Exam 1 Flashcards
The collection of data about an individual’s health state
We need to be fast, efficient, effective, and thorough
Assessment
A complete health history and full physical examination
The patients records, lab studies, objective and subjective data
Start from scratch, you get all of the health history info: vaccinations, medications, surgeries, assessment
Kind of what they do when they admit a new patient to the hospital
Can make a judgment or diagnosis from this…
Complete database
Simultaneously problem solving while self improving one’s own thinking ability
- novice thinking
- competent thinking
- proficient thinking
- expert thinking
Critical thinking
The process of analyzing health data and drawing conclusions to identify diagnoses.
A method of collecting and analyzing clinical information with the following components:
-clustering data & attending to initially available cues
(62yr, male, pale, diaphoretic, anxious)
-formulating diagnostic hypotheses
(hypoglycemic?)
-gathering data relative to the tentative hypotheses
(also irritable, shaky, and hungry)
-evaluating each hypothesis with the new data collected
(yes those support hypoglycemia)
-arriving at a final diagnosis
(risk for hypoglycemia)
Diagnostic reasoning
Rapid collection of the database, often compiled concurrently with lifesaving measures
There’s an emergency so you’re only going to focus on that specific emergency situation
Emergency database
The total of all the conditions and elements that make up the surroundings and influence and development of a person
Environment
A systematic approach emphasizing the best research evidence, the clinician’s experience, patient preferences and values, physical examination, and assessment
Evidence based practice
One used for a limited or short term problem, concerns mainly one problem, one cue complex, or one body system
Looks at just their specific problem rather than looking at all their other data
Sinus problems for example, you’re only really going to do an assessment on sinuses and not other areas
Focused / Problem centered database
Used in all settings to monitor progress on short term or chronic health problems
Seeing a patient for a 2nd time and reevaluating what you did for them last time
May need to change antibiotics
Follow up database
The view that the mind, body, and spirit are interdependent and function as a whole within the environment
Looking at your patient and not only taking care of physical needs but also spiritual needs and emotional needs
Ex.) Chaplin, bibles, giving them someone to talk to, or things to do
Holistic health
Used to evaluate the cause and etiology of disease, focus is on the function or malfunction of a specific organ system
Medical diagnosis
Used to evaluate the response of the whole person to actual or potential health problems
Nursing diagnosis
What are the 6 components of the nursing process
- assessment
- –physical as well as looking at labs, xrays, etc.
- diagnosis
- outcome identification/expected outcomes
- planning
- –establish priorities, set timelines
- implementation
- evaluation
What the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
O- objective, O- observed
Objective data
Any action directed toward promoting health and preventing the occurrence of disease
Prevention
What the person says about himself or herself during history taking
S- subjective S- says
Subjective data
A dynamic process and view of health, a move toward optimal functioning
Wellness
A 6 phase, interactive process, that applies a problem solving approach
Nursing process
What 3 components make up decisions about care
Clinician's experience \+ Evidence based techniques \+ Patient's preference and values
What are first level, second level, and third level priority problems?
First level: Their life is in danger
Second level: Risk for things, urgent
Third level: Can be addressed after more serious issues
A set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross cultural situations
- who is the patient?
- how can we help him/her?
- what do they understand about our health care system?
- what is her/her heritage, cultural background, health and illness beliefs and practices?
Cultural and linguistic competence
A professional health care that is culturally sensitive, appropriate, and competent
Cultural care nursing
The nonphysical attributes of a person - the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups
Culture
A condition that is culturally defined
Culture bound syndrome
A social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, and religion
Ethnicity
Tendency to view your own way of life as the most desirable, acceptable, or best and to act superior to another culture’s lifestyles
Ethnocentrism
The balance/imbalance of the person, both within one’s being (physical, mental, spiritual,) and in the outside world (natural, communal, metaphysical)
Health/illness
The degree to which a person’s lifestyle reflects his or her traditional heritage, whether it is American Indian, European, Asian, African, or Hispanic
Heritage consistency
The belief in a divine or superhuman power or powers to be obeyed and worshiped as the creator and ruler of the universe, and a system of beliefs, practices, and ethical values
Religion
The process of being raised within a culture and acquiring the characteristics of that group
Socialization
A federal law that mandates that when people with limited English proficiency (LEP) seek health care in health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them
Title VI of the Civil Rights Act of 1964
A desirable or undesirable state of affairs and a universal feature of all cultures
Values
Individuals whose parents were born in a different country but they themselves were born in the U.S.
Naturalized people
Immigrants who are in the U.S. for work or education and will return home when they are finished
Work or education immigration
Immigrants who come from a place of war
Refugees
Immigrants who do not have documented paper work
Illegal
The National Standards for Culturally and Linguistically Appropriate Services in Health Care states what..
“Health care organizations should ensure that patients receive from all staff members effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language”
The unusual and disproportionate frequency of a given health problem (diabetes, hypertension, certain cancers) within a population when compared with other populations
–maybe certain demographics do not have access to healthy foods so they will have high blood pressure
Health disparities
The cultural care style implying that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting int which they are practicing
Culturally sensitive
The cultural care style implying that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care
Culturally appropriate
The cultural care style implying that the caregivers understand and attend to the total context of the individuals situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences
Culturally competent
To be culturally competent you should have a knowledge of..
- your own personal heritage
- the heritage of the nursing profession
- the heritage of the health care system
- the heritage of the patient
Heritage consistency is made up of traditional and modern hertage.. what are these 2 types
Traditional- when you live within the norms of your culture
Modern- when you become acculturated to the norms of the dominant or main society in which you live
What are the 4 basic characteristics of culture
Culture is..
- learned
- shared
- adapted
- dynamic and ever changing
What are some health practices or health related behaviors that may be promoted based on a patient’s religion
Meditating Exercising/physical fitness Sleep habits Vaccinations Willingness to undergo physical examination Truthfulness about how patient feels Caring for children
Adapting to and acquiring another culture
Acculturation
Developing a new cultural identity and becoming like the members of the dominant culture
Assimilation
Dual pattern of identification or identifying/expressing 2 different identifications and often of divided loyalty
Biculturation
The theory in which life events have a cause and effect, the human body is mechanical, things can be made smaller and observed
Biomedical
The theory that human life is opposing categories, an aspect of nature, forces of nature, and must be kept in balance
- Yin and Yang
- Yin is cold and so it is foods eaten with a hot illness
- Yang is hot and so it is foods eaten with a cold illness
Naturalistic
The theory that the world is seen as an arena where super natural forces dominate
Magicoreligious
What does RESPECT stand for in cultural competence
R- realize you must know heritage of your self and patient
E- examine patient within cultural context
S- select simple questions and speak slowly
P- pace questioning throughout exam
E- encourage patient to discuss meaning of health and illness with you
C- check patient’s understanding and acceptance of recommendations
T- touch patient within boundaries of their heritage
Using a patient’s family member, friend, or child as an interpreter for a limited English proficiency (LEP) patient
Ad hoc interpreter
Imagining that inanimate objects (blood pressure cuff) come alive and have human characteristics
Animism
The use of euphemisms to avoid reality or to hide feeling
Avoidance language
The examiner’s response used when the patient’s word choice is ambiguous or confusing
Clarification
Questions that ask for specific information- elicit a short, one or two word answer such as “yes or no” or a forced choice
Closed questions
The response in which an examiner gives honest feedback about what he or she has seen or felt after observing a certain patient action, feeling, or statement
Confrontation
The use of impersonal speech to put space between the self and a threat
Distancing
Infantilizing and demeaning language used by a health professional when speaking to an older adult
Elderspeak
Direct computer entry of the patient health record while in the patient’s presence
Electronic health recording
Viewing the world from the other person’s inner frame of reference while remaining yourself, recognizing and accepting the other person’s feelings without criticism
Empathy
The tendency to view your own way of life as the most desirable, acceptable, or best and to act in a superior manner to another culture’s way of life
Ethnocentrism
The examiner’s statements that inform the patient, the examiner shares factual and objective information
Explanation
The examiner’s response that encourages the patient to say more, to continue with the story
Facilitation
A private room or space with only the examiner and the patient
Geographic privacy
The examiner’s statement that is not based on direct observation, but is based on the examiner’s inference or conclusion, it links events, makes associations, or implies cause
Interpretation
A meeting between the examiner and patient with the goal of gathering a complete health history
Interview
Using medical vocabulary with the patient in an exclusionary and paternalistic way
Jargon
A question that implies that one answer would be better than the other
Leading questions