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
A message conveyed through body language- postures, gestures, facial expression, eye contact, touch, and even where one places the chairs
Nonverbal communication
Asks for longer narrative information, unbiased, leaves the person free to answer in any way they choose
Open ended questions
The examiner’s response that echoes the patient’s words, repeats part of what the patient has just said
Reflection
Final review of what the examiner said, condenses facts and presents a survey of how the examiner perceives the health problem or need
Summary
Speech used by age 3 or 4 in which three or four word sentences contain only the essential words
Telegraphic speech
Messages sent through spoken words, vocalizations, tone of voice
Verbal communication
What 4 things are a result of a successful interview
- Accurate data
- Health history
- Rapport/trust
- Education
What should you share with the patient during an interview
Where When Introduction Explanation Duration Expectation Confidentiality Cost
What are the 4 situational responses
Confrontation
Interpretation
Explanation
Summary
What are the 10 interviewing traps
- false assurance - you’ll be fine
- unwanted advice - if I were you..
- using authority - nurse knows best
- avoidance language - saying passed instead of dead
- distancing - saying “my friend” about themselves
- professional jargon - myocardial infarction
- leading/biased questions - you don’t smoke do you..
- talking too much
- interrupting
- using why questions - makes them feel small
7 Nonverbal behaviors
Physical appearance Posture Gestures Facial expression Eye contact Tone of voice Touching
What could you do when interviewing a hearing impaired patient?
Use a dry erase board to communicate
Keep eye contact so they are able to read your lips easier as well as talking slowly
Could use an interpreter or signing if you know how
What should you do when interviewing someone who is acutely ill?
Take care of things such as vomit before proceeding with the interview
What should you do when someone comes to an interview drunk or under the influence?
Wait until they have sobered up to interview them
What should you do when a client starts to ask you personal questions?
Try to redirect their attention and questions else where
What should you do when a client becomes sexually aggressive?
Could say, “this is not appropriate, I am your nurse”
As well as getting a male employee in the room with you
What should you do if a client becomes angry and is threatening or violent?
Call lights, use vocera, get out of the situation and call security
What is the purpose of the health history?
To collect data on just what the patient is telling you
What are the 8 parts of a health history?
Biographical data Source of history Reasons for seeking care Present health or history of present illness Past health Family history Review of systems Functional assessment including ADLs
What are you gathering during the biographical data portion of the health history?
Time and date Patient's name Address Phone # Age Birth date Birthplace Sex - body parts Marital status Race Ethnic origin Culture/religion and practices Occupation
What are you gathering during the source of the history portion of the health history?
Who is the source of information and are they reliable
-alert, giving correct info, consistent
What are you gathering during the reasons for seeking care portion of the health history?
A brief statement from the patient on why they came in today
Symptoms - what the patient feels
Signs- what you witness/observe
What are the critical characteristics used to explore the patient during the present health & history of illness portion of the health history?
- Location of “pain”
- Character/quality: dull, sharp, burning
- Quantity/severity: pain scale
- Timing: when did the pain begin
- Setting: what were you doing
- Aggravating or relieving factors: makes it worse or better
- Associated factors: what else happens if you feel pain
- Patient’s perception: what do they think is causing it
What can help you with the critical characteristics of the present health & health history portion?
PQRSTU
- provocative
- quality & quanity
- region
- severity/scale
- timing/onset
- understanding patient’s problem
What are you gathering during the past health portion of the health history?
Childhood illness, accidents, injuries Hospitalizations Operations Immunizations Last exam date Allergies Medications
What are you gathering during the family history portion of the health history?
The age, health, and cause of death of relatives
Family history of diseases
What should you NOT do when reviewing systems?
Do not use normal, negative, or good
What all are you looking at when doing a review of systems?
General overall state of health Skin Hair Head Eyes Ears Nose/sinuses Mouth/throat Neck Breast Axilla Respiratory system Cardiovascular Peripheral vascular Gastrointestinal Urinary system Genitals Sexual health Musculoskeletal Neurologic Hematologic Endocrine
What all are you looking at when doing a functional assessment?
Self esteem and self concept Activity and exercise Sleep and rest Nutrition and elimination Interpersonal relationships and resources Spiritual resources Coping and stress management Personal habits Environment (home and work) hazards Intimate partner violence Occupational health Health promotion
Pondering a deeper meaning beyond the concrete and literal
Abstract reasoning
Concentration, ability to focus on one specific thing
Attention
Being aware of one’s own existence, feelings, and thoughts and being aware of the environment
Consciousness
An acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness, and usually resolves when the underlying cause is treated
Delirium
A gradual progressive process, causing decreased cognitive function even though the person is fully conscious and awake, and it is not reversible
Dementia
Using the voice to communicate one’s thoughts and feelings
Language
Ability to lay down and store experiences and perceptions for later recall
Memory
Prolonged display of a person’s feelings
Mood
Awareness of the objective world in relation to the self
Orientation
Awareness of objects through any of the five senses
-Is the patient feeling paranoid as if people are out to get them
Perceptions
What the person thinks - specific ideas, beliefs, the use of words
-it is consistent and logical
Thought content
The way a person thinks, the logical train of thought
-Does the patient make sense, can I follow what they are saying
Thought process
Define mental status
A mixture and good balance of emotional (feelings) and cognitive functioning (knowing)
It is apparent when a person’s response is much greater than the expected reaction to a traumatic event in life.
A significant behavioral or psychological pattern that is associated with distress or disability.
It also puts the patient at risk for pain, disability, or death
Mental disorder
What is an organic disorder?
Organic disorders have some known, specific cause of the disease
-dementia, alcohol, hallucinations caused by drugs
What is a psychiatric mental illness?
This is where there is no known cause for the illness.
- No drugs, no tumors, no lesions of the brain
- Schizophrenia, anxiety
The mental status exam allows you to see..
the emotional and cognitive functioning of the patient
What are the 4 main headings of a mental status exam
ABCT
- Appearance
- Behavior
- Cognition
- Thought processess
It is necessary to perform a full mental status examination when…
- When you discover any abnormalities in affect or behavior
- Patients whose screenings suggest an anxiety disorder or depression
- When the family is concerned about a person’s behavioral changes
- When brain lesions are apparent from things such as trauma, tumor, brain attack, or strokes
- When aphasia is apparent (the impairment of language- it is second to brain damage)
- When symptoms of psychiatric mental illness are apparent
What 4 factors affect the mental health exam
- Any known illness or health problems in general
- Current meds whose side effect could be depression
- The unusual education/behavioral level
- Responses to a persons history indicating stress levels, sleep, or drugs
Going in and out of consciousness
Lethargic - should wait until the patient is conscious
The first heading of the mental status exam, appearance, assess what?
Posture
Body movements
Dress
Appropriate
The second heading of the mental status exam, behavior, assess what?
Levels of consciousness
Facial expression
Speech
Mood & affect
Showing no emotion from serious news
Flat affect
Having emotions that are easily aroused or expressed
Labile effect
The third heading of the mental status exam, cognition assess what?
Orientation Attention span Recent memory Remote memory 4 unrelated words test
The loss of ability to speak, understand, and write language
Aphasia
When you pick up an item and have the patient identify it
Word comprehension
When you provide your patient with a sample text for them to read
Reading
When you have you patient form a sentence and write it out
Writing
The fourth heading of the mental status exam, thought processes and perceptions, assess what?
Thought process
Thought content
Perceptions
GAD 7
Generalized Anxiety Disorder
-screening for depression
Describe a mini-mental status exam
It is a 5-10 minute exam that screens to detect dementia, delirium, and psychiatric mental illnesses
It tests only cognitive functioning while the full mental status exam looks at the ABCTs
How does an aging adult’s cognitive functions decline
They are losing: their independence their home some of their abilities -hearing, reading, writing, memory ---decline in the 4 words test -----those with dementia/alzheimers wont be able to do it
What are the 5 levels of consciousness
Alert Lethargic (somnolent) Obtunded Stupor (semi-coma) Coma
Level of consciousness when you talk to them and they respond appropriately
Alert
Level of consciousness when they are not fully alert, they drift off, but they will wake up or be aroused when you say their name
Lethargic (somnolent)
Level of consciousness when they sleep most of the time, you will have to talk a little louder and shake a little harder, will act confused when they are aroused, speech may be mumbled or incoherent
Obtunded
Level of consciousness when they are spontaneously unconscious, they respond only to talking very loudly or vigorously shaking them or pain, they will have appropriate motor responses, can really only groan and mumble
Stupor (semi-coma)
Level of consciousness when they are completely unconscious, if it is deep there will be no response to pain or any external stimuli, if it is light they can have some reflex activity but not on purpose
Coma
How loud or soft a sound is (intensity)
Amplitude
The length of time a note lingers
Duration
An infection acquired in the hospital/during hospitalization
Nosocomial infection
An instrument that illuminates the ear canal, enabling the examiner to look at the ear canal and tympanic membrane
Otoscope
An instrument that illuminates the internal eye structures, enabling the examiner to look through the pupil at the fundus (background) of the eye
Ophthalmoscope
The number of vibrations (or cycles) per second of a note
Can also be called frequency
Pitch
A subjective difference in a sound due to the sound’s distinctive overtones
Quality
In what order should you use the 4 assessment techniques
- Inspection
- Palpation
- Percussion
- Auscultation
What is inspection? When, why, and how should you do it..
When you look at the patient, visual, concentrated watching
When: Should always do first, from the moment of first contact
Why: Just looking at the patient can give you a large amount of data
How: Start with the body as a whole (general survey) and then move into individual body system assessments
What is palpation? When, why, and how should you do it..
When you apply touch to the patient to assess their texture, temperature, moisture, organ locations as well as size, swelling vibrations, pulsations, rigidity, spasticity, crepitation, lumps and masses, tenderness, or pain
When: Should be second, after inspection
Why: It will confirm notes that were taken during inspection
How: Be slow and systematic, be calm and gentle, rub your hands together to make sure your hands are warm, palpate the tender areas last
Fingertips- used for texture and swelling
Fingers & thumbs- used for masses and lumps
Dorsa of hands & fingers- used for skin temperature
Base of fingers- used for vibration
What is percussion? When, why, and how should you do it..
Assessing underlying structures by tapping, using different parts of your hands for different jobs, useful if going at least 5cm deep
When: Should be third, after palpation
Why: You can see the density, size, and location of organs, detect abnormal superficial masses, and see deep tendon reflexes by using the things like the percussion hammer
How: Use short strokes and listen to the sound that is produced
What is auscultation? When, why, and how should you do it..
Listening to body sounds
When: Should be done last, unless its the abdomen, then it should come before palpation to avoid messing with bowel sounds
Why: Allows you to discover normal and abnormal organ functions
How: Use a stethoscope, place firmly against the skin
Diaphragm is for high pitched sounds: breath, bowel, normal heart tones
Bell is for soft, low pitch sounds: extra heart tones, murmurs
A brief time period when Korotkoff sounds disappear during auscultation of blood pressure, common with hypertension
Auscultatory gap
Heart rate less than 50 beats per minute in the adult
Bradycardia
Instrument for measuring arterial blood pressure
Sphygmomanometer
Amount of blood pumped out of the heart with each heartbeat
Stroke volume
Heart rate of more than 90 beats per minute in the adult
Tachycardia
What are the 4 components of a general survey and other aspects to look at as well
Physical appearance
Body structure
Mobility
Behavior
Height, weight, BMI, waist circumference, vitals
What are you looking at in the physical component of a general survey
Do they appear their age Is their sexual development appropriate Are they A&O x 3 Do they have even skin color with no lesions Is their face symmetrical
What are you looking at in the body structure component of a general survey
The height is appropriate and in normal range
The nutrition is adequate and weight is in normal range
The body parts are symmetrical
Posture is erect and comfortable: tripod or flat
Body build and contour is equal: arm span equal, pubis is located in the middle
What are you looking at in the mobility component of a general survey
Note how the patient was brought in
Is the base of their gait shoulder width apart
Is there accurate foot placement with smooth, even, and well balanced associated movement such as arm swing
Is there full ROM in each joint
Check to make sure there is no involuntary movements
What are you looking at in the behavior component of a general survey
Appropriate facial expressions and eye contact
Cooperative, pleasant, and congruent mood and affect
Clear and understandable speech
Appropriate dress for gender, season, age, culture
Personal hygiene is good, well groomed for SES, appropriate makeup
Weight should include what 2 things..
BMI and waist circumference
Name the underweight to class 2 obese BMI rankings
< 18.5 underweight
18.5 – 24.9 normal
25-29.9 overweight
30-34.9 class 1 obese
35-39.9 class 2 obese
What should waist circumference be depending on gender
Greater than 40 in women and greater than 35 in men suggests an increased risk for CVD, DM, and HTN
Normal temperature
98.6F (96.4-99.1)
Normal adult pulse
60-100 bpm or 50-90
Normal adult respirations
12-20 breaths a min
Normal adult blood pressure
120/80
110/70
100/60
Abnormal adult blood pressures
120-139/90-99 prehypertension
140-159/90-99 stage 1 hypertension
greater than 160 / greater than 100 stage 2 hypertension
Name the body changes that an aging adult will see
Body proportions are going to be redistributed, loss of muscle and weight with sharp, bony hips and ankles
Wider gait to compensate for unbalanced shorter steps, will probably use canes or walkers
Height will decrease, shorter trunk, longer limbs
Shallower respirations with an irregular pulse
Abnormal finding that occurs in childhood, causes a delay in puberty, causes hypothyroid/adrenal problems, and causes a deficiency in growth hormone
Hypopituitary dwarfism
Abnormal finding that occurs in childhood and causes excessive growth hormone
Gigantism
Abnormal finding where there is excessive growth hormone in adulthood after normal body growth has occurred.. there will be an overgrowth of hands, feet, face, head but no change in height
Acromegaly (hyperpituitaryism)
Abnormal finding of tall, thin stature, flat feet.. its inherited
Marfan’s syndrome
Abnormal finding where they have a normal trunk size, short arms and legs
Achondroplastic dwarfism
