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16 Cards in this Set
- Front
- Back
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Patient's verbal descriptions of their health problems
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Subjective Data
(remember: the subject (the patient) gives you subjective data) |
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Observations or measurements of a patient's health status
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Objective data
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An interview between you and the patient
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Directive Interview
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the symptom or group of symptoms about which the patient first consults medical professionals
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Chief Complaint (CC)
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a brief review of essential functioning of various body parts or systems
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Review of Systems (ROS)
(AKA screening examination) |
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refers to a detailed interview prompted by the chief complaint or presenting symptom
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History of Present Illness (HPI)
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total sum of a patient's health status prior to the presenting problem.
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Past Medical History (PH)
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provides a holistic framework for assessment of the patient's health history, from which you will derive a broad range of nursing diagnoses.
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Functional Health Patterns
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Information you obtain through use of the senses
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Cues
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Your judgement or interpretation of cues
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Inference
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comparison of data with another source to confirm its accuracy
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validation
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What are the purposes for performing a health assessment
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to establish a thorough database about your patient
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Components of a nursing health history
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-patient's physical and developmental status
-emotional health -social practices and resources -goals, values, lifestyle -expectations about the health care system -physical exam findings -summary of lab results -medical diagnosis and treatment |
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What is the difference between cues and inferences?
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- Cues are subjective or objective data that can be directly observed by the nurse.
- Inferences are the nurses interpretation or conclusions based on the cues. (for ex - a nurse observes cues that an incision is red, hot, and swollen: the nurse makes the inference that the incision is infected.) |
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Communication techniques used in gathering health assessment data
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-interview can be focused or comprehensive
-free of distractions -open ended questions -back channeling -close ended questions (used to focus) |
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FINISH
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FINISH
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