Test 1 Flashcards
What the person says about his/her self
Subjective data
What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
Objective data
Analyzing health data and drawing conclusions to identity diagnoses
Diagnostic reasoning
Hypothetico-deductive process
- Attending to initially available cues
- Formulating diagnostic hypothesis
- Gathering data relative to the tentative hypothesis
- Evaluating each hypothesis with new data collected
Cue
Is a piece of information, sign, symptom or a piece of laboratory or imaging data
Hypothesis
Tentative explanation of a cue or a set of cues that can be used to further investigation
Nursing process
-Assessment
-Diagnosis
-Outcome identification
-Planning
-Implementation
-Evaluation
First level priority
Emergent - immediate - life threatening
Second level priority problems
Next in urgency - prompt intervention
Third level priority problem
Important to the patient but can be attended to after.
Evidence based practice
Most current best techniques
Four types of data
Complete - total health database
Focused or problem centered database
Follow up database
Emergency database
Holistic health
Whole person essence
SDOH
Social determinants of health
SDOH
Economic stability
Education
Social and community context
Neighborhood and built environment
Health and health care
Acculturation
Adopting the culture and behavior of the majority culture
Acculturation stress
Losses and changes when adjusting to beliefs, routines, and social role
Beliefs and causes of illness
Biomedical
Naturalistic
Magicoreligious
FICA
-Faith
-Importance/ influence
-Community
-Address/action
Ten traps of interviewing
-Providing false assurance or reassurance
-Giving unwanted advice
-Using authority
-Using avoidance language
-Distancing
-Using personal jargon
-Using leading or biases questions
-Talking too much
-Interrupting
-Using WHY questions
Physical environment
Place distance between you and client 4-5 feet
Equal status seating
eye level placing chairs at 90 degrees.
Open-end questions
Topic to be discussed but in general terms
Closed or direct question
yes, no, or forced choice
Healthy literacy
ability to understand instructions, navigate health care systems and communicate concerns.
Oral teaching
-Say: Feel for lumps about the size of a pea.
Don’t say: Feel for lumps about 5 to 6 millimeters.
-Say: Birth control
Don’t say: Contraception
-Say: Cook chicken until it is no longer pink.
Don’t say: Cook chicken to an internal temperature of 165° F.
Interprofessional communication
communication that occurs between 2 or more individuals from different health professions (e.g., nursing, therapy services, physicians)
SBAR
Situation, Background, Assessment, Recommendation
Eight critical characteristics:
-Location
-Character or Quality
-Quantity or Severity
-Timing (Onset, Duration, Frequency)
-Setting
-Aggravating or Relieving Factors
-Associated Factors
-Patient’s Perception
PQRSTU
P: Provocative or Palliative.
Q: Quality or Quantity
R: Region or Radiation.
S: Severity Scale
T: Timing
U: Understand Patient’s Perception of the Problem
CAGE
Cut down, Annoyed, Guilty, and Eye-opener
Nonverbal communication
-Physical appearance
-Posture
-Gestures
-Facial expressions
-Voice
-Touch
Assimilation
unidirectional in linear fashion
Bicultralism
reciprocal change maintaining ethnic identity.
Medication reconciliation
comparison of a list of current medications with a previous list
Biographic data
When did the person enter the United States and from what country?
Respiratory System.
asthma, emphysema, bronchitis, pneumonia, TB
Hematologic System.
Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
Perception of Health
Ask the person questions such as: “How do you define health?
Source of History
- Person providing information and relation to child
- Your impression of reliability of information
- Any special circumstances (e.g., the use of an interpreter)
Endocrine System.
History of diabetes or thyroid disease; excessive hunger, thirst, or urinating
HEEADSSS
Education and employment
Eating peer-related
Activities
Drugs
Sexuality,
Suicide/depression
Safety
Mental Status
Mental status is a person’s emotional (feeling) and cognitive (knowing) function.
Organic disorders
brain disease i.e. dementia, alcohol and drug intoxication, withdrawals.
Affect
temp expression
Mood
durable prolonged display of feelings
Abstract reasoning
pondering - deeper meaning beyond the concrete and literal.
Perceptions
five senses
Components of the Mental Status Examination
Appearance, Behavior, Cognition,
and Thought processes, or
A, B, C, T
Aphasia
impairment of language ability secondary to brain damage
PHQ-2
works as a screening tool for depression.
Denver II screening
gives you a chance to interact directly with the young child to assess mental status
Summary Checklist: Mental Status Assessment
- Appearance
Posture
Body movements
Dress
Grooming and hygiene
Pupils - Behavior
Level of consciousness
Facial expression
Speech (quality, pace, articulation, word choice)
Mood and affect - Cognitive function
Orientation
Attention span
Recent and remote memory
New learning—the Four Unrelated Words Test
Judgment - Thought process
Thought process
Thought content
Perceptions
Screen for suicidal thoughts - Perform the Mini-Mental State Examination, MoCA, or the Mini-Cog
Skills requisite for the physical examination
inspection, palpation, percussion, and auscultation.
Palpation
follows and often confirms what you noted during inspection - applies to your sense of touch.
Percussion
tapping the person’s skin with short, sharp strokes to assess underlying structures.
Production of Sound
-amplitude
-pitch
-quality
-duration
otoscope
funnels light into the ear canal and onto the tympanic membrane
ophthalmoscope
illuminates the internal eye structures
The Toddler
Erikson’s stage of developing autonomy.
Hyperthermia
fever, is caused by pyrogens secreted by toxic bacteria
Hypothermia
caused by accidental, prolonged exposure to cold
tympanic membrane thermometer (TMT)
eardrum
tachycardia
over 95 beats/min or over 100 beats/min
sinus arrhythmia
irregularity that is commonly found in children and young adults
bradycardia
adult a resting heart rate less than 50 beats/min
systolic
max pressure felt on the artery during L ventricular contraction.
diastolic
resting pressure - blood exerts constantly between each contraction
pulse pressure
difference between systolic and diastolic pressure
mean arterial pressure (MAP)
the pressure forcing blood into the tissues averaged over the cardiac cycle
Five factors of BP
-cardiac output
-vascular resistance
-volume
-viscosity
-elasticity of arterial walls
Cardiac output
blood pumps more into blood vessels causes container walls to increase
Peripheral vascular resistance
constricted vessels - pressure will need to push the contents
Volume of circulating blood
how tightly the blood is packed into the arteries
Viscosity
thickness of blood
auscultatory gap
a period when Korotkoff sounds disappear
Korotkoff sounds
which are the components of a BP reading first described by a Russian surgeon in 1905
Tympanic Membrane and Temporal Artery
toddlers who squirm at the restraint
nociceptors
detect painful sensations
Aδ
myelinated and larger in diameter; thus they transmit the pain signal rapidly
Aδ
localized, short term, and sharp in nature
C
unmyelinated and smaller, and they transmit the signal more slowly
interneurons
fibers synapse
anterolateral spinothalamic tract.
pain signals then cross over to the other side of the spinal cord and ascend to the brain
Nociception
(1) transduction, (2) transmission, (3) perception, and (4) modulation
transduction
noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery
perception
signifies the conscious awareness of a painful sensation
