1-4
Week One: Skin, Hair, Nails, Head, Neck and Related Lymphatic
• Subjective Data (always collected first)
o Info that the client experiences,
... [Show More] feels, states, documented in “direct quotes”
Example: What they report that they ate for breakfast
***subjective data comes/asked first
o Pain (5th Vital Sign)
o Symptoms
o Emotional Status
o Weight is subjective data if patient is asked to report weight
o Biographical Data (name, age, occupation, etc) Funds ATI p. 129
Health History: info based on the client’s own perception
History of illness and injury: past and present
Family history (3 generations): may skip a generation, check whether is maternal or paternal
Review of Systems: Interview of each system
• Example: If you ask the pt how tall they are
***Social History: alcohol, smoking, drugs, caffeine
• SATA Question “CADS” caffeine, alcohol, drugs, smoking
Psychosocial: relationship, educational level, support system, occupation hx, financial status, ability to perform ADL’s,
spiritual health, ethnicity, culture, self-concept
Practices: Western Medicine, Eastern, Holistic, etc.
***Health Patterns: exercise, diet, sleep, level of stress (what, how often, specifics)
o Note: accuracy of subjective data depends on the nurse’s ability to clarify the info gathered with follow up questions
o ***OLDCART & ICE: used to clarify subjective data (p.121) and for pain assessment “say “no pain” for Video
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving Factors
Treatment (ICE)
• Impact on ADL’s
• Coping Strategies
• Emotional Response
o ***Inspect, palpate, percuss, auscultate
• Objective Data
o What you observe by examination; measurable
o Focus on areas of interest such as chief complaint
o Done in a systematic fashion (head to toe)
o Examples: checking vital signs, measuring weight, auscultating the lungs
• General Survey: First part of inspection; similar to head to toe assessment
o 4 + 2components of General survey: physical appearance, mental status, neurologic (mobility), behavior, allergies,
immunizations
o Physical Appearance
Nourishment
Color of skin (cyanotic, etc.)
Older for age
Body shape (banana, pear, hourglass, etc.)
o Mental Status
Orientation (A&Ox?) to person, place, time [Show Less]