Exam 1 Flashcards
5 Core competencies identified by Institute of Medicine (IOM) that are essential for all health care professionals to demonstrate in all areas of practice
1) Provide patient-centered care
2) Work in interdisciplinary teams
3) Use evidenced-based practice
4) Apply quality improvements
5) Use informatics
Components of a health assessment
1) Conducting a health history
2) Performing a physical examination
3) Reviewing other data from the health record (as available)
4) Document findings
A health history consists of
subjective data collected during an interview. Includes:
1) Information about the current state of health of patients
2) The medications they take
3) Previous illnesses and surgeries
4) A family history
5) Review of symptoms (ROS)
Patients may report feelings or experiences associated with health problems. These patient reports are called?
Symptoms and are subjective
Primary source data
Subjective data acquired directly from a patient
Secondary source data
Data acquired from another individual (such as family member)
During physical examination what is collected?
Objective data is collected using the techniques of: 1) Inspection 2) Palpation 3) Percussion 4) Auscultation for each body system. 5) Height 6) Weight 7) Blood pressure 8) Temp. 9) Pulse rate 10) Respiratory rate all measured
Serves as the baseline for the evaluation of subsequent changes and decisions related to care
The patient’s health record
What does the EHR include?
1) Data from the history
2) Physical examination
3) Laboratory and diagnostic tests
4) Surgical procedures
5) Progress notes
Circumstances contributing to the context of care include?
Setting or environment physical psychological or socioeconomic circumstances involving the patient, and the expertise of the nurse.
Types of data organization
1) body system format (e.g. cardiovascular, musculoskeletal, auditory, visual)
2) Conceptual format (e.g oxygenation, perfusion, mobility)
Clinical judgement
An interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response.
Process of clinical judgement include 4 components
1) Noticing
2) Interpreting
3) Responding
4) Reflecting
A process in which the nurse uses patterns of reasoning (involving analysis of intuition) to gain an understanding of the situation
Interpreting
Reflection-in-action
Reflecting on past experiences while in the midst of another situation
Reflection-on-action
Thinking about a situation that has occurred and developing a better understanding of what happened & the appropriateness of the patient outcomes
Primary prevention
Prevent a disease from developing through the promotion of healthy lifestyles
Secondary prevention
Consists of screening efforts to promote the early detection of disease
Tertiary prevention
Directed toward minimizing the disability from acute or chronic disease or injury & helping the patient to maximize his/her health.
4 Overarching goals of Healthy People 2020
1) Attain high quality, longer lives free of preventable disease, disability, injury, & premature death
2) Achieve health equity, eliminate disparities, & improve health of all groups
3) Create social & physical environments that promote good health for all
4) Promote quality of life, healthy development, & healthy behaviors across all life stages
What are the 4 foundational health measures that are indicators of progress towards goals for healthy people 2020?
1) General health status
2) health related quality of life & well being
3) determinates of health
4) Disparities
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission?
Comprehensive assessment. The key words are new admission
After collecting data, the nurse begins data analysis with which activity?
Organizing the data collected
Components of health assessment include?
1) conducting a health history (the collection of subjective data)
2) performing a physical examination (the collection of objective data)
3) documenting the findings
Collection and analysis of data are components of formulating a nursing diagnosis and care plan.
Information gathered during a health history include
- how patients define health
- their beliefs about attaining and maintaining health (such as how they view their responsibility for their health, which health behaviors they currently practice, which unhealthy behaviors they are willing to change)
Patients expectations for health are based on?
His/her life experiences, experiences of family & friends, the culture in which they live.
Phases of an interview
Introduction
Discussion
Summary
How a nurse conducts him/her self in an interview includes
What is said to a patient
personal appearance
body language
tone of voice
Discussion phase of interview
Nurse collects health history by facilitating a discussion regarding various aspects of patients health. Conversation is patient-centered (patients free to share concerns, beliefs, values in own words).
During this phase, a variety of communication skills & techniques are used to enhance the conversation and data collection
Phases of an interview bullet points
Introduction phase
Nurse:
1) Introduces self to patient
2) Describes the purpose of the interview
3) Describes the interview process
Discussion phase
Nurse:
1) Faciliates & maintains a patient-centered discussion
2) Uses various communication techniques to collect data
Summary phase
Nurse:
1) Summarizes data w/patient
2) Allows patient to clarify the data
3) Communicates an understanding of the problems to the patient.
Numerous factors affect the interview
1) Physical setting
2) Nurses behavior
3) types of questions asked
4) how questions are asked
5) Personality/behavior of patient
6) how they are feeling during interview
7) nature of information being discussed or the problem confronted may affect the data revealed
Nurses ______ skills are instrumental in a successful interview
interpersonal
When conducting an interview consider patient variables such as?
Age & physical, mental & emotional status
When a patient is in physical or emotional distress what assessment should you conduct?
Focused assessment to limit the number and nature of questions to those which are absolutely necessary for the given situation, and save any additional questions for later.
Permission giving technique
The nurse communicates to the patient that it is safe to discuss such topics
Begin an interview with?
Open-ended questions
Directive questions lead patients to?
Focus on one set of thoughts. This type of question is most often used in reviewing symptoms or evaluating an individual’s functional capabilities
The ____ is an essential tool in obtaining a patients history
question-answer format
Data collection can be facilitated by using the following techniques
1) Active listening
2) Facilitation
3) Clarification
4) Restatement
5) Reflection
6) Confrontation
7) Interpretation
8) Summary
Active listening involves?
Listening with a purpose to the spoken words as well as noticing nonverbal behaviors
Facilitation uses?
Phrases to encourage patients to continue talking. These include verbal responses such as “go on”, “uh huh”, “then” & nonverbal responses such as head nodding and shifting forward in your seat with increased attention.
When someone is overly talkative the use of ________ may help to maintain direction and flow of the conversation
Closed-ended questions
LEP
Limited english proficiency
Who mandates the provision of interpreting services for patients with LEP (Limited english proficiency); this is also an element w/in the accreditation guidelines for health care agencies
State and federal laws
Cultural differences: Patient-centered care is provided when nurses develop?
Cultural competence to accept and respect differences, & identify cultural factors that may influence patients’ beliefs about health and illness
Who places accountability for cultural competence w/all health care professionals?
The health care system
Define cultural competence
The ongoing process in which the health care professional continuously strives to achieve the ability & availability to work effectively w/in the cultural context of the patient (individual, family, community)
To deliver culturally competent care, nurses must?
Interact w/each individual as a unique person who is a product of past experiences, beliefs, and values that have been learned and passed down from one generation to the next.
A comprehensive health history may be performed during?
1) A hospital admission
2) With an initial clinic
3) home visit
4) When the patient’s reason for seeking care is for the relief of generalized symptoms such as weight loss or fatique
The history for a problem based/problem focused health assessment included data that is?
Limited in scope to a specific problem. however, it must be detailed enough so the nurse is aware of other health related data that may affect the current problem. A focused interview is also used when a patient seeks help to address an urgent problem such as relief from asthma attacks or chest pain.
The history associated with an episodic or follow up assessment generally focuses on?
A specific problem or problems for which a patient has already been receiving treatment. It focuses on the changes that have taken place since the last visit, with an interest in disease management & the early detection of complications or a decline in health. Example is a cancer patient going for episodic visits for treatment.
A comprehensive health history includes the following components:
1) Biographic data
2) Reason for seeking care
3) History of present illness
4) Present health status
5) Past health history
6) Family history
7) Personal & psychosocial history
8) Review of symptoms (ROS)
What is biographic data?
1) Name
2) Gender
3) Address, telephone number, e-mail
4) Birthdate
5) Birthplace (important when born in foreign country)
6) Race/ethnicity
7) religion
8) marital status
9) occupation
10) contact person
11) source of data
Symptom analysis
A systematic method of collecting data about the history & status of symptoms
Symptom analysis: OLD CARTS
Onset: When did symptoms begin
Location: where are the symptoms
Duration: how long do symptoms last
Characteristics: Describe the characteristics of the symptoms
Aggravating and alleviating factors: What affects the symptoms
Related symptoms: are other symptoms present
Treatment: describe self Tx before seeking care
Severity: describe severity of the symptoms
The present health status focuses on?
The patient’s conditions (acute & chronic), medications the patient is currently taking, and allergies the patient has experienced
What is included in past health history?
1) Childhood illnesses
2) Surgeries
3) Hospitalizations
4) Accidents or injuries
5) Immunizations
6) Last examinations
7) Obstetric history
When conducting family history ask about the presence of?
- Alzheimer’s disease
- cancer (all types)
- diabetes mellitus (type 1 or 2)
- coronary artery disease (including myocardial infarction)
- hypertension
- stroke
- seizure disorders
- mental illness (including depression, bipolar, schizophrenia)
- substance abuse
- endocrine diseases (specify)
- kidney disease
Personal & psychosocial history: What is including in the personal history?
1) general statement of his/her feelings about self
2) cultural/religious affiliations & practices
3) Education
4) Occupational history
5) Work satisfaction
6) perception of having adequate time for leisure & rest
7) current hobbies/interests
What is included in a personal & psychosocial history?
1) Personal status
2) Family & social relationships
3) Diet/nutrition
4) Functional ability
5) Mental health
6) Tobacco, alcohol, illicit drug use
7) health promotion activities
8) environment
AUDIT
A screening questionnaire Alcohol Use Disorders Identification Test
General symptoms
Pain; general fatigue, weakness, fever; problems w/sleep; unexplained changes in weight
The nurse is assessing a patient’s activity level. Which question or comment best facilitates discussion with the patient regarding his or her level of activity?
“Do you exercise during the week?”
“Do you keep in shape?”
“Tell me what form of exercise you do on a daily basis?” Incorrect
“What do you do to get exercise?”
“What do you do to get exercise?”
In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. history of present illness biographic data present health status review of symptoms
history of present illness
It is not present health status because present health status includes the patient’s perception of his or her level of health
The nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system? Review of systems Functional health patterns Health perception database Nursing process
Functional health patterns
- Review of systems is very different from the body function format. Functional health patterns are based on body systems (e.g., respiratory and cardiovascular systems). Health perception database is an area of functional health patterns. Nursing process is the method used to identify patient problems and act on them.
Two levels of infection control guidelines
Standard precautions & transmission based precautions
