- database is used to make a judgement of diagnosis about the health status
of the individual
Nursing Process - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Sources of Data - ANSWER - Client
- Family/Significant Others
- Health Care Team
- Medical Records
What is Objective Data? - ANSWER information that is measured through
physical examination, observation, or diagnostic testing
What is Subjective Data? - ANSWER what the patient tells us their symptoms
are, including feelings, perceptions, and concerns
,Health History includes... - ANSWER - Biographical data
- Reason for seeking care
- Present or past health or hx of present illness
- Family hx Review of Systems
- Functional Assessment or ADLs
Biographical Data - ANSWER Name
Address and Phone #
Age and DOB
Birthplace
Gender
Marital status
Ethnic Origin
Occupation - usual and present
Characteristics of Symptoms - ANSWER Location
Character or quality
Quantity or severity
Timing
Setting
Aggravating or relieving factors
Associated factors
, Patient's perception
Past Health - ANSWER Childhood illnesses
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric history
Immunizations
Last examination date
Allergies
Current medication
PQRSTU mnemonic stands for... - ANSWER P: Provocative or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing (onset, duration and frequency)
U: Understanding of patient's perception
Family History - ANSWER Age and health or cause of death of blood relative
Health of close family members (spouse, children)
Family history of various conditions such as heart disease, high blood
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