Unit 6 - Generak Survey (Collecting Subjective Data)

Questions and rationale

General Survey Questions

1. What are your name, address, and telephone number (including cell phone number and email address)?

2. How old are you?

What are your name, address, and telephone number (including cell phone number and email address)?

Answers to these questions provide verifiable and accurate identification data about the client. They also provide baseline information about level of consciousness, memory, speech patterns, articulation, or speech defects. For example, a client who is unable to answer these questions hascognitive/neurologic deficits.

How old are you?

Establishes baseline for comparing appearance and development to chronologic age.

History of Present Health Concern

1. Do you have any present health concerns?

2. Have you had any high fevers that occur often or persistently?

3. Have you noticed any alteration to your heartbeat or a feeling that your heart is either racing or skipping beats?

4. Are you having any difficulty breathing or trouble catching your breath? If so, does this occur at rest or with mild, moderate, or strenuous exercise?

Do you have any present health concerns?

This allows the client to voice their concerns and provides a focus for the examination.

Have you had any high fevers that occur often or persistently?

A pattern of elevated temperatures may indicate a chronic infection such as tuberculosis or blood disorder such as leukemia.

Have you noticed any alteration to your heartbeat or a feeling that your heart is either racing or skipping beats?

An alteration in heartbeat felt by a client is called a “palpitation” and can be caused by various circumstances, including sinoatrial node dysfunction, thyroid dysfunction, medication reaction, or alteration in fluid volume

Are you having any difficulty breathing or trouble catching your breath? If so, does this occur at rest or with mild, moderate, or strenuous exercise?

Difficulty with breathing or dyspnea can be a sign of chronic heart failure (CHF), pneumonia, asthma, bronchitis, chronic obstructive pulmonary disease (COPD), or other chronic lung disease.

Personal History

1. Do you know what your usual blood pressure is?

2. When and where did you last have your blood pressure checked?

3. Are you aware if your heartbeat is unusually fast or slow? Have you ever been diagnosed with a murmur or other heart condition?

4. What medications do you take? Please list prescription and over-the-counter medications, vitamins and minerals, and any herbal supplements taken routinely or on an as-needed basis.

5. What allergies do you have to medications, foods, insects, or the environment?

Do you know what your usual blood pressure is?

Knowing their blood pressure indicates that the client is involved in their own health care and provides a baseline for comparison.

When and where did you last have your blood pressure checked?

Answer provides a baseline for comparison, and indicates if client consults professionals for health care, relies on possibly erroneous equipment in public places (e.g., drug stores), or has approved equipment at home that they are trained to use

Are you aware if your heartbeat is unusually fast or slow? Have you ever been diagnosed with a murmur or other heart condition?

Often, a client will know that their heart rate frequently runs either high or low, especially if taking certain medications. In addition, well-trained athletes will often have a lower than average heart rate due to their level of physical fitness. This is a normal variation in those individuals. Those taking beta blockers may also have a low heart rate.

What medications do you take? Please list prescription and over-the-counter medications, vitamins and minerals, and any herbal supplements taken routinely or on an as-needed basis.

Having a complete list of all medications, vitamins, and herbal supplements is essential in assessing the general status of the client. Many medications have side effects that can alter a client’s vital signs and may even affect general appearance. It is important to have the client bring a list from home that contains all the information needed, including names; dosages; route of administration; and time given for all medications, vitamins, and supplements. Ask client to bring actual medication containers if possible.

What allergies do you have to medications, foods, insects, or the environment?

It is important to gather a client’s list of allergies in order to provide safe nursing care.

Family History

1. Do you have any family history of heart disease, diabetes, thyroid disease, lung disease, high blood pressure, or cancer?

   Are you aware of any other family

   history?

Do you have any family history of heart disease, diabetes, thyroid disease, lung disease, high blood pressure, or cancer?

Are you aware of any other family history?

Frequently, diseases such as heart disease, diabetes, thyroid disease, lung disease, hypertension, or cancer can be hereditary; thus, it is important to ask about them when assessing the general status of your client. Even if there is no personal history of these diseases, the client’s family history would put the client at an increased risk of developing such diseases in the future.

Lifestyle and Health Practices

1. What is your educational background?

2. Are you currently employed? If so, what is your occupation? If not, do you have any disability, or are you seeking employment?

3. How satisfied are you with your life?

4. How often do you seek health care?

5. Do you use any tobacco products including cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?

6. Do you drink alcohol? If so, how much and how often? What type of alcohol do you drink?

   Do you use any illicit drugs? If so, which one(s) and how often?

7. Do you use any recreational drugs/ medical marijuana, cannabidiol (CBD) oils? Explain how often and for what purpose.

8. Do you follow any special diet?

9. Do you exercise regularly? What type of exercise do you do and how often?

What is your educational background?

This gives you a basis for communication and understanding your client’s level of comprehension.

Are you currently employed? If so, what is your occupation? If not, do you have any disability, or are you seeking employment?

An occupation can provide insight into the client’s condition and may lead to identification of significant health concerns.

How satisfied are you with your life?

Asking about life satisfaction can help elicit evidence of or potential for psychological problems such as anxiety, depression, or suicidal ideation, as well as information about developmental level.

How often do you seek health care?

This question provides insight into the client’s health practices.

Do you use any tobacco products including cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?

Tobacco use causes vasoconstriction of blood vessels, which leads to hypertension and/or peripheral vascular disease. Tobacco use can also cause chronic lung disease and/or cancer. Note that e-cigarettes may cause as much or more harm as regular tobacco cigarettes.

Do you drink alcohol? If so, how much and how often? What type of alcohol do you drink?

Do you use any illicit drugs? If so, which one(s) and how often?

Excessive alcohol and/or illicit drug use may indicate poor lifestyle management and may represent psychological illness. These behaviors can also lead to obesityor malnutrition depending on which substance is abused. For example, methamphetamines often cause anorexia and malnutrition, whereas alcoholism can lead to abdominal obesity and malnutrition.

Do you use any recreational drugs/ medical marijuana, cannabidiol (CBD) oils? Explain how often and for what purpose.

In 2018, 11.8 million adults and young adults reported marijuana use (National Institute on Drug Abuse [NIDA], 2019). Although little research on prevalence of CBD use in the United States has beencompleted, a 2019 Gallup poll revealed that 14% of Americans say they use CBD products (Brenan, 2019). The Gallop poll reported that 40% of users utilize CBD products for pain, 20% for anxiety, and 11% for sleep. The poll also reported that 50% did not use CBD products, and 35% of those polled were not at all familiar with CBD products.

Do you follow any special diet?

Clients with hypertension may follow a low-sodium (low-salt) diet. Other clients with obesity may follow a low-fat, low cholesterol, low-carbohydrate diet. Clients with diabetes may consume a specific number of carbohydrates eachday and not eat concentrated sweets or sugar. There are many different diets available to clients. Some are prescribed, whereas others are not. It is important to know what dietary restrictions clients have, as these diets directly affect the client’s general status.

Do you exercise regularly? What type of exercise do you do and how often?

Exercise status can directly affect the musculature and build of a client. Exercise also may reduce anxiety and depression!