NUR 220 - Quiz 2 Flashcards
what does ANO stand for?
alert and oriented
ANO x1
knows who they are
ANO x2
name + where they are
ANO x3
name, place, time
ANO x4
name, place, time, situation
ANO is used to gather what?
neurological baseline
mneumonic used to assess level of conciousness (LOC)
AVPU
what does AVPU stand for?
A- awake
V- verbal stimulation
P- painful stimulation
U- unresponsive
what is the Glasglow Coma Scale used to measure?
eye opening, verbal response, motor response
how does scoring work for the Glasglow Coma Scale?
- higher the better
- decrease of 2 points is significant
what is the earliest and most sensitive indicator of alterations in cerebral function?
change in Level of Consiousness
what must be done before obtaining a health history?
neuro assessment
is health history subjective or objective data?
subjective
what is the purpose of health history?
to get a database which is used to create a plan, prevent disease, resolve problems, and minimize limitations
what are the three phases of an interview?
- oritentation phase
- working phase
- termination phase
purpose of orientation phase
gain patient trust and set agenda
purpose of working phase (2)
- gather accurate, relevant, and complete info on patients condition
- pick up on verbal + nonverbal cues
purpose of termination phase (3)
- summarize findings with patient
- check for accuracy
- tell them you will be back
what are some factors than can affect patient answers?
- personality
- feeling at time of interview
- nature of information being asked
factors that can affect your interviewing
- task complexity
- time constraints
common phrase used for open-ended questions
“tell me more”
purpose of open-ended quesitons
allow patient to describe their condition and concerns to you
purpose of direct close-ended questions
to get a patient to describe problem more accurately and fully
why are leading questions risky?
patient may give you the answer they think you want to hear
what is probing?
asking more open ended questions as patient is telling their story to get more info
facilitation
verbal + nonverbal phrases that encourage talking
restatement
repeat what patient said back to them
reflection
repeate what patient said and encourage more information
confrontation
tell patient what they are saying is not adding up with data
interpretations
share your take on the data so that patient may confirm or deny
summarize
summary of what was discussed
how should you deal with anger?
directly to identify source
how should you deal with crying?
be compassionate and delay questioning until theyre ready
pneumonic for present illness/ health concert
PQRST
what does PQRST stand for?
P- provoke
Q- quality (what does it feel like)
R- radiate
S- severity (0-10)
T- time
what are some age related variations when interviewing?
- older adults need more time and childhood history may not be necessary
- children may have adult answering for them
age group for depression
25-44
what is PHQ-9 (patient health question) used to screen for?
- screens for depression
- 4 or more checks in grey section = depression
what is GAD-7 used to screen for?
- anxiety
- 15 and up = anxiety
- 10 and up = referred
what is the Mini-Cog
- assess cognitive impairment
- three word recognition, clock drawing, three word recall
- score 3 or less = impaired
Mini-Mental State Exam
- 30 = perfect score
- 23 and below = cognitive issue
AUDIT screening tool
- 8 and above = harmful alcohol use
CAGE questionaire mneumonic
C- cut down drinking
A- annoyed by people criticizing
G- guilty
E- eye opener (drink first thing in AM)
what score indicates alcohol abuse on CAGE questionaire
2 or more
COWS
- clinical opiate withdrawl scale
- assesses physical dependence to drugs
HITS screening tool
- screens for abuse
- 10 or more = partner violence
