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Health assessment I
Test #1 Lecture Dr. Heaton
| Question | Answer |
|---|---|
| internal factors in communication | 1. liking others 2. empathy-viewing from their shoes 3. ability to listen-active |
| external factors in communication | 1. privacy 2. refuse interruptions 3. physical environment 4. dress 5. note taking 6. recording |
| how many direct questions should you ask at a time? | 1 but if unavoidable pause in between |
| Types of Responses | Patients perspective Facilitation Silence Reflection Empathy Clarification Our perspective: Confrontation Interpretation Explanation Summary |
| 10 Traps | 1. False 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" question |
| older adult considerations in the interview | -takes longer -slow speech -in appropriate pronouns |
| acute ill considerations in the interview | -glean information from family or when becomes stable |
| 4 different types of space | 1. intimate 0-1.5' (breath & body odor) 2. personal 1.5-4' (physical assessment) 3. social 4-12' (much interviewing occurs here) 4. public 12'+ (impersonal) |
| mental disorder | a significant behavioral or psychological pattern that is associated with distress or disability & has a significant risk of pain, disability, or death or loss of freedom |
| organic vs. psychiatric mental illnesses | organic has a known cause vs. psychiatric etiology unknown yet |
| mood & affect | mood: a prolonged display of feeling that color the whole emotional life affect: is temporary expression of feelings |
| abstract reasoning | pondering a deeper meaning beyond the concrete & literal |
| thought process | the way a person thinks |
| thought content | is what the person thinks |
| MMSE | mini mental state examination A&O Registration (point & identify) Naming Reading |
| Mini Cog | 3 word recall & draw a clock |
| lethargic | not fully alert drifts off to sleep when no stimualation but can arouse with voice |
| obtunded | sleeps most of time difficult to arouse & needs shout or vigorous shaking |
| stupor or semi-coma | unconscious only responds to persistent vigorous shake or pain |
| coma | unconscious no response to pain or external/internal stimuli |
| delirium | clouding of consciousness |
| dementia | decreased cognitive ability |
| Biomedical model | absence of disease=healthy |
| Reason for seeking care should be documented how? | Patients own words Use quotations |
| Health history PQRSTU | Provocative/palliative Quality/quantity Region/radiation Severity Time Understand patients perception |
| During a health hx if person was hospitalized or had an operation what information should be recorded? | hospital, Dr., what was done/what illness, complications, how long hospitlization |
| Obstetrical hx | G-# of pregnancies T-reached term P-early/ask how early A-incomplete/ask whether spontaneous/induced L-# living kids |
| When asking about course of pregnancy what things should be addressed? | length of pregnancy & labor, complications, date of delivery, c-section/vaginal, weight/sex/condition of baby |
| What to document about allergies? | types: medications, food, & skin irritants what happens? |
| nutritional status | balance between nutrient intake and nutrient requirements |
| Consume sufficient nutrients to handle | everyday routine needs AND any increased demands |
| People who have optimal nutritional status are: | typically more active, fewer physical illnesses, & live longer |
| Vulnerable groups for undernutrition | Infants & children Elderly Pg women Recent immigrants Low income families Hospitalized people |
| Having undernutrition effects people by... | lower resistence to infection & disease, delayed wound healing longer hospital stays & higher health care costs, impaired g&d |
| Cultural & religious considerations | latin: chili pepper is not food viantmese: low dietary consumption Religious mormons: no caffiene/alcohol jewish: animals are prepared certain way |
| Nutrition screening includes: | height & weight hx diet routine labs |
| Screening tools used for whom: MST & MNA | MST (malnutrition screening tool) older adults MNA (mini nutritional assessment) geriatric |
| methods to collect nutritional info | Comprehensive nutritional assessment 24 Hr - recall Questionnaire or interview Food frequency questionnaire Food diaries Direct observation |
Created by:
midnight1854
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