Assessment
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| wellness | optimal functioning; not just the absence of illness, perfect health or the biopsychosocial ideal
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| medical model | goal is to cure; mechanistic; objective data based on scientific proof
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| nursing model | goal is to care; holistic/comprehensive; scientific but also intuitive
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| symptoms | subjective
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| signs | objective; you observe with your own senses
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| pyrexia | with fever
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| normal rectal | +1 degree
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| normal axillary | -1 degree
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| how should you assess a small child's temperature? | axillary or tympanic
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| safety point for temperature? | 102.2; be aware of sudden and abrupt changes in tempeerature
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| metabolism changes with fever? | increases 13% for every 1 degree celsius of increase; ensure nourishment and hydration
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| pulse strengths | 3+ bounding; 2+ normal, 1+ weak/thready; 0 absent
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| apnea | absence of repirations; about 15seconds
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| eupnea | normal rate (12-20)
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| tachypnea | rapid (>20)
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| bradypnea | slow (<12)
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| systolic | maximum force exerted against arterial wall during ventricular contraction
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| systole | Systolic; maximum force exerted against arterial walls during ventricular contraction
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| diastolic | minimal force exerted agains arterial wall when ventricles are relaxed
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| pulse pressure | MAP; subtract diastolic - systolic; Normal 30-50
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| BP regulators | peripheral resistance; elasticity of vessel walls; pumping action of th heart; blood volume; blood viscosity
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| bp cuff too large | lower BP measured than actual
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| bp cuff too small | higher BP measured than actual
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| when to measure head circumference? | every visit to 2years old; annually to age 6
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| orthostasis | BP drops as person rises by at least 25/10mmHg
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| When should peek-a-boo be achieved? | 1 year old
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| Culture | The system of shared beliefs, values, customs, behaviors, and artifacts that the members of society use to cope with their world and with one another and that are transmitted from generation to generation through learning
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| Cultural competence | treating every patient with equal respect and dignity regardless of culture, race or ethnicity
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| Provider causes of health disparities | conscious or unconscious biases; ineffective communication; inability to build trust; time limitations
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| External Environment | presence of others; physical; space; comfort; note-taking
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| Internal Environment | mutual respect; empathy/sympathy; acknowledgment of feelings; confidentiality; openness and optimism
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| Phases of the Interview | Introduction, Working and Closing
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| Introduction phase | salutations, explanations
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| Working phase | communication, data gathering, body language, responses
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| Closing phase | futher explanation and questions; summarize findings; plan next steps
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| When to assess LOC? | Assess LOC and language first in order to determine the depth of assessment that's needed
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| Continuum of consciousness | alert --> lethargic --> obtunded --> stupor --> comatose
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| Glasgow Coma Scale | common level of consciousness tool r/t eye opening, verbal response and motor response
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| Components of Cognition | ABCT
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| ABCT -- A | Appearance: posture, body movements, hygiene and groomin
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| ABCT -- B | Behaviors and Moods: appropriate, continuum of mood and affect
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| ABCT -- C | Concentration (Cognitive Signs): Orientation, attn span, recen and remote memory, new learning, judgment
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| ABCT -- T | Thought Processes: Abnormals are hallucinations, delirium, dementia
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| delirium | drugs/illness; internal; usually something fixable
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| dementia | impaired memory, cognition, brain-related causes; i.e. poor vascular supply to the brain; alzheimers
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| Mental Status Assessment | We CANNOT measure it directlyl Indirect measures of cognitive and emotional status and observations of behaviors
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| Folstein MMSE | perfect score = 30
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| Mental Status Screening | clock drawings; Set Test for the elderly
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| Screening for Depression | CDI, BDI, ZUNG, CES...
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| CAGE test | Use for suspected illicit substances
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| CAGE -- C | Have you ever felt you ought to cut down on your drinking or drug use?
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| CAGE -- A | Do you get annoyed at criticism of your drinking or drug use?
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| CAGE -- G | Do you ever feel guilty about your drinking or drug use?
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| CAGE -- E | Do you ever take an early morning drink or use drugs first thing in the morning?
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| What drug has the most impact on a person's daily life? | food
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| IBW ranges | <70% is undernutrition; >120% is overnutrition
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| Good fats | polyunsaturated and monounsaturated
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| Bad fats | saturated fats and trans fats
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| BRAT | for gastroenteritis: bananas, rice, apples and toast
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| Waist to hip ratio | greater than 1 for men or greater than 0.8 for women indicates obesity
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| Rxnship between TIBC and iron | inversely proportional
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| 4 types of assessments | pyramidal: emergency, follow-up, episodic, and complete
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| Present Illness - acronym | PQRSTU
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| PQRSTU - P | Provocative and palliative factors; what makes it worse and what makes it better
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| PQRSTU - Q | Quality or Quantity: descrive the pain with the adjectives
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| PQRSTU - R | Region or Radiation: where does i t start, where does it move to (radiate) where is it more severe?
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| PQRSTU - S | Severity Scale: rate your pain
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| PQRSTU - T | Timing: before or after meals, awakens from sleep; how often? constant?
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| PQRSTU - U | Understand patient's perspective:r/t employment
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| GPA - P | Para is deliveries
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| Review of Systems (ROS) | what is reported, not what is found through physical examination; an expansion of the health history
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Created by:
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