NUR 265 Exam 1
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, subjective data what the patient tells you
objective data what the nurse is getting data
primary subjective data data right from the patient
primary objective data I observed it
secondary subjective data caregiver/parent observations
secondary objective data observe charted info, info from the doctor or aid, lab results
examples of subjective data sore throat, ear pain, shortness of breath, headache, no PND
examples of objective data lung sounds, pink/moist pharynx, positive cough, history of URI
diagnostic reasoning the process of analyzing health data and drawing conclusions to identify
diagnoses
diagnostoc reasoning steps 1. attending to cues
2. formulate diagnostic process
3. gather data relative to hypothesis
4. evaluate each hypothesis w/ the new collected data to form final diagnosis
nursing process Assessment
Diagnosis
Planning
Implementation
Evaluation
1st level priority Emergent, life threatening, and immediate
ex: not breathing
2nd level priority urgent
ex: acute mental status change, acute pain, untreated med problems, abnormal
labs
3rd level priority needs attention but not priority
ex: education, mobility, rest, coping
complete database head to toe physical, comprehensive, health history, primary care