Exam 1 (Wilson/Giddens 1, 2, 3, 4, 6) Exam
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Components of Health Assessment Health history, physical examination, documentation of data
Health History Subjective data collected during an interview. Includes patient's
current state of health, medications, previous illnesses and surgeries
and family history. Symptoms
Primary source data Data acquired from patient directly
Secondary source data Data acquired from another individual, such as a family member
Physical examination Objective data; Signs
Documentation of Data complete, accurate, and descriptive documentation
Primary prevention prevent a disease from developing through the promotion of healthy
lifestyles
Secondary prevention early identification of the disease before it becomes symptomatic to
halt the progression of the pathologic process
Tertiary prevention minimize severity and disability from disease through
appropriate therapy for chronic disease
Phases of the interview Introduction, Discussion, summary
Introduction Phase Introduces self to patient, describes purpose of interview, describes
interview process
Discussion Phase Facilitates and maintains patient-centered discussion. Uses various
communication techniques to collect data
Summary Phase Summarizes data with patient. Allows patient to clarify data. Validates to
patient that he or she understands problems
Physical setting private, quiet, comfortable room free from environmental
distractions where the nurse and patient can sit face to face
Open-ended questions broadly stated question encourage a free-flowing, open response; aim
is to elicit responses of more than one or two words
Close-ended questions Require only one or two words to answer; "Do you have feel short of
breath"