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1080 Holistic Health Assessment > Week 1-6 > Flashcards

Week 1-6 Flashcards

1
Q

definition of holistic health assessment

A

Acknowledges and addresses physiological, psychological, sociological, developmental, spiritual, and culture needs of patient

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2
Q

what does a health assessment include

A

history and physical assessment

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3
Q

when presenting health concerns we use what technique

A

OLDCARTSS

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4
Q

what does OLDCARTSS stand for

A

-onset
-location
-duration
-characteristic
-aggravating/alleviating factors
-radiation
-time
-severity
-social environment

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5
Q

what is included in health history

A

past medical history (diagnosis, surgeries)
-family history
-medications
-immunizations
-allergies
-lifestyle choices
-psychosocial (family, living situation, employment)
-impact on function (how is condition affecting daily life)

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6
Q

what is the purpose of a physical assessment

A

-obtain baseline data
-supplementing/confirming data obtained in health history
-help establish diagnosis and plan of care
-evaluating physiological outcomes of care and health status

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7
Q

physical assessment techniques (IPPA)

A

-inspection (using senses)
-palpation (touching and feeling)
-percussion (tapping for sound)
-auscultation (listening to breath, heart, vascular using stethoscope)

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8
Q

what is included in the head to toe exam

A

-general health survey
-vital signs
-skin/dermatological
-HEENT (head, eyes, ears, nose, throat)
-respiratory system
-cardiovascular system
-peripheral vascular system (veins, arteries not in chest/abdomen)
-gastrointestinal system
-genito-urinary system
-sexual/reproductive health
-neurological system
-mental health
-cognition
-nutritional/fluid balance

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9
Q

what is clinical judgement

A
  • Interpretation/conclusion about clients needs, concerns, health problems
  • Decision to take action
  • Use standard approaches OR improvise new ones to benefit patient response
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10
Q

what is the clinical judgement model (CJM)

A
  • Framework for nurses’ decision making
  • Noticing all aspects of client situation
  • Critical thinking
  • # 1 faze is noticing
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11
Q

what is the basis of the general survey for mental health

A

noticing mental state and behaviors of initial encounter

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12
Q

parts of the general mental health survey (ASEPTIC)

A
  • Appearance & behavior
  • Speech
  • Emotion
  • Perception
  • Thought process
  • Insight
  • Cognition
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13
Q

what is family and community in context of health

A
  • Set of relationships that influence each other’s lives
  • Future obligations & care giving functions
  • Any combination of 2+ people bound together overtime
  • Family is whoever patient says
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14
Q

what are the characteristics of family

A
  • Connect need for stability with need for growth and change
  • Flexible structure
  • Cohesive unit
  • Influence on environment
  • Hardiness & resiliency in coping
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15
Q

what is community

A
  • People, residents
  • Place, physical/geographical location
  • Function, aims/interests/activities
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16
Q

what are healthy community components

A
  • Collective relationships to create supportive living environment
  • Collective capacity to solve problems
  • Adequate housing conditions
  • Safe environment
  • Sustainable resources (employment, health care, education)
  • Meets basic needs of residents
  • Diverse, innovative & sustainable economy
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17
Q

what is the premise of infection prevention and control routine practices

A
  • everyone is potentially infectious
  • Same safe standards for every patient encounter
  • Prevent exposure & spread of microorganisms
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18
Q

what is the chain of infection

A
  • Infectious agent (pathogens that cause disease/infection)
  • Reservoir (agents pathogens live in & multiply)
  • Portal of exit, body openings/artificial openings (how pathogens leave human body)
  • Mode of transmission direct/indirect contact (transmission of pathogens)
  • Portal of entry (entry of pathogens)
  • Susceptible host (factors that cause vulnerability to pathogens)
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19
Q

how can you interrupt the chain of infection

A
  • Optimizing patient health
  • Protective gear
  • Hand hygiene
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20
Q

what are the moments of hand hygiene

A
  • Before initial patient contact
  • Before aseptic procedure
  • After bodily fluid exposure risk
  • After final patient contact
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21
Q

types of communication

A
  • Essential component in building patient/family relationship
  • Complex, ongoing interactive process
  • Verbal, active listening (words, feelings, essence)
  • Non-verbal, body language, gestures, expression
  • Ineffective, poor patient outcomes & negative patient experience
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22
Q

what is the purpose of therapeutic interviewing

A
  • Obtain health history
  • Identify health needs & risk factors
  • Determine specific changes in wellness & pattern of living
  • Relate client’s interpretation & understanding of conditions
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23
Q

what are the types and sources of data gathering

A
  • Subjective data, stated by client/family
  • Objective data, observed by heath care provider
  • Primary source, patient/interpreter
  • Secondary source, charts/family members
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24
Q

what are the three types of interviews

A
  • Comprehensive (everything birth-present)
  • Focused (presenting symptom only)
  • Emergent (impacts on right now care)
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25
Q

what are the phases of interviewing

A
  • Pre-interactive phase (before client is present)
  • Beginning phase (setting the tone)
  • Working phase (open & close ended questions
  • Closing phase (wrap up, next steps, questions)
26
Q

what is the purpose of health history

A
  • Collect relevant subjective data
  • Ask right questions to find answers
27
Q

what is privacy

A
  • Unique definition for everyone
  • Information privacy, client’s control of their health information (collected, used, disclosed)
28
Q

what is confidentiality

A
  • Duty to protect information
  • Intimate/private knowledge
29
Q

what is personal health information

A
  • Any identifying client information (verbal, written, electronic)
30
Q

what is the role of the CNO in privacy and confidentiality

A
  • Practice standards on privacy & confidentiality
31
Q

what are hard situations related to privacy and confidentiality

A
  • Violence
  • Illicit drug use
  • Police (no automatic access to patient information & chart)
  • Driving concerns
32
Q

what is information gathering documentation

A
  • Communication of client’s health status & needs
  • Communication to other member of circle of care
  • Legal record
33
Q

what are the expectations of information gathering documentation

A
  • Factual, accurate, relevant
  • Organized & complete
  • Proper grammar, spelling, language, punctuation
34
Q

what are the important parts of written documentation for information gathering documentation

A
  • No erasing/white out
  • Legible writing in PEN
  • No blank spaces
  • Pertinent specific facts (avoid generalized information)
  • ORGANIZE thoughts
  • Begin each entry with date and time (24 hour)
  • End with signature & designation (WFN-1)
35
Q

what are the styles of assessment documentation

A

SOAP
- Subjective (from patient history)
- Objective (physical)
- Assessment
- Plan
SBAR
- Situation
- Background (relevant health history)
- Assessment
- Recommendation

36
Q

what is cognitive development

A
  • Uses experiences to move through stages (birth- adulthood)
  • Thinking becomes more sophisticated & complex
37
Q

how does cognition change with age

A
  • Process, remember, consider information becomes slower
  • Learning takes longer
  • Slightly decreased short term memory
  • Long term memory & decision making remains intact
38
Q

what are atypical changes of cognition

A
  • Unusual changes for cognitive deterioration
  • Memory loss of recent events
  • Tangentiality (changes ideas while speaking)
39
Q

what is delirium

A
  • Abrupt onset, usually brief duration
  • Impaired attention
  • Altered levels of consciousness
  • Incoherent speech
  • Often symptom of different issue
  • Assessment, confusion assessment method CAM & IWATCHDEATH
40
Q

what is dementia

A

Dementia
- Slow development, progressive deterioration of brain
- Does not remit
- Normal attention & consciousness
- Ordered speech
- Must have change in function & memory impairment
- Instrumental activities of daily living (IADL) deteriorate first
- Activities of daily living (ADL) deteriorate last
- Includes Alzheimer’s, Parkinson’s, Lewy Body
- Assessment, clock drawing test, RUDAS, functional dementia scale

41
Q

what is depression

A
  • 15-20% develop late life depression
  • Reversible, frequently diagnosed as dementia (incorrect treatment given)
  • Physical/social limitations
  • Low energy
  • Assessment, Cornell Scale for Depression, Geriatric Depression Scale (GDS), suicide risk
42
Q

assessment of cognition

A
  • Medical history (head injuries)
  • ADL’s & IADL’s
  • Cognitive screening & advanced physical exam
  • Imaging (head CT/MRI)
43
Q

what is the modified cognitive approach

A
  • Slow down
  • Sit directly in front
  • Ensure all aids are provided
  • Simple instructions (redirect wandering thoughts)
  • Limit environment stimulus
  • Repetition & prompting
44
Q

factors of cognition prognosis

A
  • Onset (sudden/gradual)
  • Mood/behavior changes
  • Course of decline
  • Current level of function (IADL’s & ADL’s)
  • History of confusion
45
Q

what is the MMSE

A
  • Mini mental state exam
  • 30 questions used to assess cognition
  • Screen for dementia, memory, orientation
46
Q

what is the RUDAS

A
  • Rowland university dementia assessment scale
  • Planning, sequencing & organizing
  • Minimizes effects of education level, language, cultural background
47
Q

driving and cognition

A
  • Dementia increases risk of accident
  • Driving capacity depends on cognition, function, medications, behavior, physical abilites
48
Q

what is the mental health assessment continuum

A
  • Mental health is not linear
  • Mental health & mental illness are not the same thing
  • Not static
49
Q

what are mental health positive reinforcements

A
  • Individual
  • Family
  • Community
  • Society
50
Q

what is mental health promotion

A
  • Strategies to improve population mental health
  • Activities, available resources
  • Campaigns
51
Q

what is positive mental health

A
  • Interpret reality accurately
  • Healthy self-concept
  • Relate to others
  • Sense of meaning
  • Creativity/productivity
  • Behavioral control
  • Cope/adapt with change & conflict
52
Q

what is the DSM-V

A
  • Diagnostic & statistical manual of mental disorders
  • Standardize assessment data & outcomes
  • Prevent indiscriminate outcomes
  • Used to get broad understanding of client
  • Not client conforming to diagnosis
53
Q

what are mental health domains

A
  • Biological, theories that explain neurobiological changes in relation to mental disorders
  • Psychological, process of thoughts, feelings, behaviors influence cognition & emotion
  • Social, influence of social forces
  • Spiritual, connections between individual & universe
54
Q

components of mental health history

A
  • Medical & family history
  • Medications
  • Violence/trauma
  • Substance abuse
  • Suicidal/homicidal
  • Hallucinations/delusions
55
Q

What is the mental health physical exam (ASEPTIC)

A
  • Appearance
  • Speech
  • Emotion/affect
  • Perception
  • Though process/content
  • Insight/judgment
  • Cognition
56
Q

patients seek mental health treatment when

A
  • Intolerably painful
  • Life crisis
  • Crime
  • Unmanageable
  • Interrupt daily function
57
Q

what is the stigma surrounding mental health

A
  • Negative stereotype & discrimination
  • Limits access to life opportunities
  • Criminalization of illness behaviors
  • Limits access to healthcare
58
Q

what is STOP criteria

A
  • identify stigmatizing behaviours & advocate for inclusive attitudes
  • Stereotype people with mental health conditions
  • Trivializes/belittles people with mental health conditions
  • Offends people with mental health conditions
  • Patronizes (treats them as less) with mental health conditions
59
Q

what is recovery oriented care

A
  • Focuses on pursuing recovery, not achieving it
  • Shared decision making
  • Concentrates on wellness
  • Self-expectations have strong influence on behavior & outcomes
60
Q

what are the pillars of recovery

A
  • Choice, public funded services & different models of care
  • Community, connection to recovery community
  • Integration, manageable tasks

1080 Holistic Health Assessment (5 decks)

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