Exam 2 Flashcards
symptoms
symptoms are subjective: patient’s self report (includes sensations, feelings, etc) ex: nausea, pain, dizzy, tired, etc
signs
signs are objective, can be measured, seen, heard, etc. ex: redness, cough, BP, cyanosis, petechia, etc
PQRSTU- P
provacative/palliative- what helps/hurts the pain?
PQRSTU - Q
quality- what does it feel like? sharp, stabbing, dull?
PQRSTU - R
region- where is the pain?
PQRSTU - S
severity- how bad does it hurt on a scale of 1-10?
PQRSTU - T
timing- morning, night, constant?
PQRSTU - U
understanding patient perspective
components of a complete health history
biographic data, reason for seeking care, surgeries, medication, family health history, allergies, review of systems
associated factors
any symptoms outside of chief complaint
Gordon’s functional health
ADLs, health perception, nutrition, elimination, activity, cognition, sleep, self perception, relationships, sexuality, coping, values
medication reconciliation
have pt provide adequate information about what medications they are prescribed and if they are complying- consider any obstacles
mental health assessment- nurses role
gather information, assess for risks, referral
substance abuse screening
opiod risk tool- self reported screening tool that assesses for opiate abuse risk before patients are prescribed them. Craft screening uses part A and B to determine risk.
Domestic violence
RADAR, assessment of immediate safety, danger assessment