Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assessment > Lecture 1 - Communication, Health History, and the Nursing Process > Flashcards

Lecture 1 - Communication, Health History, and the Nursing Process Flashcards

1
Q

What is the Nursing Process?

A

Involves 5 dynamic steps:

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation/
    Intervention
  5. Evaluation

Important: the nursing process is not linear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the purpose of Assessment?

A

Inform clinical judgement about the patient’s state of health, and to identify factors impacting it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What two things must an effective assessment Include?

A
  1. A systematic approach to data collection
  2. Critical judgement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is Diagnostic Reasoning?

A

An analysis of health data that recognizes problems and targets priority needs.
“Develop a sense of intuition” - Prof

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the four components of Diagnostic Reasoning

A
  1. Dealing with signs and symptoms
  2. Formulate hypothesis
  3. Collect data on each of these assumptions
  4. Evaluate each hypothesis with this new data
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the three levels of priority setting?

A

1st - immediately life threatening
2nd - Require prompt intervention to prevent deterioration
3rd - Important, but no imminent threat or short-term harm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are some examples of first-priority issues?

A

Unestablished airway, cardiac issues, hemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some examples of second priority issues?

A
  1. Mental status change
  2. Kidney injury
  3. Stroke
  4. Acute pain
  5. Migraine
  6. Risk of infection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are some examples of third priority issues?

A
  1. Broken bone
  2. Mobility issues
  3. Mild illness
  4. Excessive drinking
  5. Smoking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are some examples of collaborative problems?

A

Diabetes, cancer, autoimmune disease, unemployment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe the Rational (or Reflective)
Approach to communication

A

Approach all interactions as an inquirer, using reflexivity to govern your conduct an assessment while considering intrapersonal, interpersonal, and contextual factors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is Unconditional Positive Regard?

A

Keeping an optimistic view of the patient and their strengths. Show empathy for their emotional responses and lived experiences

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are some ways to maintain a comforting physical environment for the patient to ensure effective communication?

A

–> Keep a distance of 1.5 m and sit 90 degrees from them. Remain at eye level
–> Minimize interruptions
–> Do not sit patients with their back to the door
–> Be honest about note taking and keep it minimal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the purpose of open-ended questions in the interview?

A

Allows patient to share personal experience (subjective data). Often used at the beginning of the interview.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the purpose of closed ended questions during the interview?

A

Used to fill in specific gaps in narrative or for clarification. Helpful in closing interview.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the five types of verbal responses a nurse can use to encourage the patient to lead discussion?

A
  1. Facilitation
  2. Silence
  3. Reflection
  4. Empathy
  5. Clarification
17
Q

What are the three types of verbal communication a nurse can use while leading conversation?

A
  1. Interpretation
  2. Explanation
  3. Summary
18
Q

What does Dx stand for?

A

Diagnosis

19
Q

What is the definition of Hx

A

Health History: collection of subjective and objective data.
Can be focused or whole.

20
Q

What is the purpose of taking Hx?

A

To identify health issues and strengths and guide the physical exam. Is the basis for more of nursing/medical care

21
Q

What information does the Hx include?

A
  1. Bio
  2. Reason for seeking care
  3. Current health/illness history
  4. PMHx
  5. FamHx
  6. RoS
  7. ADLs and IADLs
22
Q

What kind of Information is reviewed in the Bio?

A

Name, Birth Date and Age, Sex and Gender, Birthplace, Address and phone number.

Always record source of information: Patient, POA, etc.

23
Q

What information is covered in Reason for Seeking Care?

A

Direct quote from patient as well as symptoms (subjective) and signs (objective)

24
Q

How is information about current health and illness collected?

A

PQRSTU collects data about characteristics of symptoms.

P: Provocative or Palliative?
Q: Quality and Quantity
R: Region or Radiation
S: Severity
T: Timing
U: Understanding of patient

25
Q

What information is collected in the PMHx?

A

–> Allergies
–> Medication use
–> Previous/ongoing illness, injury, procedures, hospitalizations
–> Date of last examination
–> Vaccination status
–> OBS/GYN history

26
Q

What acronym is used to quantify a female’s past OBS history?

A

GTPAL; all answers are numbers

G: Gravidity
T: Term deliveries
P: Preterm deliveries
A: Abortions
L: Living children

27
Q

What kind of information is collected in the FamHx?

A

Age, health, and cause of death of immediate blood relatives.

28
Q

What is the purpose of RoS?

A

Review of Systems is used to evaluate the past/present state of each system, double-check information collected earlier, and evaluate health promotion practices.

29
Q

When performing an RoS, what language should be used?

A

Positive statements such as presence of absence. Avoid negative terms such as denies, refuses, not adheres, or not compliant.

30
Q

What kind of Information is collected in a Functional Assessment?

A

–> Occupation
–> Education
–> Family & relationships
–> Exercise & nutrition
–> Sleep/rest
–>Personal habits
–> Substance use
–> ADLs/IADLs

31
Q

When is the acronym SOAP used? What does it stand for?

A

Used in charting:

Subjective information
Objective observation
Assessment
Plan

32
Q

When is the acronym SBAR used? What does it stand for?

A

Used in verbal communication with colleagues:

Situation
Background
Assessment
Recommendation (both ways)

33
Q

Which four things govern evidence-informed clinical decision making?

A

–> Evidence and research
–> Physical examination and assessment of patient
–> Clinical Expertise
–> Patient preferences and values

34
Q

What is episodic/problem-centered care?

A

Care + Assessment done with intentions of treating/managing a specific health concern, without intentions of continuing the relationship.

Health Assessment (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions