(1) Subjective information refers to the information obtained by talking with the appraisee, including the main complaints of the appraisee, complaints from relatives and the description of the appraisee's health obtained by asking questions.
(II) Objective Data Observable or sensible changes have taken place in the body surface or internal structure of the assessed person after illness, such as jaundice, hepatomegaly, heart murmur, etc. These changes are clinically referred to as signs. When the assessed observes or feels these changes with the help of sensory organs, laboratories or instruments, these changes become objective data. Physical signs are an important basis for forming nursing diagnosis.
Case:
Third, the method of collecting health information.
(1) Really? interview
It is a complex, targeted, formal and orderly dialogue between the evaluator and the assessed. Successful conversation is the key to ensure the integrity and accuracy of health history.
(I) Purpose of the interview ① Its purpose is to obtain the complete basic information of the health history of the assessed before the physical examination; (2) Evaluators can get a lot of important evidence from the conversation, which is helpful to establish nursing diagnosis; ③ It can also provide clues for further physical assessment.
(2) What are the main factors affecting the talks and what should be paid attention to during the talks?
1. Relationship with the appraised person? We should establish an equal, relaxed and friendly cooperative relationship.
2. Speaking skills?
Before the talks begin:
Throughout the talks:
During the conversation: Generally speaking, the conversation begins with the chief complaint and is conducted purposefully and orderly. Questions should be used interchangeably with open questions and closed questions. In order to confirm or confirm what the appraisee said, you can ask questions directly.
In order to ensure the accuracy of the information obtained, it is necessary to verify the vague, suspicious or contradictory contents during the talks. The commonly used verification methods are: ① clarification: ② retelling; 3 rhetorical questions; (4) the method of asking questions.
3. Environment?
4. Culture
5. What is the age difference?
6. Health status?
The health history obtained through interviews is subjective information about the health status of the assessed.
Second, physical fitness assessment methods (Chapter 4 of this book)
After collecting the health history, the examiner will make a physical assessment. Physical fitness assessment is a set of basic examination methods. The examiner uses his own senses, with the help of simple auxiliary tools such as stethoscope, sphygmomanometer and thermometer, to make a detailed observation and systematic examination of the assessed's body, so as to understand his physical condition.
What is obtained through physical assessment is objective information about the health status of the assessed.
(a) Description of physical evaluation:
(1) The inspector wants the instrument.
(2) Inspectors should be meticulous, gentle, comprehensive, systematic, detailed and formal in operation.
(3) check the environment.
(4) The inspection shall be carried out in a certain order, from head to toe, with left and right controls.
(5) review at any time according to the change of illness,
(6) Use both hands and brain, while examining and thinking about its anatomical position and pathophysiological significance.
(2)? Prescription for physical fitness assessment
[visit] (? Check)
The inspection method of visually observing the state of the inspected person is simple and has always been the first step of inspection. Visual observation can observe the whole body and many whole body and local manifestations. The light used in the inspection should be soft and colorless. When observing superficial parts, you can directly use natural light or indoor lighting.