NSG 201 Exam 2 Flashcards
Subjective vs. Objective data
subjective: what the person says about themselves
objective: what you obtain from physical data
Genograms Purpose
- Accurate family outline of the hx of diseases, & conditions that could make the pt more vulnerable/susceptible to
- when they know they would be more vulnerable it leads to earlier screening and surveillance
- Includes: gender, age, relationship (imemdiate family and also the spouse to view prolonged disease exposure). relative medical conditions
Items included in the Health History
- Biographical data
-name, age, address, contact info, dob, gender/gender identification, occupation, marital partner status, race/ethnicity, primary language - Source of Health hx: who= source of info
primary= patient
secondary= other sources - Reason for seeking care
-the “cc” or chief complaint - Hx of presenting illness
-meds, current illness, allergies
-OLDCARTS—onset, location, duration, characteristics, aggravating factors, related symptoms, treatment, severity - Past health events
-childhood illnesses, accidents/injuries, hospitalizations, surgeries, obstetric hz, immunizations, last exam date, last menstrual period - Family hx- blood relative
-use a genogram
Functional, Personal, and Psychosocial Assessment
Psychosocial: personal status, relationships, nutrition, functional ability, mental health, substance abuse, health promotion, environment
Functional: ADLs (activities of daily living), spiritual assessment, for alcohol use
Review of Systems
- Address each body system
- use specific questions
- not objective data
- pt’s descriptions/perception of health
- terminology
Lifecycle Considerations
Children: most data obtained from an adult. By age 7, most can answer basic questions
Adolescence: may need alone time w/ the pt
Older adults: include ADLs, functioning
Cognitive Function Assessment
- Orientation- time/place/person/situation
- Attention span- ability to concentrate by noting complete thoughts: ability to concentrate w/ no distractibility
- Recent Memory- last 24 hours
- Remote Memory- verifiable, past events
- New learning- 3/4 unrelated words- requires more effort and avoids unverifiable material
Factors that Influence the Interviewing Process
- Age- usually teens and adults can handle questions, children need the assistance of a guardian and to use appropriate terms w/o talking down, and elders might need assistance
- Culture- Be respectful and don’t assume
- Language- LEP, use a certified translator
- Stress- limit the number of questions and think of the nature of the questions
- Sensory Impairment- Be patient
- Cognitive Impairment- we may need a second source of info
OLDCARTS
onset location duration characteristics aggravating factors related symptoms treatment severity
Interviewing based on G & D stage
-can be a good baseline to understand how to present questions & what goals are important to that age group, can also help if someone did not attain their goals in an age development stage and need to reframe questioning/interviewing to be more appropriate
Assessment Tools
CAGE- alcohol use- substance abuse screening tool w/ 4 questions, if score >2, significant clinical finding
FICA- spiritual assessment- looks at faith, importance, community, address issues
Katz- aka ADLs (activities of daily living)- scores how independently dependent individual is
MMSE- used to evaluate mental status; widely used as test of cognitive function in elderly
Levels of Prevention
- Primary- strategies that target modifiable risk factors
- prevention of diseases before any symptoms
* Immunizations, safe sex, smoking cessation, seat belts - Secondary- strategies focused on early disease detection
- screenings include:
* Cancer: mammogram, prostate markers
* Bone density
* colonoscopies
* BP
* Blood glucose - Tertiary- strategies minimize the damage after the onset of disease
- cardiac rehab, AA, support groups, any intervention focused on lessening disease complications
Domains of Learning & Strategies
Cognitive- knowledge Affective- emotional Psychomotor- self-reliance Srtategies: 1) VARK: Visual Auditory Reading/Writing Kinetic 2) Bloom's Taxonomy -create, evaluate, analyze, apply, understand, remember
SMART Goals
SMART- know exactly what you want to accomplish
Measurable- how will you know you met goals?
Achievable- make sure your goal is not too far to reach, but far enough away to be challenging
Relevant- link the goal to something important to you, something that inspires you
Timely- when do you want your goal to be met?
Bloom’s Taxonomy (Learning Domain Strategy)
- Create- produce new or original work
- design, assemble, construct, conjecture, develop, formulate, author, investigate - Evaluate- Justify a stand or decision
- appraise, argue, defend, judge, select, support, value, critique, weigh - Analyze- Draw connections among ideas
- differentiate, organize, relate, compare, contrast, distinguish, examine, experiment, question, test - apply- use info in new situations
- execute, implement, solve, use, demonstrate, interpret, operate, schedule, sketch - understand- explain ideas or concepts
- classify, describe, discuss, explain, identify, locate, recognize, report, select, translate - remember- recall facts and basic concepts
