NURS 125 - Collecting Data Notes

Expected Outcomes

• Distinguish subjective data collection from objective data collection.
• Distinguish signs from symptoms.
• Assess signs and symptoms using the 10 characteristics of a sign or symptom.
• Define and complete a beginning general survey.
• Describe the components and planning of a health history.

The General Survey

• Begins with the first moment of the encounter and continues throughout the health history.
• First component of the assessment.
• Aids in forming a holistic view of the person.

Components of the General Survey

1. Behavior

   • Level of consciousness (LOC)
   • Facial expression
   • Speech

2. Physical Appearance

   • Overall appearance
   • Breathing
   • Hygiene and dress
   • Skin color and lesions
   • Body structure and development

3. Mobility

   • Posture
   • Range of Motion (ROM)
   • Gait
   • Position of comfort

Level of Consciousness (LOC)

• Assessed through:
  • Orientation: Person, place, time (oriented x 3)
  • Levels of consciousness include confusion, agitation, drowsiness, lethargy, obtunded, stupor, and coma.

Assessment Techniques for LOC

• Spontaneous observation upon entering the room.
• Usual voice: State the patient’s name and ask them to open their eyes.
• Loud voice: Repeat the request more loudly if there is no response.
• Tactile: Lightly touch the patient’s arm/shoulder.
• Pressure: Apply pressure to the nail bed if no response.
• Painful stimuli, e.g., trapezius pinch, but ensure not to cause harm.

Initial Data Collection

Anthropometric Measurements

• Height, weight, calculation of BMI.

Vital Signs

• Reflect health status, cardiopulmonary function, and overall well-being.
• Assess drugs the patient is on prior to vital signs collection.
• Monitoring frequency and establishing baseline readings.

Baseline Data Considerations

• Monitor changes over time: medication dosages, endocrine disorder indicators.
• Pediatric assessments: percentiles, metabolic disorders, weight for age.

Health History Components

1. Demographic Data
   2. Reasons for Seeking care
      • History of present illness (10 attributes)
   3. Health history, allergies & response
   4. Current medications and indications
   5. Family history
   6. Personal and social history
   7. Review of systems
   8. Functional health questions

Signs vs Symptoms

• Signs: Objective data; observable evidence (e.g., rash).
• Symptoms: Subjective; what the patient feels (e.g., pain).

10 Attributes of Signs and Symptoms

1. Location
2. Associated signs and symptoms
3. Timing
4. Environmental or exposure factors
5. Relieving factors
6. Severity/quantity
7. Nature/quality
8. Aggravating factors
9. Patient perspective
10. Significance to client

Cultural & Environmental Considerations

• Culture influences beliefs about health.
• Consider the health status, risk factors, and personal backgrounds affecting medical perceptions.

Documentation Principles

• Accurate and thorough recording of health assessments, observations, and patient interactions is vital.

Review of Systems (ROS)

• Utilize standardized questions, pivot based on patient responses regarding changes or concerns, and approach systematically (head to toe).

Teaching & Health Promotion

• Identify opportunities for providing health education based on gathered information and address patient concerns throughout the assessment.