Nur 265 1 Flashcards
when the point of view is from the patient
subjective
when the data source is the patient themselves
PRIMARY source data
When the spouse or partner tells the doctor data
SECONDARY source data
data the nurse gleams directly
PRIMARY OBJECTIVE data
Doctors’ notes- nurses’ reports- charts- lab values -x-ray results are examples of
SECONDARY OBJECTIVE data
FIRST LEVEL (PRIORITY)
Emergent life-threatening not breathing!
SECOND LEVEL( PRIORITY)
Urgent acute pain mental status changes safety risk -needs to follow up
THIRD LEVEL(PRIORITY)
needs attention but not a priority –problems with lack of knowledge, mobility, rest or coping
COMPLETE database (DATA COLLECTION TYPES)
full hx, head-to-toe —visiting nurses and upon admission to hospital
FOCUSED database (DATA COLLECTION TYPES)
1 or 2 systems looked at –like urgent care model usually a short term problem
FOLLOW-UP database (DATA COLLECTION TYPES)
Do you know if the earlier interventions worked?? after focused
EMERGENT database (DATA COLLECTION TYPES)
early rapid collection of info
coming up with a goal
planning
doing what you planned
implementation
checking if the plan worked
evaluation
figuring out the problem
Nurse Diagnosis
Formulating hypothesis from cues gathering data relative to each hypothesis
nursing process and health assessment
yes or no questions
closed ended
internal empathy, like people, good listener, self-awareness being aware of your biases
Factors that affect communication
inspection
using our eyes
palpation
hands to touch
percussion
fingers o make sound
auscultation
eras or equipment to hear
olfaction
smelling
tactile
fingertips back of hand for temp
palm pulsations
masses and edema
flatness dullness
percussive sound
resonance hollow
lungs
hyperresonance
lungs too
tympany
abdomen
external factors-
Privacy -quiet-lighting -how they are dressed eye contact
