-Focused or problem centered Database
-Describes the current and past health state and forms a baseline against which all future changes can be measured.
-Collect a “mini” database, more targeted than the complete database.
-The *proficient* nurse understands a patient situation as a whole rather than a list of tasks. At this level you can see long term goals for the patient.
-The *expert* nurse vaults over the steps and arrive at the clinical judgement in one leap. Has an intuitive grasp of a clinical situation.
-Gather data to relevant
-Use an organized and comprehensive approach
-Differentiate between expected vs. unexpected
-Begin with open ended questions
-Dont give false reassurance
-Dont use authority.
-what the patient tell you
-Things you can *see* and *measure*
-knowing if there are any cultural considerations you need to be informed about
-getting a translator.
-Secondary source- immediate family members, possibly friends
-If your not sure if they are reliable you can ask twice or ask a question you know the answer too.
2. Giving Unwanted advice
4.Using Avoidance Language
6.Using Professional Jargon
7.Using Leading or Biased Questions
8.Talking to much
10. Using “why” questions
-They will say a subjective symptom and you will pay attention to the sign or objective abnormality.
-Present health or History of present illness
-Review of systems
-Functional Assessment (including activities of daily living)
-Perception of health
2.Character or Quality-specific descriptive terms
3. Quantity or Severity -pain scale 1-10
4.Timing-(onset, duration, frequency)
5.Setting-What where you doing or where where you when it started
6.Aggravating or Relieving Factors- what makes it worse? what makes it better?
7.Associated Factors-primary symptom associated with any others?
8.Patients Perception-How does it affect daily actives?
-Level of consciousness
-Body build, contour
-obvious physical deformities
-Range of motion
-Mood and affect
-Body Mass index
————————– X 703
Height (in inches)2
Height(in meters) 2