WEEK 1 Flashcards
when coming into patient room
identify yourself, ask 2 patient identifiers to make sure its the right person, ask them consent to be interviewed
history of present illness
Most important aspect of patient’s subjective data
80% of cases- diagnosis can be established by patient history alone
close ended questions
yes or no. more constrained. avoid.
open ended questions
what are you experiencing? what have you tried so far?
better
review of systems
describe possible symptoms they may have experienced, “head to toe”.
ICE
ideas, concerns, expectations
ask patient to describe these to you
I- what do you think is wrong with you?
C- what made you approach us today? whats on your mind? what concerns you about this symptoms
E- what do you expect to achieve after todays encounter?
avoid asking why questions
it can be interpreted as somewhat aggressive.
symptom analysis
acronym 1
PQRSTA
P- provocation, palliation
Q- quality (dull pain, sharp pain)
R- region (where), radiation (does pain go somewhere else)
S- severity (on a scale of 1-10. when you experience chest pain does it affect your ability to exercise)
T- timing (how long does it last, when)
A- associated symptoms
SOCRATES
site onset character radiation associated symptoms timing exacerbating and relieving factors severity
DO NOT USE
U, u
mistaken for zero, 4, or cc
instead write out unit
DO NOT USE
IU
mistaken for IV or number 10
write out international unit
DO NOT USE
QD, qd, q.d
mistaken for each other
write daily
DO NOT USE
QOD, qod, q.o.d. (every other day)
write every other day
DO NOT USE
trailing zero***
lack of leading zero
decimal point is missed
write X mg
*** exception: trailing zero can be used for lab results, not med orders
write o.X mg
DO NOT USE
MS
Can mean morphine sulfate or magnesium sulfate
Write “morphine sulfate” and Write “magnesium sulfate”
DO NOT USE
MSO4 and MgSO4
Confused for one another
for sodium, the absolute value of sodium level is not the primary determinant of how severe the consequences of hypo/hyper natremia may be… it is the
rate of at which the patient develops the abnormal serum sodium that is a more sig determinant of how severe the consequences may be.
hyponatremia
sodium
increased water input
decreased water output
