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Health assessment I

Test #1 Lecture Dr. Heaton

QuestionAnswer
internal factors in communication 1. liking others 2. empathy-viewing from their shoes 3. ability to listen-active
external factors in communication 1. privacy 2. refuse interruptions 3. physical environment 4. dress 5. note taking 6. recording
how many direct questions should you ask at a time? 1 but if unavoidable pause in between
Types of Responses Patients perspective Facilitation Silence Reflection Empathy Clarification Our perspective: Confrontation Interpretation Explanation Summary
10 Traps 1. False Reassurance 2. giving unwanted advice 3. using authority 4. using avoidance language 5. engaging in distancing 6. using professional jargon 7. using leading or biased questions 8. talking too much 9. interrupting 10. using "why" question
older adult considerations in the interview -takes longer -slow speech -in appropriate pronouns
acute ill considerations in the interview -glean information from family or when becomes stable
4 different types of space 1. intimate 0-1.5' (breath & body odor) 2. personal 1.5-4' (physical assessment) 3. social 4-12' (much interviewing occurs here) 4. public 12'+ (impersonal)
mental disorder a significant behavioral or psychological pattern that is associated with distress or disability & has a significant risk of pain, disability, or death or loss of freedom
organic vs. psychiatric mental illnesses organic has a known cause vs. psychiatric etiology unknown yet
mood & affect mood: a prolonged display of feeling that color the whole emotional life affect: is temporary expression of feelings
abstract reasoning pondering a deeper meaning beyond the concrete & literal
thought process the way a person thinks
thought content is what the person thinks
MMSE mini mental state examination A&O Registration (point & identify) Naming Reading
Mini Cog 3 word recall & draw a clock
lethargic not fully alert drifts off to sleep when no stimualation but can arouse with voice
obtunded sleeps most of time difficult to arouse & needs shout or vigorous shaking
stupor or semi-coma unconscious only responds to persistent vigorous shake or pain
coma unconscious no response to pain or external/internal stimuli
delirium clouding of consciousness
dementia decreased cognitive ability
Biomedical model absence of disease=healthy
Reason for seeking care should be documented how? Patients own words Use quotations
Health history PQRSTU Provocative/palliative Quality/quantity Region/radiation Severity Time Understand patients perception
During a health hx if person was hospitalized or had an operation what information should be recorded? hospital, Dr., what was done/what illness, complications, how long hospitlization
Obstetrical hx G-# of pregnancies T-reached term P-early/ask how early A-incomplete/ask whether spontaneous/induced L-# living kids
When asking about course of pregnancy what things should be addressed? length of pregnancy & labor, complications, date of delivery, c-section/vaginal, weight/sex/condition of baby
What to document about allergies? types: medications, food, & skin irritants what happens?
nutritional status balance between nutrient intake and nutrient requirements
Consume sufficient nutrients to handle everyday routine needs AND any increased demands
People who have optimal nutritional status are: typically more active, fewer physical illnesses, & live longer
Vulnerable groups for undernutrition Infants & children Elderly Pg women Recent immigrants Low income families Hospitalized people
Having undernutrition effects people by... lower resistence to infection & disease, delayed wound healing longer hospital stays & higher health care costs, impaired g&d
Cultural & religious considerations latin: chili pepper is not food viantmese: low dietary consumption Religious mormons: no caffiene/alcohol jewish: animals are prepared certain way
Nutrition screening includes: height & weight hx diet routine labs
Screening tools used for whom: MST & MNA MST (malnutrition screening tool) older adults MNA (mini nutritional assessment) geriatric
methods to collect nutritional info Comprehensive nutritional assessment 24 Hr - recall Questionnaire or interview Food frequency questionnaire Food diaries Direct observation
Created by: midnight1854