When studying, ensure that you study the normal and the abnormal findings, when
listed.
Subjective vs objective data
Subjective data: What person SAY about him or herself during history taking
o Ex. Patient say…., Nausea noted from patient
Objective data: What you as the health professional observe by inspecting , percussing,
palpating , and auscultating during the physical examination .
Types of databases
1. Complete total health database
o A complete health history and a full physical examination.
o Describe the current and past health state and forms a baseline against future
changes. Yield the first diagnosis
o Use with Third-level priority problems and Collaborative problems
2. Focused or Problem-Centered Database
o For limited or short-term problem
o Collect a mini database, smaller in scope and more target than the complete
database
o Concern only one problem, one body system, and one cue complex
o Use with Second- level priority problem.
o Ex.2 days after surgery Mr.C suddenly has a congested cough, shortness of
breath, and fatigue. The history and examination focus primarily on the
respirator and cardiovascular system.
3. Follow- Up database
o Status of any identified problem should be evaluated at regular and appropriate
intervals.
o Use in follow up both short term and chronic health problem
o Ex. What change has occurred? Is the problem getting better or worse?
4. Emergency database
o Urgent, rapid collection of crucial information and compiled with lifesaving
measure.
o Diagnosis must be swift and sure
o Ex. Name, age, allergic, past medication, level of consciousness, type and
screen
o Use with First-level priority problem.
Nursing process
Nursing process include 6 phases
1
, 1. Assessment: Collect data; Review clinical record, interview, health history, physical
examination, functional assessment, cultural and spiritual assessment, consultation,
review of the literature
o Use evidence base assessment technique
o Document relevant data.
2. Diagnosis: Compare clinical finding with normal and abnormal variation and
developmental events, Interpret data by identifying clusters of cues, validate
diagnosis, document the diagnosis.
3. Outcome identification: Identify expected outcome, individualize to the person,
culturally appropriate, realistic and measurable include timeline.
4. Planning: Establish priorities, develop outcome, set timeline for outcome,
identify intervention, integrated evidence-based trends and research, document
plan of care.
5. Implementation: Implement in safe and timely manner, used evidence-based
interventions, collaborate with colleagues, use community resource, coordination
care delivery, provide health teaching and health promotion, document
implementation and any modification.
6. Evaluation: Progress toward outcome, conduct systematic, ongoing, criterion-
based evaluation, Included patient and significant other.
Identifying priorities for problems
o First-level priority: Those that are emergent, life threatening and immediate
such as establishing and air-way or supporting breathing.
o Second-level priority: Next in urgency, requiring prompt intervention to
forestall further deterioration.
o Third-level priority: Important to patient's health but can be addressed after
more urgent problem are addressed. Intervention to treat this problem are long
term, and response effect is take more time.
o Collaborative problem: the approach to treatment involves multiple disciplines.
Collaborative problem are certain physiologic conditions in which nurse have the
primary responsibility to diagnose the onset and monitor the changes in status. Ex.
Patient had diabetes which represent collaborative problem . With this problem the
sudden imbalance of insulin and blood sugar has profound implication on the central
nervous system and GI system, in this case Nurse, Doctor, Dietitian, and case manager
have to collaborate. Anything that use a lot of people from variety of major is
belong to collaborative problem.
Table 1.1
Step to Setting Priorities
1. Assign high priority to First-Level priority problems
Using ABC plus V to determine
A: Airway problems
B: Breathing problems
C: Cardiac problems
V: Vital sign concerns (high fever, irregular pulse, lower level of respiration)
2. Next attend to Secondary- Level priority problems : mental status change,
Untreated medical problem who requiring immediate attention (diabetes patient
2
, who has not receive insulin), acute pain, abnormal laboratory problem, risk of
infection
3. Address Third-level priority problems: Health problem that is not fit into the
previous categories (e.g. patient with lack of knowledge, activities, rest)
Evidence-based practice: it is the conviction that all patients deserve to be treated with the
most current and best-practice techniques. It is a systematic approach to practice that
emphasizes the use of the best evidence in combination with the clinician’s experience as well as
the patient preference and values, to make decisions about care and treatment.
o clinical decision making depends on all four factors:
(1) the best evidence from a critical review of research literature;
(2) the patient's own preferences;
(3) the clinician's own experience and expertise;
(4)finally physical examination and assessment
Health promotion and disease prevention: they are programs focus on keeping people
healthy. Health promotion programs aim to engage and empower individuals and communities to
choose healthy behaviors, and make changes that reduce the risk of developing chronic diseases
and other morbidities.; guidelines to prevention emphasize the link b/t health & personal
behavior; the pt view of health will impact how often they seek medical advice
Health care disparities: health care disparities are unfair or avoidable heath differences that
affect people who are in a social, economic, or environmental disadvantage. The vulnerable
population which includes ethnic and racial minorities, people with disabilities and the LGBT
community;
o Determinant of Health and Health Disparities
o Individual health status is influence by a constellation of personal, social, economic, and environmental
factors, collectively known as The Determinants of Health.
o Evidence base research shown that Poverty has the greatest influence on health status.
o The purpose of Healthy People 2020 are to address the multiple determinants of health and evaluate
intervention that go beyond the traditional health care provider-patient model.
o Health Care Disparities Among Vulnerable Populations
o Health disparities affect people who experience social, economic, and environmental disadvantage. These
people are "vulnerable populations" and include ethnic and racial minorities, people with disabilities, and
the LGBT community.
Beliefs about causes of illness: theories about the causation of disease have been formulated
on the basis ethnic identities, religious beliefs, social class philosophic perspectives and
traditional beliefs. However, disease causation maybe viewed in three major ways: biomedical or
scientific, naturalistic or holistic, or magicoreligious.
Biomedical: theory believes that all events in life have a cause and effect, the human body
functions mechanically. The germ theory states that microorganisms such as bacteria and
viruses cause specific disease conditions.
Naturalistic or holistic: found by American Indians and Asians, it is the believe that human
life is only one aspect of nature and a part of the general order of the cosmos. It is the
believe that the forces of nature must be kept in natural balance or harmony.
3
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