I. Observation
It is a way for nurses to systematize health information by using their own senses or using simple diagnosis and treatment instruments. Including visual observation, tactile observation, auditory observation and olfactory observation.
Second, the nursing physical examination
It is one of the methods to collect objective data in nursing evaluation. Nurses conduct a comprehensive physical examination of patients according to the order of various systems of the body by means of seeing, touching, knocking and listening.
Third, talk about
1. formal talk: talk according to the plan drawn up by both nurses and patients in advance. Medical education network is often used to collect medical history.
2. Informal conversation: casual conversation with patients in daily work. This way can make people feel relaxed and natural, and help nurses understand the real feelings of patients.
Scope and sources of data collection
(l) General information: name, gender, age, marriage, place of origin, occupation, education level, nationality, religious belief, date of hospitalization, disposition of admission, mode of admission and introduction of admission.
(2) Brief course of the disease: including inducement, onset time, main manifestations of the disease, what kind of treatment was given before admission, main pain at present, and preliminary medical diagnosis.
(3) Living habits: diet (including eating habits, appetite and partial eclipse), sleep (how many hours to rest every day, whether you are energetic during the day) and urination (frequency, quantity and characteristics).
(4) Past health status, hereditary diseases and infectious diseases in the family.
(5) Whether there is a history of drug or food allergy.
(6) Whether there are hobbies such as drinking, year, daily amount, etc.
(7) Health awareness and health care measures taken.
(8) Psychological activities: including personality characteristics, current psychological state, whether there are any major changes in life and psychological endurance in recent years, and the ability to cope with stress at ordinary times.
(9) Understanding of diseases, expected health status and requirements for nursing.
(10) Social status: including family members' occupation, cultural status, economic status, family members' concern for patients, knowledge and attitude towards diseases, interpersonal relationships around them, and ignorant relatives and friends.
(1 1) Nursing physical examination: including temperature, pulse, respiration, blood pressure, consciousness, development, nutrition, body position, body length, weight, skin and mucosa, head and neck examination, chest and abdomen examination, limb activity, motor system examination, various catheters and wounds.
(12) Relevant auxiliary examination data: such as the results of X-ray examination, electrocardiogram examination, laboratory examination and various special examinations.