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NU215 exam 1
| Term | Definition |
|---|---|
| Subjective data | information from the patient, family, caregiver, or health charts. |
| objective data | something we can measure |
| what are the benefits of subjective information? | bring something to our attention that we cant feel or see, provides a more complete picture of the patient |
| what are the challenges of subjective information? | might not get everything, and source might not be telling the whole truth |
| what are the benefits of objective information? | nonbiased and you are able to compare measurements |
| what are the challenges of objective information? | could be inaccurate, tend to be concise and you have to document it. |
| how do you prepare for the health assessment? | review clients record, review clients status with other health care team members, educate about clients diagnosis and tests performed |
| Collection of subjective data | biographical info, history of present health concern (what brought them in); physical symptoms related to each body part or system, past health history, family history, health and lifestyle |
| collection of objective data | physical characteristics, body functions, appearance, behavior, measurements and results of lab tests. |
| ______ data validates ______ data | objective, subjective |
| what are methods of data collection? | interview, observation and physical assessment |
| assessment skills | cognitive, problem-solving, psychomotor, interpersonal and ethical skills. |
| 6 dimensions of nursing assessments | physiological, psychological, psychosocial, cultural, developmental, and spiritual |
| how do you communicate with patients/clients | body language, verbal and nonverbal communication and listening |
| how will communication be different or same during the physical assessment? | youre touching them and seeing how they are responding to the touch, which could cause the patient to completely shut down |
| what do you do when performing an interview to collect subjective data? | establish a trusting relationship and develop rapport, also gather information to identify problems and provide focuses for a physical assessment |
| 4 interviewing phases | pre-introductory introductory phase working phase summary and closing phase |
| Introductory phase of interview | explain purpose of assessment, discusses types of questions that will be asked, assures confidentiality, establishes trust and rapport, and tell patient your role and how long you will be with them |
| working phase of interview | where you are gathering all your info and performing the assessment such as biographic, reasons for seeking healthcare, history of present health concern, past health history, family history, view of body systems, lifestyle and health practices |
| summary/closing phase of interview | summarizes information gathered, problems and goals are validated with client, helpful to let client know when interview will end and terminate relationship |
| how do you prepare yourself and your environment for an assessment | always be professional, confident, respectful and courteous, inform client of what you are doing, maintain privacy, and establish nurse-client relationship |
| considerations to make when doing an assessment | age, developmental, cognitive and physical levels, individualize each assessment and plan of care, safety for yourself and the patient |
| SOLER | S: sitting- dont stand over your patient O: open- no crossed arms or legs L: Lean in - dont kick back and relax E: eye contact R: relaxed |
| nonverbal communications | appearance: expectation is clean Demeanor: how you carry yourself facial expression: how they see you attitude: positive and open Silence: always used in a positive way attentive listening: eye contact and nodding convey acceptance: not shocke |
| what to do when interacting with an angry client | approach in a calm reassuring, in-control manner, allow client to vent, avoid any arguments with or touching the client, obtain help from other health care professionals as needed, facilitate personal space |
| what to do when interacting with a depressed client | express interest in and understanding of the client and respond in a neutral manner, take care not to communicate in an upbeat, encouraging manner |
| what to do when interacting with a manipulative client | provide structure and set limits, differentiate between manipulation and a reasonable request, and obtain an objective opinion from other nursing colleqgues |
| what to do when interacting with a seductive client | set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors, encourage client to use more appropriate methods of coping in relating to others |
| what to do when discussing sensitive issues | be aware of own thoughts and feelings regarding dying, spirituality and sexuality, ask simple questions in a nonjudgemental manner, allow time for ventilation of clients feelings as needed |
| nonverbal communications to avoid | excessive or insufficient eye contact, distraction and distance, and standing |
| COLDSPA | C: character- what is going on O: Onset L: Location D: Duration S: Severity P: Patterns A: Alleviates or aggravates it |
| interview techniques | direct questions and open-ended questions |
| direct questions during an interview | ask for specific info, will often clarify previous info, offers additional data, doesnt encourage client to ramble, useful for gathering biographic info |
| open-ended questions during an interview | goal is to elicit more in-depth responses, such as how do you feel |
| nontherapeutic communication techniques | asking personal questions, giving personal opinions, changing the subject, automatic responses, false reassurance, biased or leading questions, rushing through an interview, and reading the questions, sympathy, asking for explanations, approval or disappr |
| review of body systems | SHN, head & neck, eyes, ears, mouth & throat & nose & sinuses, thorax & lungs, breasts & regional lymphatics, heart & neck vessels, peripheral vascular, abdomen, genitalia, anus & rectum & prostate, musculoskeletal, neurologic |
| lifestyle and health practices of an interview | description of typical day, nutrition and weight management, activity level and exercise, sleep and rest, medication and substance use, self-concept and self-care responsibilities, social activities, relationships, values and beliefs, education and work |
| what you should do as you are going into a physical assessment | wash hands prior and after, explain procedure, respect clients requests and desires, leave when they change clothes, begin with less intrusive procedure (vitals), consider patient positioning, and explain everything |
| what are the different body positions | sitting, supine, dorsal recumbent, sims, standing, knee-chest, and lithotomy |
| inspection | look and observe before touching, need good lighting, and completely expose a part being examined |
| what are the different types of palpation | light, deep, and bimanual |
| light palpation | about half an inch |
| deep palpation | about 1-2 inches to feel organs |
| bimanual palpation | using 2 hands, such as when checking the kidneys |
| percussion | used to elicit pain, determine location, size and shape, determine density, detect abnormal masses, and elicit reflexes |
| types of percussion | direct, blunt, and indirect |
| direct percussion | hands directly on the body, like sinuses |
| blunt percussion | hit down the back and larger space, usually used for kidney tenderness |
| indirect percussion | something between hand and skin |
| what to do when using auscultation | eliminate distracting noises, expose body part being auscultate, angle down toward nose, warm before use, explain what youre doing and avoid listening through clothes |
| bell | low-pitched sounds |
| diaphragm | high-pitched sounds |
| what is the 5 step nursing process | 1. assessment 2. Diagnosis 3. Planning 4. Interventions 5. Evaluation |
| Assessment phase of nursing process | collecting subjective and objective data, always the first step, systematically collect, validate, organize and communicate the client data, who is the client? collect info on physical, psychological, emotional, sociocultural and spiritual |
| methods of organizing data | 1. functional assessment strategy 2. review of body systems |
| methods of assessment | observation, interviewing, physical exam, and intuition |
| types of interviews | screening (broad) and focused (targeted) |
| types of screening interviews | yearly check ups, physicals |
| types of focused interviews | when someone goes to the hospital for chest pain |
| assessing data/recognizing and analyzing cues | look at significance, what is normal or abnormal, what risk factors are present |
| diagnosis phase of nursing process | 2nd step in process, RN validates, analyzes and integrates assessment information to identify clients needs and problems |
| how to accurately identify client needs/problems | start with considering client concern/problem/issue, collect valid and pertinent data, differentiate nursing from collaborative data, focus on priority (what you need to do first) |
| PES diagnostic tool | P: Problem/concern/issue E: Etiology- contributing factors or causes S: Signs and symptoms |
| nursing hypothesis | actual problem- acute pain Potential problem- risk for infection wellness- potential for enhanced organized infant behavior |
| planning/generating solutions during nursing process | set appropriate goals, provides measurable changes in response to nursing care, and outcome statements include time limits |
| what are the outcome statements | short term goals: < 1 week Long term goals: weeks or months on going goal: will maintain |
| nursing initiated action | independent, doesnt require supervision, an example is assessing clients level of anxiety |
| physician initiated action | nurses carry out a written order, however not blindly, example is medicate with pain drugs per order |
| collaborative action | example dietician, OT, consult with social worker |
| reflection during nursing process | effectiveness of actions, compare clients responses to goal to determine if goal is achieved, conclude if you need to revise the plan, discontinue the plan or continue the plan. |
| what skills are used during an assessment | inspection, palpation, percussion, auscultation |
| APSEP | A: Anatomy P: Physiology S: Subjective boxes E: Equipment that you will need to perform assessments P: Physical assessment |
| preparation for survey of general health status | perform systematic examination, recording general characteristics and impressions of the client, observe any significant abnormalities |
| general survey | physical development and body build, gender and sexual development, apparent age as compared to reported age, skin condition and color, dress and hygiene, posture and gait, level of consciousness, behaviors, facial expressions, speech, vital signs |
| assessing vital signs | physical examination begins with vital signs, provides data that reflects body systems status such as cardiovascular, neurologic, peripheral vascular and respiratory |
| what is the order of vital signs | 1. temperature 2. pulse 3. respiration 4. blood pressure 5. pain scale |
| body temperature | balance between internal and external environment of the body or balance between the heat produced by the body and the heat lost from the body |
| what are the 2 types of body temperature | core temperature and surface temperature |
| core body temperature | temp of deep tissues of the body, most accurate, ranges between 96.0-99.9, reach average temp of 98.6 at age 5, accurate measurement is usually done using a pulmonary catheter. |
| surface body temperature | temp of the skin, subcutaneous tissues and fat, constantly rises and falls in relation to environment, also has to do with circulation, use dorsal side of hand to check this temp |
| regulation of body temperature | sensors in skin and core regulate body temp and the hypothalamus |
| why do we need to pay more attention to an infant when its cold outside | they cant shiver and therefore cannot regulate their body temperature when they are cold thus they may get hyperthermia faster and easier. |
| factors affecting heat production | BMR, muscle activity, thyroxine output, chemical thermogenesis, |
| how does BMR affect heat production | rate of energy utilization in body required to maintain essential activities such as breathing, walking, speaking and others, decreases with age |
| how does muscle activity affect heat production | increases metabolic rate such as walking, jogging |
| how does thyroxine output affect heat production | increase in hormone, increases rate of cellular metabolism throughout body |
| how does chemical thermogenesis affect heat production | stimulation of heat production in the body through increased cellular metabolism |
| factors that affect body temperate | age, diurnal variations, strenuous exercise, hormones, and stress |
| how does age affect body temperature | infants greatly influenced by the temperature since they cant shiver, elderly are extremely sensitive to environmental changes due to decreased thermoregulatory control |
| how does diurnal variations (circadian rhythms) affect body temperature | body temp fluctuates throughout the day, varying as much as 1 degree between early morning and late afternoon, point of highest body temp between 8 pm-12 am, lowest point reached during sleep between 4-6 am |
| pyrexia, hyperplexia, hyperthermia or fever | increased body temperature |
| febrile | fever, elevated temperature |
| afebrile | without fever |
| hypothermia | decrease in core temperature below the low limit of normal |
| rise in temperature causes | hyperthermia, viral or bacterial infections, malignancies, trauma, various blood, endocrine and immune disorders |
| sites commonly used to asses body temperature | oral, axilla, rectal and tympanic membrane |
| types of thermometer | mercury in glass, electronic/digital thermometer, temporal artery thermometer, temperature sensitive strips, infrared thermometer |
| where does oral thermometer need to be placed? | in sublingual fossa |
| tympanic thermometer | never in the ear, needs to be in ear canal, not accurate on children under 1, for children pull ear down and back for adults pull ear up and back |
| pulse | wave of blood created by contraction of left ventricle of the hurt, represents stroke volume output and compliance |
| stroke volume output | amount of blood entering arteries with each ventricular contraction |
| compliance | ability of the arteries to contract and expand |
| cardiac output | stroke volume X heart rate, |
| pulse for adults at rest | heart pumps 4-6 liters of blood per minute, also known as the cardiac output |
| factors affecting pulse rate | age, gender, exercise, fever, medications, hemorrhage, and stress |
| assessing the pulse | either palpate or auscultate using 2 fingers, except for apical pulse, or stethescope |
| amplitude of pulse | +1: thready and weak +2: is normal +3: bounding +4: for carotid |
| average pulse | 60-100, dont reach this til 12 years old |
| tachycardia | over 100 beats/min |
| bradycardia | less than 60 beats/min |
| amplitude | pulse strength, refers to force of blood with each beat |
| elasticity of the arterial wall | expansibility of arterial wall, healthy normal artery feels stright, smooth, soft and pliable whereas in elderly people is often inelastic, rigid, hard, twisted or tortuous and irregular when palpated. |
| pulse sites | temporal, carotid, apical, femoral, radial, brachial, popliteal, posterior tibialis, and dorsalis pedis |
| respiration | the act of breathing, intake of oxygen and output of carbon dioxide |
| external respiration | interchange of O2 and CO2 between alveoli and pulmonary blood |
| internal respiration | throughout body, interchange of gases between circulating blood and cells of body tissues |
| inhalation/inspiration | act of intake of air into lungs |
| exhalation/expiration | act of breathing out gases from lungs to environment |
| ventilation | movement of air into and out of the lungs |
| hyperventilation | very deep and rapid breathing |
| hypoventilation | very shallow respiration |
| control centers for respiration | medulla oblongata and pons, chemoreceptors located centrally in medulla, and peripherally in carotid and aortic bodies |
| eupnea | normal breathing (12-20 for adults, which happens around the age of 12) |
| bradypnea | abnormally slow breathing |
| tachypnea | abnormally fast breathing |
| apnea | cessation of breathing, normal for infants as long as it doesnt last longer than 15 seconds |
| rhythms of respiration | regular, irregular, dyspnea and orthopnea |
| dyspnea | difficulty breathing |
| orthopnea | ability to breath easier in an upright position |
| first heart sound | lub, occurs at beginning of ventricular systole, caused by closure of tricuspid and mitral valves |
| second heart sound | dub, marks beginning of ventricular diastole, caused by closure of aortic and pulmonary valves |
| arterial blood pressure | measure of pressure exerted by blood as it flows through arteries |
| systolic pressure | max pressure developed upon ejection of blood from left ventricle into arteries |
| diastolic pressure | lowest pressure and is a measure of peripheral resistance |
| auscultatory method of obtaining BP | must determine Korotkoff's sound |
| phases of korotkoff's sound | phase 1: first faint sound, slowly becomes stronger phase 2: sounds have a swishing quality phase 3: sounds are forceful and powerful phase 4: sounds begin to decrease phase 5: sound disappears |
| average blood pressure | 120/80, not reached until 14 years old, however this is now considered prehypertensive |
| pulse oximetry | noninvasive and indirect method of measuring oxygen saturation in blood, light of 2 different wavelengths passed through patient to photodetector, measures how much light has been absorbed by oxygen in the blood. |
| pain definition | unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both, pain is whatever the person says it is. |
| acute pain | usually associated with a recent injury |
| chronic nonmalignant pain | associated with a specific cause or injury and described as a constant pain that persists for more than 3-6 months, pain in 1 or more anatomic regions, associated with significant emotional distress or significant functional disability |
| cancer pain | often due to the compression of peripheral nerves or meninges, or from the damage to these structures, following surgery, chemotherapy, radiation, or tumor growth and infiltration |
| pain descriptors | cutaneous, visceral, phantom, neuropathic, deep somatic, and intractable |
| cutaneous pain | skin or subcutaneous pain |
| visceral pain | abdominal cavity, thorax, or cranium pain |
| deep somatic pain | ligaments, tendons, bones, blood vessels, and nerve pains |
| phantom pain | perceived in nerves left by a missing, amputated, or paralyzed body part |
| neuropathic pain | causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels |
| intractable pain | high resistance to pain relief |
| physiologic responses to pain | anxiety, fear, hopelssness, focus on pain, reports of pain, moans and cries, decrease in cognitive function, mental confusion, altered temperament, increased heart rate, increased blood pressure. |
| seven dimensions of pain | physical, sensory, behavioral, sociocultural, cognitive, affective, and spiritual |
| factors affecting pain | age, socio-cultural values/interpretations, emotional such as anxiety, fatigue or depression, past experiences with pain, source and meaning, knowledge level |
| objective measuring tools for pain | Visual analog scale (VAS), Numeric rating scale (NRS), numeric pain intensity scale (NPI), verbal descriptor scale, simple descriptive pain intensity scale, graphic rating scale, verbal rating scale, faces pain scale |
| Visual Analog Scale | No Pain ---------------------------------------- pain as bad as it could be |
| numeric pain intensity scale | 0--1--2--3--4--5--6--7--8--9--10 1-3: mild pain 4-7: moderate pain 8-10: severe pain |
| Simple descriptive pain intensity scale | no pain --mild pain-- moderate pain--severe pain--very severe pain--worst possible pain |
| Face, legs, activity, cry, consolability (FLACC) behavioral scale | a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. |
| T or F: an unpleasant sensory and emotional experience which we primarily associate with tissue damage is termed pain | True |
| which is an appropriate pain assessment tool for pediatric clients? Verbal descriptor scale, number rating scale, visual analog scale or faces pain scale | faces pain scale |
| domestic violence | pattern of abusive behavior in any relationship that is used by one partner to gain or maintain control over another intimate partner |
| in the US domestic violence, child abuse, and elder abuse are seen as _________ | different categories |
| abuse can be ______, _______ & _______ | physical, emotional, or sexual |
| violence | the use of physical force to harm someone, to damage property etc. |
| aggression | a forceful action or procedure especially when intended to dominate or master, an unprovoked attack |
| positive connotation of violence and aggression | self-defense, war, getting ahead of a situation |
| negative connotation of violence and aggression | murder, torture, hate against cultural norm |
| domestic violence theories | psychopathology theory, social learning theory, biologic theory, family systems theory, feminist theory |
| psychopathology theory | personality disorder associated with the sufferer |
| social learning theory | a learned behavior causing that person to be an abuser |
| biologic theory | experienced trauma in their childhood and carried along with them |
| family systems theory | growing through and among the family functioning, how the family actually functions |
| feminist theory | inequality |
| walkers cycle of violence | the predictable pattern that abuse takes, and states that it needs to occur at least 7 times before it sticks and someone seeks help/change |
| stage 1 of walkers cycle of violence | tension building phase, abuser becomes possessive, jealous, separates victim from others, starts to escalate, criticism occurs, critic and problems come to a point and abuse occurs |
| stage 2 of walkers cycle of violence | acute battering, victim blames self because they did something that caused this to happen |
| stage 3 of walkers cycle of violence | honeymoon or hearts and flowers, "im so sorry ill never do it again" stay in this phase until the next period of abuse occurs. |
| types of family violence | physical abuse, psychological abuse, economic abuse and sexual abuse |
| prevalence of family violence | 1 in 4 women and 1 in 7 men |
| intimate partner violence (IPV) | physical, sexual or psychological harm by current or former partner or spouse. forms of abuse include psychological, sexual assault, progressive isolation, stalking, deprivation, intimidation and reproductive coercion, happens to women and men |
| child abuse | any recent act or failure to act on the part of a parent or caregiver which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act of failure to act that presents an imminent risk of serious harm. |
| categories of child abuse | neglect, emotional abuse, sexual abuse and physical abuse |
| long-term consequences of child abuse | physical, psychological, behavioral, and societal |
| elder mistreatment | includes neglect, physical abuse, sexual abuse, financial abuse, psychological abuse, exploitation, abandonment, prejudicial attitudes that decrease quality of life and are demeaning |
| consequences of elder mistreatment | physical and psychological effects |
| what are assessment challenges when trying to diagnose elder mistreatment | fear, mistrust, difficult to spot, hard to see it unless living with elder, may not be coming from a family member |
| Assessment tool for elder mistreatment | Elder Abuse Suspicion Index (EASI) |
| effects of immigration status on abuse | various acts that are considered IPV in one culture, may be accepted as a norm in another culture, stresses experienced in relocating to different country increases family stresses leading to violence |
| domestic shelters and crisis hotlines | most US communities have safe houses and crisis hotlines, The Family Violence Prevention and Services Improvement Act of 2019 |
| school violence | bullying or punking, unwanted aggressive behavior among school-aged children that involves a real or perceived power imbalance that is either repeated or a single event, consists of verbal, social, physical, or cyber |
| hate crimes | race, ethnicity, ancestry, religion, sexual orientation, gender identity, disability, types include assaults, rapes, murders, property crimes, drug offenses, prostitution |
| human trafficking | complex issue, sex trafficking, involuntary servitude, peonage, debt bondage, slavery, 3rd largest international crime industry worldwide, recognize the signs |
| war crimes | some immigrants may be victims of war crimes, complex issue, clients show signs of PTSD may not answer questions, referral to appropriate health care provider, various tools available to assist |
| preparing yourself for an assessment for family violence | universal screening for domestic violence and IPV done to everyone, examine your own feelings, beliefs, and biases, need to be active in interrupting/ ending the cycle, be aware of "red" flags, patient must be ALONE |
| collecting subjective data for family violence | safe confidential environment, discuss any legal requirements, allow client to answer questions completely, screen for PTSD, HITS, Abuse assessment, Considerations for interviewing children, Self-assessment danger assessment, assessing a safety plan |
| collecting objective data for family violence | prepare the client, get necessary equipment, provide privacy, keep hands warm, remain nonjudgemental and unbiased |
| physical exam to assess abuse includes | performing a general survey, assess mental status, evaluate vital signs, inspect skin, inspect head and neck, inspect eyes, assess ears, abdomen, genitalia and rectal area, musculoskeletal system, and neurologic system |
| assessing a safety plan | ask the client: do you have a bag ready, keep it hidden? Tell your neighbors about your abuse and ask them to call the police when disturbance occurs? Have a code word with kids, family and friends so they know when you need help? know where you are going |
| validating and documenting findings from family violence | validate any violence data collected, photos, descriptions, only used words provided by patient, dont fill in blanks based on what you think happened, legal documents, always be objective, follow health care facility or agency policy |
| analysis of data to make clinical judgements for family violence | identify abnormal findings and client strengths, cluster data to reveal any significant patterns or abnormalities, |
| which suggests physical abuse? threatening to hurt children or pets, using restraints on victim, preventing the victim from getting a job, using violence during sex? | using restraints on a victim |
| T or F: social learning theory states that violence is an innate characteristic of humans based on neurophysiological states | false |
| T or F: abused children may appear younger than stated age | True |
| growth | addition of new skills or components |
| development | refinement, expansion or improvement of existing skills or components |
| psychosocial development | mental and emotional health, self-concept, role development, coping patterns, stress, spiritual beliefs, relationships |
| Freuds psychosexual development stages | oral: 0-1 1/2 years- everything fixated on mouth, parents worried about choking anal: 1 1/2-3 years- potty training phallic: 3-6 years- focus moves from mother to self, start playing with themselves latency: 6-11 years- wait genital: adolescence |
| Eriksons theory of psychosocial development | involves intrapersonal and interpersonal response to external events, societal, cultural, historical factors, biophysical processes, and cognitive functions influence personality, each stage has a central task, if resolved in favor of positive resolution |
| process of Eriksons theory | 1. must negotiate healthy balance between 2 concepts to move to next stage 2. positive resolution for crisis necessary for positive resolution in next stage 3. basic virtues 4. if partially resolves, will experience difficulty in next tasks 5. can b |
| Eriksons theory stages | 1. trust vs. mistrust- infant 2. autonomy vs. shame and doubt-toddler 3. initiative vs. guilt- preschooler 4. industry vs. inferiority- school-ager 5. identity vs. role confusion-adolescent 6. intimacy vs. isolation- young adult 7. generativity |
| Piaget | genetic epistemologist, focused on how person learns not what they learn, acknowledged interrelationships of physical maturity, social interaction, environmental stimulation, and experience in general |
| Piagets major concepts | schema, assimilation, accommodation and equilibration |
| piagets stages of cognitive development | sensorimotor- substages: 1,2,3,4,5,6 preoperational- substages: preconceptual and intuitive concrete operational: straight facts and clear directions formal operational |
| Kohlbergs theory of moral development | expanded piagets theory, individual morality is dynamic process that extends over ones lifetime, involves affective and cogniive domains in determining what is right and wrong, reason vs. action, |
| Kohlbergs major concepts | hard stages and justice |
| Pre-conventional morality | stage 1 of kohlbergs theory, includes stage 1- obedience and punishment: behavior driven by avoiding punishment and stage 2- individual interest: behavior driven by self-interest and rewards |
| conventional morality | Kohlbergs 2nd stage, contains stage 3- interpersonal: behavior driven by social approval and stage 4- authority: behavior driven by obeying authority and conforming to social order |
| post-conventional morality | kohlbergs 3rd stage, includes stage 5- social contract: behavior driven by balance of social order and individual rights and stage 6- universal ethics: behavior driven by internal moral principles |
| biographic data for assessment | where were you born? what cultural group do you identify? educational level and employment, where do you live now? |
| history of present health concerns | current feelings and concerns about health, concerns about self image, stressors, do you have trouble making decisions? tell me about your life changes that you have needed or will make |
| personal health history | how would you describe yourself? what are strengths and weaknesses? how do you learn? have you been treated for a psychological or psychiatric problems? Tell me about medications you take? |
| Family history | who is family? describe your life growing up? Discuss any genetic predisposition or characteristic trait of a disorder you may have inherited |
| lifestyle and health practices | whatre they doing thats affecting their lifestyle and health |
| Eriksons tasks for older adults | embrace realistically reviewing and viewing life, recognizing erros and poor choices, learning from past experiences what strengths one has, acknowledging accomplishments and developing new wisdom |
| piaget tasks for older adults | described the use of formal operations as helpful in anticipating and negotiating the declining of physical and possible cognitive abilities, older adults suffer multiple losses and must problem-solve about possible increased, dependency, decreased choice |
| Kohlbergs tasks for older adults | those who had attained his 6th stage of personal principles make, use of self-evaluation, self-motivation, and self-regulation, meeting expectations of their ego, |
| Spiritual health and function | all people have a spiritual component or dimension that can be developed, spirituality is considered fundamental to the existence, although everyone has the dimension not everyone has the same depth, |
| spiritual care | nurses own background, family, culture, and religion are integral parts of interactions with patients, an exam of the nurses own spirituality, values, and beliefs is essential in being able to give spiritual care, examination leads to reflection of deep p |
| philosophical questions that need to be addressed: | who am i? why am i here? what am i doing and why am i doing it? how can i justify what i am doing? |
| FICA | F: faith I: importance of faith to the individual C: community activities within faith A: concerns of the individual about their faith |
| holism | health and well-being exist when mind, body and soul are balances and are working in harmony with each other and the universe |
| spiritual need | expression of a persons inner being that seeks meaning in the dynamic relationship among self, others and a supreme being |
| spiritual quest | spiritual journey to answer lifes philosophic questions and seek a higher level of consciousness or a deeper awareness of spiritual life |
| spiritual well-being | an affirmation of life, peace, harmony and a sense of interconnectedness with god, self, community and environment that nurtures and celebrates wholeness |
| spiritual belief systems fulfill the need to : | give meaning to life, illness, crisis, and death, sense of security for present and future, guidance in daily living habits, guidance in accepting or rejecting other people, furnish psychosocial support, strength in meeting lifes crisis, healing strength |
| factors affecting spiritual health | culture, gender, previous experiences, crisis and change, separation from spiritual ties, moral issues regarding therapy, inadequate or inappropriate care |
| cultural considerations | culture and spirituality play a role in how individuals view themselves and others, linked to individuals health, health beliefs, and health practices, influence how they understand illnesses and death and play a role in medical decisions, sometimes relig |
| lifespan considerations for normal spiritual function | infant: develops understanding of spirituality through sense of security and safety with parents toddler: through parents with rituals and routines that the family teaches them school age: linked to stories, legends and lore adults: through self |
| altered spiritual functions | verbalization of distress and altered behavior |
| nursing diagnoses related to spirituality | readiness for enhanced spiritual well being, spiritual distress, risk for spiritual distress, decisional conflict, noncompliance, risk for impaired religiosity, moral distress, |
| goals for patients with spiritual distress or spiritual alterations | should focus on providing an environment that supports usual religious practices and beliefs |
| outcome identification and planning for spirituality | expression of a sense of connectedness with self, other, the arts, or power greater than self, meaning and a purpose in life, sense of optimism and hope, being able to cope, interaction with spiritual leaders, friends and family, satisfaction with life ci |
| therapeutic use of self in spirituality | assists person to, grow in the ability to face reality, discover potential solutions to problems, good communication skills, trust and empathy needed |
| T or F: holism is the dynamic quality or essence that pervades, integrates and transcends one biopsychosocial nature | False, spirituality is |
| which is the stage where an individual has the ability to think abstractly, conceptualize and synthesize? | school-age child and adolescent |
| T or F: a change in behavior may be a manifestation or spiritual dysfunction | True a change in behavior tells a lot about a patient |
| culture | the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making |
| acculturative stress | adaptation to a new cultural environment, affects values, behaviors, beliefs, attitudes, language, and much more |
| why nurses need to know about culture | interact with many different clients every day, have their own beliefs about illness and health, when and from whom to seek care, who makes decisions concerning health care, never assume someone shares the same beliefs, |
| values | learned beliefs about what is held to be good or bad |
| norms | learned behaviors that are perceived to be appropriate or inapproriate |
| acculturation | the circumstance when person gives up the traits of their culture of origin as a result of context with another culture, to variable degrees |
| assimilation | gradual adoption and incorporation of characteristics of the prevailing culture, where dominant culture has expectations |
| cultural diversity | coexistence of a difference in behavior, traditions, and customs |
| cultural imposition | intrusive application of majority groups cultural view upon individuals and families |
| cultural relativism | belief that behaviors and practices of people should be judged only from context of their cultural system |
| enculturation | natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in ones culture through socialization |
| ethnicity | socially, culturally, and politically constructed group that holds a common set of characteristics not shared by others with whom members of the group come into contact |
| ethnocentrism | universal tendency of humans to think their ways or thinking, acting, and believing are the only right, proper, and natural ways |
| stereotyping | oversimplified conception, opinion, or belief about an aspect of an individual group |
| subculture | group of people with a culture that differentiates them from the larger culture of which they are a part |
| worldview | way individuals or groups look at universe to form basic assumptioms and values |
| cultural competence | nurses must know what is normal and abnormal to provide high-level health care |
| cultural competence process | cultural awareness, cultural skill, cultural knowledge, cultural encounters, and cultural desire |
| contexts for assessment for cultural competence | family structure and function, spirituality and religion and community, serves as context for growth and development, health and illness, and health care delivery |
| national standards for care #1 | provide effective, equitable, understandable, and respectful quality care and serves that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs |
| national standards for care #2,3, and 4 | refer to governance, leadership and workforce |
| national standards for care #5-8 | refer to communication and language assistance |
| national standards for care #9-14 | refer to engagement, continuous, improvement and accountability |
| national standards for care #15 | concerns organizations progress in implementing and sustaining the other standards, what the organization is putting into play that will help you meet the standards, |
| national standards for culturally and linguistically appropriate services in health care #1 | ensure that patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language |
| national standards for culturally and linguistically appropriate services in health care #2 | implement strategies to recruit, retain, and promote, at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area |
| national standards for culturally and linguistically appropriate services in health care #3 | ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery |
| national standards for culturally and linguistically appropriate services in health care #4 | offer and provide language assistance services, including bilingual stagg and interpreter services, at no cost to each patient/consumer with limited english proficiency at all points of contact |
| national standards for culturally and linguistically appropriate services in health care #5 | Provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. |
| national standards for culturally and linguistically appropriate services in health care #6 | Assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services |
| national standards for culturally and linguistically appropriate services in health care #7 | patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. |
| national standards for culturally and linguistically appropriate services in health care #8 | Develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. |
| national standards for culturally and linguistically appropriate services in health care #9 | Conduct initial and ongoing organizational self-assessments of CLAS-related activities and integrate cultural and linguistic competence-related measures into internal audits, performance improvement programs, patient satisfaction assessments, and outcomes |
| national standards for culturally and linguistically appropriate services in health care #10 | ensure that data on the individual patients/consumers race, ethnicity and spoken and written language are collected in health records, integrated into the organizations management info systems and periodically updated |
| national standards for culturally and linguistically appropriate services in health care #11 | Maintain a current demographic, cultural, and epidemiologic profile of the community, as well as, a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. |
| national standards for culturally and linguistically appropriate services in health care #12 | Develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. |
| national standards for culturally and linguistically appropriate services in health care #13 | Ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. |
| national standards for culturally and linguistically appropriate services in health care #14 | Regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and provide public notice in their communities about the availability of this information |
| purposes for assessing culture | to learn and to compare and contrast |
| factors affecting cultural approach to providers | ethnicity, generational status, education, religion, previous health care experiences, occupation and income level, beliefs about time and space, and communication needs/preferences |
| factors that affect disease, illness and health state | biomedical variations, nutrition/dietary habits, family roles and organization patterns, workforce issues, high-risk behaviors, and pregnancy and childbirth practices |
| culture bound syndromes | conditions perceived to exist in various cultures and occur as combination of psychiatric or psychological and physical symptoms |
| culture-based treatments | often misinterpreted in western health care settings, examples include cupping, coining, moxibustion, imbalance of hot/cold, yin/yang, some cultures see some standard western treatment as unacceptable |
| nurses challenges for culturally competent assessment | essential to show respect for beliefs in interactions with client, nurse should challenge self to learn about as many cultures as possible, interaction with groups will help nurse gain understanding, be alert for behaviors and others clarified as normal o |
| what is the verbal and behavioral system of culture, when its transmitted from one generation to the other? | culture is learned |
| T or F: conscious incompetence is when one is aware that one lacks knowledge about another culture; aware that cultural differences exist but not knowing what they are or how to communicate effectively with client from different cultures | true |
| health | state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity |
| mental health | a state of well being in which an individual realizes his or her own abilities, can cope with the normal stressed of life, can work productively and is able to make a contribution to their community |
| nurses role in mental health | nursing assessment, assess and screen for past and present mental health conditions, involves observation, communication, administering questionnaires or assisting client to complete self-assessment questionnaires, determine if need for referral |
| factors affecting mental health | economic and social factors, personality factors, unhealthy lifestyle choices, exposure to violence, cultural factors, spiritual factors, psychosocial developmental level and issues, changes or impairments in the structure or function of the neurological |
| substance abuse | pertinent conditions affecting mental health, lead to dependence syndrome, abuse may become priority, marijuana |
| risk factors for mental health disorders and substance abuse | a history of early aggressive behavior, lack of parental supervision, history of substance abuse, drug availability and poverty |
| goal of prevention of substance abuse | change the balance between risk and protective factors so that protective factors outweigh risk factors |
| personal health history for mental health | past medical history of mental health problems and counseling, head injury, meningitis, encephalitis and stroke, headaches, served in armed services, and trouble breathing or heart palpitations |
| lifestyle and health practices for mental health | OTC, alcohol and substance use, CAGE, AUDIT, |
| equipment needed for objective data collection for mental health | Glasgow coma scale, PHG-2, PHG-9, depression questionnaire, self-report depression questionnaire, and Columbia Suicide Severity Rating Scale (C-SSRS), SAD PERSONS, PTSD screening, SLUMS, SBIRT, withdrawal assessment scale |
| components of a mental status exam | A: Appearance B: Behavior C: Cognition T: Thought processes |
| level of consciousness | lethargic, obtunded, stupor, coma, decorticate, decerebrate |
| obtunded | slow, confused |
| stupor | awakes if shaken or painful stimuli |
| decorticate | hands to chest, legs internally rotated |
| decerebrate | pronated, extended |
| St. Louis University Mental Status (SLUMS) | 27-30 for clients with high school education and 25-30 for clients with less education are considered normal. 21-26 with high school education- mild neurocognitive disorder, 20-24 with less education- mild neurocognitive disorder. 1-20 with education- dem |
| Glasgow Coma Scale | eye opening response, most approriate verbal response, most integral motor response (arm), |
| Mini-Cog | instruct client to remember 3 unrelated words and repeat them back, instruct client to draw face of clock and note certain time by drawing hands of clock, ask client to repeat 3 previously stated words |
| Depression questionnaire | falling asleep, sleep during the night, waking up too early, sleeping too much, feeling sad, decreased or increased appetite,, decreased or increased weight, view of self, thoughts of death, energy level, restless, slowed down, concentration/decision make |
| SAD persons suicide risk tool | sex, age, depression, previous attempt, ethanol abuse, rational thinking loss, social supports lacking, organized plan, no spouse, availability of lethal means, sickness |
| CAGE self assessment tool (alcohol) | C: cut back on use of alcohol A: annoyed/angered when questioned about your use G: guilty about your use E: had eye-opener to get started in the morning scoring one yes suggests a possible alcohol problem |
| Alcohol Use Disorders Identification Test (AUDIT) | how often do you have an alcoholic drink? How many alcoholic drinks do you have on a typical day when drinking? How often do you have 6 or more drinks in one occasion? How often during last year have you found yourself not stopping drinking? How often du |
| warning signs of alzheimers disease | asking the same questions over again, repeating same story, word for word, again and again, forgetting how to cook, or make repairs or play cards, activities that were previously easy, losing ones ability to pay bills or balance ones checkbook. Getting lo |
| sources of voice and speech problems | dysphonia, cerebellar dysarthria, dysarthria, aphasia, wernicke aphasia, broca aphasia |
| factors involved in nutrition | healthy diet, diseases, disorders or lifestyle behaviors, increased caloric consumption, food high in fat and sugar, and decreased energy expenditure, overweight or obesity |
| healthy diet | 55-60% from carbs, with 75% being complex carbs |
| risk factors for nutrition disorders and disease | lower SES, lifestyle, poor food choices, chronic dieting, chronic diseases, dental, limited access, disorders, |
| lower SES | makes nutritious foods unaffordable |
| how does lifestyle affect nutrition | long work hours and obtaining one or more meals from a fast-food chain or vending machine |
| how does chronic dieting affect nutrition | fad diets, meet perceived societal norms for weight and appearance |
| Nutritional screening tools | 24 hour food recall |
| cultural considerations for nutrition | 1/3 of adult population in the US is obese, highest for middle aged people, especially for non-hispanic black and mexican american women, 17% children between 2-19 are obese, income and obesity related |
| ectomorph body build | tall and skinny |
| mesomorph body build | average body build with normal height and weight |
| endomorph body build | short and chubby |
| equipment needed for physical assessment for nutrition | balance beam scale with height attachment, metric measuring tape, and skin calipers |
| anthropometric measurements | height and weight, BMI, waist circumference, mid-arm circumference, triceps skin fold thickness, mid-arm muscle circumference |
| BMI equation | wight (kg)/ Height (m)^2 |
| drastically underweight BMI and weight | >16.5 BMI >118 lbs |
| underweight BMI and weight | 16.5-18.4 BMI 118-132 lbs |
| ideal BMI and weight | 18.5-24.9 BMI 130-178 lbs |
| overweight BMI and weight | 25-29.9 BMI 180-214 lbs |
| obese BMI and weight | 30-34.9 BMI 210-249 lbs |
| morbidly obese BMI and weight | 35-39.9 BMI, 250-286 lbs |
| height and weight changes with aging | wanes in 5th decade because intervertebral discs become thinner and spinal kyphosis increases, weight decreases because loss of muscle or lead body tissue |
| hydration assessment | weight, skin turgor, pitting edema, skin for moisture, venous filling, neck veins in supine position with head elevated 45 degrees, tongue, eye palpation, eye position, lung sounds, blood pressure |
| factors affecting hydration | exposure to excessively high environmental temperatures, inability to access adequate fluids, especially water, excess intake of alcohol or other diuretic fluids, taking diuretic medications, impaired thirst mechanism and high fevers |
| overhydration signs and symptoms | weight gain of 6-10 pounds in a week, pitting edema, visible neck veins, crackling lung sounds, elevated pulse rate and blood pressure |
| dehydration signs and symptoms | weight loss of 6-10 lbs in a week, tenting, flat veins in supine client, tongue is dry, sunken eyeballs, blood pressure decreased with elevated pulse |
| T or F: waist circumference is the most common measurement used to determine the extent of abdominal visceral fat in relation to body fat | True |
| T or F: dehydration of a healthy person is usually not a problem because the body is effective in maintaining a correct fluid balance | False, in the case of overhydration in a healthy person, the body is effective in maintaining a correct fluid balance |
| steps of data validation | 1. deciding whether data requires validation 2. determining ways to validate the data 3. identifying areas where data is missing |
| when to validate data? | discrepancies or gaps between subjective and objective, discrepancies in what client says at one time vs. another, abnormal and/or inconsistent findings, missing data |
| methods of validation | recheck your data through repeat assessment, clarify data with client, verify with another health professional, and compare objective to subjective data |
| Documenting data | if its not documented it didnt happen |
| information requiring documentation | nursing interview/history and physical examination including objective and subjective data. |
| guidelines for documenting data | keep confidential all documented info in the client record, document legibly or print neatly, use correct grammar and spelling, avoid wordiness that creates redundancy, use phrases instead of sentences to record data, record data findings not how obtained |
| types of assessment forms for documentation | initial assessment form, frequent or ongoing assessment form, and focused or specialty area assessment form |
| initial assessment form | nursing admission or admission database |
| frequent or ongoing assessment form | flow charts that help staff to record and retrieve data for frequent reassessments |
| focused or specialty area assessment form | focused on one major area of the body for clients who have a particular problem or areas of practice |
| SBAR | S: situation B: Background A: Assessment R: recommendation |
| verbal communication of findings | use a standardized method of data communication (SBAR), communicate face to face, allow time for receiver to ask questions, provide documents of data shared, validate what receiver has heard by questioning, ask receiver to repeat back to you exactly what |
| which guideline should the nurse follow for documentation: write normal for normal findings, use phrases instead of sentences, exclude clients understanding, and describe how data were obtained | use phrases instead of sentences |
Created by:
Kirabear8
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