Health Assessment: Objective & Subjective Data

• Objective data is factual, measurable, and observable, such as vital signs.
• Subjective data represents the patient's input, feelings, and opinions.
• BMI indicates the average optimal weight for a given height.

Changes with Infants & Children

• Assessment adjustments are needed based on age and developmental ability.
• Behavior and parental bonding are important considerations.
• Measurements and physical growth patterns must be monitored.

Changes with Aging Adults

• Normal aging consequences like posture and gait changes should be expected.
• Measurements may show a general decrease in height and weight.

Purpose of Health History

• Collect subjective data that, when combined with objective data, gives a well-rounded picture of the person's health status, past and present.
• Screen for abnormalities.

Health History Sequence

• Biographic data is collected first.

• Ascertain the source of the history.

• Understand the reason for seeking care.

• Evaluate present health status or history of present illness (HPI).

• Gather information on past health.

• Document family history.

• Perform a review of systems.

• Conduct a functional assessment, including Activities of Daily Living (ADLs).

• A symptom is a subjective sensation the person feels from the disorder.

• A sign is an objective abnormality that can be detected on physical examination or in laboratory reports.

Eight Critical Characteristics of Complaint

• Location of the symptom or issue.
• Character or quality (e.g., stabbing, throbbing, aching).
• Quantity or severity of the symptom.
• Timing, including onset, duration, and frequency.
• Setting in which the symptom occurs.
• Alleviating or aggravating factors.
• Associated factors related to the symptom.
• Patient's perception of the problem.

PQRSTU Pain Mnemonic

• P = Provocative or palliative factors.
• Q = Quality or quantity of pain.
• R = Region or radiation of pain.
• S = Severity on a scale of 1-10.
• T = Timing and onset of pain.
• U = Understanding of patient's perception of the problem.

OLD CARTS Pain Mnemonic

• O = Onset of the pain.

• L = Location of the pain.

• D = Duration of the pain.

• C = Character of the pain.

• A = Alleviating or aggravating factors.

• R = Radiation of the pain.

• T = Timing of the pain.

• S = Severity of the pain.

• The cephalocaudal approach is an organized, logical sequence, proceeding from head to toe.

ADL Functional Assessment

• Assesses self-esteem and self-concept.
• Evaluates activity and exercise levels.
• Determines sleep patterns.
• Assesses nutrition and elimination habits.
• Examines living situations and social habits.
• Explores spiritual resources.
• Looks at stress management techniques.
• Reviews personal habits.
• Investigates drug and alcohol use.
• Identifies environmental or work hazards.
• Screens for intimate partner violence.
• Assesses occupational health.

HEEADSSS Assessment (Children)

• H = Home environment.
• E = Education.
• E = Employment.
• E = Eating habits.
• A = Activities (peer-related).
• D = Drug use.
• S = Sexuality.
• S = Suicide/depression risk.
• S = Safety from injury/violence.

Internal Factors of Good Communication

• Being genuine in interactions.
• Showing empathy, not sympathy.
• Practicing active listening.
• Having self-awareness of implicit biases.

External Factors of Good Communication

• Ensuring privacy during interactions.

• Avoiding interruptions.

• Maintaining equal status seating arrangements.

• Considering appropriate dress.

• Minimizing note-taking.

• EHR is an electronic health record.

Working Phase of Interview

• Data gathering occurs.

• Open and close-ended questions are used.

• Open-ended questions allows respondents to answer in detail.

• Closed questions elicit yes or no answers (specific, forced choice).

10 NOs of Interviewing

• Providing false reassurance.
• Giving unwanted advice.
• Using authority.
• Using avoidance language.
• Distancing oneself.
• Using professional jargon.
• Asking leading or biased questions.
• Talking too much.
• Interrupting the patient.
• Asking "why" questions.

Communicating with Infants (Birth to 12 mo.)

• Use gentle handling with a calm and quiet voice.

Communicating with Toddlers (12-36 mo.)

• Give one direction at a time with simple explanations.

Communicating with Preschoolers (3-6 yr.)

• Use short directions with concrete explanations.

Communicating with School-Age Children (7-12 yr.)

• Ask questions to gather data, and remain non-judgmental.

Communicating with Adolescents (Starting at Puberty)

• Show a respectful and honest attitude, and focus on the individual.

SBAR

• S = Situation (briefly describe the situation).
• B = Background (provide pertinent background information).
• A = Assessment (state your assessment of the situation).
• R = Recommendation/Request (state what you need or recommend).