Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Health Assessment 1
Test 1: Chapters 1, 3-7
| Question | Answer |
|---|---|
| Assessment | Collection of data about the individual's health state |
| Subjective Data | What the person says about himself or herself during history taking |
| Objective Data | What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination |
| Diagnostic Reasoning | The process of analyzing health data and drawing conclusions to identify diagnoses; based on scientific method |
| Four major components of diagnostic reasoning | 1. Attending to initially available cues 2. Formulating diagnostic hypothesis 3. Gathering data relative to the tentative hypothesis 4. Evaluating each hypothesis w/ the new data collected |
| Cues | Pieces of information, a sign or symptom, or a piece of lab data |
| Diagnostic Hypothesis | Tentative explanation based on cues |
| Six Phases of the Nursing Process | Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation |
| 1970s & 1980s aspect of the Nursing Process | A clear, stepwsie, linear approach that started with assessment and ended with evaluation |
| Present aspect of the Nursing Process | A more dynamic, interactive process; practitioners move back and forth within the steps |
| Novice Nurse | No experience with a specified patient poplation and uses rules to guide performance |
| Proficient Nurse | Understands a patient situation as a whole rather than as a list of tasks, see long-term goals for patient |
| Expert Nurse | Vault over the steps and arrive at the clinical judgement in one leap, use intuition to narrow down an accurate solution, has a storehous of experience |
| Intuition | Knowledge recieved as a whole; characterized by immediate recognition of patterns |
| Critical Thinking | Enables you to analyze complex data, make decisions about the patient's problems and alternative possibilities, evaluate ech problem to decide which applies to the situation, and decide on the most appropriate interventions |
| Step 1 of Alfaro-LeFevre's critical thinking skills: Identify Assumptions | To recognize that you could take information for granted or see it as fact when actually there is no evidence for it. |
| Step 2 of Alfaro-LeFevre's critical thinking skills: Organized and Comprehesive approach | Depends on the patient's priority needs and your personal or institutional preference. Format include: a head to toe approach, a body systems approach, a regional area, or a preprinted assessment form |
| Step 3 of Alfaro-LeFevre's critical thinking skills: Validation | Checking the accuracy and reliability of data |
| Step 4 of Alfaro-LeFevre's critical thinking skills: Normal from Abnormal | Distinguish when identifying signs and symptoms. 1st step to problem identification. |
| Step 5 of Alfaro-LeFevre's critical thinking skills: Making Inferences | Drawing valid conclusions. Involves interpreting the data and deriving a correct conclusion about the health status |
| Step 6 of Alfaro-LeFevre's critical thinking skills: Clustering | Grouping together related cues, which will help you see relationships among the data |
| Step 7 of Alfaro-LeFevre's critical thinking skills: Relevant from irrelevant | Look at the clusters of data, and consider which data are important for a health problem or a health promotion need |
| Step 8 of Alfaro-LeFevre's critical thinking skills: Recognizing inconsistencies | With this kind of conflicting information, you can investigate and further clarify the situation |
| Step 9 of Alfaro-LeFevre's critical thinking skills: Identifying patterns | Helps to fill in the whole picture and discover missing pieces of information |
| Step 10 of Alfaro-LeFevre's critical thinking skills: Missing informatioin | Gaps in data, or a need for more data to make a diagnosis. |
| Step 11 of Alfaro-LeFevre's critical thinking skills: Promoting Health | Identifying risk factors for the individual's age group and cultural status |
| Step 12 of Alfaro-LeFevre's critical thinking skills: Actual and potential (risk) problems | Diagnosing from the assessment data |
| Step 13 of Alfaro-LeFevre's critical thinking skills: Setting Priorities | Used when there is more than one diagnosis. The acuity of illness often determines the order of priorities of the person's problems |
| Step 14 of Alfaro-LeFevre's critical thinking skills: Patient-centered expected outcomes | Measurable results that you expect will show an improvement in the person's problem after treatment. Outcome statement should include a specific time frame. |
| Step 15 of Alfaro-LeFevre's critical thinking skills: Specific Interventions | Interventions should aim to prevent, manage, or resolve health problems. State who should perform the intervention, when and how often, and the method used. |
| Step 16 of Alfaro-LeFevre's critical thinking skills: Evaluating and correct thinking | Look at the expected outcomes and apply them for evaluation. Analyze whether your interventions were successful or not. |
| Step 17 of Alfaro-LeFevre's critical thinking skills: Comprehensive plan | Evaluating and updating the plan. Record the revised plan of care adn keep up to date. |
| First-level priority problems | Emergent, life threatening, and immediate. Ex. establishing an airway or supporting breathing |
| Second-level priority problems | Require your prompt intervention to forestall further deterioration. Ex. Mental status change, acute pain, acute urinary elimination problems, untreated medical problems, etc. |
| Third-level priority problems | Those that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ex. knowledge deficit, altered family processes, and low self-esteem |
| Collaborative problems | Certain physiologic complications in which nurses have the primary responsibility to diagnose the onset and monitor the change in status |
| Medical diagnosis | Used to evaluate the etiology (cause) of disease |
| Nursing diagnosis | Used to evaluate the response of the whole person to actual or potential health problems |
| Biomedical Model | Views health as the absence of disease |
| Biomedical Focus | The diagnosis and treatment of those pathogens and the curing of disease |
| Holistic Health | Views the mind, body and spirit as interdependent and functioning as a whole within the environment. Treatment requires the services of numerous providers |
| Health Promotion and Disease Prevention | Focus on teaching and helping the consumer choose a healthier lifestyle |
| Complete (Total Health) Data Base | Includes a complete health history and a full physical examination. Describe the current and past health state and formas a baseline within all future changes can be measured. |
| Complete Data Base for well person | Must describe the person's health state, perception of health, strengths or assets, support systems, and any risk factors or lifestyles changes |
| Complete Data Base for ill person | Includes a description of the person's health problems, perception of illness and response to the problems |
| Episodic or Problem-Centered Data Base | A limited or short-term problem, concerns mainly one problem, one cue complex, or one body system |
| Emergency Data Base | Calls for a rapid collection of the data, often complied concurrently with lifesaving measures |
| Biomedical or scientific Theory of Illness Causation | Based on the assumption that all events in life have a cause and effect. |
| Magicoreligious | The world is seen as an arena in which supernatural forces dominate |
| Heritage Consistency | Includes a determination of a person's cultural, ethnic, and religious background and socialization experiences |
| Heritage Consistent | Traditional- living within the norms of the traditional culture |
| Heritage Inconsistent | Modern- acculturated to the norms of the dominant society |
| Four basic characteristics of culture | 1. Learned from birth 2. Shared by all members 3. Adapted to specific conditions 4. Dynamic and ever changing |
| Religion | Refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods |
| How religion influences health practices | Benefits health by 1. promoting health behavior and lifestyles, 2. offering support that buffers and affects stress and isolation, 3. leading to thoughts of hope, optimism and positive expectation |
| Socialization | The process of being raised within a culture and acquiring the characteristics of that group |
| Assimilation | The process by which a person develops a new cultural identity and becomes like the members of the dominant culture |
| Biculturalism | Dual pattern of identification and often of divided loyalty |
| Acculturation | The process of adapting to and acquiring another culture |
| Heritage | The cultural beliefs and practice of the family |
| Spirituality | Borne out of each person's unique life experience and his or her personal effort to find purpose and meaning in life |
| Culture Shock | The state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility to the stranger's perceptions and expectations |
| Culture Bound Syndrome | Some people have a condition that is culturally defined |
| When you have a successful interview | Gather complete and accurate data, Establish rapport and trust, Teach the person about the health state, Build rapport for a continuing therapeutic relationship, and Begin teaching for health promotion and disease prevention. |
| Communication | Exchanging information so that each person clearly understands the other |
| Goal of the interview | To record a complete health history |
| Verbal Communication | The words you speak, vocalizations, the tone of voice |
| Nonverbal Communication | Body language- posture, gestures, facial expression, eye contact, foot tapping and touch. |
| Open-ended Questions | Use for narrative information and calls for long paragraph answers |
| Closed Questions | Use for specific information and calls for short one- to two- word answers |
| Nine types of verbal responses | Facilitation, silence, reflection, empathy, and clarification- involves your reactions to the facts the person communicated. Confrontation, interpretation, explanation, and summary- involves you to express your thoughts and feelings |
| Facilitation | These responses encourage the patient to say more, to continue with the story ('mm-hmm') |
| Silence | Is golden after open-ended questions. Allow the patient time to think and to organize what he/she wishes to say. |
| Reflection | This response echoes the patient's words and repeating part of what the person has just said. |
| Empathy | Recognizes a feeling and puts it into words, accept it, and allows the person to express it without embarrassment |
| Clarification | Used to summarize the person's, simplify them to make them clearer, then ask if you are on the right track. |
| Confrontation | You have observed a certain action, feeling, or statement and you now focus the person's attention on it. You give your honest feedback about what you see or feel. May confront the person when you notice parts of the story are inconsistent. |
| Interpretation | Based on your inference or conclusion. Links events, makes assumptions, or implies cause. |
| Explanation | With these statements, you inform the person. You share factual and objective information. |
| Summary | This is a final review of what you understand the person has said. |
| Ten Traps of Interviewing | 1.Providing False Assurance or Reassurance 2.Giving Unwanted Advice 3.Using Authority 4.Using Avoidance Language 5.Engaging in Distancing 6.Using Professional Jargon 7.Using Leading or Biased Questions 8.Talking Too Much 9.Interrupting 10. Using 'Why' ? |
| Closing the Interview | The summary is a final statement of what you and the patient agree the health state to be. |
| When interviewing a child | You must build rapport with two people- the parent and child. By focusing on the parent, the child can observe your interaction with the parent, see that the parent accepts and like you, and relax |
| When interviewing an infant | Nonverbal communication is the primary method. They respond best to firm, gentle handling and a quiet, calm voice |
| When interviewing a preschooler (2-6 yrs) | They are egocentric. Communication is direct, concrete, literal, and set in the present. Use short, simple sentences with a concrete explanation. |
| When interviewing a school-age child (7-12 yrs) | Child is more objective and realistic. Want to know how things work and why things are done. |
| When interviewing an adolescent | Attitude must be one with respect. Stay in character. Do not assume they know anything about a health interview. Keep questions short and simple. Avoid silence and reflection. Value peers. |
| When interviewing an older adult | Always address by last name. Interview usually takes longer. Adjust the pace of the interview and avoid trying to hurry them along. |
| Complete Health History | Includes: 1.Biographical data 2.Reason for seeking care 3.Present health or history of present illness 4.Past history 5.Family history 6.Review of systems 7. Functional assessment or activities of daily living |
| Biographical Data | Name, address and phone number, age and birthdate, birthplace, gender, marital status, race, ethnic origin, and occupation. |
| Reason for seeking care | Brief spontaneous statement in the person's own words about the reason for the visit. States one (possibly two) symptoms or signs and their duration. |
| Present health or history of present illness | Final summary of any symptom the person has should include these 8 characteristics: Location, Character or Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, and Patient's Perception |
| Past history | Childhood Illnesses, Accidents or Injuries, Serious or Chronic Illnesses, Hospitalizations, Operations, Obstetric History, Immunizations, Last Exam Date, Allergies and Current Meds |
| Family history | Age, Health or cause of death of relatives. Note- heart conditions, diabetes, hypertension, cancer |
| Review of systems | Head-to-toe examination. Purpose: 1.Evaluate the past and health state of each system, 2.To double-check in case any missing info was omitted, and 3.To evaluate health promotion practices |
| Functional assessment or activities of daily (ADLs) | Includes self-esteem, self-content, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, etc. |
| Source of History | 1.Record who furnishes the information 2. Judge how reliable the informant seems and how willing he or she is to communicate 3.Note any special circumstances, such as the use of an interpreter |
| Location | Be specific; ask the person to point to the location. Note the precise site. Is the pain localized or radiating? Is the pain superficial or deep? |
| Character or Quality | Calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Use similes. |
| Quantity or Severity | Attempt to quantify the sign or symptom such as 'profuse menstrual flow soaking 5 pads a hour.' Avoid adjectives and ask how it affects daily activities. |
| Timing | Onset, Duration, and Frequency. When did the symptom first appear? Give the specific date and time, or state specially how long ago the symptom started prior to arrival. |
| Setting | Where was the person or what was the person doing when the symptom started? What brings it on? |
| Aggravating or Relieving Factors | What makes the pain worse? Is it aggravated by weather, activity, food, meds, standing, bent over and so on? What relieves it (rest, meds or ice pack)? Ask 'What have you tried?' or 'What seems to help?' |
| Associated Factors | Is this primary symptom associated with any others (urinary frequency and burning associated w/ fever and chills? |
| Patient's Perception | Find out the meaning of the symptom by asking how it affects daily activities. |
| PQRSTU | P:Provocative or Palliative; Q:Quality or Quantity; R:Region or Radiation; S:Severity Scale; T:Timing; and U:Understand Patient's Perception |
| Mental Status | A person's emotional and cognitive functioning |
| Consciousness | Being aware of one's own existence, feelings, and thoughts and aware of the environment. |
| Language | Using the voice to communicate one's thoughts and feelings |
| Mood | More durable, a prolonged display of feelings that color the whole emotional life |
| Affect | A temporary expression of feelings or state of mind |
| Orientation | The awareness of the objective world in relation to the self |
| Attention | The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli |
| Memory | The ability to lay down and store experiences and perceptions for later recall |
| Abstract reasoning | Pondering a deeper meaning beyond the concrete and literal |
| Thought process | The way a person thinks, the logical train of thought |
| Thought content | What the person thinks- specific ideas, beliefs, the use of words |
| Perceptions | An awareness of objects through the five senses |
| Four headings of mental status assessment: ABCT | Appearance, Behavior, Cognition, and Thought processes |
| Appearance of ABCT | Posture, Body movements, Dress, Grooming and hygiene |
| Behavior of ABCT | Level of consciousness, Facial expression, Speech (quality, pace, articulation, word choice), Mood and affect |
| Cognitive functions of ABCT | Orientation, Attention span, Recent and remote memory, New learning--the Four Unrelated Words test, Judgment |
| Thought processes of ABCT | Thought processes, Thought content, Perceptions, Screen for suicidal thoughts (when indicated) |
| MiniMental State Examination | A simplified scored form of the cognitive functions of the mental status examination. Only 11 questions. Useful for initial and serial measurement. Good screening tool to detect dementia and other organic disease. |
| Denver II screening test | For children from birth to 6 yrs. Helps identify those who may be slow in development in behavioral, language, cognitive, and psychosocial areas. |
| Behavioral Checklist | For school-age children ages 7 to 11. Covers five major areas: mood, play, school, friends, and family relations. |
| Set Test | Use with an aging population, ages 65 to 85 yrs. Designed to screen for dementia. Assessing the person's alertness, motivation, concentration, short-term memory, and problem-solving ability. |
| Dysphonia | Disorder of voice. Difficulty or discomfort in talking, w/ abnormal pitch or voice, due to laryngeal disease |
| Dysarthria | Disorder of Articulation. Distorted speech sounds; speech may sound unintelligible; basic language intact. |
| Aphasia | Disorder of language comprehension and production. True language disturbance, defect in word choice and grammar or defect in comprehension |
| What must be present to report IPV? | The patient must be willing |
| Abuse during pregnancy increases risk for: | Miscarriage; depression, substance abuse-mother; low birth weight, increased risk of child abuse-infant |
| What professional organizations have called for routine, universal screening for IPV? | American College of Nurse Midwives(ACNM), Association of Women's Health and Obstetrics and Neonatal Nursing(AWHONN), Emergency Nurses Association(ENA), etc. |
| What do you do if a patient answers yes to any of the Abuse Assessment Screen questions? | You need to ask questions designed to assess how recent and how serious the abuse was. |
| What must be present to report elder/child abuse and/or neglect? | Only a reasonable suspicion is needed |
| What risk factors may contribute to child abuse? | Disabilities or mental retardation, social isolation of families, lack of understanding of children needs and child development, history of domestic abuse, poverty, unemployment, substance abuse, young, single nonbiological parents, stress and distress |
| What could ongoing child abuse lead to? | Shaken baby syndrome, death or long-term disability. Changes in brain structure and chemistry- long-term physical, psychological, emotional, social, and cognitive dysfunction in adulthood. |
| At what age can a child generally be expected to provide a history at the level of most adults? | Over the age of 11, but because of how you ask the questions. |
| Why is it important to evaluate the child's age and development level? | Because is it possible that the child could have suffered the injury that is being reported based on their developmental level. |
| What about the child's medical history is important? | Has the child had previous hospitalizations, injuries, or does he/she suffer from any chronic medical conditions? Medications? |
| What are some situations in which the elderly may be in an abusive/ neglectful relationships? | Physical findings that are inconsistent with the history provided by the patient, family member, or caregiver. |
| Why is it important to access medication use when assessing for elderly abuse? | Medications and abnormal blood values related to medication side effects and underlying hematologic disorders can affect ease of bruising or formation of ecchymosis. |
| What should be documented in a case of abuse? | Detailed, nonbiased progress notes, the use of injury maps, and photographic documentation. Written documentation need to be verbatim but within reason. |
| Why should abused persons be assessed for prior abuse? | Cumulative trauma has been shown to be associated with more severe mental and physical health problems. They can have an impact on the current health condition. |
Created by:
Futuredoctor09
Popular Nursing sets