Unit 1: assessment of the whole person Flashcards
Diagnostic Reasoning
process of analyzing heath data and drawing conclusions to identify diagnoses.
1) attend to initial cues
2) formulate diagnostic hypothesis
3) gather data relative to tentative hypothesis
4) evaluate each hypothesis with new data collected – > arriving at final diagnosis
Nursing process
1) assessment
2) diagnosis
3) outcome identification
4) planning
5) implementation
6) evaluation
assessment
Collect Data: review clinical record, health history, physical exam, functional assessment, risk assessment, review of literature, evidence-based assessment techniques, document relevant data
diagnosis
- Compare clinical findings with normal and abnormal variation and developmental events
- interpret data: identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses
- validate diagnoses
- document diagnoses
outcome identification/planning
- identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include timeframe
- establish priorities
- develop outcomes
- identify interventions
- integrate evidence based trends and research
- document plan of care
implementation
- implement in safe and timely manner
- evidence-based interventions
- collaborate with colleagues
- use community resources
- coordinate care delivery
- provide health teaching and promotion
- document implementation and any modification
Evaluation
- progress toward outcomes
- conduct systematic, ongoing, criterion-based evaluation
- include patient and significant others
- use ongoing assessment to revise diagnoses, outcomes, plan
- disseminate results to patient and family
Critical Thinking Skills
1) identifying assumptions: make sure you are careful to not automatically see something as a fact if it isn’t, don’t take certain information for granted
2) identifying an organized and comprehensive approach: PRIORITIES
3) Validation: check accuracy and reliability of data collected. corroborate with family members, social worker
4) distinguishing normal from abnormal: learn this through experience and gained knowledge
5) making inferences: hypothesis. interpret data and make hypothesis.
6) clustering related cues: find relationships in data
7) distinguishing relevant from irrelevant: full health assessment then take what is actually important
8) recognizing inconsistencies: conflicintg information given versus your findings, etc.
9) identifying patterns: helps fill in the whole pictures and fills in missing information
10) identify missing information: gaps in data, need for more data prior to diagnosis
11) promoting health: identify risk factors,
12) diagnosising actual and potential (risk) problems: see nursing diagnoses
13) setting priorities: when there is more than one diagnosis.
14) identifying patient-centered expected outcomes: timeframe and specific results you are looking for
15) determining specific interventions: prevent, manage or resolve health problems
16) evaluating and correcting thinking: successful interventions, outcomes consistent with goals?
17) determining comprehensive plan: revised plan of care for future
nursing diagnoses
clinical judgements about a person’s response to an actual or potential health state.
1) ACTUAL diagnoses: existing problems that are amenable to independent nursing interventions
2) RISK diagnoses: potential problems that an individual does not currently have but is particularly vulnerable to developing
3) WELLNESS diagnoses: focus on strengths and transitions to an individual’s higher level of wellness.
types of priorities
1) first-level priorities: emergent, life-threatening, immediate
A airway problems
B breathing problems
C cardiac/circulation problems
V vital sign concerns
2) second-level priorities: next in urgency, prompt intervention to forestall further deterioration (mental status change, acute pain, risk of infection)
3) Third-level priorities: important to patient’s health but can be addressed later (chronic low self esteem, dysfunctional family process)
**Collaborative problems–> approach to treatment involves many disciplines (exp: alcoholic)
setting priorities
1) make a list of current meds, medical problems, allergies, reasons for seeking care.
2) determine the relationships among the problems
4 types of data
1) complete (total health) database
complete health history and full physical exam
2) focused/problem-centered database
for a limited or short term problem
3) follow up database
check the status of any identified problems
4) emergency database
rapid collection of data about an individual’s health state
holistic health
views the mind, body, and spirit as interdependent and functioning as a whole within the environment.
- includes culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations.
- health promotion and disease prevention
culture and genetics
34% of total us population is emerging minority
- hispanics 24.3%, blacks 13.2%, asian/pacific islander 8.9% and american indian 0.8%
- largest growing pop is hispanic
- 2nd largest is asian, then blacks, american indians, alaska natives, and native hawaiians and islanders.
- median age in 2007 was 36.6, 1/4 younger than 18
- hispanic median age = 27, blacks 31, amican indian and alaskans = 30, hawaiin and islanders = 30 ==> all cose to 1/2 pop under 18
- white median ages are between 36 and 40
legal resident
granted lawful permanent residence
natualization
the conferring, by any means, of citizenship upon a person after birth
non-immigrant
an alien who seeks temporary entry to the US for a specific purpose
parolee
an alien, allowed to the US for urgent humanitarian reasons or when their entry is significant to the public’s benefit
permanent resident alien
alien admitted to the us as lawful permanent resident
refugee
presecution or a well-founded fear of persecution
unauthorized residents
not legal residents and foreign born
medical diagnosis
used to evaluate the cause and etiology of disease, focus is on the function or malfunction of a specific organ system
Title VI of the cycle rights act of 1964
a federal law that mandates that when people with limited engligh proficiency seek health care in health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them.
heritage
culture, ethnicity, religion and spirituality, socialization, time orientation (reflection towards past, present and future thinking)
culture vs. ethnicity
culture: socially transmuted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways and characteristics that influence a world view
ehtnicity: social group within a cultural and social system that shares common cultural and social heritage that include language, history, lifestyle, religion or all of these.
health disparity
cultural competence
your own personal heritage, the heritage of the nursing prof, heritage of the health care system, heritage of the patient
heritage consistency
concept that describes the degree to which one’s lifestyle reflects his or her respective “whatever” culture
* determination of a person’s cultural, ethnic, and religious background and socialization (being raised within a culture and acquiring characteristics of that group) experiences
- traditional - living within the norms of the traditional culture
- modern - acculturated to the norms of the dominant society
INDICATORS: childhood occurred in county of origin or ehtnic neighborhood, extended family supports the traditional activities, family home within ethnic community in which they belong, name not anglicized, social activities primarily within ethnic group, knowledge of language and cultural values
heath-related beliefs that may be effected by culture, ethnicity, heritage, religion
vaccinations, meditating, exercise/fitness, sleep habits, willingness to undergo physical exam, pilgrimage, truth about feelings, coping with stress, genetic screening and concealing, disabilities, caring for children
3 major views on causes of illness
1) biomedical/scientific: assumes cause and effect, views the body and a machine, life can be divided into parts, endorses germ theory
2) Naturalistic/holistic: forces of nature must be kept in balance, embraces idea of opposing categories or forces
- yin/yang - asians, health = all aspects of person are in perfect balance. Yin = cold, yang = hot - basis for chinese medicine
- hot/cold - hispanics, arab, black, asians. four humors of the body (blood, phlegm, black bile, yellow bile) regulate basic body function. uses cold, heat, dryness and wetness to treat.
3) Magicoreligious: super natural powers predominate in area of health and illness
- voodoo, witchcraft, faith healing
amulets
objects, such as charms, that project the person from evil eye. exp: glass eye (turkey), sting with bead (mexican),
folk healers
- hispanics: curanero, espiritualist, yerbo, parera, sabedor
- african american: hougan, spiritualist,
- american indian: shaman, medicine man
- asians: herbalist, accupuncturist,
culture bound syndromes
- aisan: shenkui/dhat - anxiety or panic syndromes with dizziness, backache,weakness, insomnia. Casued by excessive semen loss. represents loss of vital essence, life threatening.
- african: low blood/high blood/thin blood - nutrients into blood, weakness of blood
- eurpoean: hysteria - biarre complaints and behavior because the uterus leaves the pelvis for another part of the body
- american indian/alaska: ghost - tremor, hallucinations, sense of danger.
- central and south americans: empacho - pain in stomach and intestines from balls of food
CLAS
culturally & linguistically appropriate services
- culturally competent care, language access services, organizational supports for cultural competence
the interview: internal and external factors
internal
- liking others, empathy, ability to listen
external
- privacy, refuse interruptions, physical environment, drew, note-taking, tape and recording, electronic medical record
interview responses
- facilitation: mmhmm, go on
- silence: following open-ended questions, avoid interrupting train of thoughts
- reflection: ehcos the patients words
- empathy: recognize a feeling and put it into words
- clarification: repeate what you think they are saying
- confrontation: indicate your thoughts and feelings on conflicting info
- interpretation: could it be because..? infer after getting a lot of info
- eplanation: explain why they are receiving certain care or what will happen during their visit
- summary: summarize what you both discussed to ensure their understand
the interview = contract between nurse and patient
- time and place of interview
- introduction of healthcare providers roles
- purpose of interview
- timeline
- expectation for participation
- presence of others (yes or no?)
- what is kept confidential and what cannot be
- costs for the patient
non-verbal interview skills
physical appearance/body language, gestures, facial expression, eye contact, voice, touch
interviewing the infant
non-verbal communication.
interviewing the preschooler
2-6 years olds are egocentric
_ simple words
interviewing school-age child
age 7-12
can tolerate and understand other people’s viewpoints
more objective vs. realistic. how things work, why they are done.
able to reason, see other sides,
can add important data to health history
interviewing the adolescent
begin with puberty
respectful attitude, totally honest communication, ice icebreakers, POSTIVIE REINFORCEMENT
interviewing the older adult
fining the meaning of life, spiritual, purpose of existence
longer interview, memory issues, adjust the pace of the interview, touch is a good skill to use when appropriate
interviewing people with special needs
Hearing-impaired: ask preferred communication (lip reading, writing). sign language interpreter,
acutely ill: emergent exams still need to try to communicate with the patient. attend to comfort first, then choose priorities, closed direct questions, explain when you can,
under the influence of drugs or alcohol: simple, direct, non-threatening questions, avoid concentration. most important is last time they used and how much
sexually aggressive: be clear that you are not ok with that.
crying: let it happen, it helps the patient
Health History Sequence
- biographic data
- reason for seeking care
- present health or history of present health
- past history
- family history
- review of systems
- functional assessment or activities of daily living
Adult Health History
- First date and time of interview
1) biographic data: name, address, phone, age, birthdate, birth place, gender, race, ethnicity, occupation, language and communication needs (record the source: self, son, mother)
2) reason for seeking care: brief statement in patient’s own words for why they are at the appointment. (symptom - subjective from patient’s feelings, sign - objective abnormality you can see, take samples for, etc. )
3) present health or history of present health: the chief complaint from first time it started until today in the hospital. use PQRSTU
4) past health: childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, obstetric history, immunizations, las exam date, allergies, current meds
5) family history: - *remember to add other info when the person is an immigrant - when did you come to this country, spiritual beliefs, immunizations, nutrition, health perception
6) review of systems: evaluate past and present health of each body system, find any omitted data from initial questions, evaluate health promotion practices
7) functional assessment: measures a person’s self-care abilities. self esteem, sleep, nutrition, interpersonal relationships, spiritual resources, coping/stress management, personal habits, alcohol, drugs, environmental hazards, intimate partner violence, occupational health
health assessment considerations for children
add developmental history and nutritional data, prenatal status, labor and delivery, economic status, home environment,
health assessment considerations for adolescents
HEEADSSS - home environment, education and employment, eating, peer related activities and drugs, sexualtiy, suicide/depression, safety from injury and violence,
health assessment considerations for older adults
how aging affects them, recognize positive health measures,
