exam 1 Flashcards
what is objective data and examples ?
observational data, vital signs
what is subjective data and examples
data that the patient tells the nurse during history taking
what are the 5 steps of the nursing process?
A: assessment, recognize cues
D: diagnosis, analyze the cues
P: planning, prioritize hypotheses and generate solutions
I: implementation, take action
E: evaluation, outcome of process
what is the fasting growing minority population in the US?
hispanic/ latino
describe elements of assessment phase of nursing process
recognize the cues
definition of evidence-based practice, and type of info utilized for best
integration of research evidence, clinical expertise, clinical knowledge along with patients values and preferences
best evidence from literature review, patients own preference, clinicians experience
definition of follow up bases
used to evaluate and document ongoing short and long term health problems
elements of health data base, when it is appropriate to obtain
culturally competent and appropriate care
develop cultural sensitivity, basic knowledge, applying knowledge to improve health outcomes, apply universal understanding to all contextual aspects of care, provide cultural care across cultural boundaries
obtaining appropriate info as apart of health assessment
establish trust, teach the client, trusting rapport, focus on health promotion and disease prevention , gathering accurate/ complete data, gain understanding of persons belief system, concern, perception, subjective data and note
how should the physical environment be in an interview?
“equal status” seating, nice temp.
how do you start interviews?
hi my name is____, i need to ask you a few questions about ______.
interview techniques ?
verbal communication: tone, vocalization
nonverbal: body language, unconscious messages may be more reflective of true messages
open ended and closed ended questions
confrontation in an interview
clarifying inconsistent information
non-therapeutic techniques
Providing false assurance or reassurance, Giving unwanted advice, Using authority, Using avoidance language, Engaging in distancing,Using professional jargon ,Using leading or biased questions, Talking too much, Interrupting, Using why questions
teaching during interviews
informing person by sharing factual and objective information
(teaching materials such as for smoking cessation)
biased/ leading questions definitions
be aware of your own self-awarenes ”implicit bias” set aside your own
personal prejudices to care for all types of clients
anger- clarity in documenting
the nurse will want to assess the patient’s understanding about anger, their perceptions of their angry behavior, and their readiness to learn
use of interpreters
safe and informed communication, trained certified medical interpreter, verbal and nonverbal ques, speaking patients language does not imply understanding of cultural diversity
use of direct questions
target specific topics, vulnerable populations that need special attention include acutely ill person,
someone with drug/alcohol abuse, sexually aggressive, emotionally distraught
such as crying, angry/threatening violence and a person with anxiety
interruptions during interviews
avoid interruptions, put cell phones on silence, inform staff of no interruptions
active listening techniques
non-verbal communication, making sure you are paying attention
what info should be included in documentation of health history?
Biographic data, History source, Reason for seeking care, History of present illness, Past health, Family history, ROS, Functional assessment including ADL’s
purpose of health history?
reason for seeking care, patients own words
what is the “history of the present illness”
collect all provided data, be as accurate and precise as possible, patients own words
what may be an example of a patient’s symptom and an example of the quality of the symptom
symptom: subjective description from the patient
sign: objective observation (abnormality) detected on the physical exam or in
lab reports
patient’s perception of present illness and the relationship to quality of life/functional assessment
self-esteem, Activity/exercise, Rest/sleep, Nutrition and elimination, IPR’s and resources, Spiritual resources, Coping/stress management, Personal habits, Illicit/street drugs, Environment/work hazards, Intimate partner violence, Occupational health
patient drug allergies
make sure you get every allergy the patient knows of
aspects of the Mental Health Assessment which can be gathered from observation
appearance, behavior, cognition, thought process, perform the exam when abnormality is noted
delirium, dementia, cognition
delirium: a mental state that causes confusion, disorientation, and a reduced awareness of one’s surroundings
dementia: the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person’s daily life and activities
cognition: being able to be oriented to person, time, place,
use of the MMSE tool in determining psychiatric mental illness versus other medical illnesses
test of cognitive functions
of memory, orientation to time and place, naming, reading, copying or
visuospatial orientation, writing, and the ability to follow a 3 stage command.
quick and easy with 11 standard questions.
information covered in the AUDIT questionnaire
how often one drinks alcohol, many drinks, last year containing anything fo alcohol, ijuries bc of alchol, higher the score more at risk
older adult and alcoholic beverage use
decrease in metabolic functions, decrease muscle mass, rick of cognitive decline, falls, depression, GI disturbances
use of TWEAK questionnaire
screening at risk women, especially pregnant
intimate partner abuse
physical abuse, sexual abuse, stalking, psychological aggression
registered Nurse and report of abuse
mandatory reporters, always include in interviews/assessments
sounds that may be heard with the bell and diaphragm of the stethoscope
DIAPHRAGM—THE FLAT EDGE, USED TO LISTEN FOR HIGH PITCHED SOUNDS
BELL—DEEP, HALLOW CUPLIKE SHAPE USED TO LISTEN FOR SOFT PITCHED SOUNDS
what may be assessed with palpation
TEXTURE, TEMPERATURE, MOISTURE, SWELLING, ORGAN LOCATION AND SIZE, VIBRATION, PULSATION AND CREPITATION, RIGIDITY OR SPASTICITY, PRESENCE OF LUMPS OR MASSES, PRESENCE OF PAIN OR TENDERNESS
correct order in performing the physical assessment
inspection, palpation, percussion, auscultation
steps to help a patient be more comfortable before and during the exam
YOUR PATIENT WILL USUALLY BE ANXIOUS CONSIDERING THE ANTICIPATION OF THE EXAM (AND
CONCERNS OF THE OUTCOME) AND THE ENVIRONMENT. REMEMBER—IF THIS IS THE FIRST TIME MEETING THIS PERSON—YOU ARE A STRANGER.
TO DECREASE THE ANXIETY FOR THE PATIENT—APPEAR UNHURRIED AND CONFIDENT DURING THE EXAM REDUCING THE PATIENT’S ANXIETY MAY ALLOW THE PATIENT TO FEEL MORE COMFORTABLE WHICH
WILL ASSIST IN ACCURATE GATHERING OF DATA.
components of the general survey
physical appearance, body structure, mobility, behavior, measuring weight, measurements, waist circumference,
charting a patient’s level of consciousness
is the person alert, oriented,
responds to questions and responds appropriately?
list what is included in obtaining a patient’s vital signs
blood pressure, RR, heart rate, temperature, o2 stats
definition of spirituality
broader term that encompasses something larger than ones own existence with a belief in transcendence
purpose of using a doppler
detect blood flow
physiologic processes that can affect a patient’s vital signs
age, gender, infection, medication, pain, anxiety, stress, circadian rhythm, recent activity, menstrual cycle
assessing and documenting a patient’s pain level
ask patient if they are in pain 0-10
different levels of managing immediate priorities
first level: emergent, life threatening
second level:next extend to this level to prevent further deterioration
third level:important, but may be addresses after more urgent problems resolved
definition of religion
organized system of beliefs as a shred experience that can assist in meeting ones individuals spiritual needs
palpation techniques
fingertips, fingers/thumbs, dorsa, base of fingers
