Quiz 1 Flashcards
Subjective data
aka review of systems
info pt says
Health history
info based on client’s perception
demographics
hx of illness
family hx
review of systems
social hx
Focused interview
starts with open ended Qs and ends with focused Qs
helps determine differential dx
Differential diagnosis
correct dx out of all possible dx
Objective data
what you observe by examination
How should subjective and objective data be kept?
separate in documentation
What are the methods for validating data?
repeat an assessment
consult w/ another clinician to review data
talk to family
ask clarifying Qs
compara objective vs subjective
What is the order of assessment?
inspect
palpation
percussion
auscultation
depends on system
abdomen:
inspection
auscultation
palpation
percussion
What is important to do with assessment findings?
label
be cautious with abbreviations
What are different types of pain rating scales?
numeric rating scale 0-10
Wong-Baker FACES
PAINAD (pain assessment in advanced dementia)
FLACC (face, legs, activity, cry, consolability)
POLDCART
Previous hx
Onset
Location
Duration
Characteristic
Aggravating factors
Relieving factors
Time
PQRST
Provoking factors
Quality
Radiates to (or Region)
Severity
Time
When inspecting, what should be assessed for each body system?
color
size
shape
contour
symmetry
movement
drainage
color
When palpating, what should be assessed?
size
mobility
position
temperature
texture
tenderness
How is light palpation done?
one handed
with finger pads of dominant hand circular motion
1 cm depth
How is deep palpation done?
extended fingers of non dominant hand
downward
2-4 cm depth
Why is percussion done?
to check if it is hollow or dense
What are the 3 types of percussion?
direct
blunt
indirect
How is direct percussion done?
tapping the boyd with fingertips of dominant hand
not used often
How is blunt percussion done?
placing palm of non dominant hand flat against the body surface and striking the non dominant hand
assesses pain and tenderness
screens kidney issues
How is indirect percussion done?
tapping middle finger of nondominant hand over area being examined
most used
The less dense the tissue…
the louder and longer the tone
Tympany
loud high pitched
drum like tone
medium duration
ex: gastric bubble in stomach or air filled intestines
Resonance
loud low pitched
hollow tone
long duration
ex: air moving in thorax
Hyperresonance
abnormally loud low tone
longer duration
air trapped in lungs
ex: COPD pts (barrel chest)
Dullness
high pitched tone
soft sound
short duration
heard over solid body organs
Flatness
high pitched tone
very soft sound
very short duration
ex: bone, muscle
What is the diaphragm on the stethoscope used for?
high pitched sounds
What is the bell on the stethoscope used for?
low pitched sounds
What precaution should be used for every patient?
standard precautions
What order should vital signs be taken?
Temp
Pulse
Respiratory rate
Blood pressure
Pain rating
Oxygen saturation
What does culture have a direct impact on?
an individual’s worldview
What are examples of ethnic identities?
black people
jewish people
mexicans
asian people
What are examples of race?
asian
african american
american indian
white
What can lead to stereotyping?
failing to recognize variations in cultural practices
Ethocentrism
tendency for people to think that their ways of thinking, acting, and believing is the only right way
How does cultural competence ensure high quality care?
allows us to further differentiate an expected finding/outcome from an abnormal finding/outcome
When are interpreter services needed?
medication
consent
teaching
What is an appropriate way to refer to a deaf person?
not okay - hearing impaired
okay - deaf, hard of hearing, person w/hearing loss
Is it appropriate to ask a deaf person if they can read lips?
no
