Exam 1 Flashcards
1
Q
Biographical data includes…
A
Name, address, age, birth, gender, race, languages, occupation, religion….etc
2
Q
sources of patient history
A
patient or relative/friend
- judge the reliability of the informant
-reliable when same answer after same question asked
3
Q
What will the patient say when the reason for seeking care?
A
Brief spontaneous statement in persons own words
4
Q
COLDSPA
A
- Character
- onset
- location
- duration
- severity
- pattern
- associated factors
5
Q
Character
A
how does it feel, look, smell, sound, etc.?
6
Q
Onset
A
When did it begin; is it better, worse, or the same since it began?
7
Q
Location
A
Where is it, does the pain radiate?
8
Q
Duration
A
How long does it last? Does it Recur?
9
Q
Severity
A
How bad on a scale 1-10; what is the patients perception of this?
10
Q
Pattern from COLDSPA
A
What makes it better? (aka alleviating factors)
- What makes it worse? (aka precipitating/aggravating factors)
11
Q
Associated factors
A
What other symptoms do you have with it?
- will you be able to continue doing your work or other activities (leisure or exercise?)
12
Q
Past Health topics?
A
- Problems such as birth
- Childhood illnesses
- immunizations to date
- Adult illnesses (physical, emotional, mental)
- Surgieries
- Accidents or injuries
13
Q
Family history topics
A
- Age & health or cause of death of relatives
- family history of various conditions such as “heart disease, high BP, stroke, diabetes, etc.”
- Family tree
14
Q
Review of systems
A
SHEEM TBH
- skin, hair, nails
- Head/neck
- Ears
- Eyes
- Mouth, Throat, nose, sinyses
- Thorax and lungs
- Breasts, and lymphatics
- Heart & neck vessels
15
Q
Lifestyle question (simple)
A
Description of a typical day/activities on a typical day
16
Q
evidence based practice
A
combo of scientific evidence, nurse’s experience and expertise, and client’s preferences
17
Q
first step interviewing
A
asking patients name and birth to foster trust
18
Q
alter interview based on..
A
patients age and experiences in life
19
Q
laundry list of discriptors
A
examples used in coldspa
20
Q
First question to ask when talking about diet?
A
What did you eat in the last 24 hrs?
21
Q
Types of social activities
A
Recreation/relaxation
- Societal contributions
22
Q
Types of relationships (3 things)
A
- Family
- Sig. others
- Pets
23
Q
Neonate years
A
1st 4 weeks of life
24
Q
Infant years
A
1 month to 1 yr
25
toddler years
1-3 yrs
26
Pre-school child years
3-5 yrs
27
School-aged child years
6-12 yrs
28
Adolescent years
13-18 yrs
29
Young Adult years
19-40 yrs
30
middle age adult yrs
41-65 yrs
31
Older adult years
over 65 yrs
32
Functional assessment includes...
(SSDRACS)
- Self-esteem, self-concept
- sleep/rest
- diet
- relationships
- activity/exercise
- coping/stress management
- spiritual resources
33
Pediatric patient assessment questions
mom and dad will play a role in the interview
- birth history is important
- Developmental milestones
- Denver II Screening tool
34
Pregnant patient assessment
- chief complaints w/ duration
- History of everything medically
- Socio-economic history
- Contraceptive history
- History of allergy
35
Older adult patients assessment questions to ask
same format for functional assessment but with additional questions
- important to recognize positive health measures
- affirm things they are doing right
36
Older person may..
shrug off symptoms
- take time to figure out why they came for examination
- have many chronic problems
37
Past health questions for older patients
General health in the past 5 yrs
- Accidents or injuries, serious or chronic illnesses, hospitalizations, operations
- last exam
- obstetric status
38
older patient "family history" questions
- not useful for predicting family diseases
- helps to know which diseases family member had
39
What is a health risk
The chance or likelihood that something will harm or otherwise affect your health
40
What is a risk factor
Any attribute that increases the likelihood of developing a disease or injury
41
Identify patients early enough to...
provide treatment & avoid/reduce symptoms & other consequences, improving health outcomes
(Ex: age, sex, family health history, lifestyle, genes, ethnicity...)
42
Components of ROS (review of systems)
(MM SHEF)
- Male genital System
- Musculoskeletal system
- Sexual health
- Hematologic system
- Edocrine system
- Female genital system
43
If the client answers in the affirmative to a PREVIOUS symptom/problem, you...
Document the following information:
- When did it occur/ when were they diagnosed?
- (if injury/trauma), what was the nature of the injury?
- How was it treated?
- How did the recovery go?
- Any lingering effects?
44
If the client answers in the affirmative to a CURRENT symptom/problem, you...
document the following information:
- COLDSPA
45
ROS: General Overall Health State
- Present weight (history of weight), fatigue, weakness or malaise, fever, chills, sweats or night sweats
46
ROS: Skin
- History of skin disease (eczema, psoriasis, hives), - - pigment or color change
- change in mole
- excessive dryness or moisture
- excessive bruising
- rash or lesion
47
ROS: Hair/Nails
Hair: Recent loss/change in texture
Nails: Change in shape, color, or brittleness
48
ROS: Health Promotion for skin/oral
- amount of sun exposure; method of self-care for skin & hair
- Pattern of daily dental care, use of dentures, bridge & last dental checkup
49
ROS: Nose & Sinuses
- Discharge & its characteristics
- any unusually frequent or severe colds, sinus pains, nasal obstructions, nosebleeds, allergies, or hay fever, or change in sense of smell
50
ROS: Mouth & Throat
- Mouth pain
- frequent sore throat
- bleeding gums
- toothache
- lesion in mouth or tongue
- dysphagia
- hoarseness of voice
- tonsillectomy
- altered taste
51
ROS: Neck
- Pain, limitation of motion,
- lumps or swelling
- enlarged, tender nodes
- goiter
52
ROS: Breast
- pain
- lump
- nipple discharge
- history of breast disease
- Any surgery on breasts
53
ROS: Health promotion on Breast
- Perform Breast self-examination, including its frequency & method used; last mammogram
54
ROS: Axilla
- Tenderness, lump, swelling or rash
55
ROS: Respiratory System
- History of lung disease (asthma, bronchitis, pneumonia, etc)
- Chest pain w/breathing
- wheezing
- noisy breathing
- SOB
- cough
- sputum
- pollution exposure
56
ROS: Health promotion for Resp. system
- Last chest x-ray study, TB skin test
57
ROS: Cardiovascular
- Chest pain
- Pressure
- Tightness
- Palpitation
- Cyanosis
- Dyspnea on exertion
- Edema
58
ROS: Health Promotion for Cardiovascular
- Date of last ECG or other heart tests; cholesterol screening
59
ROS: Peripheral Vascular
- Coldness
- Numbness/ tingling
- swelling of legs
- Discoloration in hands or feet
- varicose veins
60
ROS: Health Promotion for peripheral vascular
- Does work involve long-term sitting/standing? Avoid crossing legs at knees
61
ROS: Gastrointestinal
- Appetite
- Food intolerance
- heartburn
- Indigestion
- vomiting
MANY MORE
62
ROS: Health Promotion for Gastrointestinal
Use of antacids or laxatives
63
ROS: Urinary system
- Frequency
- Urgency
- Nocturia
- Dysuria
- Color
64
ROS: Health Promotion for Urinary System
Measures to avoid or treat UTI, use of legal exercises after childbirth
65
ROS: Male genital system
- Penis or testicular pain
- Sores or lesions
- Penile discharge
- Lumps
- Hernia
66
ROS: Health Promotion for Male genital system
Perform testicular self-examination? How frequently?
67
ROS: Female genital system
- Menstrual history
- Vaginal itching
- Discharge & its characteristics
- Age at menopause
- Postmenstrual bleeding
68
ROS: Health Promotion of Female Genital system
Last gynecologic checkup & last pap test
69
Sexual relationship questions to ask
Are you having sex?
- How many partners?
- Condoms?
- Erection issues?
- Any STD contact?
70
ROS: Musculoskeletal System (joints, muscles, and back included)
- History of arthritis/ gout
In joints: Pain, stiffness, swelling
In muscles: pain, cramps, weaknesses?
In the back: Any pain, stiffness, limitation of motion?
71
ROS: Health Promotion for Musculoskeletal system
- How much walking per day?
- what are the effects of limited ROM on ADLs (grooming, feeding, toileting?)
- Any mobility aids used?
72
ROS: Neurologic System (Motor, sensory, and mental status included)
- History of seizure, stroke, fainting, blackouts?
- Motor function: Weakness, tic or tremor, paralysis, or coordination problems?
Sensory function: Numbness/tingling?
Cognitive function: Memory disorder
Mental status: Any nervousness, mood change, depression, or history of mental heath dysfunction or hallucinations?
73
ROS: Health Promotion for Neurological System
Data about interpersonal relationships & coping patterns
74
ROS: Hematologic Systems
- Bleeding tendency of skin or mucous membranes
- excessive bruising,
- lymph node swelling
- exposure to toxic agents or radiation
- blood transfusion & reactions
75
ROS: Endocrine System
History of diabetes
- Diabetic symptoms
- History of thyroid disease
- intolerance to heat/cold
- change in skin
- excessive sweating
76
What should you record when documenting
Record the presence/absence of ALL symptoms so that it is very clear what Q's you asked
77
The ROS (Review of systems) is only used for what?
Subjective Data
78
Objective assessment techniques/alternative words
inspection: Looking
Palpation: touching
Percussion: Tapping
Auscultation: Listening
79
What is comfort?
a person's sense of psychosocial, emotional, and physical well-being
80
What is pain according to a patient?
Pain is whatever the experiencing person says it is
81
What is Nociceptive Pain
Nerve fibers in PNS & CNS are functioning & intact
- Begins outside the NS from actual or potential tissue damage
82
Four phases of Nociceptive pain
Transduction, Transmission, Perception, and Modulation
83
What is neuropathic pain
Abnormal processing d/t injury of nerve fibers
- not predictable processes & phases
84
Sources of pain (4 things)
- Visceral pain
- Deep somatic pain
- Cutaneous pain
- Referred pain
85
What are the 7 Dimensions of Pain
- physical
- sensory ( ex. 7 out of 10)
- behavioral
- sociocultural
- cognitive (beliefs, attitudes)
- affective (feelings/emotions to pain)
- spiritual (meaning & purpose to pain)
86
pain assessment questions to ask
Coldspa
86
Does the patient self-report?
Yes and always
87
Pain elicits a stress response in the human body that triggers the...
SNS resulting in physiologic responses such as:
- Anxiety
- focus on pain
- Inc. resp. rate
- Dec. urinary output
88
Physical exam: Joints
note:
- size
- contour
- circumference
- AROM/PROM
89
Physical exam: Abdomen
- inspect/auscultate/palpate
- Contours/symmetry
- Guarding/organ size
90
Physical exam: Muscles/skin
inspect:
- color/swelling
- masses/deformity
- sensation changes
91
Is pain a normal part of the aging process?
NO, it is not
92
What is mental status:
A person's emotional & cognitive functioning
- it is inferred indirectly through the assessment of behavior
93
Assessed behaviors for MENTAL STATUS include:
- LOC
- language
- Mood & affect
- orientation
- attention
- memory
- perceptions
94
What is cognition?
it is the brain's ability to process, retain, & use info
- this includes reasoning, judgment, perception, attention, comprehension, & memory
95
What are the components of a mental status exam?
(ABCT)
- Appearance
- Behavior
- Cognition
- Thought Process
96
A full mental status exam when initial screening suggests what?
- Depression
- Anxiety
- Brain lesions (trauma)
- Symptoms of psychiatric illness
97
Contributions from health history for mental status exam?
- Alcoholism
- Medications that may cause confusion or depression
- Changes in sleep pattern. social interactions, or drug use
98
the "A" in ABCT
appearance
- posture
- body movements
- dress
- grooming & hygiene
99
the "B" in ABCT
Behavior
- LOC
- Facial expressions (mood & affect)
- Speech
100
the "C" in ABCT
Cognitive Functions
- Orientation: time, place, person
- Concentration
- Recent memory
- Judgement
101
the "T" in ABCT
Thought Process
- thought content (self explanatory)
- screen for anxiety, depression, suicidal thoughts
102
Mini-mental status exam only looks at what?
Cognitive functioning, not mood or thought process
103
mini-mental status exam avg score is
27
104
For mini-mental status exam, between what scores show no cognitive impairment?
24-30
105
the mini-mental status exam is useful for detecting what?
organic diseases
- dementia, delirium
106
What is the mini-cognitive exam for?
- Tests executive function
- People with NO cognitive impairment should be able to successfully complete
107
What is a mental disorder?
A behavioral pattern associated w/ distress, impaired functioning, and risk of disability
108
What is an organic disorder?
a Brain disease of specific organic origin - Dementia, delirium, intoxication
109
Psychiatric mental illness is what?
an organic etiology not yet established - Anxiety disorder, schizophrenia
110
Developmental considerations for Psychosocial assessment
- Can take older patients longer to respond, but should still be logical.
111
What is culture?
Culture is the patterns of behavior & thinking that people living in social groups learn, develop, and share
112
Cultural groups is categorized around...
racial, ethnic, religious, or socially common practice patterns
113
What is subcultural?
People within a culture whose practices or beliefs are separate from the dominant culture
114
What is multiculturalism?
Cultures and subcultures coexist within a given society in which no one culture dominates
115
What are ethnic groups?
- Common characteristics
- Nationality, language, values, customs, share a cultural heritage
116
When asking a patient "With what culture do you identify?" the areas of assessment are?
- use of traditional healing practices
- preferences for care
- health benefits
- religious or cultural practices at specific times
117
risks related to cultural assessment
- powerlessness
- fear
- anxiety
- hopelessness
- inadequate family coping skills
118
What is spirituality?
- It is personal but a universal human experience
- connects to something bigger than self
- may have elements of religion
119
Spirituality is a search for:
peace, purpose, transcendence, connection w/others or nature
120
What is religion
it is an organized framework of believers with similar beliefs, moral values, & spiritual practices to express faith & worship of god or a higher power
121
Risks related to spiritual assessment
- Expressing fear of dying
- depression or withdrawal
- changes in eating or sleeping patterns
- expressing anger, bitterness, shame, & hopelessness
122
What triggers stress in one person might...
not cause stress in another
123
What is a Stressor?
An external influence that threatens to disrupt equilibrium that is needed ti maintain homeostasis
124
Stressors may be what?
- May be physical, mental, or emotional
- May be positive/negative, depending on perception
- additional sources of stressors include:
-- Work & financial disruptions, discrimination, elections.
125
What are Biogenic stressors
Directly trigger stress response without any cognitive process
- Ex. caffeine, amphetamines, extreme temperature
126
psychosocial stressors
Environmental events, either real or imagined
- Facilitate activation of stress response rather than directly triggering it
- Depends on how person perceives stressor
127
What are the 4 categories of stressors?
- Acute, time-limited
- sequence events following the initial stressor
- chronic intermittent
- chronic permanent
128
Internal stressors consist of what?
internal environment
129
Internal environment definition
Person's physical, spiritual, cognitive, emotional, and psychologic well-being
130
External environment stressors:
Triggers outside the individual that require change or disrupt homeostasis
- Positive stressors cause eustress
- Negative stressors cause distress
131
What are the physiologic indicators of stress?
- Stimulation of sympathetic, neuroendocrine systems
- Perception of potential stressor triggers physiologic manifestations
- prolonged exposure to perceived stressors can lead to disease, and may even be fatal
132
What are the Psychologic indicators
Fear
- The perceived threat to safety or well-being
Anxiety
- Apprehension, dread, mental uneasiness, & a sense of helplessness in response to an actual or perceived threat to the well-being
Anger
- Subjective sense of intense displeasure, & irritation
Depression
- Persistent, abnormally low mood characterized by feelings of emptiness, hopelessness, sadness, or despair
133
What are the cognitive indicators?
Changes in mental processes
- problem-solving
- cognitive structuring
- manifestations of impairments in cognitive abilities
- suppression
- self-control
- fantasizing
134
What is coping?
individual applies cognitive & behavioral measures to handle internal & external demands that the individual perceives as exceeding available resources
- Integration of environmental cognitive measures to mitigate or diminish the stress response
135
Stress Management Techniques: Cognitive strategies (1 thing)
Cognitive refraining
136
Stress Management Techniques: Behavioral strategies
- Physical exercise
- Journaling
- Mindfulness
137
What is mindfulness?
A stress management technique (adaptive coping strategy)
- Being aware of surrounding & senses at the point in time
138
What are examples of Maladaptive coping?
- Withdrawing from social gatherings
- Frenzied social life
- malnutrition
- excessive sleeping
- excessive drinking
139
What is nutrition?
Nutrition is the study of the nutrients & how they are handled by the body, as well as the impact of human behavior & environment on the process of nourishment
140
What is nutritional Health?
- Physical result of balance of nutrient intake & nutritional requirements
- poor nutritional health may be from over or undernutrition
141
What are the factors that affect food choice?
- taste
- smell
- habits
- availability
142
What is the purpose of a nutritional assessment?
To identify individuals malnourished or at risk of developing malnutrition
- provide data to develop a nutrition plan
- See the effectiveness of nutritional care
143
What is the purpose of a nutritional screening
- to identify those at nutritional risk or to establish a baseline (similar to nutritional assessment)
144
What is part of the Nutritional Health History
- Previous medical problems
- current medications
- Surgical history
- Allergies
- Alcohol/tobacco use
145
Types of nutritional-related complaints
- Weight loss/gain
- Changes in energy level
- change in appetite/taste
146
What is dysphagia
difficulty swallowing
147
What is undernutrition
occurs when nutritional reserves are depleted or when nutrient intke is inadequate to meet day-to-day needs
148
vulnerable groups
infants, children, pregnant, immigrants, low-income peeps
149
Risk factors for obesity
lack of sleep
- genetics
- culture
- oversized food portions
150
signs of malnutrition: skin
dry
- flaky
- scaly
- cracks
- lesions
151
signs of malnutrition: hair
- dry
- sparse
- corkscrew hair
152
signs of malnutrition: eyes
- foamy plaques
- dryness
- pale red
153
signs of malnutrition: lips and tongue and gums
lips: cheilosis (cracked lips), ulcers
Tongue: Red, pale, atropic
Gums: Bleeding
154
signs of malnutrition: nails and musculoskeletal
nails: brittle, ridged, spoon-shaped
musculoskeletal: pain in calves, thighs, joint pain, muscle wasting
155
Culture considerations for nutrition
- understand differences in food intake
- socioeconomic status
- work schedule
- religion
- food traditions
156
older adults nutrition SUBJ DATA and OBJ DATA
- adequate intake?
- physiological changes
- socioeconomic changes
- psychosocial changes
OBJ DATA
- Height
- TSF and skin elasticity
157
What is the circadian rhythm
- A Biological rhythm that have daily cycles
- light & darkness
- awake is when body temp is highest and vice versa
158
Non REM cycle (NREM) stages
stage N1: very lightsleep, last few minutes
Stage N2: light sleep (50% of sleep)
Stage N3:/N4: deep sleep
- Sleeper difficult to wake
- eyes dont move
159
REM sleep desc
- occurs 70-90 min after sleep begins
- most dreams occur (2 hrs a night)
- body and brain highly active( brain may be learning)
160
Functions of sleep and psychologic effects of inadequate sleep
Physiological effects
- Restores normal levels of activity
- Necessary for protein synthesis
psychologic effects
- irritability
- poor concentration
- difficulty making decisions
161
Factors affecting sleep
- sleep quality
- quantity of sleep
- daytime exercise
- emotional stress/physical pain or illness
- diet
- motivation
- environment
- regular sleep schedule
- bedtime hygiene habits
- substance use
- medications
- environment
162
Sleep assessment questions
- Ask about sleep patterns, history, and any recent changes
- identify usual sleep requirements
- ask about sleep problems
- 0-10 sleep scale
163
Lifespan considerations: Infants for sleep
- irregular schedule
- SIDS (sleep on back)
164
Lifespan considerations: Children
- Need consistent sleep schedule
- Nightmares
165
Lifespan considerations: Adolescents
- Shift in sleep-wake patterns
- Nocturnal emissions
-
166
Lifespan considerations: Pregnant individuals for sleep
- inc. need for sleep during first trimester
- comfort!
167
Lifespan considerations: Older adults
- earlier sleep and wake times
- inc. in disturbed sleep
168
Insomnia assessment findings
- Inability to attain an adequate amount of sleep and feel rested
- difficulty falling and staying asleep
- waking up too early
- waking up tired
- acute insomnia - Lasts a few days possibly due to personal or situational stressors
- Chronic insomnia - Lasts a month or more
169
Any discrepancy with family should be...
DOCUMENTED!
170
Purpose of family assessment
To examine relationships that can potentially impact a clients health
- identifying strengths, problems, and areas of opportunity
171
Why do nurses perform a family assessment?
- family members and illness intertwine
- To analyze opportunity, problems, and strengths
172
the 3 components of the family assessment
- Structure
- Development
- Other environmental components
173
the 3 family structures
- Internal structure ( family comp. gender, Rank order, Subsystems, boundaries, power structure)
- external structure
- context
174
Internal structure: composition
who makes up the family?
Can be depicted graphically a a genogram
175
Family assessment: Gender
Can determine role and behavior in the family
176
Family assessment: Rank order
Sibling rank of each family member
177
Family assessment: subsystem
Gender, generational, or interest-based subsystem
178
Family assessment: Boundaries (function equals?)
Functional = clear boundaries, good connections
179
Family assessment: Dysfunctional
rigid boundaries, poor connections
180
Family assessment: Differentiation of self
Balance btw feeling & thinking
181
Family assessment: Distribution of Power
- Power Hierarchy
- Shared Power
182
What is the Family attachment diagram used for?
Can be used to assess the Internal Structure!
183
Family assessment: External Structure and External Systems
- Extended structure
- Doesn't reside in the home but can provide support
- The "cut off" family member
External Systems
- Significant people (co-workers, neighbors, church, classmates)
184
What is an Ecomap?
Used to assess EXTERNAL structure "E to E"
185
Family Assessment: Context
(This is where culture plays a role)
- Race &/or ethnicity
- Social Class
- Religion
- Environment
186
Achieving various stages of development is important to the...
health of the family and its individuals
187
A static family is considered...
dysfunctional
188
The 4 family functions
- Instrumental function
- Affective function
- Expressive Function
- Health Care function
189
Instrumental function
- Is family meeting the routine daily living needs of its members
- ADL's = activities of daily living
(bathing, toileting, grooming, ambulating, positioning, feeding)
190
Affective Function
Are family members providing mutual support to one another?
- Is each individual family member allowed to attain emotional maturity through self-differentiation?
- Is healthy socialization occurring?
- What subgroups exist within the family & what function do they serve?
- Do boundaries exist within the family? are they rigid or permeable?
191
Expressive Function
How are ______ expressed?
How are ___ conveyed?
How do the ___ members _____ __ one another?
What is the ____-______ communication like?
- How are emotions expressed
- How are needs conveyed?
- How do the firm members listen to one another
- What is the non-verbal communication like?
192
Health Care function
How does the family view illnesses?
- How does the family respond to/cope with illness?
- What are the family's health promotion practices?
193
What is ethnicity? (Includes family)
- Subgroups with a common ancestry, history, and cultural identity
- Family coping
- Family stress
- Family communication
MANY OF THESE ARE IMPACTED BY CULTURE
194
Family Assessment: Analyze the data
Identify patterns
- highlights strengths (deliver " commodities")
- Cluster data to reveal abnormal findings
195
Family assessment: Multigenerational families
Effective functioning families often demonstrate....
If there is a multigenerational pattern of maladaptive behaviors, this can make interventions...
- patterns of positive behaviors
-more difficult to implement
196
What is assessment?
- gathering data on individual health status
- identify concerns and needs
197
Nursing assessment: The nurse documents for individual's potential for:
- inc. risk
- Current health promotional activities
- Relevant physical, psychological, social, cultural and environmental factors
198
Holistic nursing assessment def
Collects holistic subj. and obj. data to determine a client's function to make a professional clinical judgment
199
Physical medical Assessment Focuses primarily on
The client's physiologic development status
200
Mind, body, and spirit are _____ and _____ as a whole
interdependent and function as a whole
- Multifaceted basis of disease
201
What forms the core of nursing?
Health promotion and disease prevention
202
What 2 things are considered open systems?
individual and human environment
203
Collection data is done by these three methods:
- Observation
- Interview
- Examination
(these three methods are interwoven in practice)
204
Primary data source for collecting data and secondary data sources?
Primary: Patient
Secondary:
- family membesrs
- friends
- lab tests
- Medical records
205
4 types of health assessment
- initial/comprehensive (or baseline) assessment
- Problem-focused (or system-focused) assessment
- Time-lapsed reassessment/ongoing assessment (monitoring)
- Emergency assessment
206
What is constant data?
Facts that do not change over time
ex: birth date/blood type
207
What is variable data?
Data that can change over time
(can be quick, slow, frequent, or rare)
208
4 types of databases
- complete (total health) database
- Focused or Problem-centered database
- Follow-up database
- Emergency Database
209
Complete (total health) database description
- includes a complete health history and a full physical exam.
- Describes current and past health state and forms a baseline to measure all future changes
- Yields first diagnoses (for initial/comprehensive Assessment)
210
Focused or Problem-Centered Database
- For limited or short-term problems
- Collect "mini" database, smaller scope and more focused than complete database
- Concerns mainly one problem, or one body system
- History and examination follow the direction of presenting concern (for problem/system focused assessment)
211
Follow-up database
The status of all identified problems should be evaluated at regular and appropriate intervals
- Note changes that have occurred
- Evaluate whether the problem is getting better or worse
- Identify coping strategies being used (for time-lapsed/ongoing assessment)
212
Emergency database
- Rapid collection of data, often compiled concurrently with lifesaving measures
- Diagnosis must be rapid and comprehensive in nature (for emergency assessment)
213
