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Chapter 28
Patient Assessment study notes
| Question | Answer |
|---|---|
| Biophysical | The science of applying physical laws and theories to biologic problems. |
| Cognitive | Pertaining to the operation of the mind; referring to the process by which we become aware of perceiving, thinking, and remembering. |
| Congruence | Agreement; the state that occurs when the verbal expression of the message matches the sender's nonverbal body language |
| Familial | Occurring in or affection members of a family more than would be expected by chance |
| Holistic | Considering the Pt. as a whole including the physical, emotional, social, economic, and spiritual needs of the person. |
| Present Illness | The chief compliant, written in chronology sequence with dates of onset |
| Psychosocial | Pertaining to a combination of psychological and social factors |
| Rapport | Relationship of Harmony and accord between the Pt. and the healthcare professional. |
| Signs | Objective finding determined by a clinician such as a fever, rash or high BP |
| Symptoms | Subjective complaints reported by the Pt. such as pain or visual disturbances. |
| When you're conducting an interview with a new Pt. you should use? | The therapeutic nonverbal language to enhance the quality of the Pt. interaction. EX(establish eye contact, control over use of gestures but nod head as needed to indicate interest and empathy) |
| During the initial phase of the interview the MA should? | Introduce themselves and state the purpose of the interview. |
| Database | The record of the Pt. name, address, date of birth, insurance information, personal data, history physical examination and laboratory finding. |
| Chief Complaint (CC) or present illness | The purpose of the visit |
| Past History (PH) or past medical history (PMH) | Pt, previous health usual childhood diseases (UCD or UCHD)/ include medication and frequently used over the counter (OTC) medication |
| Family History (FH) detail about? | Pt. parents/ siblings/ their health |
| Social History (SH) | includes information about the Pt. lifestyle, hobbies, entertainment preferences, education, occupation, use of tobacco, alcohol, sleeping habit, sexually active Last menstrual period (LMP) |
| Systems review (SR) or review of systems (ROS) these question provide a guide to the? | Pt. general health and help detect conditions other than those covered under the present illness. |
| Regression is? | Demonstrated when a Pt. reverts to previous behavior |
| Giving advice can interfere with? | therapeutic communication |
| The MA should always include the Pt. in? | The therapeutic communication |
| Closed questions provide? | specific information about the Pt. |
| Projection occurs when? | An Individual accuses another person of having feelings the individual possesses |
| Body language delivers more than? | 90% of the message |
| Asian Pt. may avoid eye contact because? | Its apart of their cultural |
| Teenagers value? | Privacy |
| Complete privacy is required for? | Pt. interview |
| Feedback verifies that the Pt? | Understands the information provided |
| Congruence is? | Reflected in verbal and nonverbal messages that are the same |
| Unwarranted reassurance can interfere with? | A therapeutic relationship |
| Reflection refers to? | The Pt.'s emotions |
| Personal value systems affect? | Judgments and interactions with others |
| The child should be? | Included in therapeutic communication |
| Crossed arms and legs may? | Intimidate the Pt. |
| The therapeutic distance is? | Approximately an arm's length away |
| Durations refers to? | The length of time the Pt. has had the symptoms |
| The Physician performs a? | System review when doing the physical assessment |
| Choices should be offered only if? | The Pt. can refuse |
| Linear communication is initiated by? | The sender, sent via a channel to the receiver, who returns details of the message via feedback to the sender |
| Rapport indicates that the? | MA has a harmonious relationship w/ Pt. and staff members |
| Open ended questions allow you to? | Gather more details bout the Pt. chief complaint |
| Clarification involves? | Summarizing/ seeking reinforcement of the Pt. information |
| Direct questions provide? | Specific information |
| Therapeutic listening displays? | Empathy and allow the pt. to discuss her concerns |
| Details about a wound documented in? | The objective area of the progress notes |
| Pain cannot be? | measured; it is a subjective assessment |
| MA should never? | Skip lines between documentation entries |
| SOAPE documentation is used? | in the POMR chart |
| Subjective data include the Pt. report of? | The symptoms of the disease |
| Referral are part of? | The Pt.plan |
| Complaints of pain are? | Subjective reports |
| Initial diagnosis is a? | Working diagnosis, which is formed from the physician's first impressions of the Pt. symptoms |
| Judgmental statement should never? | appear in the medical record |
| POMR organizes what? | Pt. information for quick review |
| A symptom is a? | Pt. perception of health problem |
| ROS is the? | Physician's findings during the physical examination |
| Information provided by the pt. about their health problem is known as? | Subjective data |
| feedback is an essential part of? | Communication cycle |
| holistic care assesses all of the Pt.'s' | Needs not just the physical problem |
| Objective data | Are the measurements and specific identifiers recorded about the Pt.'s health |
| Anxiety can? | Increase BP readings |
| Pt. in denial? | Rejects health information |
| With suppression the pt. is? | consciously aware of the information but refuses to admit it |
| A pt. with a functional disorder has? | Symptoms but no clinical evidence of disease |
| Disorders of the neurologic system includes? | problems w/speech and balance |
| Hypertension and leg cramps are indicator of? | CV disease |
| Sign of disease is a clinically evident indicator of? | Health problems |
Created by:
chass
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