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Health Assessment > Unit 1 > Flashcards

Unit 1 Flashcards

Chapter 1-4

1
Q

What are the 4 broad goals of ANA?

A

promote health, prevent illness, treat human responses to health or illness, advocate (individuals, families, communities, and populations)

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2
Q

What are the care responsibilities for a nurse?

A

independent interventions, patient teaching, therapeutic communication, phys procedures)

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3
Q

Once you are a member what’s your role

A

scholarship and research, advocacy, nursing values

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4
Q

APRN education

A

BSN; MSN; Doctorate (2015)

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5
Q

Types of APRN roles

A

NP, CNM, CRNA, CNS

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6
Q

What is health assessment?

A

Gathering info about the health status of the patient analyzing and synthesizing those data, making judgements about nursing interventions based on those findings and evaluating patient care outcomes

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7
Q

Subjective assessment

A

comes from the patient (pain)

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8
Q

A health assessment includes

A

Health history, physical assessment, psychological, sociocultural (Knowing cultural needs), spiritual, economic (trouble affording meds + bills), lifestyle

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9
Q

Objective assessment

A

based off facts using senses (groining, med history

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10
Q

Nursing process begins with a?

A

complete and accurate health assessment

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11
Q

What is wellness?

A

Integrated method of functioning, which is oriented toward maxing the potential of which the individual is capable

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12
Q

What is healthy people

A

list of goals 10yrs in advance to resolve issues that are going in society.
2020: teenage pregnancy
2024: homelessness and kids not going to school

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13
Q

Do nurses collab to promote higher levels of wellness?

A

Yes

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14
Q

Ten foci

A

goals, evaluation, and revision

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15
Q

What is a primary prevention

A

strategies aimed at preventing problems (before they’re sick). Ex: education

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16
Q

What is secondary prevention

A

early diagnosis, prompt treatment. Ex: pap smear, looking for evidence)

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17
Q

Tertiary prevention

A

preventing complications of existing disease, promoting highest health level possible. Ex: meds, monitor levels, recommending to see another doctor

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18
Q

What is the nursing process?

A

Assessing, diagnosing, planning, implementing, evaluating

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19
Q

What is assess stage?

A

complete, accurate health data compilation

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20
Q

What is diagnose stage?

A

determine patient’s condition

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21
Q

What is plan stage?

A

formulation of goals. Patient outcomes are more specific than goals

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22
Q

What is plan care stage?

A

determine resources, nurse interventions, write plan of care

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23
Q

What is implement stage?

A

any treatment, monitor health status (control problem), assist ADL

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24
Q

What is Evaluate stage?

A

efficiency in meeting patient goals, did plan work?

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25
Q

Critical thinking

A

requires knowledge skills, experience, continually reevaluating, self-correcting, striving for improvement

  • Purposeful, outcome directed (result-oriented) thinking
  • I have an issue with a patient what will I do?
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26
Q

Diagnostic reasoning

A

gathering data to draw inference and propose nursing diagnoses
- based on critical thinking
- 7 step process : identify abnormal data, cluster data, draw inferences, purpose nursing diagnoses

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27
Q

Whats the 7 step process of health assesment

A

check for presence of defining characteristics, confirm or rule out nursing diagnosis, document conclusions, collab problems

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28
Q

3 types of assessments

A

emergency, comprehensive, focused

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29
Q

What is an emergency assessment?

A

life- threatening or unstable situation (whats wrong and what to do; possible dying)

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30
Q

What is a comprehensive assessment?

A

complete health history and physical assessment
- annually for outpatients, admitted to hospital, every 8 hrs in critical care

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31
Q

What is a focused assessment?

A

used most often for nurses
ex: patient had open heart surgery (pain, on O2, difficulty moving, edema)
- Assess/evaluate: cardio, vascular, pulmonary, integumentary
- pull up patient history applicable to situation

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32
Q

what is priority setting

A

prioritizing assessment when figuring out diagnosis. Most important thing first and least important last

33
Q

Frequency of assessment varies due to?

A

patient needs, health care setting, nurse’s role, data collection purpose

34
Q

Well visit assessment (frequency)

A

most common (preventative)
- 0 to 10 yrs: monitor growth, development
- 11 to 24yrs
- 25 to 64yrs
- 65 yrs+ : treatment of acute, chronic illness

35
Q

State the components of a comprehensive health assessment

A

cognitive/emotional development, and physical gowth
- identify: expected growth, development patterns, expected variations, aberrations, and deviations

36
Q

What are the three frameworks for collecting health assessment data

A

functional assessment, head to toe, and body systems

37
Q

Functional assessment

A

focuses on functional patterns all humans share

38
Q

Head to toe assessment

A

most organized; top to bottom

39
Q

Body systems approach

A
  • organizational for documentation, communication
  • promotes critical thinking
40
Q

Evidence based practice

A

-relies on research findings
- clearly defines problem and chooses an intervention based on findings

41
Q

Communication process

A
  • complex, ongoing, interactive
  • continuous dynamic, subject to interpretation and understanding
42
Q

Therapeutic communication

A

caring and empathetic

43
Q

Nonverbal communication skills

A
  • physical appearance/ facial expression
  • posture
  • gestures, eye contact
  • touch: essential, dominant component of phys exam
44
Q

Verbal communication skills

A
  • effective interviewing skills (learned via practice and repetition)
  • speech patterns (moderate pace, clear articulation)
  • Patient w limited english ( clear lang at normal volume)
45
Q

Active listening

A
  • ability to focus on pt’s and their perspectives
  • talking abt difficult feelings helps pts to heal
46
Q

What does purpose, reflection, elaboration, and silence have to do with communication?

A
  • ask pts to elaborate
  • summarize main points
  • assist pts to more completely describe difficulties
  • purposely allow pts time to gather thoughts and accurate answers
47
Q

What does focusing, clarification, and summarizing have to do with clear communication?

A
  • redirecting pts to topic being discussed
  • questions to make sure pts meaning when things are unclear
  • reviewing and condensing important info
48
Q

types of non therapeutic responses

A
  • false reassurance (its going to be okay)
  • sympathy (be empathetic instead)
  • unwanted advice
  • biased questions (you dont smoke do you? , you only have sex w girls right?)
  • changes of subject
  • distractions
  • tech or overwhelming words
  • interrupting
49
Q

Describe sensitivity to intercultural communication, including working with patients who have limited knowledge of the English language, and being sensitive to gender-related issues.

A
  • Assess the degree to which people identify with cultural norms. Limited English: can use interpreter, cover one concept at a time, use simple terms or phrases, can pantomime questions, wait for responses.
  • Gender-related issues: Gender affects how someone processes information.
50
Q

Pre-interaction phase of interview process

A

gather data from medical record.

51
Q

Beginning phase of interview process

A

introduce self. getting patient to relax. privacy is essential.

52
Q

Working phase of interview process

A

collect data by asking specific questions. (closed and open ended questions.) also chart the patients history and health problems.

53
Q

differentiate primary from secondary data

A
  • Primary: individual patient
  • Secondary: charts, info, family members, and other health care providers.
53
Q

Closing phase of interview process

A

summarizing and stating the two or three most important patterns or problems. ask whether the patient need anything else.

54
Q

emergency healthy history

A

nurses collect the most important information and defer obtaining details until patient is stable.

55
Q

Focused health history

A

the focused health history involves questions that relate to the current situation

56
Q

Comprehensive health history

A

Takes place during an annual physical examination, for sports participation screening and during hospital admission

57
Q

Identify the components of the comprehensive health history

A

Demographic data, the reason for seeking care, history of present illness(onset, location, duration, character, associate factors, relieving factors, timing, and severity.), Past health history(medical and surgical), current meds, allergies, family history, and activities of daily living. with pediatric patients, observe growth and fine motor skills

58
Q

review of systems

A
  • questions about all body systems that help to reveal concerns as a part of a comprehensive health assessment.
  • ask about any symptoms related to each body system. also can obtain data about the patient’s health promotion practices.
59
Q

Gordon’s nursing framework

A

Holism and the totality of the person’s interactions with the environment form the philosophical foundations of Gordon’s functional health patterns. View the individual as a whole being using interrelated behavioral areas. Nurses can perceive and record complex interactions of the individuals biophysical state, psychological make up and their relationship to the environment. Data is collected and organized into the Functional Health Patterns. Assessment information is displayed as a concept map

60
Q

demonstrate knowledge of precautions for infection control and safety.

A

diligent hand hygiene, use of gloves(reduce risk of acquiring infections from patients, and prevent transmission) and standard precautions.

61
Q

Identify specific characteristics of inspection

A
  • performed on every part of the body.
  • purpose to gain an overall impression of the patient and to assess the severity of the situation. note physical behaviors and any odors.
  • observe overall characteristics such as age, gender, level of alertness, body size, shape, skin color, hygiene, posture, and level of discomfort and anxiety.
62
Q

light palpation

A
  • avoid tender or painful area until the end. appropriate for assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin.
  • approximately 1 cm in depth.
63
Q

Deep palpation

A

pressure should be firm enough to dress approximately 1-2 cm. observe patient for any signs of pain.

64
Q

physical properties of sound and sound conduction

A
  • intensity or loudness (volume)
  • pitch/frequency: vibration oscillation speed
  • duration (length of time sound lasts)
  • quality (subjective descrp of sound)
65
Q

Describe the techniques of direct and indirect percussion

A

direct: tap fingers directly on skin
indirect: use non dominant hand as barrier on which to strongly tap

66
Q

describe the qualities of auscultation to be assessed with a stethoscope

A

vary depending on the body part listened to (BP, hear, lungs, abdomen)
- described with intensity, pitch, duration, and quality.

67
Q

Some equipment used during the physical examination

A

** GATHER ALL EQUIPMENT**
- vital signs equipments (thermometer, alcohol, BP cuff/machine, second hand, stethoscope)
- scale, flashlight
- meterials for recording findings

68
Q

Document findings from the four basic examination modes

A
  • Inspection: visualization of general appearance
  • palpation: sense of touch
  • percussion: tapping to assess cond. of hollow/fluid filled spaces
  • Auscultation: listening to assess organ and tissue condition
69
Q

Describe the multiple purposes of the patient medical record

A

it is a legal document as well as a method of communication among health care providers, care planning, quality assurance, financial reimbursement, education, and research.

70
Q

discuss the significance of accurate and timely documentation

A
  • accuracy permits comparison of current findings with future data to detect changes in patient status.
  • timeliness is important for when you wait to enter data you may forget important information or chart on the wrong patient.
71
Q

describe the relationship between reporting patient assessment data and ensuring patient safety

A

assessment data provides baseline data. it is important to protect patient confidentiality at all times

72
Q

Discuss ethical and legal considerations when documenting and reporting assessment information into the patient record.

A
  • take into account HIPPA laws (health insurance portability and accountability act); protection of specific health info
  • report any incidents ASAP
73
Q

SOAP notes

A

subjective; objective; analysis; plan; interventions; evaluation

74
Q

PIE notes

A

problem, interventions, evaluation

75
Q

DAR notes

A

data, action, response

76
Q

CBE notes

A

charting by exception; outside normal limits, assessment data requires additional documentation

77
Q

Look at SBAR desktop pic

A

Health Assessment (7 decks)

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