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
