Subjective Data Assessment Flashcards

Questions and Answers

What are general questions to ask in every assessment? (Select all that apply)

Personal/family history. (correct)

Do you have any pets?

Do you smoke, drink, do drugs. (correct)

Medications. (correct)

Which of the following are communication questions to ask during an assessment? (Select all that apply)

Do you have any health concerns?

I will be asking questions about your health, are you comfortable? (correct)

What brings you in today? (correct)

What is your favorite food?

Which questions are relevant to peripheral vascular assessment? (Select all that apply)

Do you have any leg or arm pain? (correct)

Have you ever traveled abroad?

Do you have a history of heart disease?

Have you noticed any skin changes in your arms or legs? (correct)

What are some abdominal questions that can be asked? (Select all that apply)

Do you have abdomen pain? Signup and view all the answers

Which of the following questions pertain to heart and neck vessel assessments? (Select all that apply)

How many pillows do you sleep with at night? Signup and view all the answers

What lung and thorax questions could be relevant in an assessment? (Select all that apply)

Have you ever had shortness of breath? Signup and view all the answers

Which questions are relevant to neurological assessments? (Select all that apply)

Do you have a history of seizures? Signup and view all the answers

Study Notes

General Questions for Every Assessment

Collect personal and family medical history for comprehensive evaluation.
Inquire about lifestyle habits: smoking, alcohol consumption, and drug use.
Document current medications taken by the patient.
Identify any known allergies to prevent adverse reactions.
Assess general health status including diet, exercise, and occupational risk factors.
Discuss any specific health concerns or issues related to the system being evaluated.

Communication with Patients

Introduce yourself by stating your name and position clearly.
Ask an open-ended question such as "What brings you in today?" to facilitate dialogue.
Explain the assessment process, ensuring patients understand and feel comfortable.
Address any cultural considerations that may impact the assessment.
Confirm the purpose of the visit: "I understand you are here for a ___ assessment, is that correct?"
Describe examination procedures clearly, using phrases like "I will be looking, feeling, and listening to you."

Peripheral Vascular Questions

Assess for pain in arms or legs using PQRSTU (provocation, quality, region, severity, timing, understanding).
Check for any observed skin changes in the limbs.
Inquire about temperature fluctuations in arms or legs.
Look for signs of leg vein abnormalities: enlarged or crooked veins.
Ask about presence of leg sores or ulcers.
Assess for swelling in arms or legs.
Inquire about swollen glands in the vicinity.

Abdominal Questions

Assess any changes in appetite that may indicate health issues.
Inquire about difficulty swallowing (dysphagia).
Identify any dietary restrictions or foods that cannot be consumed.
Discuss any reported abdominal pain.
Inquire about nausea or vomiting episodes.
Ask frequency of bowel movements for gastrointestinal health evaluation.
Request a 24-hour dietary recall to assess nutrition and habits.

Heart and Neck Vessel Questions

Screen for chest pain or tightness using PQRSTU assessment.
Inquire about instances of shortness of breath (dyspnea).
Determine how many pillows the patient uses for comfort during sleep, indicating potential orthopnea.
Ask if the patient has experienced coughing episodes.
Discuss fatigue levels: whether they tire easily and can keep up with family members or coworkers.
Investigate if there have been changes in skin color, such as turning blue or ashen.
Inquire about swelling in feet or legs.
Ask about nocturia (waking at night to urinate) and stress levels.

Lung and Thorax Questions

Assess for the presence of a cough during respiratory evaluation.
Check for any history of shortness of breath.
Inquire about chest pain experienced while breathing.
Document recent tuberculosis skin test results along with pneumonia or influenza vaccinations.

Neurological Questions

Screen for frequent or severe headaches that may indicate neurological issues.
Inquire about any past head injuries and the use of helmets for protection.
Assess for dizziness or vertigo symptoms.
Investigate any history of seizures.
Inquire about tremors that could suggest neurological dysfunction.
Discuss muscle weakness in the body, asking for specific areas affected.
Evaluate coordination issues that may impact daily activities.
Check for numbness or tingling sensations in extremities.
Ask about any swallowing difficulties to assess cranial nerve function.

Description

Explore essential questions for gathering subjective data during patient assessments. These flashcards cover various aspects like personal history, health status, and communication techniques essential for healthcare professionals. Test your knowledge and ensure you're prepared for effective patient interactions.