Patient History
Family History
A patient says, "My stomach hurts." Is this subjective or objective data.
What does BP stand for?
Blood pressure
What is a normal finding when assessing the eyes?
PERRLA. Pupils equal and reactive to light.
What does BMI stand for?
Body Mass Index
Give TWO examples of information that may be collected as part of a social history.
Tobacco use, alcohol use, drug use, occupation, lifestyle.
A BP is 138/86mmHg is what type of data?
Objective
What does HR represent?
Heartrate
What is a normal lung assessment finding?
Clear and equal breath sounds bilaterally.
What TWO measurements are needed to calculate BMI?
Height and weight
A patient works around industrial chemicals. Which type of history does this belong to?
Environmental / Social
True or False: A patient's report of "I have a HA" is objective data
False -- It is subjective.
What is the generally expected normal resting adult respiratory rate?
12-20 breaths per minute
Which skin finding is abnormal: warm/inact or cyanosis of the lips?
Cyanosis of the lips
Why is accurate height and weight measurement important?
They can help monitor changes in health and may be used for medication dosing and BMI calculations.
A patient reports recent anxiety, depression, and excessive stress. Which type of history is being assesed?
Why should concerning or abnormal VS be documented and reported?
They may indicate a change in patient status and require appropriate follow-up according to protocol.
A RR of 28 breaths/min is called what?
Tachypnea
Document the pupil finding and report it to the nurse.
Name two actions that improve accuracy when measuring height and weight.
Examples: use functioning equipment, account for heavy outer clothing, use correct units, position patient appropriately, zero out scale, etc.
A patient reports a father had an MI at age 54, smokes 1 pack per day, and works around industrial chemicals. Name ALL three types of history represented.
Family, social, and environmental
During an assessment, the left arm is significantly weaker than the right. What should the healthcare worker do?
Document the finding and report it appropriately.
A patient has a temp of 98.6, HR 112, RR 24, BP 88/54, and O2 97%. Which finding is of greatest concern?
BP 88/54
Name TWO abnormal findings that could indicate concern on a head to toe assessment?
Examples: unequal pupils, cyanosis, edema, new confusion, abnormal lung sounds, etc.
A patient weighs 154 lbs and is 62 inches tall. The BMI is approximately 28.2 What is the best interpretation?
BMI should be considered along with other patient information and assessment findings; BMI along does not provide a complete diagnosis.