Nursing 1080A/B Lecture Notes - Lecture 4: Medical History, Vital Signs, Perspiration
9 Dec 2016
School
Department
Course
Professor
Document Summary
Interview: components: demographic data, reason for interview (rfp; rfa; rfr, medical history (hx) (current and past, surgical hx , family hx, medication profile, social hx, review of systems (term 2) Sources: primary or secondary, health record review, lab values/ test results, family doctor, literature. Match nontherapeutic responses with their examples: false reassurance (cid:498)don"t worry, it will be alright(cid:499) (cid:498)comes from several sources, equipment, other patients, colleagues or cell phones(cid:499) (cid:498)the nurse documents about trouble swallowing and asks the patient about dysphagia(cid:499) Feeling what the patient feels from your view point. Usually given from the nurses prospective, not the patients: biased question, unwanted advice. When the patient says (cid:498)i"m feeling a bit nauseous today(cid:499) the nurse replies, (cid:498)what did you have to drink(cid:499: changing the subject. Then signature along with your credentials or status (rn) Status is not your degrees, it is simply why you are working there. Document what you"ve done, not documented not done.
