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Assessment

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Question
Answer
wellness   optimal functioning; not just the absence of illness, perfect health or the biopsychosocial ideal  
medical model   goal is to cure; mechanistic; objective data based on scientific proof  
nursing model   goal is to care; holistic/comprehensive; scientific but also intuitive  
symptoms   subjective  
signs   objective; you observe with your own senses  
pyrexia   with fever  
normal rectal   +1 degree  
normal axillary   -1 degree  
how should you assess a small child's temperature?   axillary or tympanic  
safety point for temperature?   102.2; be aware of sudden and abrupt changes in tempeerature  
metabolism changes with fever?   increases 13% for every 1 degree celsius of increase; ensure nourishment and hydration  
pulse strengths   3+ bounding; 2+ normal, 1+ weak/thready; 0 absent  
apnea   absence of repirations; about 15seconds  
eupnea   normal rate (12-20)  
tachypnea   rapid (>20)  
bradypnea   slow (<12)  
systolic   maximum force exerted against arterial wall during ventricular contraction  
systole   Systolic; maximum force exerted against arterial walls during ventricular contraction  
diastolic   minimal force exerted agains arterial wall when ventricles are relaxed  
pulse pressure   MAP; subtract diastolic - systolic; Normal 30-50  
BP regulators   peripheral resistance; elasticity of vessel walls; pumping action of th heart; blood volume; blood viscosity  
bp cuff too large   lower BP measured than actual  
bp cuff too small   higher BP measured than actual  
when to measure head circumference?   every visit to 2years old; annually to age 6  
orthostasis   BP drops as person rises by at least 25/10mmHg  
When should peek-a-boo be achieved?   1 year old  
Culture   The system of shared beliefs, values, customs, behaviors, and artifacts that the members of society use to cope with their world and with one another and that are transmitted from generation to generation through learning  
Cultural competence   treating every patient with equal respect and dignity regardless of culture, race or ethnicity  
Provider causes of health disparities   conscious or unconscious biases; ineffective communication; inability to build trust; time limitations  
External Environment   presence of others; physical; space; comfort; note-taking  
Internal Environment   mutual respect; empathy/sympathy; acknowledgment of feelings; confidentiality; openness and optimism  
Phases of the Interview   Introduction, Working and Closing  
Introduction phase   salutations, explanations  
Working phase   communication, data gathering, body language, responses  
Closing phase   futher explanation and questions; summarize findings; plan next steps  
When to assess LOC?   Assess LOC and language first in order to determine the depth of assessment that's needed  
Continuum of consciousness   alert --> lethargic --> obtunded --> stupor --> comatose  
Glasgow Coma Scale   common level of consciousness tool r/t eye opening, verbal response and motor response  
Components of Cognition   ABCT  
ABCT -- A   Appearance: posture, body movements, hygiene and groomin  
ABCT -- B   Behaviors and Moods: appropriate, continuum of mood and affect  
ABCT -- C   Concentration (Cognitive Signs): Orientation, attn span, recen and remote memory, new learning, judgment  
ABCT -- T   Thought Processes: Abnormals are hallucinations, delirium, dementia  
delirium   drugs/illness; internal; usually something fixable  
dementia   impaired memory, cognition, brain-related causes; i.e. poor vascular supply to the brain; alzheimers  
Mental Status Assessment   We CANNOT measure it directlyl Indirect measures of cognitive and emotional status and observations of behaviors  
Folstein MMSE   perfect score = 30  
Mental Status Screening   clock drawings; Set Test for the elderly  
Screening for Depression   CDI, BDI, ZUNG, CES...  
CAGE test   Use for suspected illicit substances  
CAGE -- C   Have you ever felt you ought to cut down on your drinking or drug use?  
CAGE -- A   Do you get annoyed at criticism of your drinking or drug use?  
CAGE -- G   Do you ever feel guilty about your drinking or drug use?  
CAGE -- E   Do you ever take an early morning drink or use drugs first thing in the morning?  
What drug has the most impact on a person's daily life?   food  
IBW ranges   <70% is undernutrition; >120% is overnutrition  
Good fats   polyunsaturated and monounsaturated  
Bad fats   saturated fats and trans fats  
BRAT   for gastroenteritis: bananas, rice, apples and toast  
Waist to hip ratio   greater than 1 for men or greater than 0.8 for women indicates obesity  
Rxnship between TIBC and iron   inversely proportional  
4 types of assessments   pyramidal: emergency, follow-up, episodic, and complete  
Present Illness - acronym   PQRSTU  
PQRSTU - P   Provocative and palliative factors; what makes it worse and what makes it better  
PQRSTU - Q   Quality or Quantity: descrive the pain with the adjectives  
PQRSTU - R   Region or Radiation: where does i t start, where does it move to (radiate) where is it more severe?  
PQRSTU - S   Severity Scale: rate your pain  
PQRSTU - T   Timing: before or after meals, awakens from sleep; how often? constant?  
PQRSTU - U   Understand patient's perspective:r/t employment  
GPA - P   Para is deliveries  
Review of Systems (ROS)   what is reported, not what is found through physical examination; an expansion of the health history  


   





 
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Created by: vlarberg on 2005-06-11



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