NURS 125: Collecting Data Summary

Expected Outcomes

  • Distinguish between subjective and objective data collection

    • Subjective data: Information based on personal views or feelings
    • Objective data: Information measured and observed through examinations

  • Distinguish signs from symptoms

    • Signs: Objective evidence of disease observable by the healthcare provider
    • Symptoms: Subjective experiences reported by the patient

  • Assess signs and symptoms using the 10 Characteristics of a Sign or Symptom

  • Define and complete a beginning general survey of the patient

  • Describe the components of a health history, including planning and sequencing

The General Survey

  • Definition: Starts from the first encounter with the patient and continues throughout the assessment.
  • Purpose: To develop a holistic impression of the patient's overall condition.
  • Focus Areas:
    • Physical Appearance: Overall appearance, breath, hygiene, skin color, and lesions
    • Behavior: Level of consciousness, facial expressions, speech
    • Mobility: Posture, range of motion (ROM), gait, position of comfort

Level of Consciousness (LOC)

  • Assessment: Observations and responses of the patient indicating the level of awareness.
    • Orientation: Person, place, time (Orientated X 3)
    • **States of Consciousness:
      • Normal
      • Confusion
      • Agitation
      • Restlessness
      • Drowsiness
      • Lethargy
      • Obtunded
      • Stupor
      • Coma**
    • Observation Techniques:
      • Spontaneous observation
      • Usual and loud voice prompts
      • Tactile and pressure stimuli
      • Pain responses (e.g., trapezius pinch)

Initial Data Collection

Anthropometric Measurements
  • Height and Weight
  • BMI Calculation: Indicates overall health status.
Vital Signs
  • Importance: Reflects health status and function of cardiovascular and body systems.
  • Frequency: Depends on the patient's baseline and health conditions.

Baseline Data Changes

  • Tracks changes in:
    • Medication dosages
    • Signs of endocrine disorders or other health issues
Pediatric Assessment
  • Monitoring developmental percentiles and detecting possible health concerns such as:
    • Failure to thrive (FTT)
    • Metabolic disorders
Cardiac/Renal Patient Assessment
  • Daily Weight Measurements for monitoring changes.

Health History and Interviewing Process

Objectives
  • Gather essential information for patient care.
  • Establish a therapeutic relationship with the patient.
Steps in Conducting the Interview
  1. Determine the type of assessment needed (Urgent, Focused, Comprehensive)
  2. Use appropriate data sources:
    • Primary: Patient
    • Secondary: Family members, charts
  3. Respect and maintain patient comfort throughout the process.
Components of the Health Interview
  1. Demographic Data
  2. Reasons for Seeking Care (History of Present Illness)
  3. Health History and Current Medications
  4. Family and Social History
  5. Review of Systems (ROS) and functional health questions
Sensitive Topics to Address
  • Alcohol and drug use
  • Sexual history
  • Domestic violence
  • Mental health history

Assessment of Signs and Symptoms

Differences:
  • Signs: Objective findings obtained through physical exams.
  • Symptoms: Subjective feelings reported by patients.
10 Attributes of Assessment:
  1. Location
  2. Associated Signs and Symptoms
  3. Timing
  4. Environmental/Exposure Factors
  5. Relieving Factors
  6. Severity/Quantity
  7. Nature/Quality
  8. Aggravating Factors
  9. Patient Perspective
  10. Significance to the Client
Pain Assessment Scales
  • Numeric Scale (0-10): Gauge the severity of pain.
  • Faces Pain Scale: Visual assessment for patient pain levels.

Cultural and Environmental Considerations

  • Cultural Influences: Affect beliefs and understanding of health.
  • Environmental Factors: Safety, community involvement, and resources can impact health outcomes.

Documentation and Review of Systems

  • Use standardized questions and the ROS to guide physical exams and validate health data.

Important Note

  • Someone who appears comfortable may still be experiencing pain; behavior alone is not a reliable indicator of pain levels.