CLASS 1 - Introduction to Pathophysiology, Health Assessment, and the Pharmacotherapy System Flashcards
What is assessment?
the collection of data about an individual’s health state
What is functional assessment?
measuring a patient’s self-care ability (general physical health and absence of illness, ADLs+ IADLs, social relationships and resources, self-concept and coping, home environment)
What is a cue?
A cue is a client response that enables the nurse to form patterns in order to formulate or support a diagnosis
What is diagnostic reasoning?
The process of analyzing health data and drawing conclusions to identify diagnoses
describe relational practice
- Accounts for the fact that health, illness, and the meanings they hold for a person are shaped by the person’s gender, age, ability, and other indiv contexts.
- Relational approaches focus nurses’ attention on what is significant to people in the context of their everyday lives and how capacities and socioenvironmental limitations shape peoples’ choices.
Define reflectivity
A central skill of relational practice. Process of continually examining how you view and respond to patients on the basis of your own assumptions, cultral and social orientation, past experiences, and so on.
What are the 5 phases of the nursing process?
assessment, diagnosis, planning, implementation, evaluation
Describe the assessment phase
collect, organize, validate, and document data
Describe the diagnosis phase
analyze data, identify health problems, risks, and strengths, and formulate diagnostic statements
Describe the planning phase
prioritize problems and diagnosis, formulate goals and designated health outcomes , and identify nursing interventions
Describe the implementation phase
reassess the patient, determine the nurse’s need for assistance, implement nursing interventions, supervise delegated care, and document nursing activites
Describe the evaluation phase.
collect data related to outcomes, complete data w outcomes, relate nursing actions to patient goals / outcomes, draw conclusions about problem status and continue, modify, or end the patient’s care plan
Describe Inspection as an assessment technique
Looking.
Concentrated watching; close and careful scrutiny of the patient as a whole and then of each body system; always performed first.
Describe Palpation as an assessment technique
Feeling.
Applying sense of touch to assess patient.
Describe Percussion as an assessment technique
Tapping.
Tapping the patient’s skin w short, sharp strokes to assess underlying structures.
The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.
Describe Auscultation as an assessment technique
Listening
most body sounds are v soft and must be channeled w a stethoscope
What information is included in Complete Health History Data?
Biographical data, reason for seeking care, current health, PMHx (resolved and ongoing comorbids), family health history, Functional assessment, H2T/ROS
Biographical data
Ask patient to self-identify these characteristics, do not assume you know.
- Patient’s name, age, birthdate, birthplace, other recent countries of residence, sex, gender, relationship status, and usual and current occupation or daily activity pattern
- Primary + preferred language
- Patient’s authorized representative
How would you document the source of history for a patient?
Record who provided the info, whether its a patient, caregiver, parent, etc.
Judge how reliable the informant seems and how willing / able the person is to communicate
Note any special circumstances such as the use of an interpreter.
Ex. Patient herself, who seems reliable
Ex. patient’s son, Billy Bob, who seems reliable
Ex. Mr. R. Fuentes, interpreter for Theresa Catillo, who does not speak English.
What is a patient’s reason for seeking care?
Brief, spontaneous statement in the patient’s own words that describes the reason for the visit. States one or two symptoms or signs and their duration.
How would you document a patient’s reason for seeking care? What should you avoid?
Whatever the patient says is their reason for seeking care is recorded and enclosed in quotation marks to indicate their exact words.
“Chest pain” for 2 hrs
“My child has an earache and was fussy all night”
“I need a yearly physical examination for work”
“I want to start jogging, and I need a checkup”
“I would like to cut down the amount of ciagarettes I smoke”
Avoid using the patient’s reason for seeking care as a diagnosis; do not translate the patient’s statement into the terms of a medical diagnosis.
What are the components of PMHx?
Childhood illnesses, accidents + injuries, serious or chronic illnesses, hospitalizations, operations, obstetricial history, immunizations, most recent examination dates, allergies, current medications
How do you document Current Health for the ill patient?
Chronilogical record of the reason for seeking care from the time the symptoms first started until now.
Your final summary of any symptom the patient has should include the OPQRSTU assessment
What does OPQRSTU stand for?
Onset + duration Precipitation / Palliation Quality Region / Radiation Severity (can also include quantity) Timing (freq + duration) Understanding (patient's own)
What questions would you ask a patient about the Onset of their symptoms?
When did this first occur?
Was this sudden, gradual or an ongoing problem?
Has it happened before?
Give specific date + time or state specificallt how long ago the symptom atarted PTA
What questions would you ask a patient about the Precipitation / Palliation of their symptoms?
Do believe something precipitated the event or ‘brought this on’? Describe.
Is there anything that makes it better or helps it to ‘go away’? (palliation)
What makes it worse?
Examples: rest, an activity, cold, heat, medications, eating, stress, etc.
What questions would you ask a patient about the Quality of their symptoms?
Describe the problem or symptom in detail e.g. Describe the pain.
Can you describe it to me?
Examples: dull, sharp, crushing, burning, constant, throbbing, shooting, etc.
Use similes – does blood in the stool look like sticky tar? Does blood in vomitus look life coffee grounds?
What questions would you ask a patient about the Region / Radiation of their symptoms?
Does this occur in a specific location on the body and does it radiate out to other areas?
Examples: Pain in the shoulder radiation to the jaw.
Is the pain localized to this site or radiating? Is the pain superficial or deep?
Example: Numbness in L arm, then 10 minutes later numbness began in the L leg.
What questions would you ask a patient about the Severity of their symptoms?
This can be a single estimate of severity or a comparison (did it get worse or better?).
Attempt to quantify the sign or symptom (ex - profuse menstrual flow, soaking 5 pads per hour)
If “0” is not pain and “10” is the worst pain you can imagine…
Ask how it affects daily activities - When you walk up a flight of stairs does your breathing feel like you have been walking for a while or like you have been running?
What questions would you ask a patient about the Timing (freq + duration) of their symptoms?
How long does the symptom last? Is it constant? Does it come and do (intermittent)? Does it resolve and reappear?
Is there a pattern you have noticed?
Examples: Does it always start at the same point in an activity? Does it always go away with 2 minutes of rest?
How long has this been going on? (duration)
What questions would you ask a patient about their understanding of their symptoms?
What do you think causes this? This is the patient’s understanding of the event – not necessarily accurate but can be helpful in diagnosis. Patient’s usually know their symptoms quite well and notice small differences/changes.
How does it affect your daily activities?
What do you think it means?
Example: Does this feel like your arthritic pain or do you think it is something else?
Is this headache different from your usual migraine?
What is the difference between Evidence Based Practice and Evidence Informed Practice?
EIP includes more than the use of the best practice techniques to treat patients - includes patient preferences and values as a form of evidence
Define the SOAPIE Acronym (for documentation)
Subjective date Objective data Assessment Plan Intervention Evaluation
Describe the Biomedical Model of Health.
Predominant model of the Canadian Healthcare System
Health = absensce of disease
Focus on the diagnosis and treament of pathogens + curing disease
