Data collection interview and HX Flashcards
What is:
-A systematic method of collecting data about a patient
Health assessment
What type of assessment is done in times of life-threatening situations
Emergency
What type of assessment is:
-Based on patient issues
-Usually involves one or two body systems only
Focused
What type of assessment is:
-Complete health history PLUS physical assessment
-Also includes medication reconciliation
Comprehensive
What type of assessment:
-Occurs after the initial assessment
-Continues throughout hospital stay
Routine or Time-lapsed
What is a cue?
-Visible signs
-Physiological changes
-Behaviors or patterns
What is:
-A rational and dynamic process used by the nurse to plan and provide patient care
The nursing process
Successful completion of each step of the nursing process depends on:
Thorough completion of previous step
What is an inference?
-Response to patient cues and other evidence
What is:
-A specific conclusion following a general theory
Deductive reasoning
What:
-Starts with cues and develop a conclusion
Inductive reasoning
What is:
-Actually observed or seen
Objective data
What is:
-What the patient reports but is not clearly seen
Subjective data
Subjective or Objective?
-Pt states they feel nauseated
Subjective
Subjective or Objective?
-Vomited 300mL brown fluid with undigested food
Objective
Subjective or Objective?
-Lung sounds clear bilaterally; respiratory rate 30; using abdominal muscles to breathe
Objective
Subjective or Objective?
-Pt complaining of shortness of breath
Subjective
What are the 8 components of health history
- Biographical data
- Chief complaint/ reason for visit
- History of present illness
- Family history of illness
- Lifestyle
- Social data
- Psychological data
- Patterns of health care
During the interview, what data is gathered
-Subjective data from Primary (Pt) and secondary sources
What is important about Verbal and Non-verbal communication
-When the verbal does not match the non-verbal
-If your patient cannot speak the language
What:
-Allows the nurse to focus in on what pt views as being most important
-Enables nurse to clarify points, obtain missing information
The focused interview
In OLDCARTS, what does the O stand for and what question would you ask
-Onset
-When did this start?
In OLDCARTS, what does the L stand for and what question would you ask
-Location
-Point to the location
In OLDCARTS, what does the D stand for and what question would you ask
-Duration
-When it occurs, how long does it last
In OLDCARTS, what does the C stand for and what question would you ask
-Character
-Describe it to me
In OLDCARTS, what does the A stand for and what question would you ask
-Aggravating factors
-What makes it worse?
In OLDCARTS, what does the R stand for and what question would you ask
-Relieving factors
-What makes it better
In OLDCARTS, what does the T stand for and what question would you ask
-Timing
-What have you tried
In OLDCARTS, what does the S stand for and what question would you ask
-Severity
-On a scale of 1-10, how much is the issue impacting your life
All general survey information is __________ data
Objective
When observing the patient’s physical appearance, what should you look for?
-Does the pt’s appearance match what would be expected for gender and age
-Any signs of distress
-Features symmetrical?
-Obvious disabilities
