EXAME FÍSICO: tudo sobre a Anamnese (Coleta de dados) | Profª Juliana Mello

Summary

In this video, Professor Juliana Melo discusses the importance of collecting data or the nursing history as part of the physical examination process. She emphasizes its critical role in the nursing process, as it serves as the foundation for diagnosing and planning patient care. The video covers the difference between objective and subjective data, highlighting the significance of both in understanding a patient's condition. The content also mentions various data sources, including patient interviews, family members, medical records, and other healthcare professionals. For more in-depth study, viewers are encouraged to explore comprehensive resources available on the website.

Takeaways

• 😀 The video focuses on the collection of data or nursing history as part of the physical examination process, which is essential for professional practice and approval in nursing.
• 😀 An e-book with a comprehensive, updated study guide on physical exams is available on the website, featuring 79 pages of theory and 118 practice questions.
• 😀 The collection of data is a critical first step in the nursing process, as per the resolution of the Federal Nursing Council (Cofen), forming the foundation for further stages such as diagnosis and intervention.
• 😀 The collection of data involves using a variety of methods and techniques to gather information about the patient, family, or community, assessing their responses to health issues.
• 😀 There are two types of data: objective (measured by the healthcare professional during physical examination) and subjective (reported by the patient).
• 😀 Objective data include measurable signs such as vital signs or physical observations made by the nurse during the exam, like blood pressure readings.
• 😀 Subjective data are those shared by the patient, such as pain levels, symptoms, and their perception of health issues, which can then be verified through physical examination.
• 😀 Other sources of data can include the patient's family, other healthcare professionals, and medical records like patient charts and test results.
• 😀 The video also highlights the importance of family involvement in data collection for patients who cannot communicate, like infants or critically ill adults.
• 😀 The process of data collection is split into two phases: anamnese (history-taking) and physical examination, each involving different techniques and methods to understand the patient’s health condition.

Q & A

What is the purpose of the 'Coleta de Dados' or 'Histórico de Enfermagem' in nursing practice?

The purpose of 'Coleta de Dados' or 'Histórico de Enfermagem' is to gather essential information about the patient, their family, or a community to understand their health status, identify problems, and determine how they are responding to health issues. This process is the first step in the nursing process.

What are the two types of data collected during the nursing history?

The two types of data collected are 'objective data,' which are obtained by the nurse through physical examination or measurements (like vital signs), and 'subjective data,' which are reported by the patient, such as feelings of pain or discomfort.

What role do subjective and objective data play in nursing assessments?

Subjective data reflects the patient's personal experiences and perceptions, while objective data provides measurable information observed by the healthcare professional. Both types are crucial for forming a comprehensive understanding of the patient's health status.

What is the importance of the nursing history in the nursing process?

The nursing history is fundamental in the nursing process as it forms the foundation for all subsequent steps, including diagnosis, planning interventions, and evaluating outcomes. It helps the healthcare team understand the patient's needs and responses to health conditions.

How does the nurse obtain objective data during the physical exam?

Objective data is obtained through direct observation and measurement by the nurse. This includes checking vital signs, conducting physical exams, and using various assessment techniques to gather tangible, observable data.

Why is the patient's own report considered an essential source of data?

The patient's own report is considered an essential source of data because they are the best authority on their own experiences, feelings, and symptoms. Their descriptions provide valuable insights into how they are responding to health challenges.

What other sources can provide information during the data collection process aside from the patient?

Other sources of information include the patient's family, healthcare professionals, medical records, and test results. These sources contribute to a holistic understanding of the patient's health status, especially when the patient is unable to communicate effectively.

What does the term 'Anamnese' refer to, and how does it relate to nursing history?

Anamnese refers to a detailed patient interview typically used in medical practice to collect health history. In nursing, this concept is closely related to 'Coleta de Dados' or nursing history, which serves a similar purpose but uses different terminology and frameworks specific to nursing practice.

What are the main components of an adult patient's anamnese (nursing history)?

The main components of an adult patient's anamnese include identification data, the patient's main complaints, the current health condition (history of the present illness), past medical history, family health history, personal and social history, and a review of systems.

How does the nurse decide which data to collect during the nursing history?

The nurse decides which data to collect based on the patient's current health situation and the purpose of the assessment. The data should cover key aspects of the patient's condition, including symptoms, personal health history, and family health background, while considering the resources available and the patient's communication ability.