Complete (total health) database - ✅✅ This type of database includes a complete
health history and a full physical examination. It describes the current and past
health state and forms a baseline against which all future changes can be measured.
It yields the first diagnoses.
Focused or Problem-Centered database - ✅✅ This type of database is for a
limited or short-term problem. Here you collect a "mini" database, smaller in scope
and more targeted than the complete database.
Follow-Up Database - ✅✅ This type of database is used in all settings to follow
up both short-term and chronic health problems.
Emergency Database - ✅✅ This type of database is an urgent, rapid collection of
crucial information and often is compiled concurrently with lifesaving measures.
Diagnostic reasoning - ✅✅ This is the process of analyzing health data and
drawing conclusions to identify diagnoses
Medical Diagnosis - ✅✅ This deals with disease or medical condition. For
example: If a patient had a stroke, this would provide info about the patients'
pathology.
Nursing Diagnosis - ✅✅ This deals with human response to actual or potential
health problems and life processes
Subjective Data - ✅✅ This type of data relates to what the person says about
himself or herself
Objective Data - ✅✅ This type of data relates to what the professional obtains
through physical examination
Modify communication techniques as indicated by each patient's developmental
stage, special needs, or cultural practices. - ✅✅ with older adults avoid "elder-
speak" (similar to baby talk), face hearing impaired clients so they can read lips,
What are the ten traps of interviewing? - ✅✅1. Providing false assurance or
reassurance
, 2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions
Health literacy - ✅✅ This is the ability to understand instructions, navigate the
health care system, and communicate concerns with the health care provider.
Discuss working with and without an interpreter to overcome communication
barriers. - ✅✅ Avoid an untrained interpreter (e.g., family member). Address
questions to client not the interpreter. Never use a minor as an interpreter.
What's the purpose of the complete health history? - ✅✅ Collect subjective data
and combine it with objective data from physical examination and diagnostic tests
List the categories of information contained in a health history- ✅✅
1. Biographical data
2. Source of history
3. Reason of seeking care
4. Present history of patient: symptom analysis may be needed
5. Past health events
6. Family history
7. Review of systems
8. Functional assessment
What information must be gathered for biological data? - ✅✅ Name, birthday,
gender, and race
What information must be gathered for source of history? - ✅✅ Record who
gives the information
What information must be gathered for reason for seeking care? - ✅✅ Sxs/signs,
record whatever the patient says, include time-frame.