objective data
measurable(BP, pulse, heart-rate, weight, height, BMI), facts, seen or observed(felt, smelt, gathered on physical assessment
subjective data
given by patient/family- feelings/perceptions
systems approach
having, showering or involving a system, method or plan; using a method/systems
head to toe
awareness and assessment of physical, emotional and mental aspects of all body systems as well as the environmental and social issues affecting the client
inspection-
observation
palpation-
touch
percussion-
vibration and sound
auscultation-
listening
OLDCART
O- onset
L- location
D- duration
C- characteristics
A- aggravating factors
R- relieving factors
T- treatment
PQRST
P- precipitating factors
Q- quality/quantity
R- religion/radiation/related symptoms
S- severity
T- timing
Inspection involves using
Vision
Smell
Hearing
Inspection- assessment
Rest and activity needs
Nutritional needs
Safety and security
Hygiene and grooming
Breathing and circulation
Psychological needs
Elimination
ADL
Activities of daily living
Palpation types
Light, medium, deep and bimanual
Percussion involves
Tapping body parts to produce sound waves
Enables assessment on underlying structures
Palpation- assessment
Texture
Temperature
Mobility
Swelling
Size and shape
Tenderness
Rhythm and strength
Percussion- assessment
Pain
Determine location i.e size and shape
Determine density
Determine abdominal masses
Elicit reflexes
Auscultation characteristics
Intensity (loud/soft)
Pitch (high/low)
Duration (length)
Quality (musical, crackly, raspy)
COLDSPA
C- character
O- onset
L- location
D- duration
S- severity
P- pattern
A- associated factors
6 rights of medication administration
Patient
Dose
Route
Documentation
Medication/drug
Time