Module 1: Subjective and Objective Data Collection & Documentation

Objectives

  • Develop data collection and assessment skills

  • Competently perform a comprehensive health history and assessment of vital signs and pain on a peer

  • Demonstrate therapeutic communication

  • Perform a self-genogram

  • Differentiate normal and common abnormal assessment findings

  • Document findings of health history

  • Develop date collection and analysis skills

  • Apply pathophysiology concepts to nursing assessment.

  • Link assessment findings with common pathophysiology conditions to create nursing diagnoses

  • Practice assessment techniques safely and professionally

  • Formulate and prioritize nursing diagnosis for a client

Growth and Development

Growth and Development are two different things:

  • Growth is the acquisition of new skills

  • Development is the expansion of said skills

There are different ways to assess growth and development:

  • Assessment of Erikson’s Psychosocial Development

  • Assessment f Piaget’s Cognitive Development

  • Assessment of Kohlberg’s Moral Development

Collecting Subjective Data - The Interview

Usually starts with general survey: gait, mood, hygiene, speech, etc.

Subjective Data - what the client Says

Objective Data - What the nurse Observes

Scopes of Assessment:

  • Initial comprehensive - when a patient first arrives. New pt or initial check up

  • Ongoing or partial - Used when an issue is noticed

  • Focused or problem oriented - what is usually done, but not recognized by the board of nursing

  • Emergency

In EVERY checkup, heart and lungs MUST be CHECKED.

Subjective data;

  • Biographical information

  • history of present illness or concern

  • Past health history

  • Family history - at least parents or siblings

  • Health and lifestyle practices - diet, where they work, physical activity, etc

The Interview:

Where client and nurse relationship and trust is established

Phases of the Interview:

  • Introductory

  • Working

  • Summary and closing

Open ended questions help facilitate cooperation and understanding, allows the pt to address what they deem is important and share more information, explain what their concerns are, shows interest in the pt, and demonstrates willingness to spend time with said pt.

Special Considerations

Gerontologic Populations:

  • Assess heating acuity - check hearing 1st

Clients that may be:

  • anxious - give them time to express their feelings in a healthy way

  • manipulative - need direct statements

  • angry - give them time to express their feelings in a healthy way

  • depressed - give them time to express their feelings in a healthy way

  • seductive - give direct statements

Discussing sensitive issues (dying, spirituality, sexuality)

Using an interpreter - in NCLEX world, it has to be a licensed interpreter

Biographical Data

  • Age

  • Sex

  • Occupation

  • Allergies

  • Marital status

  • Race

  • Ethnic origin

  • Education

  • Primary language

  • Number of children

Reason for Seeking Care

Chief Complaint (CC)

  • What caused them to seek care?

  • Use pt’s own words

History of Present Illness

  • What led up to and what brought them in?

  • Chronological story of what has been happening

  • May use COLDSPA to elicit data

    • EX: Woke up, took a shower, fell in the shower, now I have pain in my lower back that won’t go away

COLDSPA:

C - Character: how does the pain feel, look like, etc.

O - Onset: When did it start?

L - Location: Where is the pain?

D - Duration: how long does the pain last?

S - Severity: On a scale from 0-10, how bad is the pain?

P - Pattern: Is it continuous? Does it come and go? Does it come at the same time or when you do something specific?

A - Associated symptoms: are there other things going on when the pain happens like vomiting, diarrhea, dizziness, etc.

Past Medical History

  • Childhood Illnesses

  • Accidents

  • Injuries

  • Serious/Chronic illnesses

  • Hospitalizations

  • Operations

  • Current Meds

  • OB History

  • Immunizations

  • Last Exam Date

  • Allergies - Always check allergies

Social/Family History

  • Lifestyle factors

  • Blood Relatives - one degree is fine (parents, siblings)

  • Chronic illnesses, what they died of, age of death

  • Genogram

Creating a Genogram

Many health problems are genetically based

Client grew up with these problems in the family and can affect them:

  • Smoking, type 2 diabetes, etc

Genograms maps out the family history with standard format

Should include as many members as the client can recall

  • Can help with identifying autosomal recessive disorders (need two copies of the same gene to have the disorder)

Family Health History:

  • Female relatives - circles

  • Male relatives - square

  • Deceased relatives - X

  • No health problems - A/W (alive and well)

  • Horizontal dotted line - spouse

  • vertical dotted line - adopted

Collecting Objective Data

General Survey:

  • First part of the physical examination

  • Requires all observational skills while interviewing and interacting with client

  • Will lead to clues about health status of client

  • Provides nurse with overall impressions of client’s whole being

Observe:

  • Skin color abnormalities

  • Dress, hygiene

  • Posture, gait, obvious deformities

  • Development and Body Build

  • Age, gender

Assess:

  • Level of Consciousness

  • Comfort, behavior

  • Facial expression, mood, affect

  • Speech

  • Mental Acuities

Standard Precautions:

  • Based on risk assessment

  • hand hygiene:

    • Alcohol-based hand sanitizer

    • Soap and water

  • Gloves

    • Not a substitute for hand hygiene

    • Change gloves as needed

  • Skin and nail care

    • Do not wear artificial nails or extensions

    • Keep natural nails less than ¼ in. long

    • Skin under rings may contain high levels of germs

Client Positioning

Examining Older Adults

Some positions may be very difficult or impossible for older clients

Allow rest periods for older adults if needed

Some adults process information at slower rates, explain procedure and integrate teaching in clear and slow manner (not all).

Preparing the Client

Explain what you’re going to do and ask for consent

Have equipment ready;

  • Thermometer

  • Protective, disposable cover for type of thermometer

  • Aneroid or mercury sphygmomanometer or electronic blood pressure measuring equipment

  • Stethoscope

  • Watch with second hand or cell phone with a timer

  • Hand hygiene

Vital Signs

Temperature

  • Core temperature: 36.5ºC to 37.7ºC (96.0ºF-99.9ºF orally

  • Methods to use: oral, temporal, tympanic, axillary, rectal

  • Variations due to

    • strenuous exercise, stress, ovulation

    • Hypoglycemia, hypothyroidism, or starvation

    • Infection, malignancies, hydration, trauma, and blood, endocrine

    • medications and immune disorders

  • Hypothermia: <36.5ºC or <96ºF

  • Hyperthermia: >38ºC or >100ºF

    • Threshold for fever is 100.4ºF

Pulse

  • Normal adult rate: 60-100 beats/min

    • Tachycardia: >100 beats/min

    • Bradycardia: <60 beats/min

  • Assess rate, rhythm amplitude, contour, and elasticity

  • Amplitude quantified as:

    • 0: Absent

    • 1+ weak, diminished

    • 2+ Normal

    • 3+ bounding

      • When feeling bounding, check blood pressure

  • Thready - not consistent

Respirations

  • Rate and character

  • Observe without letting client know

    • Usually assessed while doing pulse

  • Characteristic:

    • rate

    • rhythm

    • depth

  • Measure O2 Sat

    • SPO2 - 92% to 99% (85%-89% w/ chronic diseases)

Pulse oximetry

  • Measures amount of hemoglobin (oxygenated RBCs) in your blood

  • Works by shining two lights through fingers or earlobes

  • Normal range is 95%-100% in a healthy individual

  • <92% (at rest) requires blood gas analysis

Blood pressure

  • Systole: high point (<120 mmHg)

  • Diastole: low point (<80 mmHg)

  • Affected by blood pressure:

    • Cardiac output

    • Distensibility/elasticity of arteries

    • Blood volume

    • Blood velocity

    • Blood viscocity

  • Optimal: <120/80 mmHg

  • Normal <130/85 mmHg

  • High Normal <139/89

  • Hypertensive >140/90

    • Hypertensive 1 >130/80

  • staged by severity

Older Client Considerations:

  • Temperature may range from 95ºF to 97.5ºF

    • 100ºF can be considered a fever for older clients

  • Osteoporotic thinning and collapse of vertebrae

  • In older men, gait may be wider based, with arms held outwards. Older women tend to have a narrower base and may waddle to compensate for a decreased sense of balance

  • The older client’s arteries may feel more rigid, hard, and bent

  • In the older adult, the respiratory rate may range from 15-22

  • More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults

  • Widening of the pulse pressure is seen with aging due to less elastic peripheral arteries