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2M Flashcards

1
Q
  • reportedly by the client
  • may include S/S described by client but not noticeable to others.
  • may include demographic information, patient and family information, past & current medical conditions, etc.
A

SUBJECTIVE DATA

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2
Q
  • information that the health care professional gathers during a physical examination
  • consist of information that can be seen, felt, smelled or heard by the HCP.
A

OBJECTIVE DATA

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3
Q

sensations or symptoms (e.g. – pain, hunger), feelings (e.g. – happiness, sadness), perceptions, desires, preference, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

A

SUBJECTIVE DATA

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4
Q

Observations and measurements made by the data collector based on an acceptable standard. data directly and indirectly observed through measurements

A

OBJECTIVE DATA

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5
Q

skills need to collect objective data

A

o Inspection
o Palpation
o Percussion
o Auscultation

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6
Q

PHASES OF THE INTERVIEW

A

PRE-INTRODUCTORY PHASE
INTRODUCTORY PHASE
WORKING PHASE
SUMMARY AND CLOSING PHASE

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7
Q

nurse introduces herself and reviews the medical records before meeting the client.

A

PRE-INTRODUCTORY PHASE

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8
Q

nurse explains the purpose of the interview, discusses the types of the questions that will be asked. Explains the reason for taking notes and assures the client that information will remain confidential.

A

INTRODUCTORY PHASE

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9
Q

the nurse elicits the client with comments about major biographical data, reasons for seeking care, history of patient’s present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practice, and lastly developmental level

A

WORKING PHASE

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10
Q

nurse summarizes information obtained during the working phase, validates problems & goals with the client

A

SUMMARY AND CLOSING PHASE

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11
Q

NON-VERBAL COMMUNICATION

A

APPEARANCE
DEMEANOR
FACIAL EXPRESSION
ATTITUDE
SILENCE
LISTENING

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12
Q

appearance should be professional

A

APPEARANCE

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13
Q

an overload aspect of communication

A

FACIAL EXPRESSION

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14
Q

one of the most important nonverbal skills to
develop as a health professional is a non-judgmental attitude

A

ATTITUDE

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15
Q

allows the nurse and the client to reflect and organize thoughts which facilitate more accurate reporting and data
collection

A

SILENCE

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16
Q

most important skill to learn and develop fully in
order to collect complete and valid data

A

LISTENING

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17
Q

VERBAL COMMUNICATION

A

OPEN-ENDED QUESTIONS
CLOSE-ENDED QUESTIONS
LAUNDRY LIST
REPHRASING
WELL-PLACED PHRASES

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18
Q

are used to elicit the client’s feelings & perception

A

OPEN-ENDED QUESTIONS

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19
Q

to obtain facts and to focus on specific information

A

CLOSE-ENDED QUESTIONS

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20
Q

to provide the client with a list of words to choose in describing symptoms, conditions/feelings

A

LAUNDRY LIST

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21
Q

effective way to communicate and validate during the interview

A

REPHRASING

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22
Q

the nurses can encourage verbalization by using well placed phrases

A

WELL-PLACED PHRASES

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23
Q

COMPONENTS OF A COMPLETE HEALTH HISTORY

A

biographical data
reasons for seeking health care
history of present health concern
personal health history
family health history
review of systems for current health problems
lifestyle and health practices
developmental level

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24
Q

personal data that distinguishes individual from one another.

A

biographical data

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25
Q

o chief complaint
o onset of present health concern
o duration
o course of the health concern
o signs, symptoms, and related problems

A

reasons for seeking health care

26
Q

o allergies (reaction)
o serious or chronic illness
o recent hospitalizations
o recent surgical procedures

A

history of present health concern

27
Q

personal topics such as sexual activities etc

A

personal health history

28
Q

o pertinent health status of family members
o pertinent family history of heart disease, lung
disease, cancer, hypertension, diabetes, obesity, mental illness, genetic disorders

A

family health history

29
Q

o activity/exercise, leisure and recreational activities
o Sleep/rest
o interpersonal relationships/resources
o coping and stress management
o environmental hazards

A

lifestyle and health practices

30
Q

o current significant physical and psychosocial changes/issues

A

developmental level

31
Q

promote effective communication among multi- disciplinary health care team members and to facilitate client care

A

DOCUMENTING DATA

32
Q

ASSESSMENT FORMS USED FOR DOCUMENTATION

A
  • INITIAL ASSESSMENT FORMS
  • FREQUENT OR ONGOING ASSESSMENT FORMS
  • FOCUSED OR SPECIALTY AREA ASSESSMENT FORM
33
Q

it can be exposed/implied. A patient’s agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences

A

INFORMED CONSENT

34
Q

TYPES OF INFORMED CONSENT

A

Verbal
Implied
Written

35
Q

mutual decision making between both professional and patient over treatment option that the patient wishes to receive or not to receive

A

Purpose of informed consent

36
Q
  • when an individual clearly states their agreement to an intervention procedure.
  • should be obtained if there is any doubt of a person’s implied consent to minor procedures
A

Verbal Informed consent

37
Q
  • this is taken through participation
  • not explicitly given by the individual but is
    interfered from the person’s action and
    inactions
A

Implied informed consent

38
Q

must be obtained when procedures are:
* invasive/ has significant potential complications / side effects
* significant, irreversible side effects
* requires surgical, medical, invasive radiology,
oncology or endoscopy treatment

A

Written informed consent

39
Q

process of confirming or verifying that the subjective and objective data collected are reliable or accurate

A

VALIDATING DATA

40
Q

o excessive or insufficient eye contact
o distraction and distance
o standing

A

NON – VERBAL COMMUNICATION

41
Q

o biased or leading questions
o rushing through the interview
o reading the questions

A

VERBAL COMMUNICATION

42
Q

if client has hearing loss, speak slowly, face the client at all times, position yourself so that you are speaking on the side of the client that has the ear with better acuity

A

GERONTOLOGIC VARIATIONS IN COMMUNICATION

43
Q

o communication with the use of pictures may be helpful
o it may be necessary to use an interpreter if you need to interview a client who does not speak your language

A

CULTURAL VARIATIONS IN COMMUNICATION

44
Q

o provide the client with simple, organized information
o explain who you are along with your role and purpose
o ask simple and concise questions
o avoid becoming anxious
o do not hurry and decrease external stimuli

A

WHEN INTERACTION WITH AN ANXIOUS CLIENT

45
Q

o approach this client in a calm, reassuring in control manner
o allow client to ventilate feelings
o if the client is out of control, do not argue or touch the client
o obtain help from other health professionals as needed
o avoid arguing and facilitate personal space
o never allow the client to position himself between you and
the door

A

WHEN INTERACTING WITH AN ANGRY CLIENT

46
Q

o express interest in understanding of the client & responding a neutral manner
o do not try to communicate in an upbeat, encouraging manner

A

INTERACTING WITH DEPRESSED CLIENT

47
Q

o if you are not sure that you are being manipulated, obtain objective opinion from another colleague or health care
professional
o provide a structure and set limits
o differentiate manipulation and a reasonable request

A

INTERACTING WITH A MANIPULATIVE CLIENT

48
Q

o set firm limits on overt sexual client behavior and avoid responding to subtle seductive behavior
o if the overt sexuality continues, do not interact without business

A

INTERACTING WITH A SEDUCTIVE CLIENT

49
Q

o ask simple questions in non-judgmental manner
o allow time for ventilation of elements and feelings as needed
o make referrals as appropriate. If you do not feel comfortable in discussing sensitive topics

A

DISCUSSING SENSITIVE ISSUES (SEXUALITY, DYING, AND SPIRITUALITY)

50
Q

STEPS ON DATA ANALYSIS

A
  • identify strengths and abnormal data
  • cluster data
  • draw inferences
  • propose possible nursing diagnosis
  • check for defining characteristics
  • confirm or rule out diagnosis
  • document conclusions
51
Q

TYPES OF NURSING DIAGNOSIS

A
  • actual/problem focused nursing diagnosis
  • wellness/health promotion nursing diagnosis
  • risk/possible nursing diagnosis
  • syndrome diagnosis
  • collaborative problems and referrals
52
Q

MARJOY GORDON’S FUNCTIONAL HEALTH PATTERN

A

NUTRITIONAL – METABOLIC PATTERN
ELIMINATION PATTERN
ACTIVITY – EXERCISE PATTERN
SLEEP – REST PATTERN
COGNITIVE – PERCEPTUAL PATTERN
SELF – PERCEPTION PATTERN
ROLE – RELATIONSHIP PATTERN
SEXUALITY – REPRODUCTIVE PATTERN
COPING – STRESS MANAGEMENT PATTERN
VALUES – BELIEF PATTERN

53
Q

o determines how the client perceives and maintains his or her health
o assess compliance with current and past nursing and medical recommendation

A

HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

54
Q

o determine the client’s dietary habits and intake and metabolic needs
o assess the conditions of hair, skin, nails, teeth, and mucous membranes

A

NUTRITIONAL – METABOLIC PATTERN

55
Q

o determine the adequacy and function of the client’s bowl and bladder and urinary routines and habits for elimination
o assess for any urinary and bowel problems

A

ELIMINATION PATTERN

56
Q

o determine the client’s activities of daily living, occupation, leisure and exercise pattern

A

ACTIVITY – EXERCISE PATTERN

57
Q

o determine the client’s perception of the quality of his/her sleep and relaxation and energy levels
o assess methods used to promote relaxation and sleep

A

SLEEP – REST PATTERN

58
Q

o determine the functionality status of the five senses
o assess devices and methods used to assist the client with deficits in any of the sensory organs

A

COGNITIVE – PERCEPTUAL PATTERN

59
Q

o determine how the client perceives his/her situation, classify health goals

A

SELF – PERCEPTION PATTERN

60
Q

o determine 2 aspects: 1. Communication, what language does the client use and understand; 2. Relationship, is the client living alone or with family, support system and access to family life such as role discipline, finances, communication pattern, parenting and marital difficulties

A

ROLE – RELATIONSHIP PATTERN

61
Q

o determine the client’s fulfillment of sexual needs and perceived level of satisfaction
o assess reproductive pattern, developmental level and perceived problems which relates sexual activities, relationship and self-concept

A

SEXUALITY – REPRODUCTIVE PATTERN

62
Q

o determine the client’s ability to understand, communicate, remember and able to make decisions, changes and obstacles that the client experiences that could affect his or her decisions and how the client use coping mechanisms in times of crisis/stress

A

COPING – STRESS MANAGEMENT PATTERN

Health assess (5 decks)

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