Module 1: Introduction to adult health assessment Flashcards
What is diagnostic reasoning?
The process of analyzing health data and drawing conclusions to identify diagnoses.
4 major components
1) attending to initially available cues
2) formulating diagnostic hypotheses
3) gathering data relative to the tentative hypothesis
4)Evaluating each hypothesis with the new data collected, that’s arriving at a final diagnosis
5 phases of nursing process
Assessment, nursing diagnosis, planning, implementation, evaluation
*What are first level priority problems?
Emergencies, life-threatening, and immediate.
Ex. Establishing an airway or supporting breathing
For first-level priority problems, remember “ABCs + V”, which is
Airway problems Breathing problems Cardiac/circulation problems Vital sign concerns (I.e. High fever) (Exception: CPR for cardiac arrest, begin chest compressions immediately)
*What are second level priority problems?
Urgent, necessitating prompt intervention to forestall further deterioration.
(mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, risk to safety or security)
*What are third level priority problems?
Important to the patient’s health but can be addressed after more urgent problems
*What are collaborative problems?
Approach to treatment involves multiple disciplines, and nurses often have a primary responsibility to diagnose the onset and monitor the change in status.
What is the difference between a medical diagnosis and a nursing diagnosis?
Med diagnosis- deals with disease or medical condition
Nursing diagnosis- deals with human response to actual or potential health problems and life processes (ex. Risk for falls, impaired verbal communication)
Evidence informed practice is a systemic approach to practice and uses
The best evidence, the clinicians experience, and the patient’s preferences and values to make decisions about care and treatment
What are social determinants of health?
The social, economic, and political conditions that shape the health of individuals, families, and communities
What is The difference between health inequity and health inequality?
Health inequality – refers to differences, variations, and disparities in health status of individuals and groups
Health inequity – refers to inequalities in health that are unnecessary and avoidable and differences that are considered unfair and unjust
According to the biomedical model, and narrow definition of health is
The absence of disease
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
Complete
What is a complete database?
Used to perform a thorough or comprehensive health history and physical examination
It is a focused database?
For a limited or short term problem usually consisting of one problem, one cue complex, or one body system
What type of perspective has been promoted to counter the tendency toward culturalism in healthcare?
Critical cultural
Physical examination requires a sequential use of 4 assessment techniques. What are they?
Inspection, palpation, percussion, and auscultation
*What is inspection as a physical examination?
Close, careful observation of the patient as a whole and then of each body system.
Inspection is always perform first.
(use the patient’s body is the control and compare the right and left side of body to determine symmetry)
*What is palpation as a physical examination?
Follows and often confirms points you noted during inspection.
-apply your sense of touch to assess texture, temperature, moisture, and organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain
The fingertips are best for assessing…
For fine tactile discrimination such as skin texture, swelling, pulsation, and determining presence of lumps
Grasping with the fingers and thumb is ideal for detecting…
Position, shape, and consistency of an organ or mass
The backs of the hands and fingers are good for determining…
Temperature
The base of the fingers or the ulnar surface of the hand is best for assessing
Vibration
*Differentiate between light and deep palpation
Light palpation evaluate surface characteristics and identifies areas of tenderness.
Do you palpation assesses an organ or mask deeper in a body cavity
*What is auscultation?
Listening to sounds produced by parts of the body, such as the heart and blood vessels, the lungs, and the abdomen
The concept of relational is increasingly used to describe the complex, interrelated nature of…
Health, people, society, and nursing practice
A relational approach in nursing practice accounts for the fact that health, illness, and the meanings they hold for a person are shaped by the persons…
Social, cultural, family, historical, and geographical contexts; and the persons gender, age, ability, and other individual contexts
A piece of information, a sign or symptom or a piece of laboratory data, is the definition of what?
A cue
Early detection of disease, before symptoms emerge, is what level of disease prevention?
Secondary
Promotion of health and the prevention of illness or known health problems, protect existing state of health and promote psycho social wellness, is what level of disease prevention?
Primary
Prevention of complications want to condition or disease is present or has progressed, is what level of disease prevention?
Tertiary
What is one of the central skills of relational practice?
Reflectivity- A process of continually examining how you view and respond to patients on the basis of your own assumptions, cultural and social orientation, past experiences, and so on
Every examiner need to collect for different kinds of data, depending on the clinical situation. What are they?
Complete, episodic or problem centered, follow up, and emergency
The biomedical model of Western medicine views health as
Absence of disease. It focusses on collecting data on biophysical signs and symptoms and curing disease
The behavioural model extends beyond treating disease to include…
Primary and secondary prevention with emphasis on changing behaviours and lifestyle
The social environmental model encompasses the bio medical and behavioural model and incorporates
Socialogical and environmental aspects of health
Health assessment should consider:
- The usual and expected developmental tasks for each age group
- The cultural and social background of individuals
Assuming that people act in specific ways because of their culture is known as
Culturalism
Racialization is
“ A process by which Ethno–racial groups are categorized, stigmatized, inferiorized, and marginalized as the ‘other’.
(Closely linked to culturalism and discrimination)
What is cultural competence
The application of knowledge, skills, attitudes, or personal attributes to diverse populations with the aim of developing respectful relationships
Cultural safety is recognized as both a process and an outcome whose goal is to promote..
equity in healthcare
-Aims to eliminate power imbalances and inequitable social relationships in healthcare
People of mixed European and indigenous ancestry are known as
Métis
According to a ___________________ “Culture is a relational aspect of individuals that shift and changes over time, depending on individuals history, social context, past experiences, gender identity, professional identity and so on”
Critical cultural perspective
Which of the determinants of health claims the greatest effect on the health status of the population?
Social and economic environment
