NURS 1543 week 1

Health history

Collects objective and subjective data

Database

Used to make a judgement of diagnosis about the health status of an individual

Nursing Process

Assessment

Diagnosis

Planning

Implementation

Evaluation

Objective data

Information that can be measured through physical examiniation, observation or diagnostics testing

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I.e. lab tests, vital signs, patient behavior observed by nurse

Subjective data

What patient tells us their symptoms, including feelings, perceptions and concerns

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Gives you background as to why they seek medical care

Biographical data

Name

Address and phone #

Age and data of brith

Gender

Characteristics of a symptom

Location

Character

Quantity/severity

Timing

Setting

Pain assessment tool

OPQRSTU

O

Onset

P

Provocative or palliative

Q

Quality or Quantity

R

Region

S

Severity scale

T

Timing (onset, duration, frequency)

U

Understanding patients perception

Review of systems

Evaluate the past and current health state of the body

Double check is any data was missed

* general overall health state
* Skin, hair, nails
* Head, eyes, nose, sinuses
* Neck, breast, axils, respiratory

Interview - physical environment

Privacy

Quiet

Lighting

Spacing

Cross cultural considerations

* culture perspectives on professional interactions
* Etiquette
* Eye contact
* Space/distance

Considerations on gender and sexual orientation

* i.e. preferred pronouns

Interviewing people with special needs

Hearing impaired peo0ple

Acutely ill people

People under the influence

Aggressive people

Anxiety

Threat of violence

Documentation

Care of a client that is record of the nursing process, unused to monitor a clients progress and communicate with other care providers.

Reflect the nursing care to patient