Exam 1 Flashcards
subjective data
health history, in pt words
objective data
physical assessment, lab results, pt record
what is the client’s database?
sub and obj data, nursing diagnosis, problem list
nursing diagnosis
clinical judgment about pt response to problems, which are addressed through nursing interventions
problem list
priorities
biomedical model
absence of disease, health to disease continuum, physicians focus, assess s/s, medical diagnosis
holistic health
nursing approach of mind body and spirit
complete assessment
total health database, complete health history, full physical exam, on admission
episodic assessment (or problem centered)
used in all settings for focused assessment in regards to problems at hand
follow-up assessment
re-assessment of the problems
emergency assessment
rapid, same time as life sustaining measures: ABCD
validate data as reliable or accurate
ask sig. other, check history
first-level priority
immediate, ABCs and vital signs
Second-level priority
immediate after first level, mental status change, acute pain, untreated medical problems, abnormal lab values
third-level priority
health problems related to lack of knowledge, activity, rest, or family coping
results of successful interview
obtain description and chronology of symptoms, establish rapport and trust, teach the pt about health state and problems, build rapport for future, begin teaching for health promotion and prevention
how to establish a contract during interview
time and place for physical to follow, introduce self and role, explain purpose of interview, length it will take, expectation of participation, ask permission for others to be in for interview, explain confidentiality, and any costs
empathy
recognizing a feeling and putting it into words, permits expression from pt/ family
physical environment for interview
quiet, private, well-lit setting, pt comfort
challenges of note taking
breaks eye contact, shifts attention, interrupts pt flow, can’t see pt nonverbal, inhibits pt from sensitive topics
what can we do to facilitate the interview process?
be familiar with tool for the history, minimize notes, write when there is a pause
communication techniques
facilitation, silence, reflection, clarification, conformation, summary
facilitation
encourages pt to continue “please go on”
silence
helps pt continue talking and organize thoughts
reflection
question to get more specific information “you know you have an ulcer?”
clarification
used to clarify vague statements “what do you mean by…”
conformation
makes sure on the same path “if I understand you correctly you said…”
summary
brief restate of what pt told you, lets them know interview is coming to end
10 traps
unwanted advise, avoidance, distance, interruptions, biased ?, false assurance, using authority, professional jargon, too much talking, interrupting, why questions
what gets included when documenting history source
reliability of information
“what makes the headache worse?” example of:
aggravating factors
CAGE test is for:
excessive or uncontrolled drinking
the ‘review of systems’ in history is for:
an evaluation of past and present health state of body systems
when recording information for the ‘review of systems’ interviewer must document
the presence or absence of all symptoms under the systems heading
PQRSTU is address characteristics of
symptoms
effects of alcohol on traumatic conditions:
cirrhosis (final stage of alcohol liver disease), cancers of mouth liver and esophagus, breast cancer in women, heart damage, vehicle accident
most abused opioid
oxycodone, hydrocodone, methadone
AUDIT questionnaire
quantitative form w/ 10 questions that cover alcohol consumption, drinking behavior, and adverse consequences
increase GGT level
chronic alcohol abuse
increase AST level
months of chronic drinking
increase MCV level
heavy alcohol consumption for 4 to 8 weeks
CAGE means
cut down, annoyed, guilty, eye opener
abuse is
intent to harm
neglect has
no intent to harm
inspection
first done in physical assessment to examine general
palpation
touch to determine texture size consistency of body parts
auscultation
listening to parts for problems
percussion
sharp taps to find location size and density of underlying parts, thorax and abdomen
what order should be used for physical assessment?
inspection, percussion, palpation, auscultation except for on the abdomen it is auscultation then palpation
direct percussion
used on sinuses, strike directly on body
indirect percussion
fingers of one hand on the area and strike with middle finger of dominant hand
components of percussion note
amplitude, pitch, and quality or timbre
tympany
loud high pitch… organ filled with air, air bubble over stomach
resonance
loud low pitch normal over lungs
hyperresonance
abnormal loud low tone last longer, pt with emphysema
dullness
high pitched tone soft and short, solid organs like liver and spleen, problem over bladder (full and can’t empty)
flatness
high pitched tone very soft, over muscle or bone
Bimanual palpating
Use of both hands to capture parts like kidneys
Diaphragm
High pitched sounds, breath bowel and normal heart
Bell
Soft low pitched sounds, murmurs and extra heart sounds
Laceration
Cut from pressure (ring) split and tear skin
Ecchymosis
Excessive blood under skin, not bruise
