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NURSING 110 JUST US!!!!! > Exam 3-psychosocial assessment > Flashcards

Exam 3-psychosocial assessment Flashcards

1
Q

what are the parts of a psychosocial assessment

A

history, appearance/motor behavior, mood/affect, thought process, sensorium, judgement/insight, self concept, roles/relationships, physiologic and self care considerations

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2
Q

what is assessed in history

A

age, developmental stage, cultural considerations, spiritual beliefs

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3
Q

what is assessed in appearance/motor behavior

A

hygiene, posture, eye contact, unusual movements, speech

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4
Q

what is assessed in mood/affect

A

expressed emotions/facial expressions

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5
Q

define blunted expression

A

showing little or no emotional response

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6
Q

define broad emotion

A

showing a range of emotion

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7
Q

define flat emotion

A

showing NO emotion

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8
Q

what is assessed in thought process

A

content (what) and process (how), clarity of ideas, self harm or suicide urges

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9
Q

what is assessed in sensorium

A

orientation, memory, hallucinations, concentration

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10
Q

what is assessed in judgement

A

decision-making ability

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11
Q

What are some differential diagnoses that strokes may resemble?

A

ETOH intoxication, cerebral infection, drug overdose, epidural hematoma, hyperglycemia, metabolic disorders, migraines, bells palsy, seizures, MS, dementia

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12
Q

suicide ideation vs suicide plan

A

ideation: thinking about
plan: know what to do

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13
Q

define judgement vs insight

A

judgement-interpretation of environment

insight- understanding one’s own part in current situation

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14
Q

What is perfusion?

A

flow of blood through circulatory system to bring nutrients and oxygen as needed

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15
Q

What are the types of CVA?

A

ischemic (thrombotic and embolic) and hemorrhagic

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16
Q

What is transient ischemic attack (TIA)?

A

“mini-stroke”, temporary symptoms, sudden onset and disappearance of symptoms within 24 hours; contralateral deficits, aphasia, visual

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17
Q

Pathophysiology of ischemic strokes?

A

blockage/stenosis of cerebral artery

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18
Q

Pathophysiology of TIA?

A

mini stroke

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19
Q

Pathophysiology of thrombotic strokes?

A

thrombus (in situ) occludes large cerebral vessels

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20
Q

Pathophysiology of emboli strokes?

A

blood clot/ clump of matter travels and occludes vessel

21
Q

Pathophysiology of hemorrhagic strokes?

A

intracranial hemorrhage

22
Q

Pathophysiology of ruptured cerebral blood vessel?

A

hemorrhage from ruptured vessel

23
Q

Nursing diagnoses for cerebrovascular disorders?

A

ineffective tissue perfusion-cerebral, impaired physical mobility, self-care deficit, impaired verbal communication, impaired urinary/bowel elimination, impaired swallowing, disturbed sensory perception, ineffective coping

24
Q

what is a closed question vs an open question

A

closed question- yes or no

open question- room for elaboration

25
Q

what are some stress-interrelated concepts

A

family dynamics, perfusion, sleep, immunity

26
Q

what are some coping-interrelated concepts

A

development, addiction, anxiety

27
Q

what is the purpose of a psychosocial assessment

A
  • picture of pt’s current emotional state, mental capacity, behavioral function
  • basis for developing plan of care
28
Q

factors influencing psychosocial assessment

A

patient participation, patient health status, previous experiences, ability to understand

29
Q

define circumstantial thinking

A

unnecessary detail

30
Q

define delusions/ideas of reference

A

false beliefs about themselves

31
Q

define flight of ideas

A

excessive amount and rate

32
Q

What are non-modifiable risk factors for cerebrovascular disorders?

A

increased age, race, gender (higher incidence in men but more fatal in women), heredity, prior stroke/TIA( increases chance by 40%)

33
Q

What are modifiable risk factors for cerebrovascular disorders?

A

hypertension, atrial fibrillation, smoking, diabetes, high cholesterol, heart disease, obesity, sickle cell disease, oral contraception (especially if occurring with smoking in women older than 35), excessive ETOH

34
Q

What are stroke symptoms noted in assessment?

A

sudden and severe headache, sudden trouble seeing in one or both eyes, sudden dizziness and trouble walking, sudden confusion and trouble speaking, sudden numbness or weakness of the face, arm, leg, or all of them all usually one sided or contralateral varies according to area of brain affected

35
Q

What is FAST?

A

F-face: ask person to smile;
A-arm: ask person to raise both arms;
S-speech: ask the person to speak a single sentence;
T-time: call 911 (every minute matters)

36
Q

What are some diagnostic tests to confirm diagnosis?

A

stroke scale for LOC, CT scan, cerebral angiography, transcranial doppler ultrasound, MRI, PLAC blood test, lumbar puncture

37
Q

What are some acute stroke goals?

A

optimize cerebral circulation, cardiac, and respiratory function, prepare pt for rehab care, manage symptoms that remain ongoing, monitor emotional response

38
Q

What is neglect syndrome?

A

lack of awareness of one side of the body

39
Q

What is hemianopsia?

A

loss of 1/2 visual field in one or both eyes

40
Q

What is apraxia?

A

inability to carry out motor function even with normal strength and coordination

41
Q

What is agnosia?

A

inability to recognize familiar subjects (visual, tactile and auditory)

42
Q

Assessment in nursing process?

A

besides all symptoms of acute stroke, also consider any previous stroke or TIA, findings of physical assessment, level of consciousness, issues with communication

43
Q

define loose associations

A

disorganized jumping

44
Q

define tangential thinking

A

never get to the answer

45
Q

define though broadcasting

A

think others can hear or know what we are thinking

46
Q

in addition to overall assessment data, what kind of data should we collect

A

psychological tests, psychiatric diagnoses, and mental status exam

47
Q

Planning and outcomes for cerebrovascular disorders?

A

maintained bp within specified range, pt to participate in therapies, pt will not suffer from complications of immobility, pt will communicate effectively, nutritional needs will be met, occupational needs will be addressed, driving needs will be addressed

48
Q

Implementation for cerebrovascular disorders?

A

monitor vitals, suction as needed; monitor neurological status; monitor mental status and LOC; provide food texture that is safe for pt to consume; change positions often, assist w mobility aids; inspect skin regularly, especially under braces or splints

49
Q

Evaluation for cerebrovascular disorders?

A

monitor return of function; monitor all responses to interventions, participation in therapy, which ones are going well or not; look at pt support; avoidance of complications

NURSING 110 JUST US!!!!! (14 decks)

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