Term
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Definition
S: Situation (WHAT IS GOING ON)
B: Backgroun (WHAT HAS HAPPENNED)
A: Assessment (WHAT DO YOU THINK IS WRONG)
R: Recommendations (WHAT WOULD YOU SUGGEST HAPPEN) |
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Term
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Definition
P: Provocation/palliation
What makes the pain better of worse?
Q: Quality/quantity
What does the pain feel to you?(quality) How often does it happen?(quantity)
R: Radiation/region
Where is it? Does is spread?
S: Scale/severity
Rate your pain on a scale of 1 to 10
T: Timing/time of onset
Is there a pattern? Does it come on quickly or slowly?
U: Understanding
What do you think this pain it? |
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Term
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Definition
- Hemoglobin: RBC, 140-180 male, 120-160 female
- White blood cell count (infection): 5-10x10^9L
- Platelets (clotting): 150-400x10^9
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Term
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Definition
A - Asymmetry
B - Border
C - color variation
D - Diameter > 6mm
E - Elevation and enlargement |
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Term
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Definition
S: Subjective
O: Objective
A: Assessment (ex: enhanced health-seeking behavior request for info on skin self-exam)
P: Plan (ex: teach self-care behavior) |
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Term
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Definition
C: Cut down: feel need to cut down
A: Angry: angry when people confront you
G: Guilty: feeling guilty of drinking
E: Eye opener: ever drink in the morning? |
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Term
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Definition
- Weakness
- Trouble speaking
- Vision problems
- Headache
- Dizziness
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Term
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Definition
- A: Appearance
- B: Behavior
- C: Cognition
- T: Thought processes
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Term
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Definition
- Problem (P): brief statement of the patient's potential or actual health problem
- Etiology (E): a brief description of probable cause, contributing or related factors
- Signs & Symptoms (S): list of the cluster of the objective and subjective data that lead the nurse to pinpoint the problem
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Term
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Definition
- D: Data: objective and subjective data (just the data that help you determine which action to take)
- A: Analysis: of patient's concern/need. Impression of the data that inform actions
- R: Response: what happened to patient as a result to intervention, action, responses to care, patient outcomes
- P: Plan: goals to achieve in a designated period of time
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Term
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Definition
- G: Gravida: previous pregnancies, regarless of outcome
- T: Term
- P: Preterm
- A: Abortion
- L: Living
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