Podcast
Questions and Answers
Which of the following is an example of subjective data?
Which of the following is an example of subjective data?
- Skin color is pale
- Pulse rate of 75 bpm
- Blood pressure reading of 120/80 mmHg
- Patient reports fatigue (correct)
What is primarily assessed in a functional assessment?
What is primarily assessed in a functional assessment?
- Specific medical conditions
- Objective vital statistics
- Family medical history
- Ability to perform activities of daily living (correct)
Which component of the health history includes details of previous surgeries and chronic illnesses?
Which component of the health history includes details of previous surgeries and chronic illnesses?
- Past medical history (correct)
- Chief complaint
- Review of systems
- Social history
What is the purpose of a cultural assessment in nursing?
What is the purpose of a cultural assessment in nursing?
What normal pulse rate range is expected for adults?
What normal pulse rate range is expected for adults?
Which of the following factors are considered under social determinants of health (SDOH)?
Which of the following factors are considered under social determinants of health (SDOH)?
What is the primary aim of therapeutic communication in the nursing process?
What is the primary aim of therapeutic communication in the nursing process?
What vital signs measurement method is preferred for infants?
What vital signs measurement method is preferred for infants?
Flashcards
Health History
Health History
Information about the patient's health gathered by the nurse, either from the patient or during a physical examination.
Subjective Data (Symptoms)
Subjective Data (Symptoms)
Anything the patient tells about their health. This includes their feelings, experiences, and concerns.
Objective Data (Signs)
Objective Data (Signs)
Measurable and observable information about the patient's health. This includes physical exam findings and lab results.
Review of Systems (ROS)
Review of Systems (ROS)
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Temperature
Temperature
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Pulse
Pulse
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Functional Assessment
Functional Assessment
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Cultural Assessment
Cultural Assessment
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Study Notes
Nurse Assessment
- Recognizing Cues: Nurses assess subjective (symptoms) and objective (signs) data for changes in patient condition. Identifying warning signs is essential.
- Subjective Data (Symptoms): Patient reports feelings, experiences, and concerns (e.g., pain, dizziness, fatigue).
- Objective Data (Signs): Measurable or observable information (e.g., vital signs, physical examination, lab results).
- Health History: Comprehensive information about the patient's health.
- Components:
- Chief complaint: Main concern.
- History of present illness (HPI): Detailed description of current problem.
- Past medical history: Previous surgeries, chronic illnesses.
- Family history: Medical conditions within the family.
- Social history: Lifestyle, tobacco/alcohol use, sexual health, employment.
- Review of systems (ROS): Evaluation of all body systems for symptoms.
- Purpose: Guide diagnosis and treatment.
- Components:
- Functional Assessment: Assessing a patient's self-care abilities.
- Components: Daily living activities (ADLs), mobility, self-care, social interactions.
- Purpose: Assess independent functioning and identify potential quality of life issues.
- Cultural Assessment: Recognizing cultural beliefs affecting healthcare.
- Purpose: Identify cultural practices impacting patient decisions and compliance.
- Social Determinants of Health (SDOH): Barriers related to socioeconomic factors (e.g., income, education, healthcare access).
- Important Practices: Understanding cultural practices influencing health (e.g., diet restrictions, treatment preferences, religious beliefs).
- Therapeutic Communication: Building trust and promoting safety for the patient during information gathering.
- Purpose: Establish trust, gain information, and address patient safety and comfort during history-taking.
Vital Signs
- Temperature:
- Normal Ranges: 36-37°C (96.8-98.6°F) orally, different ranges for axillary, temporal, tympanic, and rectal (for core temperature).
- Fever Causes: Infection, inflammation, trauma.
- Pulse:
- Newborn Normal: 110-160 bpm.
- Adult Normal: 60-100 bpm.
- Factors Affecting Pulse: Fever, pain, anxiety, activity, stimulants.
- Respiration:
- Procedure: Count for one full minute (rate, depth, pattern, effort).
- Adult Normal: 12-20 breaths per minute.
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