18 Questions
What is the primary source of data in assessing a client's airway, breathing status, and circulation after a cardiac arrest?
Data directly gathered from the client
Which method of data collection involves a planned conversation with the client to identify problems or provide support?
Interview
What type of questions are closed questions typically answered with?
'Yes' or 'No'
Which type of questions require more time and aim to understand the patient's perceptions?
Open questions
What senses and instruments are used during observation to gather data?
Touch and Smell
Where does secondary source data come from in the assessment process?
Client's medical records
What are the four physical examination techniques that use the senses to detect health problems?
Inspection, palpation, percussion, and auscultation techniques
Which type of data is gathered by interacting with the client to understand their feelings, perceptions, and concerns?
Subjective data
What do we call symptoms that are noticed in a specific area or part of the body related to a particular disease?
Local symptoms
What type of data is observable, measurable, and obtained through physical examination and diagnostic tests?
Objective data
What is a method used primarily for collecting subjective data during assessments?
Interviewing the client
Which technique occurs in the initial stages of a disease, such as a running nose as an initial stage of measles?
Prodromal symptoms
What is the main purpose of a health assessment?
To gather information about the health status of the patient and make judgments for nursing interventions.
What type of assessment is performed to determine the status of a specific problem identified in an earlier assessment?
Problem-focused assessment
Which type of assessment is done during any physiological crisis of the client to identify life-threatening problems?
Emergency assessment
What is the main goal of an initial assessment?
To establish a baseline of information on the client and develop a database.
What type of questions should a nurse use to gather subjective data during a health history?
Open-ended questions
Which type of data does a nurse collect through physical examination as part of a health assessment?
Objective data
Study Notes
Physical Examination Techniques
- Uses the senses of sight, hearing, smell, and touch to detect health problems
- Four techniques used: Inspection, Palpation, Percussion, and Auscultation
Types of Data
- Two types of data collected through assessment:
- Subjective data (symptoms): gathered by interacting with the client, including feelings, perceptions, and concerns
- Objective data (signs): observable and measurable, obtained through physical examination and diagnostic tests
Subjective Data Examples
- "I drink only coffee for breakfast."
- "I have had pains in my legs for three days now."
- "I go to sleep easily each night, but I wake up about two hours later and cannot go back to sleep until it is time to get up in the morning."
Objective Data Examples
- T 98.6_F, P 100, R 12, BP 130/76
- Bowel sounds auscultated in all four quadrants
- Gait slow, shuffling, and unsteady
Types of Symptoms
- Local symptoms: noticed in a special area or part of the body as of a particular disease
- Prodromal symptoms: occur in the initial stages of the disease
- Ongoing symptoms: includes systematic monitoring and observation related to specific problem
Sources of Data
- Primary source: data gathered directly from the client using interview and physical examination
- Secondary sources: data gathered from client's family members, significant others, client's medical records/chart, other members of health team, and related care literature/journals
Methods of Data Collection
- Interview: a planned, purposeful conversation with the client to gather information
- Observation: gathering data using the 5 senses and instruments
- Physical examination techniques: using inspection, palpation, percussion, and auscultation
Interview
- A planned, purposeful conversation with the client to gather information
- Types of questions:
- Closed questions: elicit a "yes" or "no" response
- Open questions: elicit the patient's perceptions
Health Assessment
- Definition: systematic collection, validation, organization, interpretation, and documentation of data for use by health care professionals
- Includes both a health history and a physical examination
- Purpose:
- To establish a database concerning a client's physical, psychosocial, and emotional health
- To identify health-promoting behaviors and actual and/or potential health problems
- To obtain data to establish nursing care
- To provide data for diagnostic phase
Types of Assessment
- Initial assessment: performed within a specified time on admission
- Problem-focused assessment: used to determine status of a specific problem identified in an earlier assessment
- Emergency assessment: rapid assessment done during any physiologic/physiologic crisis of the client to identify life-threatening problems
Learn about the four physical examination techniques: Inspection, Palpation, Percussion, and Auscultation, which use the senses to detect health problems. Explore the types of data collected during assessments, including subjective data (symptoms) and objective data.
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