Objective information refers to the symptoms and signs of patients obtained by nurses through seeing, touching, listening, smelling or using medical instruments.
Question 2: What are subjective medical records such as death medical records, difficult medical records, superior doctors' rounds, consultation opinions and course records? Subjective medical records should be sealed and unsealed in the presence of both doctors and patients. In the event of a medical accident, patients have the right to copy or duplicate objective medical records, but subjective medical records cannot be copied or duplicated. Subjective medical record is a record of medical staff's subjective opinions on the patient's condition and treatment, which can reflect the medical staff's subjective understanding of the patient's disease and its diagnosis and treatment, as well as the subjective motivation to implement medical behavior. Therefore, this part of medical records plays an important role in the technical appraisal of medical accidents, judging whether it belongs to medical accidents and the degree of responsibility.
Question 3: How to distinguish subjective data from objective data in nursing health assessment? Objective information refers to the symptoms and signs of patients obtained by nurses through seeing, touching, listening, smelling or using medical instruments, while subjective information is said by patients themselves.
Question 4: What kind of data does the subjective holistic nutrition assessment method belong to? Subjective assessment of overall nutritional status (PG-SGA)_ medical and health _ professional data.
Subjective comprehensive nutritional assessment (SGA);
SGA is a subjective evaluation method based on medical history and physical examination, which is characterized by omitting anthropometry and biochemical examination on the basis of detailed medical history and clinical examination.
Its theoretical basis is: changes in body composition and eating, changes in digestive function, changes in digestive absorption function, muscle consumption,
Changes in physical function and mobility. There is a good correlation between SGA and body composition assessment methods in severe malnutrition.
Question 5: What are subjective data and objective data of patients? Diagnostic criteria: it is the clinical judgment criteria for making this diagnosis. The standard of this reserve is a symptom, or a symptom, or a group of symptoms and signs, or it may be a risk factor, and these standards are the reactions that individuals or groups actively express or observe. This can be subjective or objective, and there are two kinds of subjective data and objective data: the main data must appear in the short-term diagnosis; Auxiliary data may appear during diagnosis.
Question 6: Case analysis of examination questions and answers of introduction to nursing
Patient, male, 26 years old. Due to repeated dyspnea 10 years, it was aggravated by 2 days. Patient 10 years ago began to have difficulty breathing, and every cold got worse. After long-term treatment, it recurred. I couldn't lie flat because I had a cold and had difficulty breathing two days ago. I take medicine by myself, and the effect is not good. The outpatient department was admitted to hospital for severe asthma. The patient has no history of smoking, dislikes greasy food, is cheerful and can take care of himself at ordinary times. The stool is ok, but the urine output is small. Insomnia patients are fearless and irritable. No previous medical history.
Physical examination: T 36.8℃, P 120 times/minute, R 30 times/minute, BPL 30/80 mmHL young male, conscious and suffering. Sitting posture, shortness of breath, exertion when exhaling. Bucket chest, lung full of wheezing sound and slightly moist sound, distant heart sound, regular rhythm, soft abdomen, motionless liver and spleen; There is no edema in both lower limbs.
The patient's medical diagnosis is bronchial asthma. Please list the nursing diagnosis of patients.
Answer: The patient's nursing diagnosis includes:
(1) Impaired gas exchange: related to airway inflammation and ventilation dysfunction.
(2) Sleep pattern disorder: It is related to the patient's difficulty in sucking and the inability to take the correct lying position.
(3) Self-care defect: It is related to the aggravation of dyspnea after the patient's activities.
(4) There is a risk of insufficient body fluid: it is related to the patient's excessive breathing and increased water consumption in the body.
(5) Language communication disorder: It is related to the patient's shortness of breath and his inability to express himself normally.
(6) Anxiety: It is related to the patient's long illness, repeated attacks and incurability.
(7) Potential complications: respiratory failure.
Question 7: What are subjective and objective? T 5 is subjective and a kind of consciousness and spirit of human beings. As opposed to "objective", the so-called "subjective" means that the observer is the "subject" and participates in the observed things.
Fame refers to the knowledge and opinions formed in people's minds after observing actual things.
Objectivity is the original state of things.
As can be seen from the definition, subjectivity is the embodiment of human thinking, which actually does not exist. Objectivity is the state of things and the expression of actual existence.
This is what subjective and objective mean when they are used as nouns.
In addition, subjective and objective adverbs, as adverbials, indicate an attitude towards problems.
For example, we should look at the impact of this incident objectively.
This sentence objectively represents an attitude towards the impact of this incident.
Another example: you see the problem too subjectively.
Subjectivity is also an attitude here.
Question 8: What do you mean by subjective and objective?
① Subjectivity refers to people's consciousness and spirit; Objectivity refers to the material world outside people's consciousness, or to all cognitive objects. Dialectical materialism holds that subjectivity and objectivity are the unity of opposites. Objectivity exists independently of subjectivity, which actively reflects objectivity and promotes or hinders the development of objective things.
(2) Objectivity means that people's understanding starts from reality; Subjectivity means that people's understanding does not proceed from reality, that is, subjectivity. (1979 edition) resigned from the sea
To put it more popularly, for example, the door of 1.8 meters is objective and cannot be changed.
Is this door high or low? This is subjective. In the eyes of 1.6 meters, this door is very high, but in the eyes of Yao Ming, this door is very short.
Therefore, subjectivity has certain laws with the formation and change of objectivity, although many of these laws are still unknown to people. Then these laws of subjective formation and transformation are independent of human will, so they are objective.