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History (subjective data)
70%
Physical Examination (objective data)
20%
Laboratory/ Imaging Studies (Objective data)
20%
Subjective Data
pain when applying pressure, blurry vision x 5 days, and dizzy when standing up
Objective Data
raised purple lump on forehead, unable to read vision chart past 2nd line, blood pressure drops when standing up
symptom
what the patient feels/ communicates (subjective)
sign
clinical findings collected during physical examination (objective)
clinical manifestations
sings and symptoms collected
what are the three levels of health promotion
primary, secondary, and tertiary
primary
preventing disease from developing through promoting healthy lifestyles
secondary
screening efforts to promote early detection of disease
tertirary
minimizing disability from acute or chronic illness or injury and allowing for most productive life within limitations
health history
is a subjective data from the patient, if they are able to provide. sometimes it will come from a significant other. persons past and present health
therapeutic communication
single most important factor for successful interviewing
examples of therapeutic communication
active listening, clarifying, open ended questions, and slience
non- therapeutic communication
using medical terminology without defining, why questions, interrupting, false reassurance
professional communication
health literacy and appropriate use of medical terminology
environment/ physical setting
quiet, private, free from interruptions, and comfortable room temperatures.
patient comfort