NR302- Health Assessment 1-
gi gi gi
Week 3 eDapt
gi gi gi
WK2 NR 302 EDAPT
Whichgiisgiangiexamplegiofgiobjectivegidata?gi-gianswer--Hearinggiagipoppinggisoundgiwhengithegileftgikneegiisgiextended
_giinformationgiisgibeinggirecordedgiwhengithegiexaminergidocumentsgiagiperson'sgitemperaturegiisgi102.1gi°Fgiandgiheartg
tegiisgi126gibeatsgipergiminute.
Includinggithatgithegipersongisaidgitheygihavegifeltgisickgiforgithegilastgitwogidaysgiisgiangiexamplegiofgidocumentinggi_gidata.g
gianswer--OBJECTIVE,giSUBJECTIVE
Whatgiisgisubjectivegidata?gi-gianswer--Informationgiprovidedgibygithegiclientgiorgifamily
Whatgithegihealthgiexaminergilearnsgiusinggithegiassessmentgitechniquesgiofgiinspection,gipalpation,gipercussion,giandgia
scultation.
Whatgithegipersongisharesgiaboutgithemselves.gi-gianswer--1.giOBJECTIVEgiDATA
2.giSUBJECTIVEgiDATA
Selectgithegiwordsgiorgiphrasesgiingithegiclientgistatementgithatgiaregisubjectivegidata.gi-gianswer--
fellgidowngithegistairsgilastgievening,
twistedgimygiankle
putgiicegiongiit
keptgiitgielevated
Igican'tgiputgianygiweightgiongiit
tookgisomegiibuprofen
stillgiprettygibad
Agiclientgitellsgitheginursegithatgitheygiaregiveryginervous,ginauseated,giandgi"feelgihot."giWhatgitypegiofgidatagiisgithis?gi-
gianswer--SUBJECTIVE
Agiclientgitellsgitheginursegithatgitheygiaregiveryginervous,ginauseated,giandgi"feelgihot."giWhatgitypegiofgidatagiisgithis?gi-
gianswer--Swellinggiandgibruisinggiofgithegileftgiankle
Aftergicompletinggiangiinitialgiassessmentgiofgiagiclient,githeginursegihasgichartedgithatgitheirgirespirationsgiaregieupneicgian
theirgipulsegiisgi58gibeatsgipergiminute.gi-gianswer--OBJECTIVE
Indicategiifgieachgiactionsgimadegibygithegiexaminergiduringgithegiphysicalgiassessmentgiisgicompletedgitogigathergisubjec
egiand/orgiobjectivegidata.giEachgiactiongimaygifallgiintogimoregithangionegicategory.gi-gianswer--SUBJECTIVE:gi
Listening
OBJECTIVEgi:
Listening
Touching
Looking
Smelling
Selectgithegisubjectivegiwordsgiorgiphrasesgipresentgiingithegiplangiofgicaregidocumentation.
1gi/
gi10
, NR302- Health Assessment 1-
gi gi gi
Week 3 eDapt
gi gi gi
Upongiassessmentgiofgivitalgisigns,githegiclient'sgibloodgipressuregiwasgi190/92.giTheygiweregiquestionedgiaboutgitheirgim
cationgiadherence,giandgislowlygiduringgithegicoursegiofgithegiclientgiinterview,giitgiwasgisharedgithatgitheygihadginotgirefilled
rgitakengitheirgihypertensiongimedicationsgiingiovergionegiyear.
Thisgiclientgididginotgiappeargitogiunderstandgithegiseveritygiofgitheirgihealthgiissuesgiatgithisgitime.giTheygiaregiagipoorgihisto
ngiandgiseemedgitogihavegiagilackgiofgiunderstandinggiofgihowgiquicklygithisgieventgicouldgihavegitakengiagimuchgiworsegirou
.giClientgieducationgiandgisupportgiforgithegicurrentgisituationgiasgiwellgiasgiagilengthygidiscussiongiaboutgithegiconsequenc
giofginon-adherencegitogimedicationsgiwasgicompleted.gi-gianswer--
theygihadginotgirefilledgiorgitakengitheirgihypertensiongimedicationsgiingiovergionegiyear
Whichgidatagicollectedgifromgithegiclientgiisgisubjective?giSelectgiallgithatgiapply.gi-gianswer--Sensations
Listgiofgifoodsgieatengiingithegipastgi3gidays
Pastgimedicalgihistory
Feelings
Thegiclientgipresentsgiwithgisuddengionsetgiofgiblurredgivision,gidiplopiagi(doublegivision),gibilateralgiarmgiweaknessgiwithg
>giR,giandgileftgieyegiptosisgi(droop).giLumbargipuncturegirevealedgiincreasedgiproteingiingithegicerebrospinalgifluidgi(CSF)
SocialgiHistory:
Deniesgialcoholgiandgitobaccogiuse;giretiredgiteacher;gilivesgiwithgispousegiandgitwogicats.
Allergies:
AcnotexgiandgiBactrimgiDSgi-gianswer--
suddengionsetgiofgiblurredgivision,gidiplopiagi(doublegivision),gibilateralgiarmgiweaknessgiwithgiLgi>giR,Deniesgialcoholgian
obaccogiuse
livesgiwithgispousegiandgitwogicats,giAcnotexgiandgiBactrimgiDS
Selectgithegiwordsgiorgiphrasesgiusedgitogidocumentgiobjectivegidatagifromgiagirecentgifollow-upgihealthgiassessment.
Clientgideniesgitroublegibreathing,gistatesgicoughgiisgipersistent,giandgisputumgiproductiongiisgidecreasing.giLunggisound
aregicleargitogiauscultationgiexceptcracklesgiingileftgilowergilobewhichgiaregidecreasedgisincegilastgiassessment.giIncentiv
spirometergiandgicoughinggiwithgideepgibreathinggicompletedgiwithgiclientgivoicinggiirritationgiwithgithegiintervention;gicrac
esgidecreasedgiaftergipulmonarygihygiene.giOxygengisaturationgi96%giongiroomgiair.giBPgi148/92,giTgi100.6gi°Fgitympanic
HRgi114gibpm,giRRgi24gipergiminute.gi-gianswer--Lunggisoundsgiaregicleargitogiauscultation
cracklesgiingileftgilowergilobe
decreasedgisincegilastgiassessment.giIncentivegispirometergiandgicoughinggiwithgideepgibreathinggicompleted,
Oxygengisaturationgi96%.,BPgi148/92,giTgi100.6gi°F
HRgi114gibpm,giRRgi24gipergiminute.
Considergithegifollowinggiscenario,giandgithengideterminegiwhichgidatagiaregiobjectivegiandgiwhichgiaregisubjective.
Mrs.giJohnsongi(pronouns:gishe/her/
hers)gihasgibeengihospitalizedgiforgigallbladdergisurgery.giDuringgithegimorninggiassessment,githeginursegiobtainsgithegifo
winggiinformation:
Vitals:giTgi101.4gi°F,giPgi97,giRgi18,giBPgi132/90.
Mrs.giJohnsongifeelsgiwarmgitogithegitouchgibutgiisgishiveringgislightlygiandgicomplaininggiofgibeinggicold.
Whengitheginursegiasksgihergihowgishegisleptgilastginight,gishegireplies,gi"Notgiwellgiatgiall.giIgifeelgilikegiIgionlygisleptgiangihour
lginight."
Mrs.giJohnsongiappearsgitoginotgiwantgitogimovegiingibedgiandgiisgiguardinggihergiabdomen.
Whengitheginursegihergiaboutgihergipaingiongiagiscalegiofgi0-
10,giwithgi10gibeinggithegiworstgipaingiimaginablegiandgi0gibeingginogipaingiatgiall,gishegirepliesgiwithgiagipaingiscoregiofgi8.gi-
gianswer--SUBJECTIVE gi:
Mrs.giJohnsongireplies,gi"Notgiwellgiatgiall.giIgifeelgilikegiIgionlygisleptgiangihourgiallginight."
Mrs.giJohnsongiisgicomplaininggiofgibeinggicold.
OBJECTIVE:
2gi/
gi10
gi gi gi
Week 3 eDapt
gi gi gi
WK2 NR 302 EDAPT
Whichgiisgiangiexamplegiofgiobjectivegidata?gi-gianswer--Hearinggiagipoppinggisoundgiwhengithegileftgikneegiisgiextended
_giinformationgiisgibeinggirecordedgiwhengithegiexaminergidocumentsgiagiperson'sgitemperaturegiisgi102.1gi°Fgiandgiheartg
tegiisgi126gibeatsgipergiminute.
Includinggithatgithegipersongisaidgitheygihavegifeltgisickgiforgithegilastgitwogidaysgiisgiangiexamplegiofgidocumentinggi_gidata.g
gianswer--OBJECTIVE,giSUBJECTIVE
Whatgiisgisubjectivegidata?gi-gianswer--Informationgiprovidedgibygithegiclientgiorgifamily
Whatgithegihealthgiexaminergilearnsgiusinggithegiassessmentgitechniquesgiofgiinspection,gipalpation,gipercussion,giandgia
scultation.
Whatgithegipersongisharesgiaboutgithemselves.gi-gianswer--1.giOBJECTIVEgiDATA
2.giSUBJECTIVEgiDATA
Selectgithegiwordsgiorgiphrasesgiingithegiclientgistatementgithatgiaregisubjectivegidata.gi-gianswer--
fellgidowngithegistairsgilastgievening,
twistedgimygiankle
putgiicegiongiit
keptgiitgielevated
Igican'tgiputgianygiweightgiongiit
tookgisomegiibuprofen
stillgiprettygibad
Agiclientgitellsgitheginursegithatgitheygiaregiveryginervous,ginauseated,giandgi"feelgihot."giWhatgitypegiofgidatagiisgithis?gi-
gianswer--SUBJECTIVE
Agiclientgitellsgitheginursegithatgitheygiaregiveryginervous,ginauseated,giandgi"feelgihot."giWhatgitypegiofgidatagiisgithis?gi-
gianswer--Swellinggiandgibruisinggiofgithegileftgiankle
Aftergicompletinggiangiinitialgiassessmentgiofgiagiclient,githeginursegihasgichartedgithatgitheirgirespirationsgiaregieupneicgian
theirgipulsegiisgi58gibeatsgipergiminute.gi-gianswer--OBJECTIVE
Indicategiifgieachgiactionsgimadegibygithegiexaminergiduringgithegiphysicalgiassessmentgiisgicompletedgitogigathergisubjec
egiand/orgiobjectivegidata.giEachgiactiongimaygifallgiintogimoregithangionegicategory.gi-gianswer--SUBJECTIVE:gi
Listening
OBJECTIVEgi:
Listening
Touching
Looking
Smelling
Selectgithegisubjectivegiwordsgiorgiphrasesgipresentgiingithegiplangiofgicaregidocumentation.
1gi/
gi10
, NR302- Health Assessment 1-
gi gi gi
Week 3 eDapt
gi gi gi
Upongiassessmentgiofgivitalgisigns,githegiclient'sgibloodgipressuregiwasgi190/92.giTheygiweregiquestionedgiaboutgitheirgim
cationgiadherence,giandgislowlygiduringgithegicoursegiofgithegiclientgiinterview,giitgiwasgisharedgithatgitheygihadginotgirefilled
rgitakengitheirgihypertensiongimedicationsgiingiovergionegiyear.
Thisgiclientgididginotgiappeargitogiunderstandgithegiseveritygiofgitheirgihealthgiissuesgiatgithisgitime.giTheygiaregiagipoorgihisto
ngiandgiseemedgitogihavegiagilackgiofgiunderstandinggiofgihowgiquicklygithisgieventgicouldgihavegitakengiagimuchgiworsegirou
.giClientgieducationgiandgisupportgiforgithegicurrentgisituationgiasgiwellgiasgiagilengthygidiscussiongiaboutgithegiconsequenc
giofginon-adherencegitogimedicationsgiwasgicompleted.gi-gianswer--
theygihadginotgirefilledgiorgitakengitheirgihypertensiongimedicationsgiingiovergionegiyear
Whichgidatagicollectedgifromgithegiclientgiisgisubjective?giSelectgiallgithatgiapply.gi-gianswer--Sensations
Listgiofgifoodsgieatengiingithegipastgi3gidays
Pastgimedicalgihistory
Feelings
Thegiclientgipresentsgiwithgisuddengionsetgiofgiblurredgivision,gidiplopiagi(doublegivision),gibilateralgiarmgiweaknessgiwithg
>giR,giandgileftgieyegiptosisgi(droop).giLumbargipuncturegirevealedgiincreasedgiproteingiingithegicerebrospinalgifluidgi(CSF)
SocialgiHistory:
Deniesgialcoholgiandgitobaccogiuse;giretiredgiteacher;gilivesgiwithgispousegiandgitwogicats.
Allergies:
AcnotexgiandgiBactrimgiDSgi-gianswer--
suddengionsetgiofgiblurredgivision,gidiplopiagi(doublegivision),gibilateralgiarmgiweaknessgiwithgiLgi>giR,Deniesgialcoholgian
obaccogiuse
livesgiwithgispousegiandgitwogicats,giAcnotexgiandgiBactrimgiDS
Selectgithegiwordsgiorgiphrasesgiusedgitogidocumentgiobjectivegidatagifromgiagirecentgifollow-upgihealthgiassessment.
Clientgideniesgitroublegibreathing,gistatesgicoughgiisgipersistent,giandgisputumgiproductiongiisgidecreasing.giLunggisound
aregicleargitogiauscultationgiexceptcracklesgiingileftgilowergilobewhichgiaregidecreasedgisincegilastgiassessment.giIncentiv
spirometergiandgicoughinggiwithgideepgibreathinggicompletedgiwithgiclientgivoicinggiirritationgiwithgithegiintervention;gicrac
esgidecreasedgiaftergipulmonarygihygiene.giOxygengisaturationgi96%giongiroomgiair.giBPgi148/92,giTgi100.6gi°Fgitympanic
HRgi114gibpm,giRRgi24gipergiminute.gi-gianswer--Lunggisoundsgiaregicleargitogiauscultation
cracklesgiingileftgilowergilobe
decreasedgisincegilastgiassessment.giIncentivegispirometergiandgicoughinggiwithgideepgibreathinggicompleted,
Oxygengisaturationgi96%.,BPgi148/92,giTgi100.6gi°F
HRgi114gibpm,giRRgi24gipergiminute.
Considergithegifollowinggiscenario,giandgithengideterminegiwhichgidatagiaregiobjectivegiandgiwhichgiaregisubjective.
Mrs.giJohnsongi(pronouns:gishe/her/
hers)gihasgibeengihospitalizedgiforgigallbladdergisurgery.giDuringgithegimorninggiassessment,githeginursegiobtainsgithegifo
winggiinformation:
Vitals:giTgi101.4gi°F,giPgi97,giRgi18,giBPgi132/90.
Mrs.giJohnsongifeelsgiwarmgitogithegitouchgibutgiisgishiveringgislightlygiandgicomplaininggiofgibeinggicold.
Whengitheginursegiasksgihergihowgishegisleptgilastginight,gishegireplies,gi"Notgiwellgiatgiall.giIgifeelgilikegiIgionlygisleptgiangihour
lginight."
Mrs.giJohnsongiappearsgitoginotgiwantgitogimovegiingibedgiandgiisgiguardinggihergiabdomen.
Whengitheginursegihergiaboutgihergipaingiongiagiscalegiofgi0-
10,giwithgi10gibeinggithegiworstgipaingiimaginablegiandgi0gibeingginogipaingiatgiall,gishegirepliesgiwithgiagipaingiscoregiofgi8.gi-
gianswer--SUBJECTIVE gi:
Mrs.giJohnsongireplies,gi"Notgiwellgiatgiall.giIgifeelgilikegiIgionlygisleptgiangihourgiallginight."
Mrs.giJohnsongiisgicomplaininggiofgibeinggicold.
OBJECTIVE:
2gi/
gi10