health ass exam 1 Flashcards
EBP encompasses (4)
research evidence clinical expertise clinical knowledge patient values and preferences (clinical decision making depends on all four factors bc pts deserve to be treated with the most current and best-practice techniques)
holistic health
incorporating external interpersonal environment of one’s mind and body
consideration of the whole person - views the mind, body, spirit as functioning as a whole within the environment
includes lifestyle behaviors, culture, values, family and social roles, self care behaviors, job-related stress, failures, etc.\
complete (total health) database
complete health history and full physical exam
describes current and past health state
forms a baseline against which all future changes can be measured
yields first diagnosis
focused or problem-centered database
for a limited or short-term problem
smaller in scope and more targeted than the complete database
concerns mainly one problem, one cue complex, one body system
follow-up database
status of any identified problems should be evaluated at regular and appropriate intervals, is used to follow up both short term- and chronic health problems
ex: what change has occurred? is the problem getting better or worse?
emergency database
an urgent, rapid collection of crucial information
often is compiled concurrently with lifesaving measures
diagnosis must be swift and sure
may be compiled by questioning the pt, but if pt is unresponsive health care providers may need to rely on fam and friends
once the person has stabilized, a complete database can be compiled
health promotion and disease prevention
preventative services, yearly checkup
culture and genetics
cultural health rights
emerging minority
subjective data
anecdotal information that comes from opinions, perceptions, experiences
what the person says abt themselves
objective data
physical data we can observe using out sense, come in either a measurement or direct observation
what you can obtain through physical examination
sending
verbal and nonverbal communication
receiver
interprets your words and behaviors based on past experiences, culture, and self-concept
listener’s bias or any preconceived notions can sabotage the message you are trying to communicate
patient-provider’s relationship is an emotionally charged professional relationship due to relationship being built on illness/vulnerabilities
internal factors
specific to you as the healthcare team member which can help you to maximize communication skills
liking, empathy, ability to listen, self awareness/bias
external factors
defining the environment so as to foster communication
ensure privacy, avoid interruptions, physical environment, dress, note-taking
electronic health record (EHR)
federal gov mandates so as to improve quality and safety
technology interface can affect communication in the provider-patient relationship
capture of biomedical, psychological, and emotional information may not always be captured
do not allow computer to become a barrier in communication process
open-ended questions
asks for narrative information
closed/direct questions
asks for specific information
1st step in interview
introduce interview, short and formal
second step in interview
data-gathering/working phase
open-ended/closed or direct questions
nine types of verbal response that full under pt perspective and interviewer perspective: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
closing interview
gradual thereby allowing for adequate closure to allow for final expression
no new topics
summary provided as final statement
verbal behaviors
the words you speak, vocalizations, and tone of voice
9 types of verbal responses: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
nonverbal behaviors
just as important as verbal
physical appearance, posture, eye contact, voice, gestures, touch, facial expression
congruency
when verbal and nonverbal messages are congruent, the verbal message is reinforced
can be viewed as either positive or negative thereby prompting the importance of self-awareness in order to promote communication
equal status seating
pt and nurse should be seated at eye level with no barriers in between
traps of interviewing
providing false assurance or reassurance giving unwanted advice using authority distancing using professional jargon using leading or biased questions talking too much interrupting using "why" questions using avoiding language
symptoms
subjective from pt
sign
objective abnormality detected on physical examination
OLDCART
onset (when)
location (where? point at it)
duration (how long does it last intermittent/continuous?)
character (pain scale 0-10? burning/stabbing/radiating?)
aggravation / associated s/s (swelling/redness/N/V? what makes it worse/better?)
response to treatment at home (positioning? medication?)
treatment
family history
highlights diseases or conditions that an individual may be at risk for as a result of genetics
provides age and health or cause of death relatives
review of symptoms purpose
purpose: evaluate past and present state of each body system, assess that all pertinent data relative to each body system have been noted, evaluate health promotion practices
cephalocaudal approach
organized manner proceeding in a logical sequence
approach to review of systems: skin and hair
skin and hair (changes? rashes, brittle nails/hair, dry patchy skin, bruising, hair loss)
approach to review of systems: respiratory
respiratory: SOA, coughing, wheezing, asthma
hematologic: blood type, hx anemia
endocrine: diabetes and hormone issues
review of systems: uses subjective/objective data?
limit to pt statements/subjective data
do not include objective data
avoid writing negative for body systems as you want to record either:
presence or absence of symptoms
functional assessment
relevant data related to lifestyle and living environment
may require attention to privacy concerns
how to document
document both subjective and objective data
general survey: physical appearance
age (appears stated age)
sex (sexual dev. appropriate for age)
level of consciousness (AO X3: person, place, time, situation)
skin color (even tone, pigment)
facial features (symmetric with movement)
overall appearance (genera; statement presence/absence of distress)
general survey: body structure
stature (normal range of height, heritage)
nutrition (weight appears within normal range for height and body build, fat distribution)
symmetry (body parts look equal bilaterally and are in relative proportion to each other)
posture (person sits comfortably with arms relaxed at sides and head turned to examiner)
general survey: mobility
gait: foot placement (accurate, walk smooth, even, well-balanced), ROM, no involuntary movement
general survey: behavior
facial expression (maintains eye contact)
speech (clear, articulation)
dress (appropriate, clean)
personal hygiene (appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group)
mood and affect (pt is comfortable and cooperative with examiner and interacts pleasantly)
general survey: measurements
weight, height, BMI, waist circumference
purpose and components for general survey terms
study of whole person that covers general health state and any obvious physical characteristics and provides an overall impression
general survey areas
physical appearance, body structure, mobility, behavior, measurement
BMI
practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition - needs to be in conjunction with other findings
abnormal findings: dwarfism, gigantism, acromegaly, anorexia nervosa, endogenous diabetes, Marfan syndrome
nutritional assessment
way to identify individuals at nutrition risk
weight loss, inadequate food intake, recent
24 hour recall
nutritional status
balance between nutritional intake and nutrient requirements
undernutrition
occurs when nutritional reserves are depleted or when nutrient intake is inadequate to meet day-to-day needs or metabolic demands
overnutrition
consumption of nutrients (calories, fat, sodium) in excess of body needs
optimal nutrition status
sufficient nutrients are consumed every day based on what we need
BMI <18.5
underweight
BMI 18.5-24.9
normal weight
BMI 25-29.9
overweight
BMI 30-30.9
obesity
BMI >/=40
extreme obesity
comprehensive nutritional assessment
dietary history, clinical information, physical examination for clinical signs, anthropometric measures
anthropometric measures: percent usual body weight
current weight / usual weight X 100 = %
85% - 95% mild malnutrition
75-84% moderate malnutrition
<75% severe malnutrition
anthropometric measures: weight change
usual weight - current weight / usual weight X 100 = % weight change clinically significant if >5% in 1 month >7.5% in 3 months >10% in 6 months
BMI percentiles
<5th percentile - underweight
5-85th percentile - healthy weight
85-95th percentile - overweight
>95th percentile - obese
24 hour recall
pt recalls everything they have eaten in the past 24 hours
HbA1c
normal: 5-7&
used to assess for anemia
hemoglobin and hematocrit
used to assess for protein status
albumin levels
serum cholesterol
want if a pt is obese
HDL-C, LDL-C, triglycerides
ISBARR
introduction situation background assessment recommendation read back
ISBARR: I
introduction - introduce yourself with position, role, relationship to pt
include location from which you are calling
ISBARR: S
situation - initial step
background or context of situation summarized concisely (short, to the point)
identify problems that need to be addressed and relay assessment of problem
ISBARR: A
assessment -
current set of VS
lab results
interventions and their outcomes
problem-diagnosis stage: evaluation of problem and the root causes
should include analysis of pt situation based on condition, test results, response to any treatments
ISBARR: first R
recommendation - discerning solution, what you want
ISBARR: second R
read back - restate all orders given by provider
effective communication
concise, easy to follow and understand
effective communication will lead to less errors
EBP
