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Health Assesment
Communivation and Health Assessments
| Question | Answer |
|---|---|
| Identify ways to connect and build trust. | Body Language/Position Avoid Distractions Eye Contact Physical Contact Building Trust |
| List Common traps to avoid taking a history. | Bias Judgement Stigmatizing language Leading Questions Medical Jargon Talking Excessively Discomfort with Silence Over Informing I Know How You Feel |
| Subjective Data | What the patient tells you |
| Objective Data | What you observe on the patient |
| A health history includes. | Chief Complaint Past Medical History Family History Allergies Medication Social History ROS -Everything the patient tells you- (This is the interview) |
| OLDCARTS | Onset Location Duration/Timing Characteristics Aggrevating Factors Relieving Factors Treatment/Timing Severity/Sequelae |
| Considerations for non-English speaking patients | Language Barrier |
| SDOH related to diet | Access to adequate food Money Cost |
| Ways To Discuss Health Behaviors without Being Judgemental | Maintain Confidentiality Assess Motivation for Change |
| Ways to Assess Pain | Pain Scale FACES (Depends on what patient says ) |
| Describe Components of general survey | Apparent Age LOC Facial expressions Affect Posture/Gait Speech Grooming/Dress |
| Factors That Influence Vital Signs | Medications Stress Temperature Exercise Caffeine Smoking Diet Improper Technique |
| What are you looking for when palpating the Pulse | -PROCESS- Rate Rhythm Force |
| Contraindications for Taking BP | IV in arm Injury side of Mastectomy Edema |
| Rationale for taking Height and Weight | Medication Dosage Nutrition Screening Unintentional weight Loss Falling off the curve for children BMI- based on height and weight To establish fat vs. lean mass |
| Identify Normal PULSE, BP, and RR | BP: Less than 120/ Less than 80 Pulse: 60-100 RR: 12-20 |
| When taking a BP what are you listening for? | Korotkoff Sound (Clear Tapping) |
| Correct Way to Take a Pulse | -Process- |
| Contraindications for Taking Rectal Temperature | Invasive Low WBCs (ex: Leukopenia and Leukemia) Low Platelets |
| Steps for Assessing Orthostatic Hypotension and Why A Patient May Be At Risk | Check Laying Down 3-10 minutes. Then Standing Up 1-3 minutes. May Be Caused Due to Dehydration Anemia ANS Prolonged Immobilizaiton |
| Inspection of Nails and Skin | Palpitation and Inspection Feeling temperature of skin using back of hands capillary refill (3 seconds) Edema (Elasticity)Turgor |
| Ladder of Influence | observation selected data meaning assumptions conclusion beliefs action |
| Blanching | Absence of Redness when pressing on nail bed |
| Components of Blood Pressure | Systolic-Top number- first sound Diastolic- Bottom number-last sound |
Created by:
NP_MirandaH
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