N 325 Lecture Notes - Lecture 5: Scientific Method, Nanda, Vital Signs
Document Summary
Gather information about the patient"s condition: collect data, verify data, organize data identify patterns, report and record data. Step 1: collecting data: sources of data, primary: pt, secondary: family members, other health professionals, medical records, types of data, subjective: patients verbal self-report of symptoms, objective: observations or measurements, methods of collecting data. Interview: health history, biographical information, reason for seeking healthcare/admitting diagnosis, present illness or health concerns, family history, environmental history, psychosocial and spiritual health history, review of systems, physical exam, vital signs, height, weight. Inspection: palpation, percussion, auscultation, observation of patient"s behavior, diagnostic and laboratory data, standardized risk assessments: pressure ulcers, falls, dvt. Isolate data pertaining to patient"s health problems: determine the presence of abnormal findings, data validation, compare data with another source to determine accuracy, medical record, nurses or other healthcare team members, data documentation. Clinical judgement response to an actual or potential health problem or life processes. Collaborative: health care team, patients and families.
