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NSG > Phys Assess #1 > Flashcards

Phys Assess #1 Flashcards

1
Q

Learn to develop a trusting relationship with the patients, they will be in a vulnerable state if they are __

A

ill

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2
Q

Important to be self aware and knowledgeable of our own ___

A

differences

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3
Q

It is important to be self-aware and knowledgeable about one’s own culture-

A

it shows how we care for people

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4
Q

Awareness is an interactive and ongoing process-

A

it could change

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5
Q

is an integral part of becoming culturally competent

A

Cultural self assessment

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6
Q

US Demographics: Total population passed 321 million in

A

2015

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7
Q

US Demographics: 61.6% of the population identified as

A

non-Hispanic and whites

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8
Q

US Demographics: Largest and fastest growing group

A

Hispanics

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9
Q

US Demographics: Remember the US has a lot of

A

immigrants

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10
Q

US Demographics: Minority is

A

increasing

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11
Q

Emerging Minority Group Trends: Differences noted in

A

age, poverty level, and household composition

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12
Q

Emerging Minority Group Trends: All ethnic and racial minority groups exceed the national poverty level

A

they are living in poverty, related to lower levels of education, income, and correlated with higher levels of disability

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13
Q

Emerging Minority Group Trends: Low educational attainment and lower income are correlated with __

A

likelihood of disability.

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14
Q

Emerging Minority Group Trends: Family size and multigenerational families are more evident in ___

A

minority groups

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15
Q

They have little to no understanding to the US health care system-

A

immigrants

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16
Q

HC addresses the needs to this specific population if they ___

A

do not understand

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17
Q

Immigration and Health Care Concerns: Status of immigrants entering the health care system:

A

In 2014, 13.2% of population were foreign born individuals.
Expected population to double by the year 2065

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18
Q

Immigration and Health Care Concerns: Minimal understanding of the following:

A

US health care system
Medical practice interventions

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19
Q

Immigration and Health Care Concerns: Communication is an essential component:

A

Need for an interpreter
Provide materials that are based on health literacy principles

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20
Q

Immigration and Health Care Concerns: Limited understanding of the HC system, medical practice interventions, may stay away from __

A

health care and become sicker

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21
Q

Determinants of Health and Health care Disparities: Social Determinants of Health (SDOH)-

A

helps identify vulnerable patients that need the most help. They face social, economic and environmental disadvantages.

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22
Q

Constellation of related factors
Affect a person from preconception to death
EBP indicates that poverty has greatest influence on health status.

A

Social Determinants of Health (SDOH)-

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23
Q

Patients may have lower

A

ability to read and write or not at all

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24
Q

Require the greatest assistance or interventions for

A

racial minorities, people with disabilities, or members of the LGBTQ population

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25
Q

Neighborhood and built environment, Health and health care, Social and community context, Education, Economic stability

A

Social Determinants of Health (SDOH)-

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26
Q

Healthcare Disparities: Our goal to Identify, define, and recognize vulnerable populations.

A

“A particular type of health difference that is closely linked with social, economic, or environmental disadvantage.”

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27
Q

Healthcare Disparities: Work toward eliminating by utilizing available resources.

A

Us dept of health and human services: Goal of Healthy People- program of nation wide health promotion and disease.

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28
Q

Healthcare Disparities: Promotion of health care frameworks-

A

providing Accessible, culturally and linguistically competent delivery of health care to promote quality of life for all patients

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29
Q

The goal for healthy people is to eliminate ___

A

health disparity

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30
Q

Can see increased disparities in specific populations, greater obstacles in obtaining HC due to ___

A

racial or ethnic characteristics

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31
Q

Even though we want to decrease disparities, There has not been any change to ____

A

access of care or health care disparities

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32
Q

National Standards for Culturally and Linguistically Appropriate Services in Health Care

A

Set of 15 standards
They provide a blueprint to improve quality of care for diverse populations to eliminate health disparities

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33
Q

Civil Rights Act 1964- support individuals with LEP

A

LEP- limited English proficiency
Assisting with communication utilizing resources such as interpreters to make sure the pts are understanding the care they receive

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34
Q

Language barriers can decrease quality of care if they __

A

do not understand

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35
Q

Culture-Related Concepts

A

4 Basic Characteristics of culture
Terminology

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36
Q

4 Basic Characteristics of culture

A

Learned, Shared, Adapted, Dynamic

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37
Q

Learned –

A

Culture is learned from birth through a process of language acquisition and socialization.

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38
Q

Shared-

A

Shared by all members of the same cultural group.

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39
Q

Adapted-

A

Adapted to specific conditions that related to environmental and technical factors in the context of available resources.

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40
Q

Dynamic-

A

Culture Is dynamic. Very hard to define.
Not biologically or genetically determined and subcultures are going to occur when groups function within a larger culture but they break off into smaller cultures based on gender differences, age, occupation, or ethnicity

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41
Q

Ethnicity:

A

Social group with shared traits

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42
Q

Ethnic identity:

A

Self-identification with a particular ethnic group

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43
Q

Assimilation:

A

Process of adopting culture and behaviors of a major culture. Includes pt adopting practices such as dress and diet.

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44
Q

Biculturalism and integration:

A

Allow for reciprocating and maintaining ethnic identity. Allows patient to be apart of both cultures

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45
Q

Acculturative stress:

A

Based on the input from the environment include social, interpersonal, and societal factors

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46
Q

Spirituality:

A

broad encompasses something larger than one’s own existence with a belief in transcendence. Helps individuals to find a purpose and a meaning to life.

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47
Q

Religion:

A

organized system of beliefs as a shared experience that can assist in meeting one’s individual spiritual needs

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48
Q

Two concepts that can be interrelated but do not have to exist simultaneously

A

Spirituality and Religion

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49
Q

They help individuals define their feelings and beliefs.

A

Spirituality and Religion

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50
Q

Cultural interview-

A

it is very important gathering info about health related beliefs

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51
Q

If a patient is wearing a charm or amulet. Ask __

A

what is it and what is represents

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52
Q

Disease Causation Theories:

A

Biomedical or scientific- basis of western medicine
Naturalistic or holistic
Magico religious

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53
Q

Biomedical or scientific- basis of western medicine

A

Cause and effect that can provide physical and psychological illnesses—e.g., germ theory.
Does state that microorganisms such as bacteria or viruses are responsible for disease

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54
Q

Naturalistic or holistic-

A

Belief in the forces of nature that there is balance in the universe—e.g., yin/yang theory

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55
Q

yin/yang theory- Yin

A

Female or negative forces- emptiness darkness and cold.
Cold foods are going to be eaten during hot illness.

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56
Q

yin/yang theory- Yang

A

Male forces or positive forces that emit warmth and fullness, hot foods are going to be eaten during a cold illness.

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57
Q

Example of Cold diseases:

A

ear ache, chest cramps, paralysis or GI discomfort, rheumatoid arthritis, or TB.

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58
Q

Example of Hot illness:

A

abscess, sore throat, rash, and kidney disorders

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59
Q

Magicoreligious-

A

Supernatural forces dominate resulting in good versus evil—e.g., voodoo or faith healing

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60
Q

Each culture has its own healers- speak in their __

A

native tongue

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61
Q

Use of alternative, complementary, or traditional therapies based on __

A

belief system

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62
Q

Hispanic Tongue:

A

curandero, espiritualista, yerbo, or sabedor

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63
Q

Black Tongue:

A

Ougan, spiritualist, old lady

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64
Q

American Indian Tongue:

A

shaman, medicine woman, medicine man

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65
Q

____ states that the healing is not complete unless the body and mind are both healed

A

The Medicine man

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66
Q

Asian Tongue:

A

herbalists, acupuncturists, bone setters

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67
Q

Amish Tongue:

A

braucher

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68
Q

Always maintain cultural sensitivity, offer to call priest of spiritual specialist

A

If unsure ask

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69
Q

Ask if they had attempted other remedies at home, ask if they ___

A

have been seen

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70
Q

OTC meds are readily available for patients they might try it before ___

A

coming to see the doctor

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71
Q

Awareness of beliefs across the life cycle can impact perception of health care delivery and treatments

A

Developmental Competence

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72
Q

Parenteral and childs perceptions of illness

A

Consider the patients beliefs
Cultural taboos

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73
Q

Cultural taboos-

A

Avoided by both children and adults from the religion.
Specific to cultures not consuming pork or caffeine.
Jehovah witness: blood refusal
Providing care to an older adult, assess the role of the family, may not know about health promotion or programs available

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74
Q

Values held by dominant culture influence perception of older adults

A

Independence, self-reliance, and productivity
Care-dependent versus caregivers- role switch
Culture shock- coming from a different country

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75
Q

Older generation- the ability to care for themselves has ___

A

changed

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76
Q

Transcultural expression of pain: Remember that Expectations, manifestations, and management of pain are all embedded in a ___

A

cultural context.

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77
Q

Transcultural expression of pain: Pain is highly personal, depending on cultural learning, the meaning of the situation, and other factors unique to ___

A

the person.

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78
Q

Transcultural expression of pain: Considers the situation, what is causing the pain which effects how they express the paint, and ___

A

other unique factors related to pt

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79
Q

Transcultural expression of pain: Culture affects perceives, responds, and ___

A

manages the pain

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80
Q

Providing care- will see different variations of expression of pain. May turn to their social environment for ___

A

validation and comparison

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81
Q

Becoming a Culturally Competent Practitioner

A

Culturally sensitive, appropriate, competent, and cultural care

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82
Q

Culturally sensitive

A

Caregivers possess basic knowledge and understanding.

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83
Q

Culturally appropriate

A

Caregivers apply knowledge to improve health outcomes.

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84
Q

Culturally competent

A

Caregivers apply a universal concept of understanding to all contextual aspects of care.

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85
Q

Cultural care

A

Provision of health care across cultural boundaries in consideration of context

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86
Q

Care may not always align, ask questions that are not ___

A

too complex

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87
Q

When touching patient’s, use touch within _____

A

cultural boundaries

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88
Q

Pace questions through out the ____

A

assessment

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89
Q

Treat personal items with ____

A

care and respect

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90
Q

Cultural Self-Assessment: Explore your own personal history to develop cultural sensibility.

A

Use thoughtful reasoning.
Responsiveness
Discrete interactions

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91
Q

Cultural Self-Assessment: Think about the components of culture that you experience in your own daily life.

A

Purposely action to gain better understanding to help others
Only when we acknowledge our own values and beliefs are we able to fully help others.
Helps us greater understand and help our patients
When acknowledging values and beliefs we can fully take care of them

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92
Q

Ask about their influences, family traditions, where they are from to ___

A

gain info

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93
Q

Cultural Assessment: There is no one universally accepted tool that addresses ___

A

all variables.

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94
Q

Cultural Assessment: Do not apply stereotypes-

A

listen and learn.

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95
Q

Cultural Assessment: Recommended list of domains of interest that may be included:

A

Heritage, health practices and communication
Family roles and social orientation, nutrition and pregnancy, birth/childrearing
Spirituality/religion, death, and health providers

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96
Q

To gain a better understanding of our patient
After a pt recognizes a symptom they will seek self treatment- OTC

A

Cultural Assessment

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97
Q

Spiritual Assessment: Use open-ended questions to start the conversation

A

“Do you have any religious or spiritual preferences that we can support”?- answers spiritual portion

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98
Q

Spiritual Assessment: Variety of tools available

A

FICA—Faith, importance/influence, community and address/action
Brief R-COPE—examines patient’s coping mechanisms

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99
Q

Unmet spiritual needs lead to ___

A

decreased outcomes

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100
Q

Important in gather info regarding our ____

A

patient

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101
Q

Best chance what the patient perceives their ___

A

health state to be

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102
Q

First opportunity to gather information about patient’s beliefs, concerns, and perception of their individual health state

A

Interview Purpose

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103
Q

Allows for compilation of subjective data and awareness of objective data

A

Interview Purpose

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104
Q

Gather subjective data in the interview

A

What the patient says includes chest pain, heart burn, itching

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105
Q

Objective data- what we observe through our ___

A

Physical assessment

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106
Q

Successful Interview Characteristics

A

Gather, Establish, Teach, Build, Discuss

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107
Q

Gather ___

A

complete and accurate data about person’s health state including description and chronology of any symptoms.

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108
Q

Establish ___

A

trust to foster acceptance and allow for data sharing.

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109
Q

Teach ___

A

the person about their individual health state. Ways the manage health or promote

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110
Q

Build ___

A

rapport to continue therapeutic relationship.

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111
Q

Discuss ___

A

health promotion and disease prevention.

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112
Q

Gather info about ___

A

current health state, when the symptoms start, what are they, when did it change

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113
Q

Contract between you and the client

A

Interview

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114
Q

The mutual goal of the interview is

A

optimal health

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115
Q

Process of Communication: Sending

A

Verbal communication
Nonverbal communication

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116
Q

Verbal communication

A

Words you speak—vocalization
Tone used in conversation

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117
Q

Nonverbal communication

A

Body language helps to provide cues which may be correlated with truer feelings.
Recognize importance of unconscious messages that body language portrays

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118
Q

Change in demeanor or posture-

A

note It
Can be related to be forced to make difficult decision, make sure to educate them

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119
Q

Internal Factors:

A

Liking others, Empathy, Ability to listen, Self-awareness

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120
Q

Liking others—

A

using a “genuine” approach

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121
Q

Empathy—

A

develop an understanding and sensitivity for others feeling’s

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122
Q

Ability to listen—

A

make sure to use an “active” process

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123
Q

Self-awareness—

A

be aware of “implicit bias”, own belief systems. Different things as the HC team member to maximize skills

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124
Q

Process of Communication: External Factors

A

Ensure privacy, Avoid interruptions, Physical environment, Dress, Note-taking, Electronic Health Record (EHR)

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125
Q

Ensure privacy—

A

aim for “geographic” privacy but ensure “psychological” privacy

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126
Q

Avoid interruptions—

A

minimize and/or refuse

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127
Q

Physical environment—

A

“equal status” seating- same level, 4-5 ft apart for comfort and communication

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128
Q

Dress—

A

appearance and comfort

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129
Q

Note-taking—

A

keep to a minimum, offer “focused” attention so that it is not a barrier

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130
Q

Electronic Health Record (EHR)-

A

make sure the computer screen is not in between you and the client
If interviewing the team, can ask parents to leave for a moment

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131
Q

Turn off the TV to

A

minimize distractions

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132
Q

Techniques of Communication

A

Introducing the interview, Working phase,

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133
Q

Introducing the interview-

A

What it is for

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134
Q

Working phase-

A

Data-gathering phase
Verbal skills include questions to patient and your responses to what is said.

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135
Q

Two types of questions: Open-ended-

A

Broad range, narrative information. States the topic discussed in general terms. To begin the interview. “How has your health been since the last visit”- allows pt to elaborate

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136
Q

Two types of questions: Closed-

A

ask for specific information that leads to a forced choice. Yes or No.

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137
Q

Each has a different place and function in interview.

A

Open and closed ended questions

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138
Q

Verbal Responses: Assisting the Narrative

A

Facilitation, Silence, Reflection, Empathy, Clarification, Confrontation, Interpretation, Explanation, Summary

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139
Q

Facilitation—

A

Encourage to share more info

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140
Q

Silence—

A

Providing directed attentiveness, Paying attention

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141
Q

Reflection—

A

Echo or help express meaning

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142
Q

Empathy—

A

Name a feeling and allow for its expression

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143
Q

Clarification—

A

Wanting to conform info. Can be used if the patient’s word choice is confusing. Can be used to summarize the patients words or to better understand them

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144
Q

Confrontation—

A

Clarifying inconsistent information

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145
Q

Interpretation—

A

Making associations in order to identify a cause of conclusion

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146
Q

Explanation—

A

Inform the person by sharing factual and objective information

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147
Q

Summary—

A

Provide the conclusion based on verifying the info receives and verified that the interview process is ending.

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148
Q

Ten Traps of Interviewing to avoid

A

Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using why questions

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149
Q

Gives patients a false sense of provided comfort-

A

false assurance or reassurance

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150
Q

Nonverbal Skills—Congruency

A

When verbal and nonverbal messages are congruent, the verbal message is reinforced.

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151
Q

Nonverbal Skills— Incongruent

A

When they are incongruent, nonverbal message is viewed as the truer one as it is under unconscious control.

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152
Q

Make sure the nonverbal and verbal skills are __

A

matched

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153
Q

Nonverbal Modes of Communication

A

Physical appearance, Posture, Gestures, Facial expression, Eye contact, Voice, Touch

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154
Q

Physical appearance-

A

Take note of the image as an initial perception (First impression)

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155
Q

Posture-

A

Interpretation of body language and how it effects engagement

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156
Q

Gestures-

A

Can send messages

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157
Q

Facial expression-

A

Can reflect emotion and culture

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158
Q

Eye contact-

A

Differ from culture to culture, if able and culturally appropriate maintain eye contact. Be mindful of cultural diversity

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159
Q

Voice-

A

Aware of the tone, intensity, and rate

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160
Q

Touch-

A

Use caution when talking about eye contact and touch

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161
Q

Be cautious, interpreting by

A

age, gender, cultural background, pt past experiences, specific cultural setting,

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162
Q

Ending should be gradual thereby allowing for adequate closure to allow for final expression.

A

Closing the Interview

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163
Q

No new topics introduced

A

Closing the Interview

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164
Q

Summary provided as final statement- understand what the patient said

A

Closing the Interview

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165
Q

Not abrupt or awkward

A

Closing the Interview

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166
Q

Make sure to give patient the opportunity to include any last input

A

Closing the Interview

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167
Q

Communicating with Different Ages: Use “Stages of cognitive development” as a guideline to ___

A

facilitate communication.

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168
Q

Communicating with Different Ages: Consider the ___ and ___ level of the child.

A

maturity and developmental

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169
Q

Communicating with Different Ages: Consider that a health care crisis can lead to ___ as a common response.

A

regression

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170
Q

Communicating with Different Ages: Be aware of ___ to maintain engagement.

A

nonverbal behaviors

171
Q

Communicating with Different Ages: Primary method of communication with infants

A

Nonverbal

172
Q

Communicating with Different Ages: One direction at a time, keep simple, and give warnings before transitions.
Make sure they know what’s going on, mentally prepared.
May need to stoop down to their level and connect with an inanimate object

A

Toddlers

173
Q

Communicating with Different Ages: Interviewing parent of child or children- include __

A

child and parent

174
Q

Communicating with Different Ages: Address child by name to build ___

A

rapport with the child

175
Q

Stages of Cognitive Development

A

Infants- Birth to 12 months
Toddlers- 12 to 36 months
Preschoolers- 3 to 6 years
School-age- 7 to 12 years
Adolescents- Starts with puberty

176
Q

Infants- Birth to 12 months

A

Gentle handling with quiet calm voice

177
Q

Toddlers- 12 to 36 months

A

Give one direction at a time and provide simple explanations

178
Q

Preschoolers- 3 to 6 years

A

Short directions with concrete explanation

179
Q

School-age- 7 to 12 years

A

Ask questions to gather data and be nonjudgmental

180
Q

Adolescents- Starts with puberty

A

Respectful, honest attitude with focused on the individual

181
Q

May speak 1 to 2 words-

A

toddlers

182
Q

World revolves around them –

A

preschoolers

183
Q

Objective and realistic-

A

School age

184
Q

Drastic change to their self concept, communicate so they are aware-

A

adolescents

185
Q

Developmental task of finding purpose and evaluating existence

A

The Older Adult

186
Q

Address respectfully

A

The Older Adult

187
Q

Typically, the interview process will take longer.

A

The Older Adult

188
Q

Use therapeutic touch to provide empathy.

A

The Older Adult

189
Q

May need increased response time- time to interpret, process and answer the questions

A

The Older Adult

190
Q

May have a lot more information to provide, may take longer

A

The Older Adult

191
Q

Hard of hearing- facing patient and make sure they can see our mouth

A

The Older Adult

192
Q

Include questions that are related to aging

A

The Older Adult

193
Q

Consider appropriate pacing
Physical limitations

A

Typically, the interview process will take longer.

194
Q

Interviewing People with Special Needs: Consider key elements that will address vulnerable populations.

A

Acutely ill, drug/alcohol abuse, sexually aggressive, emotionally distraught (crying), angry and/or threatening violence and anxious

195
Q

Interviewing People with Special Needs: Use appropriate resources as they relate to the context of the situation.

A

Social worker, aid

196
Q

Interviewing People with Special Needs: Be alert to “personal question” queries as they may indicate ulterior motives:

A

Provide appropriate response based on personal ethics.

197
Q

Interviewing People with Special Needs: Alcoholism and drug abuse-

A

educating the drug interactions

198
Q

Interviewing People with Special Needs: Disease processes worse, can interact with all medications-

A

alcohol

199
Q

Interviewing People with Special Needs: Common admitted to the hospital-

A

Alcohol and drugs

200
Q

Being aware of maintaining cultural
Maintaining privacy and modesty

A

Being aware of maintaining cultural
Maintaining privacy and modesty

201
Q

Be mindful of your communication patterns
Being aware of your own personal bias and baggage

A

Sexual orientation

202
Q

Interpreter services may be necessary

A

Communication

203
Q

Use appropriate language
Consider verbal and nonverbal ques

A

Culture and Genetics Considerations

204
Q

Involves understanding and following directionsA patient may be literate (read) but not have health literacy (Educational level).
that lead to effective communication between the patient and the health care provider.

A

Health Literacy

205
Q

A patient may be literate (read) but not have health literacy (Educational level).

A

Health Literacy

206
Q

Provide simple and easy to use directions, use layman’s terms

A

Health Literacy

207
Q

Written materal make sure its based on standard education levels

A

Health Literacy

208
Q

Provide education in different method, videos, if they cannot read or write

A

Health Literacy

209
Q

Use 12 pt font, don’t use all capitalizations

A

Health Literacy

210
Q

Teach back for verification and clarification

A

Health Literacy

211
Q

Standardized Communication—SBAR

A

Situation, Background, Assessment, Recommendation or Request

212
Q

Situation

A

Provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location

213
Q

Backgrounds

A

Provide pertinent history as it directly relates to patient’s current health status

214
Q

Assessment

A

State pertinent assessment findings obtained with interpretation of data

215
Q

Recommendation or Request

A

State what you need or want for the patient in terms of medical treatment and/or assistance

216
Q

Communicate with other professions

A

Standardized Communication—SBAR

217
Q

Maintain standard of communication, promote effective interpersonal communication

A

Standardized Communication—SBAR

218
Q

Creates environment of respect and enhance collaboration

A

Standardized Communication—SBAR

219
Q

Maintain open lines of communication providing timely updates in an organized manner

A

Standardized Communication—SBAR

220
Q

Decrease or get rid of communication within the healthcare setting- main goal

A

Standardized Communication—SBAR

221
Q

Collect subjective data to combine with objective data from physical exam and labs to form the database for our patient

A

Purpose of Health History

222
Q

Provides a complete picture of patient’s past and present health status

A

Purpose of Health History

223
Q

Can be used as a screening tool for detection of abnormalities or find trends

A

Purpose of Health History

224
Q

Depending on what the pt is seen for the focus may differ in terms of clinical practice setting and/or nature of complaint.

A

Purpose of Health History

225
Q

Describes the individual as a whole and how they interact with the environment

A

Purpose of Health History

226
Q

Dealing w a pt who is ill, gather symptoms in chronological order,

A

Purpose of Health History

227
Q

Objective data, labs and health history=

A

database

228
Q

The Health History Sequence

A

Biographic data, Source of history, Reason for seeking care, Present health or history of present illness, Past health, Family history, Review of systems, Functional assessment including activities of daily living (ADLs)

229
Q

When performing the health history do it in an

A

orderly fashion

230
Q

The Health History Areas of focus may differ slightly in terms of

A

individual patient concerns.- issued reported
developmental considerations- delays in development
presence of health problem
no detection of health problems.
concerns r/t aging.
identification of vulnerable population.
identified barriers to communication.

231
Q

Subjective data
Determine if they have access to care or needs resources

A

The Health History

232
Q

Name, address, and phone number

A

Biographic Data

233
Q

Age, birth date, and birthplace

A

Biographic Data

234
Q

Gender (identification) and relationship status

A

Biographic Data

235
Q

Race and ethnic origin

A

Biographic Data

236
Q

Occupation: usual and present, changed occupations due to health or illness

A

Biographic Data

237
Q

Primary language- Language-concordant provider or medical interpreter

A

Biographic Data

238
Q

Includes patients information
Basic info that makes up the patient

A

Biographic Data

239
Q

If they had lost a job due to illness, know

A

what kind of job they lost and why they had to change the profession

240
Q

Record who furnishes information, usually the person, although source may be relative or friend.

A

Source of History

241
Q

Judge reliability of informant and how willing he or she is to communicate.

A

Source of History

242
Q

Reliability leads to consistency of information.

A

Source of History

243
Q

Note any special circumstances, such as use of interpreter.

A

Source of History

244
Q

Think critically about who is reliable

A

Source of History

245
Q

This info goes into the patient medical record

A

Source of History

246
Q

Drug reconciliation

A

Source of History

247
Q

Ill patient, sleepy, under the influence- not reliable info to gather

A

Source of History

248
Q

Brief spontaneous statement in (pts) person’s own words describing reason for visit

A

Reason for Seeking Care

249
Q

Document reported findings

A

Reason for Seeking Care

250
Q

Subjective sensation person feels from disorder documented in quotes

A

Symptom:

251
Q

Objective abnormality that can be detected on physical examination or in laboratory reports

A

Sign:

252
Q

Reason for care is not a diagnostic statement.- document exactly what the patient says they are there

A

Reason for Seeking Care

253
Q

Focus on patient’s prioritized reasons for seeking care.- ask the patient why they came to seek help.

A

Reason for Seeking Care

254
Q

Present Health or History of Present Illness (HPI): Collect all provided data and identify eight critical characteristics (Pain or injury, discomfort)

A

Location, character(quality), quantity(severity), timing, setting, aggravating or relieving factors, associated factors and patient’s perception

255
Q

Present Health or History of Present Illness (HPI): Make sure that collected data are precise and accurate.

A

Use measurable standards and/or patient’s own words as qualifiers.

256
Q

Present Health or History of Present Illness (HPI): Use standardized indicators to document findings

A

Reliability and validity of reported results (Pain scale)

257
Q

Go over pts past health and present illness

A

Present Health or History of Present Illness (HPI):

258
Q

Gather pts perception to try to identify what they feel is going on

A

Present Health or History of Present Illness (HPI):

259
Q

Each of the identified areas can have residual impact on present (as well as future) health status. (ex: Stroke)

A

Past Medical History

260
Q

Focus on obtaining specific pertinent information relative to each of the identified categories.

A

Past Medical History

261
Q

More accurate and detailed information obtained will lead to better clinical decision making.

A

Past Medical History

262
Q

Will provide cues as to how patient’s cope with illness and/or health concerns. Identify how they cope, what they use, how much they use.

A

Past Medical History

263
Q

Patients can become emotional when talking about the past, stop and comfort them

A

Past Medical History

264
Q

Ask them if they had any changes within the past year

A

Past Medical History

265
Q

Past Medical History: Childhood illnesses

A

Experienced or exposed to presence or absence of complications. Document actual diagnoses

266
Q

Past Medical History: Accidents or injuries

A

Type and nature of event, acute and/or residual deficit noted. (serious injuries)

267
Q

Past Medical History: Serious or chronic illnesses

A

Presence of comorbidities has pronounced effect. (Ex: COPD)

268
Q

Past Medical History: Hospitalizations

A

Types based on clinical indications, interventions used as therapy, and length of stay along with dates of occurrences

269
Q

Past Medical History: Operations

A

Facility, procedure, date

270
Q

Past Medical History: Obstetric History

A

Relevant data r/t childbearing inclusive of GPAL, labor/delivery experience, condition of infant, and postpartum course.

271
Q

Past Medical History: Immunizations

A

Correlate with CDC Guidelines. If they are up to date or if they have them.

272
Q

Past Medical History: Last Examination Date

A

Obtain last data set for commonly occurring labs/diagnostics (blood work, ECG, chest x-ray, occult blood and gender-specific testing—PAP/PSA).

273
Q

Past Medical History: Allergies

A

Note allergen and reaction. Sometimes people list the symptoms of the medication instead of the reaction. When it occurred.

274
Q

Past Medical History: Current Medications

A

Perform medication reconciliation to determine the right meds and dose
Include prescribed and OTC medication and/or herbal therapy.

275
Q

Highlights diseases or conditions that an individual may be at risk for as a result of genetics

A

Family History

276
Q

Provides age and health or cause of death of relatives (immediate)

A

Family History

277
Q

Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance

A

Family History

278
Q

Pedigree or genogram used as standardized tool to organize data

A

Family History

279
Q

Biographic data

A

Cross-Cultural Care Implications: Additional questions for new immigrants

280
Q

Spiritual resource and religion: assess if certain procedures cannot be done

A

Cross-Cultural Care Implications: Additional questions for new immigrants

281
Q

Past health: what immunizations, if any

A

Cross-Cultural Care Implications: Additional questions for new immigrants

282
Q

Health perception- to begin relationship

A

Cross-Cultural Care Implications: Additional questions for new immigrants

283
Q

How does person describe health and illness?

A

Cross-Cultural Care Implications: Additional questions for new immigrants

284
Q

How does person see problems he or she is now experiencing?

A

Cross-Cultural Care Implications: Additional questions for new immigrants

285
Q

Nutrition: taboo foods or food combinations that is important in their culture

A

Cross-Cultural Care Implications: Additional questions for new immigrants

286
Q

Evaluate past and present state of each body system (surgeries that effects them)

A

Purpose of ROS

287
Q

Assess that all pertinent data relative to each body system have been noted

A

Purpose of ROS

288
Q

Evaluate health promotion practices- Vaccinations, breast exams, testicular exams

A

Purpose of ROS

289
Q

Organized manner proceeding in a logical sequence

A

Cephalocaudal approach

290
Q

If information obtained in HPI, then it doesn’t have to be re-assessed again.

A

Items within different systems may not be inclusive

291
Q

Double check
Patients review of their own body
Make sure including questions that reflects normal process of aging

A

Review of Systems

292
Q

Functional Assessment: ADLs- Determines ability that related to their functional status

A

Self-care activities of daily living as they relate to general health status

293
Q

Functional Assessment: Objectively measure functional status

A

Monitor and assess for changes over time.

294
Q

Functional Assessment: Relevant data related to lifestyle and type of living environment

A

May include “sensitive” topics r/t lifestyle behaviors and as such may require attention to privacy concerns
Different types of “screening tools” may provide more objective validation of information with regard to substance and/or alcohol abuse. (severity)

295
Q

Maintain privacy when talking about ___

A

incontinence

296
Q

Measure pts ability to provide self care in regard to ADLs, IADLs nutrition, social relationships, self concept, and coping. Healthy living environment

A

Functional Assessment

297
Q

Learns how the pt handles day to day activities

A

Functional Assessment

298
Q

Questions are asked at the end of the interview

A

Functional Assessment

299
Q

Alcohol abuse or misuse- Cage assessment, older population may be more dependent and can drink more.

A

Cutting down?
Annoyed about criticism?
Guilty about drinking?
Drink in the morning as an eye opener?
If any says yes to 2 or more of the questions, suspect alcohol abuse. Perform more complete substance abuse questionnaire with this patient

300
Q

Perception of Health- Ask questions such as the following:

A

How do you define health? Barriers? Focus on a subject?
How do you view your situation now?
What are your concerns?
What do you think will happen in the future?
What are your health goals?
What do you expect from us as nurses, physicians, or other health care providers? To work towards

301
Q

Use open ended questions to gather as much info as possible
Ask how their health is after last visit

A

Perception of Health

302
Q

Informant will not be the PT.

A

Developmental competence- child

303
Q

Immunizations, Medications

A

Developmental competence- child

304
Q

Past health history can have a residual impact on present (and future) health status

A

Developmental competence- child

305
Q

Prenatal delivery and Postnatal period

A

Developmental competence- child

306
Q

Most info may come from the parent
Always document the source of the information and the relationship to the child, and if used an interpreter
Determining if the child met their developmental growth or milestone

A
307
Q

Development changes or issues

A

Developmental competence- child

308
Q

Nutritional changes or issues (bottle or breastfed, nutritional supplements, special formula)

A

Developmental competence- child

309
Q

Family History

A

Developmental competence- child

310
Q

Review of Systems: CHILD: Same method of inquiry used with the adult patient can now be used with the child.

A

Use an organized approach.
Include at least “two” individuals—parent and/or child.

311
Q

Review of Systems: CHILD: Tailor questions to the child’s ___

A

age and level of development.

312
Q

Review of Systems: Functional assessment-

A

focus on child’s position within the family unit. Respect the relationship of the child and caregiver

313
Q

Not ignoring the child- use inanimate objects

A

Review of Systems: CHILD

314
Q

Know about past hospitalizations, allergies and reactions

A

Review of Systems: CHILD

315
Q

IADL-

A

paying bills, laundry, shopping for groceries, effects the patients independence

316
Q

Pts emotional functioning and cognitive functioning
Relative and dynamic (changes)

A

Mental status assessment

317
Q

Mental status is a person’s

A

emotional and cognitive functioning.

318
Q

Mental status cannot be scrutinized directly like the characteristics of

A

skin or heart sounds.

319
Q

Its functioning is inferred through assessment of an individual’s behaviors:

A

LOC, Use of language, Mood/affect, Orientation, Ability to pay attention, Memory and abstract reasoning and Perception

320
Q

When asking questions the pt may take longer to answer questions

A

Older Adults

321
Q

The ability to answer questions not effected

A

Older Adults

322
Q

As the patients age it will leave the patients mind mostly intact and their general knowledge may not decrease

A

Older Adults

323
Q

Should not have any loss of vocabulary

A

Older Adults

324
Q

Recent memory allow the thought process to take place

A

Older Adults

325
Q

Remote memory should not be effected in older adults

A

Older Adults

326
Q

Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities

A

Mental disorder

327
Q

Due to brain disease of known specific organic cause

A

Organic disorders

328
Q

Delirium or dementia or alcohol and drug use and use or abuse=

A

organic disorders

329
Q

Organic etiology has not yet been established

A

Psychiatric mental illnesses

330
Q

Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.

A

Psychiatric mental illnesses

331
Q

Anxiety disorder and schizophrenia

A

Psychiatric mental illnesses

332
Q

Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent.

A

Developmental Competence Infants and Children

333
Q

Addressing concerns that parents or teachers have as developmental process associated with aging continues

A

Developmental Competence Infants and Children

334
Q

Critical issues may be seen r/t substance abuse, suicide, and impact of mental health issues being diagnosed and/or individuals receiving treatment

A

Developmental Competence Infants and Children

335
Q

Age-related changes in sensory perception can affect mental status along with chronicity of disease process (presence of comorbidity). (ex: COPD)

A

Developmental Competence Aging adults

336
Q

Experienced more Grief and despair surrounding these losses can affect mental status and can result in disability, disorientation, or depression or sadness)

A

Developmental Competence Aging adults

337
Q

Older adulthood contains more potential for losses.

A

Developmental Competence Aging adults

338
Q

Aging alone should not impact their

A

mental health

339
Q

Full mental status examination is a systematic check of emotional and cognitive functioning.

A

Components of the Mental Status Examination

340
Q

Usually, mental status can be integrated within the context of the health history interview.

A

Components of the Mental Status Examination

341
Q

Four main headings of mental status assessment: A-B-C-T

A

Appearance/Presentation
Behavior/not normal
Cognition
Thought processes/communication

342
Q

Document and note

A

abnormalities

343
Q

When a Full Mental Status Examination Is Necessary

A

Initial screenings, sudden behavioral changes, brain lesions, sudden aphasia, symptoms of psychiatric mental illness

344
Q

Suggests an anxiety disorder or depression

A

Initial screening

345
Q

Memory loss, inappropriate social interaction. May have family members reporting changes.

A

Sudden Behavioral changes

346
Q

Trauma, tumor, cerebrovascular accident, or stroke

A

Brain lesions

347
Q

Impairment of language ability secondary to brain damage. Determine the type. Expressive (cannot speak) or receptive(cannot understand)

A

Sudden Aphasia

348
Q

Especially with acute onset

A

Symptoms of psychiatric mental illness

349
Q

Enough info to identify any problems-coping skills-

A

full health history

350
Q

Known illnesses or health problems

A

Factors That Could Affect Interpretation of Findings

351
Q

Medications: Side effects, confusion, depression

A

Factors That Could Affect Interpretation of Findings

352
Q

Educational and behavioral level: Level of understanding

A

Factors That Could Affect Interpretation of Findings

353
Q

Stress responses observed in: social interactions, changes in sleep habits, stress responses, under the influence or withdrawing

A

Factors That Could Affect Interpretation of Findings

354
Q

If any of these factors are present, note them

A

Factors That Could Affect Interpretation of Findings

355
Q

Appearance, behavior, cognitive functions, and thought processes
Additional screenings as needed based on observations

A

Objective Data: Collection Addressing key areas:

356
Q

Additional screenings as needed based on observations

A

Objective Data: Collection Addressing key areas:

357
Q

Documentation of findings and what has changed since the last time seeing this pt

A

Objective Data: Collection Determination of normal versus abnormal findings

358
Q

Obtaining baseline and then trending results upon ongoing assessment

A

Objective Data: Collection Determination of normal versus abnormal findings

359
Q

Make sure to start with the basic functions first (Conscious) then

A

language barriers

360
Q

Objective Data: Appearance

A

Posture, Body movements, Dress, Grooming and hygiene

361
Q

Erect and position relaxed, comfortable

A

Posture

362
Q

Voluntary, deliberate, coordinated, and smooth and even

A

Body movements

363
Q

Appropriate for setting, season, age, gender, and social group

A

Dress

364
Q

Congruence between grooming and age

A

Grooming and hygiene

365
Q

Objective Data: Behavior

A

LOC, Facial expression, Speech, Mood and affect

366
Q

Awake, Alert, Aware, respond appropriately and reasonably to stimuli

A

Level of consciousness

367
Q

appropriate to the situation and that is changes appropriate with the topic

A

Facial expression

368
Q

Quality of speech is appropriate, note slurring and effortlessly communicate

A

Speech

369
Q

Assess body language and facial expressions

A

Mood and affect

370
Q

Objective Data: Cognitive Functions

A

Orientation, Attention span, Recent memory, Remote memory

371
Q

Discern orientation through course of interview, or use direct questioning to verify
Time:
Place:
Person:

A

Orientation

372
Q

Appropriately pay attention

A

Attention span

373
Q

Recent memory- 24 diet recall, when did you arrive at the agency. Dementia patients may make up responses

A

Recent memory

374
Q

Birthday, Anniversaries, historical events relevant to the person.

A

Remote memory

375
Q

____ is going to be lost when the cortical storage area for that memory is damaged.
Occurs in Alzheimer’s disease and dementia or other diseases when the cerebral cortex is damages

A

Remote memory

376
Q

Highly sensitive and valid memory test

A

The Four Unrelated Words Test

377
Q

Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall

A

The Four Unrelated Words Test

378
Q

Pick four words with semantic and phonetic diversity; ask person to remember the four words. Sound different and completely unrelated.

A

The Four Unrelated Words Test Assessment Process

379
Q

To be sure person understood, have him or her repeat the words.
Ask for the recall of four words at 5, 10, and 30 minutes.

A

The Four Unrelated Words Test Assessment Process

380
Q

Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.

A

The Four Unrelated Words Test Assessment Process

381
Q

Memory recall test
Tests patients ability to make new memories
Ball, pillow, dog, letter

A

The Four Unrelated Words Test

382
Q

____ are the two most common mental health disorders seen in individuals seeking health care.

A

Anxiety and depression

383
Q

Generalized anxiety disorder scale (GAD-7)

A

Consists of 7 itemized scale
Higher the score, greater the likelihood.
First 2 questions relate to core anxiety.
Greater or equal than 3 indicates diagnosis.

384
Q

Sudden onset of anxiety- lasting less than 10 mins-

A

panic attack

385
Q

Irrational fear of a specific object-

A

Phobia

386
Q

Generalized anxiety disorder, Social anxiety disorder, OCD and PTSD

A

most common

387
Q

Series of tools that can be used in

A

clinical setting

388
Q

Patient Health Questionnaire-2 (PHQ-2) complete assessment if positive

A

Asks 2 questions about depressed mood and anhedonia (lack of interest).
Little interest of pleasure of doing things, feelings of hopelessness. How bad are the symptoms. The higher the score the higher the diagnoses.
Serves as a screening tool to use full PHQ-9 tool

389
Q

PHQ-9- Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms

A

Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.

390
Q

Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief.

A

Screening for Suicidal Thoughts

391
Q

Begin with more general questions and proceed if you hear affirmative answers.

A

It is very difficult to question people about possible suicidal wishes for fear of invading privacy.
Risk is far greater skipping these questions if you have the slightest clue that they are appropriate
For people who are ambivalent, you can buy time so the person can be helped to find an alternate remedy.

392
Q

Share any concerns you have about a person’s suicide ideation with a mental health professional.

A

Screening for Suicidal Thoughts

393
Q

Share with mental health professional to get more help

A

Screening for Suicidal Thoughts

394
Q

Is the ability to compare and evaluate alternatives and reach an appropriate course of action

A

Judgment

395
Q

____ about daily or long-term goals, likelihood of acting in response to hallucinations (sensory perception for which no external stimuli exists, can strike any sense) or delusions, and capacity for violent or suicidal behavior.

A

Test judgment

396
Q

These plans should be realistic and rational.

A

Judgment

397
Q

Determined patients family obligations, plans for the future and make sure health plans are appropriate considering their

A

health condition

398
Q

Supplemental Mental Status Examination

A

Mini-Mental State Exam (MMSE) & Montreal Cognitive Assessment (MoCA)

399
Q

Concentrates only on cognitive functioning

A

Mini-Mental State Exam (MMSE)

400
Q

Standard set of 11 questions requires only 5 to 10 minutes to administer.

A

Mini-Mental State Exam (MMSE)

401
Q

Useful for both initial and serial (follow up) measurement

A

Mini-Mental State Exam (MMSE)

402
Q

Detect dementia and delirium and to differentiate these from psychiatric mental illness.

A

Mini-Mental State Exam (MMSE)

403
Q

Normal mental status average 27; scores between 24 and 30 (highest score) indicate no cognitive impairment

A

Mini-Mental State Exam (MMSE)

404
Q

Anything greater than or equal to 26 is considered normal

A

Mini-Mental State Exam (MMSE)

405
Q

Looks at orientation, ability to pay attention, language

A

Mini-Mental State Exam (MMSE)

406
Q

Patient must be able to read and write and able to see the examination

A

Mini-Mental State Exam (MMSE)

407
Q

Low education levels or decreased intellectual abilities- be careful

A

Mini-Mental State Exam (MMSE)

408
Q

Examines more cognitive domains, more sensitive to mild cognitive impairment

A

Montreal Cognitive Assessment (MoCA)

409
Q

Make sure what they are saying is logical
Assess for dementia or delirium

A

Supplemental Mental Status Examination

409
Q

Denver II screening test gives a chance to interact directly with child to assess mental status.

A

Infants and children Screening Tests

410
Q

“Behavioral Checklist” for school-age children, ages 7 to 11, is tool given to parent along with the history.

A

Covers five major areas: mood, play, school, friends, and family relations
It is easy to administer and lasts about 5 minutes.

410
Q

For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas.
An additional language test is the Denver Articulation Screening Examination.

A

Denver II screening test

411
Q

Adolescents
Follow same A-B-C-T guidelines as for adults.

A

Appearance
Behavior
Cognition
Thought

412
Q

Confusion is common and is easily misdiagnosed.
Presence of delirium can have serious affects.

A

Developmental Care of Aging Adults

413
Q

Check sensory status, vision, and hearing before any aspect of mental status.

A

Developmental Care of Aging Adults

414
Q

Delirium-

A

Acute confused state, potentially preventable especially dealing with hospitalized patients. Sudden onset of symptoms related to uti, infection, and impaired sleep. Can be paired with memory deficit

415
Q

Dementia-

A

chronic and progressive loss of cognitive abilities. Lose intellectual functions and develop slowly and over time. Impaired judgement and memory

416
Q

Depression-

A

long term depressed mood. Lack of pleasure, disturbed sleep, major depressive disorder- one or more major depressive episodes at least 2 weeks of the depressed state. At least 4 additional symptoms of depression

417
Q

dysrhythmic disorder-

A

accompanied by 2 years of depressed mood for more days than not. Ask how long they have been depressed

418
Q

Testing Aging Adults

A

Follow same A-B-C-T guidelines for the younger adult with these additional considerations.
Appearance
Behavior
Cognition
Though Process

419
Q

LOC assessment especially if they are dealing with

A

confusion

420
Q

If pt has been hospitalized for a significant amount of time they may not be able to tell specifically the

A

amount of time they have been there

420
Q

Dementia pts- if asking again it does not

A

effect the ability to learn

NSG (13 decks)

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