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NUSA 401: EXAM 1

Cultural Competency who are you meeting, where do they come from, what is their heritage, cultural background, language patient understands, speaks and reads in; health and illness beliefs and practices
elder cultural beliefs very steadfast and true to their beliefs; may not have assimilated
health balance of a person is a complex, interrelated phenomenon; within one's being-physical, mental, spiritual; outside world-natural, communal, metaphysical; everything that makes up a person, makes up their health
illness loss of a person's balance; within one's being- physical, mental, spiritual; in outside world- natural, communal, metaphysical
demographic profile of the US upwards of 300 million; 1 out of 3 people are in a group other than single-race, non-hispanic white; minority or emerging majority populations total 98 million people
hispanics largest and fastest growing group in the US
blacks second largest population in US
asians, american indians, Alaska natives, native hawaiians and other pacific isanders make up the third largest part of the population in the US
emerging majority groups tend to be younger, lower median ages, higher populations under 18 yo
dominant, non-hispanic, single-race, white population is older median age; smaller proportion under 18 yo
young old 65-74 yo
middle old 74-85 yo
old old 86-100 yo
elite old above 100 yo
in US one birth every 8 sec
in US one death every 13 sec
in US one international migrant(net) every 30 sec
net gain of one person every 11 sec
categories of interest to health care providers: immigration legal permanent residents; naturalized citizens; undocumented aliens; refugees, aslyees, parolees; legal nonimmigrant residents;
immigrants minimal working knowledge of our health care system; mostly go to the ER, don't have a doctor or insurance and cant speak the language; care given is about their perceieved needs
many new immigrants have only minimal understanding of modern health care delivery system; modern medical and nursing practices and interventions; english language
immigrants perceived needs and the nurse's care people with limited ability to speak, read, write, and understand English encounter countless barriers that limit access to critical public health, hospital and other medical and social services to which they are legally entitled.
title VI of civil rights act of 1964 services cannot be denied to people of limited english proficiency; some states(including CA) require providers to offer language assistance in health care settings
culturally sensitive possessing basic knowledge of and constructive attitudes toward diverse cultural populations
culturally appropriate applying underlying background knowledge necessary to provide the best possible health care
culture thoughts, communications, actions, beliefs, values and institutions of racial, ethnic, religious, or social groups; how have your ideals changed, how you will adapt; how you grew up will affect how you care for others
ethnicity racial background, common geographical region, food pref, etc.
religion who to bring in to give comfort, how to approach issues
indicators of heritage consistency connection with your heritage, pride in your heritage, anything in common with your heritage
health- related behaviors affected by religion meditation; exercising; vaccinations; what kind of physical exam their allowed, genetic screening, birth control
transcultural expression of pain pain is universal; but it is expressed or perceived differently; highly personal; very cultural
culture bound syndromes condition that is culturally defined; some have no equivalent in a biomed, scientific perspective; anorexia and bulimia are examples
steps to cultural competence understand one's own heritage-based values, beliefs, attitudes and practices; know what health means to you and the patient; understand how the health care system works(fluctuating)
R- RESPECT REALIZE you must know heritage of yourself and patient
E-RESPECT EXAMINE patient within cultural context
S-RESPECT SELECT simple questions and speak slowly
P-RESPECT PACE questioning throughout exam
E(second)-RESPECT ENCOURAGE patient to discuss meaning of health and illness with you
C-RESPECT CHECK patients understanding and acceptance of recommendations
T-RESPECT TOUCH patient within boundaries of his or her heritage
Goals- Why do we need to interview the patient? record complete health history; optimal health for patient; collect data, subjective and objective
subjective data what the patient is saying; put in quotes
objective data what your observing; vital signs; what you see; things that are measurable
Sending communication is behavior, conscious and unconscious, verbal and nonverbal; body language
Receiving awareness of messages you send is only part of process; health problems intensify communication because patients depend on you to get better;
communication can be learned and polished when you are a beginning practitioner; is a tool as basic to quality health care as tools of inspection or palpation
maximized communicating skill awareness of internal and external factors and their influence
internal factors of communication liking others; empathy; ability to listen
external factors of communication ensure privacy' refuse interruptions; physical environment; dress; note taking may be unavoidable; tape and video recording
challenges of note-taking breaks eye contact too often; shifts attention away from person, diminishing sense of importance; interrupts patients narrative flow; impedes observation of patients nonverbal behavior; may be threatening to patients discussion of sensitive issues
working phase data-gathering phase; verbal skills include questions to patient and your responses
two types of questions open-ended; closed; each has a different place and function in interview
responses assisting the narrative; facilitation encourages patients to say more an shows you are interested and will listen further
silent attentiveness gives patient time to think and organize what to say without interruption from you; gives you a chance to observe person unobtrusively and note nonverbal cues
reflection echoes patients words, repeating what person has just said; focuses further attention on a specific phrase; and helps person continue in his or her own way
empathy recognizes a feeling and puts it into words; names the feeling and allows expression of it
clarification use when persons words are ambiguous or confusing
confrontation frame of reference shifts from patient's perspective to yours; dont project feelings and beliefs onto the patient
interpretation based on your inference or conclusion; it links events, makes associations, implies cause, ascribes feelings; often older patients dont want to be a bother
ten traps of interviewing providing false assurance or reassurance; giving unwanted advice; using authority; using avoidance language; engaging in distancing; using professional jargon; using leading or biased questions; talking too much or interrupting; using "why" questions
cross-cultural care probability of miscommunication increases with two people from different cultural backgrounds
cross-cultural communication cultural perspectives on professional interactions; etiquette; space and distance; gender; sexual orientation
intimate zone(0- 1 1/2 ft) visual distortion occurs; best for assessing breath and other body odors
personal distance (1 1/2 to 4 ft) perceived as an extension of the self similar to a bubble; voice is moderate; body odors inapparent; no visual distortion; much of the physical assessment occurs at this distance
social distance ( 4 to 12 ft) used for impersonal business transactions; perceptual information much less detailed; much of the interview occurs at this distance
public distance ( 12ft+) interaction with others impersonal; speaker's voice must be projected; subtle facial expressions imperceptible
overcoming communication barriers working with and without interpreters; nonverbal cross-cultural communication; touch
five types of nonverbal behaviors convey info about a person vocal cues; action cues; object cues; personal space; touch
the health history: adult biographical data; source of history; reason for seeking care; present health or history of present illness; past health; family history; review of systems; functional assessment including ADLS
biographical data name; address and phone number; age and birth date; birthplace; sex; marital status; race; ethnic origin; occupation; primary language and authorized representative
source of history who furnishes info; how reliable is this person; how willing is he/she cooperate; special circumstances(interpreter)
reason for seeking care why; what are symptoms; subjective; objective data
present health or history of present illness location; character or quality; quantity or severity; timing; setting; aggravating or relieving factors; associated factors; patients perception
PQRSTU Provactive/palliative; Quality/Quantity; Region/Radiation; Severity scale(1 to 10); Timing or onset; Understand patient's perception of problem
past health childhood illnesses; accidents or injuries; serious or chronic illnesses; hospitalizations; operations; OB history; immunizations; last exam date; allergies; current meds; co-morbidities
co-morbidity one or more chronic illnesses
family history age and health or cause of death of relatives; health of close family members; any diseases that may be important to health of patient; genogram
cross cultural care health history assess if certain procedures cannot be done; immunizations; taboo foods or food combos; spiritual resources and religion; health perception; nutrition
functional assessment, including ADLs self-esteem; self-concept; activity and exercise; sleep and rest; nutrition and elimination; interpersonal relationships and resources; spiritual resources; coping and stress management; alcohol intake
what is perception of health concerns; goals; expectations of you and us
older adult: past health general health in past five years; accidents or injuries, serious or chronic illnesses, hospitalizations, operations; last exam
older adult: family history not always accurate or relevant; who is going to help them when they go home
older adult: functional assessment including ADLs interpersonal relationships, sexual relationships
health assessment and physical exam helps with the care of the patient; how well you assess effects how well you can care for your patient; assess pain and how they feel first so they arent uncomfortable during assessment
purposes of physical exam triage for emergency care; routine screening to promote health and wellness; to determine eligibility for health insurance, military service, a new job; to admit a patient to a hospital or long term care facility
use physical exam to gather baseline data about patient's health; support or refute subjective data obtained in the nursing history; ID and confirm nursing diagnosis; make clinical decisions about a patient's changing health status and mangement; evaluate the outcomes of care
cultural sensitivity culture influences a patients behavior; consider health beliefs, use of alternative therapies, nutritional habits, relationships with family and personal comfort zone; avoid stereotyping; avoid gender bias
prep for exam infection control; environment; equipment; physical prep of patient(positioning; psych prep; assessment of age groups; always have steth, pen lgiht, pen, scissors, gloves; keep mind of allergies
organization of the exam assessment of each body system; follows the nursing history; systematic and organized; head-to-toe approach; looking for symmetry; bedside; focused
inspection looking around at everything; enviro; patient; position and expose body parts as needed so all surfaces can be viewed but privacy can be maintainted
palpation feeling; pulses; poking around skin; temp of skin; diaphoresis; edema; ecchymosis
percussion tapping the persons skin with short, sharp strokes to assess underlying structures; wont do a whole lot of unless an advanced practitioner; abnormla size suggests mass or air or fluid within an organ/cavity
ausculatation listening; requires a good stethoscope, concentration and practice
diaphoresis sweating
edema swelling
ecchymosis bruise
by looking at your patient, you will be able to assess gender, race, age, signs of distress, body type, posture, gait, body movements, hygiene, grooming, dress, body odor, affect and mood, speech, signs of patient abuse and signs of substance abuse
general survey assess appearance and behavior; assess vital signs; assess height and weight
skin integument; color; moisture; temperature; texture; tugor; helps assess oxygen levels; vascularity, edema and lesions
turgor don't assess top of hand; test forearm; chest around sternum; back of neck; if it stays up= tenting--> dehydration
bony prominences make sure no pressure ulcers are forming in older patients or see skin breakdown
erythema redness; older patients more at risk due to less adipose tissue present
color of skin pigmentation; cyanosis; jaundice; erythema
vascularity capillaries more fragile; petichiae
petichiae normal change in aging; non blanching, very small
ABCD skin trama/abnormalness asymmetry, border irregularity, color, diameter
hair and scalp color, distribution, quantity, thickness, texture, lubrication;
hair loss often due to genetics or is age related(less in men)
nails condition reflects general health; state of nutrition; occupation; level of self care; age
nail beds circulation; capillary refill; color should come back in 3 sec if normal
eyes visual acuity; extraocular movements; visual fields
history for eyes any diseases; glasses; ring around eye= aging
pstosis drooping of the eye
pinpoint eyes due to medications like morphine; wont be able to see any changes; be aware of meds, if not on meds could be a neuro problem
PERRLA Pupils Equal Round React to Light Accommodation
External eye structure position and alignment; eyebrows; eyelids; lacrimal apparatus; conjunctivae and sclerae; corneas; pupils and irises
auricles(ears) texture; tenderness; lesions; color; pain; cerumen
older adults and ears ears and nose dont stop growing; hearing changes(cant hear high tone); hearing aids--> be aware
redness of ears sign of inflammation or fever
Weber's test vibrating fork on midline vertex of head; have patient report if they hear the sound in both ears or if its better in one ear; normal= can hear it in both equally
Rinne test vibrating fork at mastoid process and then later 1 to 2 in from ear canal; patient reports when they no longer hear it; time; checks for bone conduction and hearing loss
nose and sinuses excoriation and polyps; breathing; drainage
mouth and pharynx: lips color, texture, hydration, contour, lesions; anemia; cyanosis; cherry colored(CO poisoning)
mouth and pharynx buccal mucosa; gums; teeth
tongue can be indicator of medication or infection
swollen lymph nodes at back of their ears flu, cold, or strep
older adults lungs and muscles not as much elasticity; more rigid breathing
exam of thorax and lungs watch them as sleeping; rising and falling easily or not, breathing rapidly or slowly; listen after listening to heart
tactile fremitus created by vocal cords; transmitted through lungs to chest wall; palpation
need to look at subjective and objective patients may not realize something is abnormal because it has been going on for so long; its become their normal
anterior thorax observe accessory muscles; palpate muscles and skeleton; assess tactile fremitus; compare right and left sides; auscultate for bronchial sounds
auscultation of heart detects normal heart sounds; extra heart sounds and mumurs
dysrhythmia failure of the heart to beat at regular successive intervals; some are life threatening
blood pressure readings tend to be higher in right arm; always record highest reading
carotid arteries reflect heart function better than peripheral arteries; commonly auscultated
carotid bruit narrowed blood vessel creates turbulence, causes blowing/swishing sound
jugular veins most accessible; right internal follows more direct path to right atrium; note distention; assess pressure
peripheral arteries and veins blood flow; condition of skin and nails; integrity of venous system; pulses/sufficiency of arterial circ
lymphatic system upper and lower extremities; assess drainage; palpate
abdomen/ bowel sounds start at ascending; listen to for up to a minute; cant feed a patient after surgery until you hear bowel sounds; important to know bowel pattern
borborygymi gurgling; hyper bowel sounds; growling sounds when hungry
musculoskeletal system general inspection gait; postural abnormalities; age-related changes; level of activity before hospital; how well do they walk; do they have/need assisted device
older person muscle changes reduced height as they age
atrophy waste away of an organ/muscle; typically due to degeneration of cells
neurological system responsible for many functions; full assessment requires time and attention to detail; many variables must be considered during evaluation: level of consciousness, physical status, chief complain
aphasia cant verbalize but understand
intellectual function memory, knowledge, abstract thinking, association, judgement
motor function coordination; higher extremity/fine-motor control; lower extremity; balance; gross-motor function
at the end of the exam record findings; give patient time to dress, assist if needed; if findings are serious, consult health care provider before informing the patient; delegate cleaning of exam area; record complete assessment; review for accuracy and thoroughness;communicate
baseline assessment findings reflect a patients functional abilities and serve as the basis for comparison with subsequent assessment findings
integrate patient teaching throughout exam to... help patients learn about health promotion, disease prevetntion and skills to help with any current health issue
normal resting heart rate 50 to 90 bpm
aging adult temperature less likely for fever, more likely for hypothermia; less reliable of persons health state; sweat gland activity diminished
aging adult pulse rhythm might be slightly irregular; radial may feel stiff, rigid, tortuous, not necessarily vascular disease; easier to palpate
aging adult respirations decrease in vital capacity; decreased inspiratory reserve volume; shallower inspiratory phase and increase respiratory rate
aging adult blood pressure aorta and arteries tend to harden; often bp increases; difficult to distinguish between hypertension and normal aging
pain and the aging adult not a normal process of aging; although many older adults report pain;
poorly controlled pain in aging adult sudden onset of acute confusion
dementia and pain pain signals could be misinterpreted with alzheimers/dementia; less able to ID and describe pain over time even though it is still present and destructive; often communicate pain through behavior--> agitation, pacing, yelling
optimal nutrition status achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy or illness
undernutrition occurs when nutritional reserves are depleated and/or when nutrient intake is inadequate to meet day-to-day needs to added metabolic demainds
people having optimal nutrition status more active; have fewer physical illnesses, and live longer than persons who are malnourished
people who are undernutritioned are at risk for impaired growth and development; lowered resistance to infection and disease, delayed wound healing, longer hospital stays and higher health care costs
overnutrition caused by the consumption of nutrients in excess of body needs
overnutrition leads to obesity, heart disease, type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, osteoarthritis
nutrition and the aging adult at risk for undernutrition or overnutrition(poor nutrition); poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, and polypharmacy
normal physiologic changes in aging adults that directly affect nutritional status include poor dentition, decreased visual acuity, decreased saliva production, slowed gastrointestinal motility, decreased gastrointestinal absorption and diminished olfactory and taste sensitivity
aging adult and skin slow atrophy; loses elasticity; folds and sags; parchment thin, lax, dry and wrinkled; loss of collagen; sweat glands and sebaceous glands decrease in number= dry
loss of collagen in skin increases the risk for shearing, tearing injuries
aging adult increased risk of heat stroke because of decreased response of the sweat glands to thermoreg. demand
senile purpura minor trauma that may produce dark red discolored areas due to diminished vascularity of the skin
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