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health assess. Final

Health assessment final

QuestionAnswer
culturally sensitive implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations
culturally appropriate implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care
culturally competent implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status
religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator and ruler of the universe
socialization is the process of being raised within a culture and acquiring the characteristics of that group
acculturation is the process of adapting to and acquiring another culture
assimilation is the process of a person develops a new cultural identity and becomes like the members of the dominant culture
biculturalism is the dual pattern of identification and often of divided loyalty
subjective data what the patient tells you
objective data is what you observe
the nursing process includes assessment, diagnosis, outcome identification, planning, implementation and evaluation
novice nurse has no experience with specific patient populations and uses rules to guide performance.
competent nurse can see actions in the context of arching goals or daily plans for patients, between 2-3 years
proficient nurse understands a patients situation as a whole rather than as a list of tasks, can see long-term goals
expert nurses can grasp a clinical situation an zero in on the accurate solution
First-level priority problems are emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing.
Second-level priority problems are next in urgency. They require prompt intervention to prevent deterioration, and may include a mental status change or acute pain.
Third-level priority problems are important to the patient’s health, but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.
A complete (or total health) database includes a complete health history and a full physical examination.
A focused (or problem-centered) database is used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database.
A follow-up database evaluates the status of any identified problem at regular intervals to follow up on short-term or chronic health problems.
An emergency database calls for rapid collection of data, which commonly occurs while performing lifesaving measures.
The biomedical model of Western medicine views health as the absence of disease. It focuses on collecting data on biophysical signs and symptoms and on curing disease.
The holistic health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together.
verbal communication is the words you speak, vocalizations and the tone of voice
nonverbal communication is your body language, posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair
empathy means viewing the world from the other person's inner frame of reference while remaining yourself
Mental status is a person’s emotional and cognitive functions and its functioning is inferred by assessing the individual’s consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions.
The full mental status examination is a systematic check of emotional and cognitive functioning. Its purpose is to determine mental health strengths and coping skills and to screen for dysfunction.
the close, careful observation of the patient as a whole and then of each body system. Inspection
the use of touch to assess texture, temperature, moisture, and organ location and size Palpation
tapping the patient’s skin with short, sharp strokes to create percussion sounds Percussion
technique used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex. Percussion
listening to sounds made by the body, usually using a stethoscope. Auscultation
Use the stethoscope’s diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds
Use the stethoscope’s bell for soft, low-pitched sounds, such as extra heart sounds or murmurs.
the otoscope funnels light into the ear canal and onto the tympanic membrane
the ophthalmoscope illuminates the internal eye structures
the single most important step to decrease risk of microorganism transmission is to wash your hands promptly and thoroughly
The general survey is your overall impression of the patient and begins when you first encounter him or her. It covers four areas: physical appearance, body structure, mobility, and behavior.
Physical appearance includes an assessment of the person’s age, sex, level of consciousness, skin color, and facial features as well as any signs of distress
Body structure addresses In this area stature, nutrition, symmetry, posture, position, and body build or contour.
Mobility is concerned with gait and range of motion.
Behavior considers facial expression, mood and affect, speech, dress, and personal hygiene.
Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm.
The blood pressure cuff bladder length should be about 80% of the arm circumference.
The oral temperature route is accurate and convenient.
insert a rectal thermometer 2 to 3 cm or 1in into the adult rectum
the heart rate normally ranges from 50 to 90 beats per minute, but varies with age and sex.
The pulse rhythm normally has an even, regular tempo.
The force of the pulse shows the strength of the heart’s stroke volume
The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds.
The tympanic membrane thermometer (TMT) is an accurate measurer of core body temperature.
Endogenous obesity is caused by either the administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary.
Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment.
To assess respirations, count them while your hand is still in position for taking the pulse.
Blood pressure is the pressure of the blood against the blood vessel walls
Systolic pressure is the maximum pressure felt on the artery during left ventricular contraction (or systole).
Diastolic pressure is the elastic recoil (or resting) pressure the blood exerts constantly between contractions.
Pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume.
Mean arterial pressure is the pressure forcing blood into the tissues, averaged over the cardiac output.
A cuff that is too narrow yields a falsely high pressure.
A cuff that is too wide yields a falsely low pressure.
BP has a false high measurement when the legs are crossed versus uncrossed
a drop of in systolic pressure of more than 20mm Hg orthostatic hypotension
thigh pressure is normally higher than that in the arm
the pulse oximeter is a noninvasive method to assess arterial oxygen saturation
the light on the pulse ox measures the relative amount of light absorbed by oxyhemoglobin and unoxygenated hemoglobin
Nociceptive pain develops when nerve fibers in the peripheral and central nervous systems are functioning and intact.
nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS
Neuropathic pain does not adhere to typical and predictable phases
1st phase of pain is transductions which occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery
2nd phase of pain is the transmission where the pain impulse moves from the level of the spinal cord to the brain
3rd phase of pain is the modulation where neurons from the brainstem release neurotransmitters that block the pain impulse
Visceral pain originates from Large internal organs, such as the kidneys, stomach, intestines, gallbladder, and pancreas.
Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone.
Cutaneous pain is derived from the skin and subcutaneous tissues.
Referred pain is felt at a particular site, but originates from another location.
Acute pain is short-term and self-limiting, often follows a predictable track, and ends after the injury heals.
Persistent (or chronic) pain continues for 6 months or longer and can last for years.
A numeric scale is used for adults and older children.
used for young children in determining pain the Oucher Scale and the Faces Pain Rating Scale, are
the descriptor scale of pain lists words that describe different levels of pain intensity
PAINAD scale is called pain assessment in advanced dementia
nonverbal behaviors of pain, such as guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, or vital sign changes
nutritional status refers to the degree of balance between nutrient intake and nutrient requirements
optimal nutritional status is achieved is achieved when sufficient nutrients are consumed to support dat to day body needs
undernutrition occurs when nutritional reserves are depleted and or when nutrient intake is inadequate to meet day to day needs
over nutrition is caused by the consumption of nutrients, especially calories, sodium and fat in excess of body needs
nutrition screening is the first step in assessing nutritional status and is required for all patients in all health care settings within 24 hours
normal hemoglobin level is 14-18 g/dl for men and 12-16 g/dl for women
normal hematocrit level is 37%- 49% for men and 36%-46% for females
LDL cholesterol is the bad cholesterol
good cholesterol is the good cholesterol
Marasmus is due to inadequate intake of protein and calories or prolonged starvation
Kwashiorkor is due to diets high in calories but contain little or no protein, low protein diets
rickets is a sign of vitamin D and calcium deficiencies in children
the body’s largest organ system. The skin
The epidermis is the thin, tough outer layer.
The dermis is the inner supportive layer, consisting mostly of collagen or connective tissue
The subcutaneous layer is the adipose tissue below the dermis.
fine, faint hair that covers most of the body is called vellus hair
hair that is darker, thicker and grows on the scalp and eyebrows, pubic area, chest and face are called terminal hair
sebaceous glands produce a protective lipid substance called sebum
eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat
apocrine glands produce a thick milky secretion and open into the hair follicles
vitiligo is the complete absence of melanin pigment
Common causes of pruritus include dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, and lice.
in a newborn a bluish color around the lips, hands, and fingernails, may last for a few hours and disappears with warming is called acrocyanosis
erythema toxicum is a common rash that appears in the first 3 to 4 days of life, also called a flea bite
stage 1 skin appears red but unbroken, skin will not blanch
stage 2 skin is partial thickness with loss of epidermis or also the dermis.
stage 3 skin is full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater
stage 4 skin is full-thickness pressure ulcer that involves all skin layers and exposes muscles, tendons, bones
a rigid, bony box that protects the brain and special sense organs the skull,
immovable joints are called sutures
highly vascular endocrine gland synthesizes and secretes thyroxine and triiodothyronine the thyroid gland
the adam's apple is also known as the thyroid cartilage
tension headaches tend to be occipital, frontal and bandlike tightness
a bruit occurs with accelerated or turbulent blood flow
the pupillary light reflex is the normal constriction of pupils when bright light shines on the retina
accommodation is the adaptation of the eye for near vision.
pupil loses elasticity, becomes hard and glasslike, loses it's ability to change shape to accommodate for near vision presbyopia
Created by: 691650210