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Holistic Lecture > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

subjective data

A

health history, in pt words

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2
Q

objective data

A

physical assessment, lab results, pt record

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3
Q

what is the client’s database?

A

sub and obj data, nursing diagnosis, problem list

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4
Q

nursing diagnosis

A

clinical judgment about pt response to problems, which are addressed through nursing interventions

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5
Q

problem list

A

priorities

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6
Q

biomedical model

A

absence of disease, health to disease continuum, physicians focus, assess s/s, medical diagnosis

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7
Q

holistic health

A

nursing approach of mind body and spirit

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8
Q

complete assessment

A

total health database, complete health history, full physical exam, on admission

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9
Q

episodic assessment (or problem centered)

A

used in all settings for focused assessment in regards to problems at hand

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10
Q

follow-up assessment

A

re-assessment of the problems

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11
Q

emergency assessment

A

rapid, same time as life sustaining measures: ABCD

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12
Q

validate data as reliable or accurate

A

ask sig. other, check history

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13
Q

first-level priority

A

immediate, ABCs and vital signs

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14
Q

Second-level priority

A

immediate after first level, mental status change, acute pain, untreated medical problems, abnormal lab values

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15
Q

third-level priority

A

health problems related to lack of knowledge, activity, rest, or family coping

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16
Q

results of successful interview

A

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

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17
Q

how to establish a contract during interview

A

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

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18
Q

empathy

A

recognizing a feeling and putting it into words, permits expression from pt/ family

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19
Q

physical environment for interview

A

quiet, private, well-lit setting, pt comfort

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20
Q

challenges of note taking

A

breaks eye contact, shifts attention, interrupts pt flow, can’t see pt nonverbal, inhibits pt from sensitive topics

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21
Q

what can we do to facilitate the interview process?

A

be familiar with tool for the history, minimize notes, write when there is a pause

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22
Q

communication techniques

A

facilitation, silence, reflection, clarification, conformation, summary

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23
Q

facilitation

A

encourages pt to continue “please go on”

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24
Q

silence

A

helps pt continue talking and organize thoughts

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25
Q

reflection

A

question to get more specific information “you know you have an ulcer?”

26
Q

clarification

A

used to clarify vague statements “what do you mean by…”

27
Q

conformation

A

makes sure on the same path “if I understand you correctly you said…”

28
Q

summary

A

brief restate of what pt told you, lets them know interview is coming to end

29
Q

10 traps

A

unwanted advise, avoidance, distance, interruptions, biased ?, false assurance, using authority, professional jargon, too much talking, interrupting, why questions

30
Q

what gets included when documenting history source

A

reliability of information

31
Q

“what makes the headache worse?” example of:

A

aggravating factors

32
Q

CAGE test is for:

A

excessive or uncontrolled drinking

33
Q

the ‘review of systems’ in history is for:

A

an evaluation of past and present health state of body systems

34
Q

when recording information for the ‘review of systems’ interviewer must document

A

the presence or absence of all symptoms under the systems heading

35
Q

PQRSTU is address characteristics of

A

symptoms

36
Q

effects of alcohol on traumatic conditions:

A

cirrhosis (final stage of alcohol liver disease), cancers of mouth liver and esophagus, breast cancer in women, heart damage, vehicle accident

37
Q

most abused opioid

A

oxycodone, hydrocodone, methadone

38
Q

AUDIT questionnaire

A

quantitative form w/ 10 questions that cover alcohol consumption, drinking behavior, and adverse consequences

39
Q

increase GGT level

A

chronic alcohol abuse

40
Q

increase AST level

A

months of chronic drinking

41
Q

increase MCV level

A

heavy alcohol consumption for 4 to 8 weeks

42
Q

CAGE means

A

cut down, annoyed, guilty, eye opener

43
Q

abuse is

A

intent to harm

44
Q

neglect has

A

no intent to harm

45
Q

inspection

A

first done in physical assessment to examine general

46
Q

palpation

A

touch to determine texture size consistency of body parts

47
Q

auscultation

A

listening to parts for problems

48
Q

percussion

A

sharp taps to find location size and density of underlying parts, thorax and abdomen

49
Q

what order should be used for physical assessment?

A

inspection, percussion, palpation, auscultation except for on the abdomen it is auscultation then palpation

50
Q

direct percussion

A

used on sinuses, strike directly on body

51
Q

indirect percussion

A

fingers of one hand on the area and strike with middle finger of dominant hand

52
Q

components of percussion note

A

amplitude, pitch, and quality or timbre

53
Q

tympany

A

loud high pitch… organ filled with air, air bubble over stomach

54
Q

resonance

A

loud low pitch normal over lungs

55
Q

hyperresonance

A

abnormal loud low tone last longer, pt with emphysema

56
Q

dullness

A

high pitched tone soft and short, solid organs like liver and spleen, problem over bladder (full and can’t empty)

57
Q

flatness

A

high pitched tone very soft, over muscle or bone

58
Q

Bimanual palpating

A

Use of both hands to capture parts like kidneys

59
Q

Diaphragm

A

High pitched sounds, breath bowel and normal heart

60
Q

Bell

A

Soft low pitched sounds, murmurs and extra heart sounds

61
Q

Laceration

A

Cut from pressure (ring) split and tear skin

62
Q

Ecchymosis

A

Excessive blood under skin, not bruise

Holistic Lecture (4 decks)

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