Subjective data - CORRECT ANSWER✅✅What the patient tells you.
History.
History of present illness.
Reviews of systems.
Objective data (SIGNS) - CORRECT ANSWER✅✅What you see
Physical examination
Laboratory results
Radiologic findings
Vital signs
Nursing process: ADPIE (A) - CORRECT ANSWER✅✅Assessment: gathering data
Grouping together pertinent data
Prioritizing your findings
ongoing process
reliability - CORRECT ANSWER✅✅Ability of an instrument or a test to give the same result over and
over again (scale weighing the book 5lbs every time)
Validity - CORRECT ANSWER✅✅Extent to which something measures what it is supposed to measure
Sensitivity - CORRECT ANSWER✅✅Testability to correctly identify patients with a disease
Specificity - CORRECT ANSWER✅✅Opposite of sensitivity. Ability of a test to identify patients that do
not have the disease. Those who should be negative should be negative
Nursing Process ADPIE (D) - CORRECT ANSWER✅✅Diagnosis: focuses on treatment of the actual or
potential human responses
, Nursing Process ADPIE (P) - CORRECT ANSWER✅✅Planning: establishing goals for each diagnosis
Short term goals/ long term goals
Identify interventions
Nursing Process ADPIE (I) - CORRECT ANSWER✅✅Implementation: Put your plan into action
Modified as changes occur
Nursing Process ADPIE (E) - CORRECT ANSWER✅✅Evaluation: determine if the goals were met.
How will you maintain successes.
How will you address goals that were not met?
Documentation of allergies: - CORRECT ANSWER✅✅Food, insects, medication, environmental factors,
include reaction
Screening for alcohol - CORRECT ANSWER✅✅Assess what patients consider alcohol
CAGE screening tools
-Have you ever felt the need to CUT DOWN on drinking?
-Felt ANNOYED by criticism of your drinking?
- Have you ever felt GUILTY about drinking?
-Have you ever taken a drink first thing in the morning (EYE-OPENER) to steady your nerves or get rid of
a hangover?
Screening for illicit drug use - CORRECT ANSWER✅✅Prescription drug use
Ask about modes of consumption
Comprehensive health history - CORRECT ANSWER✅✅-identifying data and source of the history
-Chief complaints
-History of present illness