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Health Assessment > Ch 1-5 > Flashcards

Ch 1-5 Flashcards

1
Q

Signs

A

Objective data observed, felt, heard, or measured

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2
Q

Symptoms

A

subjective data perceived and reported by the patient

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3
Q

Subjective Data

A

data collected from sources other than the nurse’s observations

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4
Q

Objective Data

A

data that can be measured through physical exam, observation, or diagnostic testing

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5
Q

Primary Source Data

A

subjective data acquired directly from a patient

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6
Q

Secondary Source Data

A

data acquired from another individual (not patient)

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7
Q

Clinical Manifestation

A

used to describe the presenting signs and symptoms experienced by a patient

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8
Q

Comprehensive Assessment

A

involves a detailed history and physical exam performed at the onset of care in a primary care setting or an admission to a hospital or ltc facility; encompasses health problems experienced by the patient, health promotion, disease prevention, and assessment for problems associated with known risk factors, or assessment for age and gender-specific health problems

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9
Q

Problem-based/ Focused Assessment

A

involves a history and physical exam that is limited to a specific problem or complaint; commonly used in a walk-in clinic or ED, but it may also be applied in other outpatient settings

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10
Q

Episodic/ Follow-up Assessment

A

usually done when a patient is following up with health care provider for a previously identified problem

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11
Q

Shift Assessment

A

when individuals are hospitalized, nurses conduct assessments each shift; identify changes to a patient’s condition from the baseline

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12
Q

Screening Assessment

A

short exam focused on disease detection

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13
Q

Clinical Judgement

A

an interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate

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14
Q

Health Promotion

A

behavior motivated by the desire to increase well-being and actualize human health potential

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15
Q

Health Protection

A

behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within its constraints

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16
Q

Primary Prevention

A

to prevent a disease from developing through promotion of healthy lifestyles

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17
Q

Secondary Prevention

A

screening efforts to promote the early detection of disease

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18
Q

Tertiary Prevention

A

minimizing the disability from acute or chronic disease or injury and helping the patient to maximize his or her health

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19
Q

The Nursing Process (A-D-O-P-I-E)

A

Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation

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20
Q

Standard Precautions

A

precautions applied in all aspects of patient care and in all health settings

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21
Q

Transmission-Based Precautions

A

guidelines designed for the control of infections among patients with known or suspected infections caused by certain pathogens of epidemiologic significance

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22
Q

Inspection

A

data obtained by a visual exam of the body, including body movement and posture, as well as that obtained by smell

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23
Q

Palpation

A

using the hands to feel texture, size, shape, consistency, pulsation, and location of certain parts of the patient’s body

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24
Q

Percussion

A

performed to evaluate the size, borders, and consistency of internal organs; detect tenderness; and determine the extent of fluid in a body cavity (direct or indirect)

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25
Q

Tympany

A

normally heard over abdomen

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26
Q

Resonance

A

heard over healthy lung tissue

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27
Q

Hyperresonance

A

heard in overinflated lungs

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28
Q

Dullness

A

heard over liver

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29
Q

Flatness

A

heard over bones and muscles

30
Q

Auscultation

A

listening to sounds within the body

31
Q

Systolic Blood Pressure

A

maximum pressure exerted on arteries when the ventricles contract or eject blood from the heart

32
Q

Diastolic Blood Pressure

A

minimum amount of pressure exerted on the vessels; this occurs when the ventricles relax and fill with blood

33
Q

Korotkoff Sounds

A

1st: clear, rhythmic thumping corresponding to the pulse rate that gradually increases in intensity
2nd: swishing sound heard as the cuff continues to deflate
3rd: softer thump than first
4th: muffled and low pitched as the cuff is further deflated
5th: marks the cessation of sound and indicates that the artery is completely open

34
Q

Orthostatic Hypotension

A

series of bp measurements taken when patient is in a lying, sitting, and standing position to assess this; 20 to 30 mmHg drop in bp when the patient moves from lying or sitting position to standing

35
Q

Oxygen Saturation

A

measured by pulse oximeter; levels lower than 90% are considered abnormal and require further evaluation

36
Q

Heart Rate

A

60-100 bpm

37
Q

Respiratory Rate

A

12-20 breaths/min

38
Q

Temperature

A

96.4 - 99.1 F

39
Q

BP

A

<120/<80

40
Q

Oxygen Saturation

A

> 90%

41
Q

Patient-Centered

A

care that involves treating each patient as a unique individual, respecting the patient for who he/she is, and responding to needs and preferences (free to share concerns, beliefs, and values in own words)

42
Q

Permission Giving

A

with this technique, nurse communicates to patient that it’s safe to discuss sensitive topics

43
Q

Open-Ended Questions

A

encourages free-flowing and open responses (more than one or two words)

44
Q

Closed-Ended Questions

A

require only one or two words to answer

45
Q

Directive Questions

A

lead patients to focus on a set of thoughts (to gain precise details)

46
Q

Comprehensive Health History

A

performed for new patients in any setting, including hospital admission, initial clinic visit, or home visit

47
Q

Problem-Based/ Problem-Focused Health Assessment

A

data that are limited in scope to a specific problem

48
Q

Episodic/Follow-up Health Assessment

A

focuses on a specific problem/problems for which a patient has already received treatment

49
Q

Chief Complaint/ Presenting Problem

A

reason for seeking health care

50
Q

Symptom Analysis

A

systemic method of collecting data about presenting problem

51
Q

PQRST

A

Palliative/precipitating factors
Quality of pain
Region/radiation of pain
Subjective descriptions of pain
Temporal nature of pain (time pain occurs)

52
Q

OLDCARTS

A

Onset (when symptoms began)
Location
Duration
Characteristics
Aggravating factors (what makes symptoms worse)
Related symptoms
Treatment (factors alleviate symptom)
Severity (intensity)

53
Q

Allergy

A

results in rash/difficulty in breathing (not adverse effect)

54
Q

Culture

A

knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by a person as a member of society

55
Q

Ethnicity

A

characteristics that a group may share in some combination, such as common geographic origin, race, language, dialect, religious beliefs, shared tradition and symbols, literature, folklore, music, food preferences, settlement and employment patterns, and an internal sense of distinctiveness

56
Q

Race

A

genetic in origin and includes physical characteristics such as skin color, blood type, eye color, and hair color

57
Q

Spirituality

A

“a search for the sacred”; 4 themes: religious systems of beliefs and values, life meaning/purpose/connection with others, nonreligious systems of beliefs and values, and metaphysical/transcendental phenomena

58
Q

Religion

A

organized system of beliefs, rituals, and practices in which an individual participates

59
Q

Cultural Awareness/ Competence

A

process of self-reflection of one’s own culture and their reactions to people from other backgrounds

60
Q

Context of Care

A

refers to circumstance or situation related to health care delivery
may be related to setting or environment
may be related to physical, psychologic, or socioeconomic circumstances involving the patient

61
Q

Contact Precautions

A

used for infections, diseases, or germs that are spread by touching the patient or items in the room
examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV

62
Q

Droplet Precautions

A

used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing
examples: pneumonia, influenza, whooping cough, bacterial meningitis
mask and goggles/face shield

63
Q

Airborne Precautions

A

used for diseases or very small germs that are spread through the air from one person to another
examples: tuberculosis, measles, chickenpox

64
Q

Hand Hygiene

A

single most important component to reduce infection transmission

65
Q

Diurnal Cycle

A

difference between morning and night

66
Q

General Inspection

A

physical appearance and hygiene, body structure, body movement, emotional status, disposition, and behavior

67
Q

BMI

A

Healthy weight: BMI 19-24.9
Overweight: BMI 25-29.9
Obese: BMI 30 or above

68
Q

Reasons for High BP

A

obesity, side effect from meds, stress

69
Q

Three Phases of Interview

A

introduction (AIDET), discussion, conclusion

70
Q

Essential for Good Interview

A

good impression (smile, body language, appearance, hygiene, shake hands)
be prepared (have all equipment [what you need], read chart before
be attentive throughout (active listening, avoid using medical terms [explain in lay terms])

Health Assessment (10 decks)

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