NURS 363 Lecture Notes - Lecture 1: Hematocrit, Creatinine, Cholesterol
Document Summary
Interviewing is the most important part of data collection. It help to establish a relationship with the patient. Always introduce yourself and explain what you"re going to do (ask questions) and why. Always make sure to ask whether others can stay or should leave. The health history by rephrasing the question later in the interview. Use phrase poor historian if unreliable: biographical data- name, age, sex, birthdate, birthplace, marital status, race, ethnicity, occupation. Always take note of reliability and who gave the information. Check reliability (usual and present): reason for seeking care (incorporates wellness needs whereas chief complaint does not) b. i. Sign: objective abnormality; detectable on physical exam or lab reports: present health or history of present illness, characteristics of symptom: d. i. Location- specific, point to the area, superficial vs deep, radiate vs localized d. ii. Character or quality- describe: burning, sharp, aching, shooting d. iii. Associated factors- any other symptoms associated with this d. viii.
