Subjective Data - Neuro PDF

 Week 8: Subjective Data in the Neurologic System Johns Hopkins School of Nursing Selected Learning Objectives 1. Obtain an accurate nursing history of a client’s neurologic system 2. Describe findings frequently seen when assessing the older client’s nerv...

 Week 8: Subjective Data in the Neurologic System Johns Hopkins School of Nursing Selected Learning Objectives 1. Obtain an accurate nursing history of a client’s neurologic system 2. Describe findings frequently seen when assessing the older client’s nervous system 3  Collecting Subjective Data: HPI ►Do you experience headaches? C: Describe the character of the pain O: When do they occur? L: Point to the location on your head where you feel the headache. D: How long does it last? S: Does it interfere with your ADLs? Rate on a scale of 0-10. P: What relieves the headache or what makes it worse? A: Any associated symptoms? (N/V/dizziness) 4  Collecting Subjective Data: HPI ►Do you experience seizures? How often? ►Describe what happens before you have the seizures. Where on your body does the seizure start? How often? Does anything initiate a seizure? Loss of bladder control? Movement during seizure? How do you feel after? Medications? Medical ID? 5  Collecting Subjective Data: HPI ►Do you experience dizziness or lightheadedness or problems with balance or coordination? If so, how often? When does it occur? Does it occur with activity? Any falls? 6  Collecting Subjective Data: HPI ►Do you experience numbness or tingling/prickling (paresthesia)? C: Describe the sensations (e.g., pins & needles? Burning? Sand running over skin?) O: When does it begin and occur? Occurring now? L: Where do you have this sensation? D: How long does it last? Continuous? S: Does it interfere with your ability to perform activities? P: Does anything relieve or make it worse (activities, rest)? A: Does it occur with other symptoms? 7  Collecting Subjective Data: HPI SENSES ► Have you noticed a decrease in your ability to smell or taste? CN I, VII, or IX dysfunction? Brain tumor? ► Have you experienced any ringing in your ears (tinnitus) or hearing loss? CN VIII dysfunction? ► Have you noticed any change in your vision? CN II dysfunction? Increased ICP? Brain tumor? Image credits: TeachMe Anatomy 8 Collecting Subjective Data: HPI Do you have difficulty understanding when people are talking to you? Do you have difficulty making others understand you? Do you have difficulty forming words (dysarthria) or comprehending and expressing your thoughts (dysphasia or aphasia)? 9  Collecting Subjective Data: HPI ►Do you experience difficulty swallowing (dysphagia)? 10  Collecting Subjective Data: HPI Muscle Control ►Have you lost bowel or bladder control, or do you retain urine? ►Do you have muscle weakness? Do you have any loss of movements? If so, where? ►Do you experience any repetitive, involuntary trembling, quivering, shaking, or other movements? Describe these movements. 11 Collecting Subjective Data: HPI Do you experience any memory loss? 12 Collecting Subjective Data: Past Medical Hx ►Prior head injury with or without consciousness? Describe any physical or mental changes that have occurred as a result. Treatments received? ►Prior hx of meningitis, encephalitis, spinal cord injury, or stroke? 13 Collecting Subjective Data: Family Hx ►Any family hx of high blood pressure, stroke, Alzheimer’s disease, dementia, epilepsy, brain cancer, or Huntington chorea? 14 Collecting Subjective Data: Lifestyle & Health Practices ►Do you take any prescription or nonprescription medications? ►Any alcohol or recreational drug use? ►Do you smoke? ►Do you wear a seatbelt in vehicles and protective headgear when riding a bike or playing sports? 15 Collecting Subjective Data: Lifestyle & Health Practices ►Describe your usual daily 24- hour diet recall. ►Any prolonged exposure to lead, insecticides, pollutants, or other chemicals? ►Do you frequently lift heavy objects or perform repetitive motions? 16 Collecting Subjective Data: Lifestyle & Health Practices ►Can you perform your normal independent activities of daily living? ►Has your neurologic problem changed the way you view yourself or added much stress to your life? Please describe… 17  ► Weber, J. & Kelley, J. (2022). Health assessment in nursing (7th ed.). Philadelphia: Lippincott, Williams, & Wilkins. Referenc ► Image credits are listed in the notes section on applicable slides. es Otherwise, image credits are for Weber & Kelley, 2022. 18 Thank you