NURS1068 Lecture Notes - Lecture 1: Physical Examination, Mental Status Examination, Lifesaving

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Nursing process: assessment, diagnosis, outcome identification, planning, implementation, evaluation. Assessment: data collection: history: subjective data, physical examination: objective data, what the person says during health history taking, what the health care provider observes by inspecting, percussing, palpating, and. Database = patient"s record and lab studies + assessment data auscultating during the physical examination. A complete health history and results of a full physical examination. A rapid collection of data, often compiled while life-saving measures are occurring. The complete database includes a complete health history and a full physical examination. Forms a baseline against which all future changes can be measured. In primary care, the complete database is collected in a primary care setting: pediatric or family practice clinic, independent or group private practice, college health service, women"s healthcare agency, visiting nurse agency, or community healthcare agency. Episodic database is for a limited or short-term problem. Collect a mini database, smaller in scope and more focused than the complete database.

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