NURS 6011: Exam 1 Study Guide
SUBJECTIVE DATA
comes from the SUBJECT (the client/patient)
primary source
Information that your client told you when you interviewed
them
secondary source
Information that a family member told you
What should you record when documenting patient responses in
ROS?
Record what the patient states or denies in response to system-
specific prompts.
How should you document absence of complaints in ROS?
Do not use statements like 'no complaints,' instead document
'patient states' or 'patient denies.'
Why should you avoid using 'normal' in ROS documentation?
Using 'normal' involves interpreting data, which may not
accurately capture the patient's responses.
Acutely Ill Patients
,emergencies mean focusing on just the critical, relevant basics;
may need to get additional data from family or friends; don't try
to make an injured patient strain or stress themselves to answer
more than necessary
People Under the Influence
people using alcohol or drugs may not be reliable in recalling
information; ask simple and direct questions, don't be
threatening, avoid confrontation and judgment; prioritize finding
out what they drank or used, and how much
Aggressive Patients
some clients may be aggressive, threatening, or attempt sexual
advances; respond firmly that your role is that of health care
professional; you may need to verbally acknowledge you
understand their need to feel assertive; remove yourself from
dangerous situations
Anxious Patients
many sick people have some anxiety; listen to their concerns,
avoid traps of interviewing
Assessment techniques
Inspection
Palpation- feel for abnormalities
Percussion; tap to listen to sounds produced
Auscultation- listen with stethoscope
, diaphragm
large, flat side and is best for higher pitched sounds like breath,
bowel, and normal heart sounds
bell
round, bell-shaped side and is best for lower pitched sounds like
extra heart sounds or murmurs. Hold it lightly against the skin
Hearing-Impaired Patients
sign language interpreter needed; video interpretation often
available in hospitals and clinics; allow for lip reading to occur;
use written communication
Patients with Impaired Vision
Identify yourself clearly
Orient patient to their surroundings
Accommodate guide dogs
Numerical Rating Scale (NRS)
a pain scale in which a pt rates their pain on a line scale from 0
to 10
FACES
visual scale to indicate level of discomfort - useful when
language barrier exists
SUBJECTIVE DATA
comes from the SUBJECT (the client/patient)
primary source
Information that your client told you when you interviewed
them
secondary source
Information that a family member told you
What should you record when documenting patient responses in
ROS?
Record what the patient states or denies in response to system-
specific prompts.
How should you document absence of complaints in ROS?
Do not use statements like 'no complaints,' instead document
'patient states' or 'patient denies.'
Why should you avoid using 'normal' in ROS documentation?
Using 'normal' involves interpreting data, which may not
accurately capture the patient's responses.
Acutely Ill Patients
,emergencies mean focusing on just the critical, relevant basics;
may need to get additional data from family or friends; don't try
to make an injured patient strain or stress themselves to answer
more than necessary
People Under the Influence
people using alcohol or drugs may not be reliable in recalling
information; ask simple and direct questions, don't be
threatening, avoid confrontation and judgment; prioritize finding
out what they drank or used, and how much
Aggressive Patients
some clients may be aggressive, threatening, or attempt sexual
advances; respond firmly that your role is that of health care
professional; you may need to verbally acknowledge you
understand their need to feel assertive; remove yourself from
dangerous situations
Anxious Patients
many sick people have some anxiety; listen to their concerns,
avoid traps of interviewing
Assessment techniques
Inspection
Palpation- feel for abnormalities
Percussion; tap to listen to sounds produced
Auscultation- listen with stethoscope
, diaphragm
large, flat side and is best for higher pitched sounds like breath,
bowel, and normal heart sounds
bell
round, bell-shaped side and is best for lower pitched sounds like
extra heart sounds or murmurs. Hold it lightly against the skin
Hearing-Impaired Patients
sign language interpreter needed; video interpretation often
available in hospitals and clinics; allow for lip reading to occur;
use written communication
Patients with Impaired Vision
Identify yourself clearly
Orient patient to their surroundings
Accommodate guide dogs
Numerical Rating Scale (NRS)
a pain scale in which a pt rates their pain on a line scale from 0
to 10
FACES
visual scale to indicate level of discomfort - useful when
language barrier exists
