Test 1 Flashcards
Nursing process -steps
Assessment,
diagnosis,
outcome identification,
planning,
implementation,
evaluation
(*Perform the nursing actions identified in planning)- nursing process
Use community resources
Provide health teaching and health promotion
Document implementation and any modifications
Coordinate care delivery
Use evidence-based interventions
Implement in a safe and timely manner
Implement
Evaluate persons condition and compare actual outcomes with expected outcomes (progress toward outcomes)
Include patient and significant others
Ongoing assessment to revise plan or diagnoses
Communicate/inform results to patient and family
Evaluation
Review the clinical record
Health hx
Physical exam
Functional assessment
Cultural/spiritual assessment
Use evidence-based assessment techniques
Assessment
Compare clinical Findings of normal and abnormal variation in developmental events
Cluster associated data
Validate data
Confirm accuracy
Look for gaps
Interpret and Identify problem/data
Document the dx
Diagnosis
Identify expected outcomes
SMaRT components
Short term and long term goal measurement
Include a timeline
Cultural appropriate
Individualize to person
Realistic and measurable
Outcome identification
Establish priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
Document plan of care
Planning
What are the components of evidence based decision making ?
Is there scientific evidence/research evidence
Patient preferences/values/circumstances
Clinicians experience and judgement
SMaRT components ?
Specific
Measurable
Attainable
Relevant
Time bound
Closed or open ?? Benefits of it
Tell me how you are feeling?
Open ended questions:
Narrative answers
Feelings and opinions
Develops rapport
Closed or open??
Do you have pain?
Benefits?
Closed ended questions
- specific info
- yes or no
- limits rapport, neutral
Barriers to communication? Not to use
Providing false assurance or reassurance
Giving unwanted advice
Using authority (your dr knows best)
Avoidance language (they are in a better place)
Distancing (lump in “the breast”)
Adjust language to patient understanding
Leading questions (you don’t smoke do you?)
Interrupting
Don’t use why questions
Nonverbal skills (touch, voice,eye contact, gestures , facial expressions, posture , appearance
Reason for facilitation, cues, leads ?
Examples ?
Shows you are listening
Encourages to say more
- nodding head yes
- mmhmm
- eye contact, shift forward
Gives the client time to think
Silence
Echos clients words to help patient identify feelings
“You have difficulty getting the day started?”
“It’s hard getting up in the morning”
Reflection
It must be difficult not being independent
Empathy
So you have difficulty lying down if you lie flat and you need pillows?
Clarification
Before you said you do not smoke but now you mentioned smoking with your friends?
Confrontation
I always take this blanket with me.
So this blanket must be very important to you
Interpretation
You cannot eat anything for 12 hours prior to surgery
Explanation
Condenses everything discussed allows plants to make corrections if needed
Summary
Lack of interest/attention
Door, curtain, computer, temp
Patient can not hear you
Safety- fear
Psychological barriers: Shocked, fear, embarrassed
Language Barrier
Barriers to communication
Types of pain
Referred Phantom Acute Chronic Breakthrough pain
Pain that is felt in a location other than where the pain originates
Referred pain
Feeling like the limb is still there after amputated due to damaged remaining nerve endings
Phantom pain/ sensation
Short term pain which is self limiting
Cause by ?Tissue damage
Less than 6 months
Mild moderate pain- sympathetic ns ?
Severe pain- parasympathetic ns ?
Acute pain
Last longer than 6 months
Intermittent or continuous
Does not stop after injury heals
Abnormal processing of pain fibers ?
Chronic pain
How to assess pain? Physical changes with pain ?
Posture/behavior
Facial expression
Sounds
Palpation
Vitals (increased BP, Pulse, resp)
Pupil size dilation
Sweating/increased temperature
Pain that occurs between doses of pain medication
Breakthrough pain
Pain that is acute and starts outside NS
Results in actual or potential damage
Responds to opiated and inflammatories
Nociceptive pain
Abnormal processing of pain from injury to nerve fibers or CNS
Chronic
Numbness, tingling,shooting, burning, poorly responsive to pain meds
Neuropathic pain
The point at which a person feels pain
Pain threshold
Duration or intensity of pain a person will endure before outwardly responding
Pain tolerance
What is pain ?
Whatever the patient says it is and whenever they say it is occurring
PQRST pain assessment
Precipitating or palliative
Quality or quantity
Region or radiation
Severity scale
Timing
What consists of substance abuse assessment ?
Techniques to elicit (get) info from patient?
Learn terminology
Tolerance
Dependency vs addiction
Watch for withdrawal symptoms such as nausea, vomiting, anxiety, headache, tremor
???
CAGE questionnaire ?
Cut down, annoyed, guilty, eye opener
Questions to determine if your running is uncontrolled
Cut down (should you cut down?)
Are you annoyed of criticism you get about your drinking )
Have you ever felt guilty about your drinking?
Do you drink in the morning ?
Alcohol use disorders identification test
AUDIT- questionnaires with ? Such as how often do you have a alcoholic beverage?
Covers 3 domains: alcohol consumption, drinking behavior or dependence , and adverse consequences from alcohol
Frequency of use of alcohol, tobacco, rx, for non-medical use, illicit drugs
Quick assessment (substance abuse)
Who needs to be assessed for domestic violence ?
When to report??
Everyone
What percent of women and men experience rape, physical violence and/or stalking ?
36% women and 29% men
Types of violence or abuse
Sexual Physical Threats Emotional Neglect Financial
How to asses intimate partner abuse IPV
Scores?
Use your own words and be non- judgmental such as “domestic violence is so common I ask all my patient about abuse in the home.”
HITS H-hurt I- insult T-threaten S-scream
1-5 never to frequent
10 or more indicates IPV
When to assess for IPV?
Assess at every visit
Abuse assessment screen
S/s of abuse
Frequent UTIs
Chronic pelvic pain
STIs
Anxiety/depression
Back pain
PTSD
Failure to follow up
Frequent healthcare visits
S/s of human trafficking
Injury/sign of abuse
Malnourished
Disoriented
Lack of ID
Few personal belongings
Fearful, anxious, submissive
Scared of the law
Can not freely contact friends and family
Avoids eye contact
What to do if you see signs of human trafficking?
Must report
Call 911 if unsure
Contact national human trafficking resource center
What are the characteristics and risks of human trafficking ?
Victims are usually white/black and US citizens
Risk factor:
Age Poverty Unemployed Gender inequality Sexual abuse Mental or health problems
The degree of balance between nutritional intake and nutrient requirements
Intake sufficient for basic needs
Nutritional status
Optimal nutrition
Two are two primary components of this :
Health history-subjective
Physical examination-objective
Health assessment
Too much food energy or excess nutrients to the degree of causing disease or increasing risk of disease, a form of malnutrition (sedentary lifestyle)
Related conditions:
Heart disease
Diabetes 2
Stroke
Gallbladder disease
Overnutrition
What fraction of kids are overweight or obese?
What ages?
1/3
Ages 6-19
Occurs when nutritional reserves or depleted or when nutrient intake is in adequate to meet day today needs or added metabolic demands
- impaired growth
- lowered resistance to disease
- delayed wound healing
Undernutrition
How to asses food intake ? What methods??
24 hour recall
Food diary (most comprehensive)
Food frequency
Typical food intake
Direct observation
Difference between 24 hour food recall and food diary ??
Food diary may be more accurate - write down everything consumed for a certain period of time. Write down immediately after eating.
24hour recall- questionnaire to recall everything eaten within the last 24 hours. Can evoke Specific information about dietary intake.
Factors what can affect nutritional status?
Problem based hx:
Weight loss, weight gain (when it started, intentionally ?
Difficulty chewing or swallowing
(Types of food you eat)
Loss of appetite/nausea
Normal vs for an adult:
Bp:
P:
R:
O2:
T:
Bp:systolic- 90-120
Diastolic- 60-80
P:radial, apical, carotid , brachial 60-100 bpm
3+ is full, bounding
2+ is normal
1+ is weak
0 is absent
R:10-20 count for 30 sec x 2
T:98.6
O2:95-100%
How to take-
pulse:
Bp:
30 seconds and times by 2
What affects vital signs?
Stress, pain, drinking fluids, temperature, position, wrong cuff size …
??
What can influence a normal body temp ? What is being assessed?
Drinking hot or cold fluids Exercise Stress Age Gender - mensuration in women Time of day Smoking Chewing gum
Characteristics assessed for pulse?
Pulse strength , Rhythm, BPM
R-
What does a normal breathing pattern look
Like?
relaxed, regular rhythm, quiet, 12-20 per minute
Temperature methods? Accuracy of them? Trouble shooting?
Tympanic ear - accurate Oral - most convenient and accurate Temporal- fast and accurate Rectal -most accurate to core temp Axillary- arm pit - kids
What do the bp numbers mean?
Systolic ?
Diastolic?
Bp is the force of blood pushing against the side of the vessel wall. (The strength charges with the event in the cardiac cycle)
S-the maximum pressure felt in the artery during left ventricular contraction
D-blood pressure flow when heart is relaxed or resting between each contraction
What is orthostatic bp?
A change in bp after standing up after laying down.
Person may feel faint or dizzy
Types of assessments to screen for pt history?
Comprehensive health hx
Complete total health
Focused or problem- centered database
Primary, secondary, and tertiary prevention
General survey
Comprehensive health hx
A detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam.
Also includes an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers.
Complete total health
Complete health hx and a full physical examination
Yields the first diagnosis
Focused or problem- centered database
Limited or short term problem. Mainly one problem or one body system
Primary, secondary, and tertiary prevention
Primary- prevents health problems (safety glasses, vaccines, exercise)
Secondary- screening, catch problems early
Tertiary- cardiac rehab, support groups
General survey - what is it and what things to look for in patient?
A study of the whole person, covering the general health state and any obvious physical characteristics
Age sex, loc, skin color
Posture , body build
Gait, ROM
Facial expression, mood , speech, dress, hygiene
Intro for the physical , objective parameters which apply to the whole person
How the person stands at their name , so they look sick?, make eye contact? Smile, shake hand firmly? Health hx, measurements , vs
**Physical appearance , body structure, mobility, and behavior
How and when to use tools/equipment?
Oximeter ?
Thermometers?
Stethoscope ?
Etc.
Have all equipment at easy reach and laid out in an organized fashion
Make sure they care cleaned after using with sanitizer whipe
What are the 4 techniques of assessment?
What information will each technique tell you?
- inspection
- palpation
- percussion
- Auscultation
Why to use assessment techniques?
to know your patient and identify their real needs
Forms the basis of the care plan
Direct vs indirect percussion?
direct, which uses only one or two fingers, Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses)
indirect, which uses the middle/flexor finger. striking a punch-like object with a hammer or percussor. Mediate Percussion; Involves 2 hands
Know medical terminology- from packet??
??
Know definitions in culture
From crossword-mod 3
Snsn
What are some cultural competence methods?
Explore patients beliefs , values, and needs to build effective relationships with them.
Understand that each patient is unique
Causes/types of illness in culture?
Biomedical illness
Naturalistic illness
Magiocoreligious illness
What is a material vs non material cultural characteristic?
Material: dress, tools, art
Non material: verbal, religion, customs, beliefs
What are the components of a mental assessment?
ABCT:
Detailed mental status exam
Assess through health hx
Be aware of:
Meds taken
Hx of alcohol or drug use
Stress levels
Sleep disorders
Appearance
Behavior
Cog function
Thought process
What are expected age related changes? When it comes to memory/mind?
? Normal aging is associated with a decline in various memory abilities in many cognitive tasks; the phenomenon is known as age-related memory impairment (AMI)
May need more time to learn new material or tasks
A condition which is Sudden onset, interrupting the bodies homeostasis
Orientation:
Altered consciousness
Rapid mood swings/emotions
Reversible
Delirium
delirium?
What can affect it?
start of delirium is usually rapid — within hours or a few days. Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal
This condition has a slow gradual onset (organic)
Orientation:
Consciousness is not altered
Flat, agitated
Incoherent , slow, repetitive
Not reversible
Dementia
What can affect dementia :
Can be caused by vascular disease, HIV, Alzheimer’s disease
how to Assess ones orientation?
Test attention span
Recent memory
Remote memory (long term)
New learning
Components of the mental exam status ?
MMSE (mini-mental state examination
Set of 11 questions that tests orientation to time and place , naming , reading, copying orientation , writing, and following three stage command. Can also test for dementia or mental illness
Performing mini-cog? What is it?
A newly developed, reliable , quick and easy available instrument to screen for cognitive impairment in healthy older adults
Takes 3-5 minutes- ask adult to listen carefully to, then repeat the 3 words that you will say. (Short And unrelatedly words) Make sure there are no distractions. Have them do something else and then repeat again later.
Disease caused by bacteria, virus, etc
Biomedical illness
Illness caused when there is loss of natural balance
Ting/yang
Hot/cold
Naturalistic illnesses
Illness caused by supernatural forces
Folk remedies
Magiocoreligious
What is normal gait?
Walk is smooth and even
Balance with out assistance
Movement of arm symmetry are present
WT and height in 80s and 90s ?
Prominent bony areas
Muscle shrinkage and weight and height decreases- especially in males
Fat loss from face , forearms, abd and hips (even with good nutrition)
