PT. Assess Exam Review 2 Flashcards
What is HIPAA?
–Only approve health care providers can have access to PHI
–legal obligations regarding patient information are specified under privacy and security rules
What does HIPAA stand for
–Health Insurance Portability and Accountability Act
Where is it appropriate to discuss patient information with other therapists?
–Workstations so that the screens are not visible to prying eyes
–only access the information needed to perform the job
–only with other members of the health care team who need to know such information and only in a private area where visitors are not allowed
What patient information can you post on social media
–none and never
How does Culture affect the interaction between therapist and patient
–failure can encounter in patient dissatisfaction, poor adherence to treatment regimens, and unsatisfactory health outcome
–be self-aware, do not let your emotions get in the way of do the patients wishes
–adapt communication with the patient and family beliefs
–modify to accommodate
How does Learning Levels affect the interaction between therapist and patient
–emphasize oral instructions vs written instructions
–adjust language level to appropriate
–provide written materials at 5th to 8th grade level
How does Sex affect the interaction between therapist and patient
–
How does Age (younger child) affect the interaction between therapist and patient
–keep teaching/learning episode short
–use fun and game approach
–enlist family assistance
How does Language Barrier affect the interaction between therapist and patient
–enlist family assistance
–secure translator
–use an approve translation service
How does Hearing affect the interaction between therapist and patient
– speak slowly and clearly while facing the patient
–have patient use hearing aid
–emphasize visualization and touch
–enlist family assistance
what is the teach back method
–being able to explain to the patient on how a device should be use
–seeing the patient is using the device correctly before leaving them
–have the patient repeat in their own words the information you are trying to communicate
What is SMART stand for
–S: specific
–M: Measurable
–A: action oriented
–R: realistic
–T: time
What are SMART goals
–written action plan are particularly useful for involving patients in goal-setting, and self-care activities
When should you use SMART goals
–exactly what is the goal
–how will the goal be achieved
–what barriers might prevent achieving the goal
–how can barriers be overcome
–by what mechanism will follow-up occur
–how much confidence does the patient have in achieving the goal
What does SBAR stand for
–S: situation
–B: background
–A: assessment
–R: recommendation
When is SBAR used
–coordinate patient handoffs, giving short but precise essential information needed by the shift change RT
–when making recommendations to the patients’ physicians for a change in therapy or when documenting a patient encounter in the medical record
–schedule procedures at times least likely to conflict with other essential patient activity and most likely to coincide with any relevant drug
What has to happen for communication to be effective
– healthcare provider should listen to the Pt
–project undivided interest in the patient
–introduce yourself in a professional manner
–respect the patient’s beliefs and attitudes
–use a relaxed conversational style that communicates empathy and genuine concern
–open ended questions
What is a Chief Complaint
–a brief notation explaining why the patient is seeking medical care
–open-ended question
How do you calculate pack years
– is the number of years the patient has smoked multiplied by the number of packs per day
What are Signs
–objective
–measurable
–assessed values
–example: HR, BP, RR
What are Symptoms
–Subjective
–Description of onset: date, time, and type
-patient description
–Setting: cause, circumstance, or activity surrounding onset
-measured by patient perception
–Location: where on the body the problem is located and whether it radiates
–Severity: how bad it is and how it affects activities of daily living
–Quantity: how much, how large an area, or how many
–Quality: what is like and character or unique properties such as: color, texture, odor, composition, sharp, viselike, or throbbing
–Frequency: how often it occurs
–Duration: how long it lasts and whether it is constant or intermittent
–Course: is it getting better, worse, or staying the same
–Associated symptoms: symptoms from the same body system or other systems that occur before, with, or following the problem
–Aggravating Factors: things that make it worse
–Alleviating factors: things that make it better
example: pain, shortness of breath, cough
What is a fever a sign of
–infection
–other problems
What are the Progress Notes in the chart
–when the physician interviews and examines the patient to identify the patient’s progress and response to treatment
–other healthcare providers will document progress notes in the chart
What information are charted
-Admitting information
–written by the attending physician
–description of important facts related to the patient’s admission
-History and assessment notes
-Laboratory tests
-Imaging Studies
–symptoms
–vitals
–assessment
–planning
Who uses the Progress notes the most
–Are notes by the physician and other healthcare providers each day
–describes the patient’s response to the treatment
–RT/ nurses
What is DNR statues
– a legal document in which a person specifies that actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity
–Do Not Attempt to Resuscitate
–DO Not Resuscitate
How does DNR change patient care
–instituted based on patient/family wishes and physician order
–be aware of variations and specific instructions
–resuscitation should not be attempted
What is a Cough
–one of the most common symptoms seen in patients with pulmonary disease
–Protective reflex
What steps are involved in a Cough
–Inspiratory
–Compression
–Expiratory
What are the common causes for a chronic cough
–persistent
–Last more than 3 weeks
-Causes:
–Postnasal drip ( most common)
–Asthma
–COPD exacerbation
–Allergic rhinitis
–GERD
–Chronic Bronchitis
–Bronchiectasis
–Left heart Failure
–CHF
What are some of the possible complications associated with coughing
–Torn chest muscle
–Rib fractures
–disruption of surgical wounds
–Pneumothorax or pneumomediastinum
–Syncope
–Arrhythmia
–Esophageal rupture
–Urinary incontinence
What is Sputum
–Secretions from tracheobronchial tree, pharynx, mouth, sinuses, nose
–coughing or clearing the throat
What is phlegm
–secretion from lungs and tracheobronchial tree
What is hemoptysis
–expectoration of sputum containing blood
–from streaking to frank bleeding
What is a massive Hemoptysis
–400 mL/3 h or 600 mL/24 h
–emergency condition
–cancer, tuberculosis, bronchiectasis, trauma
–Streaky: pulmonary infection, lung cancer, and thromboembolic
–Odor
–Color
–Acuteness
What is a modified Brog scale
–when a patient rates their pain from 1-10
– and children use a picture chart
what are cardinal symptoms of heart disease
–Dyspnea (SOB)
–Chest pain
–Wheezing
Coughing
–Edema
–Low blood supply
–Angina
What is Angina
–heart pain
–described as “ aching” “squeezing” “ pressing” pain
–subjective symptom
What does a normal fever indicate
What is a fever
–elevation of temperature (febrile)
–from disease (infection)
–greater than 102
How does a fever affect CO2 production
–production increase 10% for each 1C elevation in body temperature
–patients with limited respiratory function may develop respiratory failure in response to fever
How does a fever affect O2 consumptions
–production increase 10% for each 1C elevation in body temperature
–patients with limited respiratory function may develop respiratory failure in response to fever
What is GERD
–Gastroesophageal Reflux
–Heartburn and regurgitation
–Extraesophageal manifestations
–produced by the abnormal reflux of gastric contents into the esophagus.
–obesity, cigarette smoking, pregnancy are common associated factors
What are the 4 classic vital signs
–HR
–BP
–BR
–Temperature
Normal BP
–120/80
Normal HR
–60-100
Normal BR
–12-20
Normal Temperature
–96/99F
–35/37C
Why would you measure input and output
What is LOC
–Level of Consciousness
Why do you measure LOC
–Measure cerebral oxygenation
–Evaluation of time, place, and person
–Status of Sensorium
-Directs treatment plan
-Patient cooperation, coordination
–if patient is conscious, alert, and oriented
What scale do you use to measure LOC
–Glasgow Coma Scale
–Motor function
–Verbal function
–Eye-opening response
What does changes in LOC indicate
–that they are not conscious enough to know what is happening
–Deterioration from restlessness to
-cerebral hypoxia
-side effect to medications or drug overdose
What is normal body temperature
–98.6 F
–daily variations
–lowest in morning
–highest late afternoon
Where is temperture measured
–oral
–axillary
–rectal
–ear
where is temperature most accurate
–rectal
–ear: if measured correctly
What is the difference between neonates and adult in temperature
–Axillary is safe and accurate in infants and small children
–have a higher temp
What is the normal pulse range
60-100 beats per min
What can influence pulse range
–the patient’s wrist is above the level of the heart
–atrial blood clots
–diabetes
– dehydration
–fever
how does hypoxia effect it
– is low oxygen rate
–not enough oxygen is going to the lungs and effects the blood flow to the heart
what is tachycardia
– rapid HR
–more than 100 beats/min
–anxiety, hypoxemia, exercise, fever, anemia
what is bradycardia
–slow HR
–less than 60 beats/min
–diseased heart, athletes, medication side effects
what is arrhthmia
–irregular heart rate, especially during sleep
what is normal rate
–60 to 100 beats/min for adults
–the younger the patient, the faster the rate
why do you measure pulse rate in lung patients
–to see they are getting better
–Volume of pulse: described as: bounding, full, normal, weak, thready, absent
–the amount of oxygen delivered to the tissues depends on the ability of the heart to pump oxygenated blood
what is pulsus alternans
–strong and weak pulses
what is pulsus paradoxus
–strength decreases with inspiration
what is systolic and what does it represent
–peak force during ventricular contraction
what is diastolic and what does it represent
–force during ventricular relaxation
What does SPEAK UP stand for
–S: Speak up
–P: Pay attention
–E: Educate yourself
–A: Ask a trusted person
–K: Know what medicine you take
–U: Use a hospital that has been carefully checked out by TJC
–P: Participate in all decisions about you treatment
Social Space
–is used during the interview component of the encounter when you establish rapport
Personal Space
–used primarily during the interview component of the initial assessment, usually after the rapport
Intimate space
–is reserved primarily for physical exam
Cultural beliefs should be explored with your patient during initial assessment stage of the clinical encounter
–concepts of health and disease
–Reponses to authority
–gender and family roles
–religious values
For most respiratory care to succeed, patient needs to
–actively participate in the treatment regimen
A good patient action plan should indicate
–Specific, measurable goals
–action needed to achieve the goal
–restrictions for goal achieve
–follow-up mechanism
–SMART Goals
What changes with a fever
–increase pulse rate
what cause tachycardia in adults
–hypoxemia (low oxygen)
what cause tachypnea in adults
–metabolic acidosis
