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subjective- what is the patient saying
objective- what the doctor discovered
pain is subjective
ow(positive tenderness)
acute- new not chronic
app_ advanced practice provider , work under supervision of doctor
charge nurse is captain of floor
nurses get 3 or 4 rooms each
techs float around as well as respiratory therapists
unit secretary- makes calls
Triage- nurse checks them in gets vitals and basic info and cheif complaint. they will decide if its an emergency
another nurse assigned to room and then doctor arrives
Differential- what were worried about
Med chart looks like:
age sex and onset of patient and cheif complaint
then gather history and background of patient (subjective)
then physical exam (objective)
arrhythmia abnormal heartbeat
afib is a specific kind of arrhythmia
pulmonary embolism shortness of breath
pneumonia is a lung infection
gerd gastro espohogial reflux disease
acid reflux
itis means inflammation to that organ
UTI can lead to pylonephritis kidney infection
G- total number of pregnancies {a plus p}
P- number of times they have given birth {birth event counts as one even if multiple children birthed in one sitting}
A- any abortions or miscarriages
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