Lecture 1 Flashcards
what would you want to know with PMHx
allergies
medications
previous illnesses
vaccinations
PMHx
Past medical history
difference between symptoms and signs
symptoms - how the patient feels (burning while peeing)
signs - what you can see (cloudy pee)
what are the steps of the nursing process
assessment
diagnosis
planning
intervention
evaluation
who are the 3rd level priority of assessment
those with important issues but no threat of immininent or short term harm
are symptoms objective or subjective3
subjective
approaching all interactions with patients as an inquirer represents what approach
relational
what does SOAP stand for
Subjective information
Objective information
Assessment
Plan
What is SBAR used for
ensuring efficient communication between HCPs
what are the 4 components of diagnostic reasoning
dealing with signs and symptoms
formulate hypotheses
collect data on assumptions
evaluate hypotheses with this new data
why would you want to know about family health
can be important for genetic disorders or to understand if things run in the family
what are the 5 verbal responses that are your reaction to the patient
facilitate
silence
relfection
empathy
clarification
what does SBAR stand for
situation
background
assessment
recommendation
are signs objective or subjective3
objective
Analysis and interpretation of health data *term
diagnostic reasoning
Health history
collection of subjective and objective data
What is SOAP used for
its a standardized method of patient documentation
name some parts of biographical data
birth date
address/phone number
Insurance info
Occupation
what is diagnostic reasoning
Analysis and interpretation of health data
what are the three essential elements in the nursing process
diagnostic reasoning
nursing process
critical thinkin
FamHx
family history
what is the relational approach in communication
approaching all interactions with patients as an inquirere
what are the second level priority of assessment
those who require prompt intervention to prevent deterioration
what are the 8 types of verbal responses
facilitate
silence
reflection
empathy
clarification
interpretation
explanation
summary
what things would you want to know in a functional assessment
exercise and nutrition
sleep
substance use
IPV
name all the parts of history to be recorded
Biographical data
reason for seeking care
current health/illness history
past medical history
family history
review of systems
functional assessment
What are ADLs
activities of daily living
what are the 3 verbal responses in which the nurse leads the discussion
interpretation
explanation
summary
Bio
Biographical data
When do you use PQRSTU
when getting characteristics of symptoms
what is the first level priority of assessment
those with immediately life threatening issues
what do you want to avoid when doing a review of systems
negative terms
RoS
review of systems
