mild to moderate dementia. The scale asks the person to rate their pain on a scale of 0-10, with 0 being no pain and 10 being the worst possible pain.
Wong-Baker FACES Pain Scale: Developed by Donna Wong and Connie Baker, it's for children 3 years or older. A series of faces ranging from a happy face (0) to a crying face (10) helps the patient choose the face that best describes their pain.
FLACC Scale: (Faces, Legs, Activity, Cries, CONSOL ability) Appropriate for children age 2 months to 7 years (not for those with developmental delays). Each category is scored 0-2, allowing a score of 0-10.
CRIES Scale: Recommended for infants under 6 months of age. Scored 0-2 for five categories: Crying, Requires Oxygen, Increased Vital Signs, Expression, and Sleeplessness. Gives a total score of 0-10.
CPOT: Critical Care Pain Observation Tool. For non-verbal or critically ill patients. Scores four categories of Facial expressions, Body movements, Compliance with ventilator, and Muscle tension on a 0-2 scale. Gives a total score of 0-8.

Source of Data Collection

Primary Source: Data about the patient is directly collected from the patient themselves, using an interview and physical examination.
Secondary source: If needed, data is gathered from family members.

Additional Pain Assessment Information

Components of pain assessment: - Location: Precise or general location, diffuses, etc. Diagram can be helpful. - Intensity: Pain's severity description translated into objective scale measure (Numeric, Wong-Baker, FLACC, CRIES, or CPOT). - Quality: Describe using words like stabbing, throbbing, cramping, vise-like, burning, superficial, etc. - Radiation: If pain is spreading from the initial location. - Duration: How long the pain has lasted.

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Description

This quiz covers the essential concepts of health assessment, focusing on both subjective and objective data collection methods. It emphasizes the importance of systematic and continuous data gathering in planning patient-centered care. Test your understanding of the different types of data collected during health assessments.