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Health Assessment > TEST #1 REVIEW > Flashcards

TEST #1 REVIEW Flashcards

1
Q

Chief Complaint (CC)

A

The SIGN (objective finding) or SYMPTOM (subjective finding) that causes the patient to seek health care

The reason for seeking health care and the CC should be recorded as direct quotes from the patient

-what concern(s) bring you here today?

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2
Q

Quality of Pain

A

Describes the way the CC feels to the patient
-Use the Patient’s own terms to describe the quality of the CC

Suggest some quality terms such as:
-Gnawing, pounding, burning, stabbing, pinching, aching, throbbing, and crushing.

What does the headache feel like?

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3
Q

Complete Health History

A

Comprehensive HX of past and present health status and covers many facets of a pt’s life.
-Gathered on initial nonemergency visit & upon admission to the hospital

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4
Q

Episodic Health History

A

Shorter and is SPECIFIC to the pt’s CURRENT REASON for seeking health care.

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5
Q

Interval / Follow-up health history

A

Builds on preceding visit to a health care facility

-Documents pt’s recovery from illness, such as the SORE THROAT & FEVER, or progress from a prior visit.

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6
Q

Emergency Health History

A

Elicited from the pt and other sources in an emergency situation.
-Only info that is REQUIRED IMMEDIATELY to treat the emergent need of the pt is gathered.

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7
Q

Associated Manifestations of the CC

A

Sings and symptoms that accompany the CC

Positive findings
-those associated manifestations that the patient has experienced along with the CC

Negative findings (Pertinent Negatives)
-Manifestations expected in the patient w/ a suspected pathology but which are denied by the patient
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8
Q

Positive Findings

A

Those associated manifestations that the pt has experienced along w/ the Chief Complaint (CC)

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9
Q

Negative Findings (pertinent Negatives)

A

Manifestations expected in the pt w/ a suspected pathology but which are denied by the pt.

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10
Q

Suspected Violence

A

It is estimated that up to 30% of injured women treated in the ER departments have suffered from DOMESTIC or INTIMATE partner violence (IPV)

If violence is suspected, you need to inquire whether the pt feels safe in his or her current environment or situation.

Using the comm technique of NORMALIZING, the nurse can screen for potential domestic and IPV

HITS screening tool
H-Have you been physically hurt?
I-Have you been insulted or did someone talk down to you?
T- Have you been Threatened w/ physical harm?
S- Has someone Screamed at you or cursed you?

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11
Q

HITS Screening tool for Suspected Violence

A

H- Have you been physically HURT?
I- Have you been INSULTED or did someone talk down to you?
T- Have you been THREATENED w/ physical harm?
S- Has someone SCREAMED at you or cursed you?

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12
Q

Educational level

A

Elicit info on the pt’s ability to read and write.
Ex.
What was the highest grade level that you completed?
Describe the type of student that you were.
Have you completed a GED certification?

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13
Q

Mistakes in Documenting

A

Use a SINGLE LINE to cross out an error, then DATE, TIME, & SIGN the correction

  • Sign each entry w/ full legal name and professional credentials
  • Do not leave space between entries
  • Never correct another person’t entry
  • Use Quotes to indicate direct pt response
  • Document in chronological order
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14
Q

Ages and stages development theory

A

Based on the premise that individuals experience SIMILAR sequential PHYSICAL, COGNITIVE, SOCIOEMOTIONAL, & MORAL CHANGES during the SAME AGE PERIODS or developmental stages

  • Developmental stages
  • Developmental tasks
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15
Q

Achieving physical or phychosocial Skills

A

An INABILITY to achieve the PHYSICAL and PHYCHOSOCIAL skills for a particular developmental stage RESULTS in POSSIBLE DELAYS or INCOMPLETE MASTERY of subsequent developmental skills

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16
Q

Ethnocentrism

A

My culture is better than yours and I could care less about you.

Condition that occurs when individuals or groups perceive their own cultural group, values, beliefs, norms, and customs to be superior to ALL OTHERS and have DISDAIN for the expression and expressor of any other way of life.

-Best way for a nurse to overcome is to acknowledge and examine one’s personal cultural biases.

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17
Q

Cultural Relativism

A
  • Belief that NO CULTURE is INFERIOR or SUPERIOR to another
  • Behavior must be assessed from the cultural aspect in which it occurs
  • Behavior must be evaluated in relation to CULTURAL CONTEXT
  • RESPECT, EQUALITY AND JUSTICE and basic rights for ALL CULTURAL GROUPS.
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18
Q

Value Orientations

A

-Provide order and give direction to thoughts and behaviors in these 5 areas

  • Time
  • Human nature
  • Activity
  • Relational
  • People to nature
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19
Q

“Time” Value Orientation

-What is the time orientation of human beings?

A
  • Past focus: Reverence for LONG-STANDING TRADITIONS.
  • Present focus: Live in the “HERE AND NOW,” perceive time in a linear fashion
  • Future focus: Willing to DEFER GRATIFICATION to ensure they can meet a future goal; tend to be disciplined in scheduling and using time
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20
Q

“Human Nature” Value Orientation

-What is the basic nature of human beings?

A
  • Humans are BASICALLY GOOD.
  • Humans are EVIL but have PERFECTIBLE NATURE
  • Humans are a COMBINATION of GOOD & EVIL, requiring self-control to perfect nature; lapses occasionally occur and are accepted
  • Humans are NEUTRAL, neither good nor evil
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21
Q

“Activity” Value Orientation

-What is the primary purpose of life?

A
  • Being orientation: Humans value resides in their INHERENT EXISTENCE and spontaneity.
  • Becoming-in-being orientation: Human’s value is inherent, but they must engage in continuous SELF-DEVELOPMENT as integrated wholes.
  • Doing orientation: Human’s exist to be ACTIVE & ACHIEVE
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22
Q

“Relational” Value Orientation

-What is the purpose of human relationships?

A
  • Linear relationships: Goals of the family take precedence over the individual’s
  • Collateral relationships: Group goals take precedence. Family and social group emphasized.
  • Individual relationships: Individual goals and accountability for own behavior emphasized
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23
Q

“People to Nature” Value Orientation

-What is the relationship of human beings to nature?

A
  • Humans DOMINATE NATURE and have control over environment
  • Humans LIVE IN HARMONY w/ nature & must maintain balance.
  • Humans are SUBJUGATED to nature & have NO CONTROL over environment
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24
Q

Evil Eye

Mediterranean, African, Spanish Cultures

A

Complimenting a child unprotected by an AMULET, GOLD CROSS, or NOT TOUCHING the child when offering a compliment

Results in:
Headaches, high fever, restlessness, weight loss etc. if you don’t touch child while complimenting

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25
Q

Chinese

-Cultural characteristics

A
  • Value silence
  • May SMILE when they DON’T UNDERSTAND
  • Hesitant to ask ?’s
  • Defer to elderly and authority figures
  • preserve family’s honor, save face
  • Value HARD WORK and giving to society
  • Health is results of balance between YIN & YANG
  • May combine Euro-American and traditional Chinese meds.
  • skeptical of multiple diagnostic tests
  • immunizations acceptable
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26
Q

Vietnamese

-Cultural Characteristics

A
  • AVOID direct EYE CONTACT
  • Disrespectful to question authority
  • Avoid asking direct questions
  • Relaxed concept of time
  • Patriarchal decision making
  • Family needs grater than individual’s needs
  • Education highly valued

Illness caused by
-Natural & Supernatural forces, Metaphysical forces, contamination by germs

  • Restore balance using HOT & COLD FOODS
  • Scientific & Folk Medicine
  • Use herbs and therapeutic diets
27
Q

Filipinos

-Cultural Characteristics

A
  • Eye Contact is avoided
  • SEX, FINANCIAL STATUS are too personal to discuss
  • Engage in small talk before discussing serious matters
  • Value Personal dignity and preservation of self-esteem
  • Strong family ties // multigenerational
  • Individual behavior reflects on family
  • Family interests more important than individual

Illness related to NATURAL, SUPERNATURAL, METAPHYSICAL forces and fatalistic view.

  • Stoic expression // avoids asking for pain meds
  • Pain should be endured
  • Pain is God’s will he will give them the strength to bear it.
28
Q

Islam

-Religion and Health Care

A
  • Monotheistic, Allah (God)
  • Imam’ are the leaders
  • Koran, Shari’a law, Hadith - holy books and artifacts
  • Holy day is FRIDAY
  • Pray 5 times a day from sunup to after sundown
  • Observe the holidays MUHARAM, RAMADAN, SHAWWAL.

DIETARY RESTRICTIONS:

  • No pork, pork products (GELATIN), alcohol
  • fasting from dawn to sundown during ramadan

MED TREATMENT

  • Med care is encouraged
  • Female bodies should remain covered
  • Sexual relations and birth control permitted w/in marriage
  • Abortion forbidden after ensoulment
  • Circumcision is practiced
  • Withdrawal of life support
  • Suicide is forbidden
  • Ceremonial cleansing of the body
  • Burial preferably the same day
  • May receive organ donations, transplanted organs, and blood transfusions
  • first words baby must hear are “There is no God but Allah, and Mohammed is His Prophet.”
29
Q

Islam core beliefs

A
  • Monotheistic
  • Allah (God)
  • Imam
  • Holy day is Friday
  • Observe: Muharam, Ramadan, Shawwal

Holy books
-Koran, Shari’a, Hadith

30
Q

Folk Remedies

A

Practices in which persons engage on their own behalf to aid in health promotion and maintenance, disease or injury prevention or protection, and disease or injury treatment

Vietnamese American May use CAO GIO (skin rubbing w/ a coin)
-Cao gio is not abuse.

31
Q

Culture Shock

A

Disorientation, uncertainty, alienation when adjusting to new culture

32
Q

Spirituality

A

A concern for the meaning and purpose of life

Ex.
belief that both animals and human beings can feel pain and joy, and therefore animals must be treated w/ the same respect shown to humans

33
Q

Agnostic

without knowledge

A

One who is unsure whether God exists

34
Q

Animistic

A

Belief that all components of the universe, including humans, have some form of life force.

-many Native American religions contain this concept

35
Q

Monotheistic

A

Believe in ONLY ONE all-powerful, omnipresent, and omnipotent God (capital G), who created the universe.

  • Judaism
  • Christianity
  • Islam
36
Q

Art of Nursing

A
  • Professional intuition develops w/ experience; guides nursing care
  • Professional intuition develops over time as nurses begin to link patterns to outcomes

Experienced nurse has a feel for the situation

  • birth
  • death
  • worsening condition
37
Q

Scientific Approach to Nursing

A
  • Involves ANALYTICAL THINKING
  • Based on SCIENTIFIC PRINCIPLES & RESEARCH DATA

Analytical thinking skills can be learned
-relationships and patterns can be identified

38
Q

Subjective Data

A

Health history interview is a means of gathering subjective info:

  • Subjective because they CANNOT BE VERIFIED by an independent observer
  • Includes what the pt says and what the pt thinks, attitudes and beliefs
39
Q

Objective information

A

Physical assessment findings:

-Info that is OBSERVABLE & MEASURABLE

40
Q

Nursing Diagnosis

A

-A clinical judgement about individual, family, or community responses to actual or potential health problems/life processes.

  • Formed after the assessment data are analyzed
  • Holistic perspective

NANDA-I
-North American Diagnosis Association International

41
Q

4 steps in the Nursing Diagnosis

A
  1. Collecting Information
  2. Interpreting information
  3. Clustering Information
  4. Naming the cluster (NANDA label)
42
Q

3 Types of Nursing Diagnosis

A

Actual

  • problem oriented
  • Ex. Acute Pain; Impaired Skin Integrity

Potential

  • Increased vulnerability
  • Ex. Risk for infection; risk for falls

Wellness

  • Striving for health
  • Readiness for Enhanced Self-Care
43
Q

Writing a Nursing Diagnosis

A

Descriptor
-Ineffective, Impaired, Deficient, Readiness for…

Label

  • Actual or potential health problem or wellness factor that the nurse has synthesized from the cluster
  • Ex. Ineffective BREATHING PATTERN

Related Factors

  • Related to…
  • ORIGIN of the health problem & can be changed w/ nursing intervention
  • Ex. Ineffective breathing pattern RELATED TO pain; fatigue RELATED TO anemia

Defining characteristics
-Signs, symptoms, and statements made by the pt that validate the existence of the actual or wellness nursing diagnosis

44
Q

Maslow’s Hierarchy of Needs (w/ explanation)

-From Bottom to Top

A

Physiological
-Breathing, food, water, sex, sleep, homeostasis, excretion

Safety
-Security of body, employment, of resources, morality, family, health, of property

Love belonging
-Friendship, family, sexual intimacy

Esteem
-Self-esteem, confidence, achievement, respect of others and by others

Self-Actualization
-Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

45
Q

Maslow’s Hierarchy of Needs

-(List only)

A
  1. Physiological
  2. Safety
  3. Love/Belonging
  4. Esteem
  5. Self-Actualization
46
Q

Patient Outcomes

A

-Statement of the expected change in pt behavior denoting progress toward resolution of the altered human response over a specific time period.

  • Written after pt goals.
  • Realistic, objective, measurable
  • Time frame (short term, long term)

Adjectives are AVOIDED:
-More, less, increased, and decreased

Measurable verbs are USED:
-State, identify, & list

47
Q

Short-term Pt outcomes

A

Time frame over a relatively short period of time, such as 1 hour, 1 day, or 1 week

48
Q

Long-term Pt Outcomes

A

Extend over weeks or months

49
Q

SOAPier

A 
S-Subjective data - pain level
O-Objective Data - X rays / BP // Assessment 
A-Analysis of Data
P-Plan
I- Intervention
E- Evaluation
R- Revision
50
Q

Nurse’s Roll in Pt Interview

A
  • Set the tone
  • Facilitator of interview
  • Establish trust
  • mutual respectful dialog
  • Often 1st person on healthcare team to interact w/ pt
51
Q

Factors Influencing the Interview

-(W/ Explanations)

A

APPROACH
-Gather info 1st // introduce yourself. Name and title
ENVIRONMENT
-Private room
-minimize distraction
CONFIDENTIALITY
-essential for trust
-assuring confidentiality eases pt concern
-ask pt privately if fam or friends should stay in the room during interview
NOTE TAKING
-show pt the form
-MAKE EYE CONTACT // sit at their level
TIME, LENGTH DURATION
-allow enough time for interview
-select a block of time that doesn’t conflict w/ meals
BIASES/PRECONCEPTIONS
-personal beliefs, attitude, value systems, biases can impact the interview

52
Q

Factors Influencing Pt Interview

list only

A
  1. Approach
  2. Environment
  3. Confidentiality
  4. Hippa (Health Insurance Portability and Accountability ACT
  5. Note Taking
  6. Time, Length, Duration
  7. Biases/Preconceptions
53
Q

Stages of the Interview Process

A

Stage 1:
-JOINING – establish trust, get to know the pt.

Stage 2:
-WORKING – Data collected // procedure done

Stage 3:

  • TERMINATION – Info summarized and validated
  • “We have about 5 more min. Is there anything else you would like to add or mention??”
54
Q

Open-ended Questions

A

Effective Interviewing technique

  • Encourage general info
  • Provides pt w/ sense of control

Begin with HOW, WHAT, WHERE, WHEN & WHO

55
Q

Facilitating Techniques

A
  • Head nod

- “go on” Encourages pts to continue

56
Q

Asking “WHY” during interview

A

Why questions should be avoided because the MAKE PT’S DEFENSIVE

57
Q

Using Reflection in the Interview

A

In reflecting, the nurse directs the pt’s own questions, feelings, and ideas back to the pt and provides opportunity for pt to reconsider or expand

Ex. “what do you think about that?”
-“Sounds as if you are pretty angry with him.”

58
Q

Probing

A

Repeated or persistent questioning of the pt about a statement or a behavior increases pt anxiety
CAN CAUSE:
-confusion, hostility, and a tendency to withdraw from the interaction

Go onto the next part of the of the interview and ask permission to return to the topic instead of probing

59
Q

Defending

A

It is NOT HELPFUL for the nurse to defend the object of the attack by the pt. Defending implies that the pt has neither the right to hold such opinions or feelings nor the right to express them.

60
Q

False Reassurance

A

Vague and simplistic responses that question the pt’s judgement, devalue and block pt feelings, and communicate a lack of understanding and sensitivity on the part of the nurse.

-Often increases pt anxiety

61
Q

When a pt is crying…

A

It is important to show empathy and ALLOW the pt to cry.
-Offering tissues indicates to the pt that it is OK to cry and conveys a message of thoughtfulness

-When the pt has regained composure, proceed w/ the interview

62
Q

Interviewing an APHASIC pt

A
  • Ask simple questions that require a “yes” or “no” answer and allow additional time for pt responses
  • If pt cannot be understood, use a written interview format, letter boards, or “yes” “no” cards
  • Allow pt to contribute to info gathering
  • When someone is speaking for the pt, nurse should speak and direct questions to the pt.
63
Q

Hearing Impaired pt interview

A
  • Remain within sight so pt can READ LIPS
  • Ensure hearing aid is in and turned on
  • Minimize background noise
  • Face pt and direct all communication to the pt.
  • Use facial expressions and body language

Often, then best approach is to:
-Allow for more time
Use a written form for gathering data

64
Q

Medical Jargon

A

Can be seen by pt as unwillingness to share or attempts to hide info, or it can give the impression that the nurse FEELS SUPERIOR to the pt and is unwilling to engage in collaboration or mutual problem solving

Health Assessment (8 decks)

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