chap 2 Flashcards

1
Q

subjective data consists of

A
  • sensations/symptoms
  • feelings
  • perceptions
  • desires
  • preferences
  • beliefs
  • ideas
  • values
  • personal info
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2
Q

health history

A

collection of info obtained from pt & other sources

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3
Q

data from health history is basis for

A

plan of care

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4
Q

interviewing

A

direct method of gathering info that allows for questions to adapt to responses

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5
Q

phases of interview

A
  • introduction
  • working
  • summary & closing
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6
Q

preintroductory phase

A
  • nurse reviews medical record

- may reveal past health history and reason for seeking care

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7
Q

introductory phase

A
  • introduction
  • purpose for interview
  • discussing questions
  • explain why taking notes
  • confidential info
  • verify client privacy
  • develop trust
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8
Q

working phase

A
  • biographical data
  • reasons for care
  • present health concern
  • past health history
  • family history
  • review of body systems
  • lifestyle/health practices
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9
Q

summary & closing phase

A
  • summarize info
  • validate problems and goals
  • identify and discuss plans
  • any other concerns
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10
Q

nonverbal communication

A
  • appearance
  • demeanor
  • facial expression
  • attitude
  • silence
  • listening
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11
Q

verbal communication

A
  • open/closed ended questions
  • laundry list
  • rephrasing
  • well placed phrases
  • inferring
  • providing info
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12
Q

nonverbal comm to avoid

A
  • excessive/insufficient eye contact
  • distraction and distance
  • standing
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13
Q

verbal comm to avoid

A
  • biased/leading question
  • rushing
  • reading the questions
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14
Q

special consideration

A
  • gerontologic variations

- cultural variations

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15
Q

emotional variations

A
  • depressed
  • anxious
  • angry
  • seductive
  • discussing sensitive issues
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16
Q

when talking about reasons for seeking care, ask which 2 questions?

A
  • what is your major health concern at this time?

- how do you feel about having to seek health care?

17
Q

braden scale

A

tool for predicting ulcer risk

18
Q

five A’s of behavioral change

A
  • ask
  • advise
  • assess
  • assist
  • arrange
19
Q

rephrasing

A

helps clarify info client has stated

20
Q

chief complaint

A

brief statement describing symptoms, problem, diagnosis, or condition that is reason for care

21
Q

lifestyle and health practices

A
  • typical day
  • nutrition
  • 24 hour dietary intake
  • who purchases/cooks food
  • activity on typical day
  • rest/sleep habits
  • medication and substance abuse
  • self concept
  • social activities
  • relationships
  • values/belief system
  • past, present, future education/work
  • stress levels
  • environment
22
Q

additional assessments

A
  • functional
  • mental
  • cultural
  • nutritional
  • skin
  • age specific
  • disease specific
23
Q

in review of body systems you should only include what info

A

client’s subjective information

24
Q

review of body systems

A
  • each body system is addressed

- client asked specific questions