NURSING 277 Lecture Notes - Lecture 5: Chest Pain, Pain Scale
Document Summary
Biographic data includes name, address, phone number, age and birth date, birthplace, gender, marital partner status, race, ethnic origin, and occupation. Record who furnishes the info person him/herself is most reliable but may be an interpreter or caseworker, relatives and friends are less reliable. Note if the person seems well or ill. Sample statements: patient herself, who seems reliable or patients son, john. Brief, spontaneous statement in the persons own words that describes reason for the visit. States one (maybe two) symptoms of signs & their duration. Symptom = subjective sensation that the person feels from the disorder. Sign= objective abnormality that you as the examiner could detect on a physical examination or in lab reports. Record persons exact words and record a time frame. Sample statements: chest pain for 2 hours or sore throat for 3 days now and just getting worse . Present health or history of present illness. For healthy person i feel healthy right now .
