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MB6 46-54

objective can be quantified
subjective can not be quantified; personal thoughts, opinion, observations.
primary source original object or document
secondary source something (i.e. article) written about a primary source
Purpose of a nursing interview -to conduct a thorough assessment of the patient, gathering all relevant data and information. Also to start building relationship.
4 components of nursing health history (there are more) 1.biographical 2.chief complaint 3.past health history 4.family history 5.review of symptoms 6.patient profile
open-ended vs. close-ended questions close ended can be answered with yes or no
When do you need to validate data? New patient - 2 forms of ID Doc's RX is illegible Aide returns with vitals that are abnormal Discrepancies between subjective and objective data (laughing/Oh I'm in pain)
Describe frameworks for organizing assessment data NANDA, NIC, NOC, Maslow and PattyWhack.
Define Diagnosis the art or act of identifying a disease from its signs and symptoms
Define Nursing Diagnosis A nursing diagnosis is part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. N/D are based on data obtained during the nursing assessment
Define Defining Characteristic A property held by all members of a class of object that is so distinctive that it is sufficient to determine membership in that class. A property that defines that which possesses it.
Define Related Factors – A contributing cause in any action pertaining to a particular diagnosis
Define Risk Factor - a risk factor is a variable associated with an increased risk of disease or infection
Define Health Problem a condition that has an adverse effect on the normal or proper function of an organism or its parts.
Created by: Marshall3