collecting four types of data Flashcards
what are the four different types of databases that an examiner needs to establish depending on the clinical situation
complete, focused, or problem centered, follow-up, and emergency
what does the complete total health database include
a complete health history and a full physical examination
what does the complete total health database describe
current and past health state and forms baseline to measure all future changes
where is the complete total health database often collected
primary care setting
ex: pediatric or family practice clinic
independent or group private practice
college health service
women’s health care agency
visiting nurse agency
community health agency
when you work in a primary care setting what responsibilities do you have
you are the first health professional to see the patient and have primary responsibility for monitoring the person’s health care.
what do you have the opportunity of doing when collecting a complete database
opportunity to build and strengthen your relationship with the patient.
for a well person what must a complete database include
describe the person’s health state;
perception of health;
strengths or assets such as health maintenance behaviors
individual coping patterns
support systems
current developmental tasks
any risk factors or lifestyle changes
for an ill person what must a complete database include
description of the person’s health problems, perception of illness, and response to the problems.
for both a well and ill person what must a complete database screen for
screen for pathology and determine the ways people respond to that pathology or to any health problem.
why must you screen for pathology in a complete database
because you are the first, and often the only, health professional to see the patient.
This factor is important because it provides additional information about the person that leads to nursing diagnoses.
why is screening for pathology in a complete database important
This screening is important to make appropriate referrals, help the patient make health care decisions, and perform appropriate treatments
what does the complete health database note
the responses to health problems
why is noting the responses to health problems in the complete health database an important factor
it provides additional information about the person that leads to nursing diagnoses.
in acute hospital care when is the complete health database gathered
on admission to the hospital
who may collect data related specifically to pathology in the hospital
admitting physician
what additional information may be collected during admission to the hospital
the patient’s perception of illness
functional ability or patterns of living
activities of daily living
health maintenance behaviors
response to health problems
coping patterns
interaction patterns
spiritual needs
health goals.
why might some items collected during admission be deferred until the patient is stabilized and able to provide information
it depends on patient condition and reason for admission
describe focused or problem centered database
collect “mini” database, smaller scope, and more focused/targeted than complete database
what type of problem is focused or problem centered database used for
limited or short problem
such as one problem, one cue complex, or one body system
give an example of when a focused or problem-centered database would be used
abdominal pain– focus on abdomen
in what settings is focused/problem centered databased used
all settings; primary care, long term care, and hospital
describe follow-up database
status of all identified problems should be evaluated at regular and appropriate intervals
what questions would the status of condition most likely answer during a follow-up database
What change has occurred? Is the problem getting better or worse? Which coping strategies are used?
what setting is follow-up database used in
all settings; in order to follow up both short-term and chronic health problems
give an example of a situation in which a follow-up database would be used
a patient with heart failure may follow up with his or her primary care practitioner at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies
describe emergency database
rapid collection of data often compiled concurrently with life saving measures
during emergency database how must a diagnosis be given
must be swift and sure
give an example of a situation in which an emergency database would be used
a person is brought into an ED with suspected substance overdose.
The first history questions are “What did you take?” “How much did you take?” and “When?”
The person is questioned simultaneously while airway, breathing, circulation, level of consciousness, and disability are being assessed
once an emergency database has been established an the patient has been stabilized what database can be used next to gather more data
complete database can be compiled.
how might an emergency database be compiled
by questioning the patient, or if the patient is unresponsive, health care providers may need to rely on family and friends.
