Week 1-6 Flashcards
definition of holistic health assessment
Acknowledges and addresses physiological, psychological, sociological, developmental, spiritual, and culture needs of patient
what does a health assessment include
history and physical assessment
when presenting health concerns we use what technique
OLDCARTSS
what does OLDCARTSS stand for
-onset
-location
-duration
-characteristic
-aggravating/alleviating factors
-radiation
-time
-severity
-social environment
what is included in health history
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)
what is the purpose of a physical assessment
-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
physical assessment techniques (IPPA)
-inspection (using senses)
-palpation (touching and feeling)
-percussion (tapping for sound)
-auscultation (listening to breath, heart, vascular using stethoscope)
what is included in the head to toe exam
-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
what is clinical judgement
- Interpretation/conclusion about clients needs, concerns, health problems
- Decision to take action
- Use standard approaches OR improvise new ones to benefit patient response
what is the clinical judgement model (CJM)
- Framework for nurses’ decision making
- Noticing all aspects of client situation
- Critical thinking
- # 1 faze is noticing
what is the basis of the general survey for mental health
noticing mental state and behaviors of initial encounter
parts of the general mental health survey (ASEPTIC)
- Appearance & behavior
- Speech
- Emotion
- Perception
- Thought process
- Insight
- Cognition
what is family and community in context of health
- 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
what are the characteristics of family
- Connect need for stability with need for growth and change
- Flexible structure
- Cohesive unit
- Influence on environment
- Hardiness & resiliency in coping
what is community
- People, residents
- Place, physical/geographical location
- Function, aims/interests/activities
what are healthy community components
- 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
what is the premise of infection prevention and control routine practices
- everyone is potentially infectious
- Same safe standards for every patient encounter
- Prevent exposure & spread of microorganisms
what is the chain of infection
- 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)
how can you interrupt the chain of infection
- Optimizing patient health
- Protective gear
- Hand hygiene
what are the moments of hand hygiene
- Before initial patient contact
- Before aseptic procedure
- After bodily fluid exposure risk
- After final patient contact
types of communication
- 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
what is the purpose of therapeutic interviewing
- Obtain health history
- Identify health needs & risk factors
- Determine specific changes in wellness & pattern of living
- Relate client’s interpretation & understanding of conditions
what are the types and sources of data gathering
- Subjective data, stated by client/family
- Objective data, observed by heath care provider
- Primary source, patient/interpreter
- Secondary source, charts/family members
what are the three types of interviews
- Comprehensive (everything birth-present)
- Focused (presenting symptom only)
- Emergent (impacts on right now care)
what are the phases of interviewing
- 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)
what is the purpose of health history
- Collect relevant subjective data
- Ask right questions to find answers
what is privacy
- Unique definition for everyone
- Information privacy, client’s control of their health information (collected, used, disclosed)
what is confidentiality
- Duty to protect information
- Intimate/private knowledge
what is personal health information
- Any identifying client information (verbal, written, electronic)
what is the role of the CNO in privacy and confidentiality
- Practice standards on privacy & confidentiality
what are hard situations related to privacy and confidentiality
- Violence
- Illicit drug use
- Police (no automatic access to patient information & chart)
- Driving concerns
what is information gathering documentation
- Communication of client’s health status & needs
- Communication to other member of circle of care
- Legal record
what are the expectations of information gathering documentation
- Factual, accurate, relevant
- Organized & complete
- Proper grammar, spelling, language, punctuation
what are the important parts of written documentation for information gathering documentation
- 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)
what are the styles of assessment documentation
SOAP
- Subjective (from patient history)
- Objective (physical)
- Assessment
- Plan
SBAR
- Situation
- Background (relevant health history)
- Assessment
- Recommendation
what is cognitive development
- Uses experiences to move through stages (birth- adulthood)
- Thinking becomes more sophisticated & complex
how does cognition change with age
- Process, remember, consider information becomes slower
- Learning takes longer
- Slightly decreased short term memory
- Long term memory & decision making remains intact
what are atypical changes of cognition
- Unusual changes for cognitive deterioration
- Memory loss of recent events
- Tangentiality (changes ideas while speaking)
what is delirium
- Abrupt onset, usually brief duration
- Impaired attention
- Altered levels of consciousness
- Incoherent speech
- Often symptom of different issue
- Assessment, confusion assessment method CAM & IWATCHDEATH
what is dementia
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
what is depression
- 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
assessment of cognition
- Medical history (head injuries)
- ADL’s & IADL’s
- Cognitive screening & advanced physical exam
- Imaging (head CT/MRI)
what is the modified cognitive approach
- Slow down
- Sit directly in front
- Ensure all aids are provided
- Simple instructions (redirect wandering thoughts)
- Limit environment stimulus
- Repetition & prompting
factors of cognition prognosis
- Onset (sudden/gradual)
- Mood/behavior changes
- Course of decline
- Current level of function (IADL’s & ADL’s)
- History of confusion
what is the MMSE
- Mini mental state exam
- 30 questions used to assess cognition
- Screen for dementia, memory, orientation
what is the RUDAS
- Rowland university dementia assessment scale
- Planning, sequencing & organizing
- Minimizes effects of education level, language, cultural background
driving and cognition
- Dementia increases risk of accident
- Driving capacity depends on cognition, function, medications, behavior, physical abilites
what is the mental health assessment continuum
- Mental health is not linear
- Mental health & mental illness are not the same thing
- Not static
what are mental health positive reinforcements
- Individual
- Family
- Community
- Society
what is mental health promotion
- Strategies to improve population mental health
- Activities, available resources
- Campaigns
what is positive mental health
- Interpret reality accurately
- Healthy self-concept
- Relate to others
- Sense of meaning
- Creativity/productivity
- Behavioral control
- Cope/adapt with change & conflict
what is the DSM-V
- 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
what are mental health domains
- 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
components of mental health history
- Medical & family history
- Medications
- Violence/trauma
- Substance abuse
- Suicidal/homicidal
- Hallucinations/delusions
What is the mental health physical exam (ASEPTIC)
- Appearance
- Speech
- Emotion/affect
- Perception
- Though process/content
- Insight/judgment
- Cognition
patients seek mental health treatment when
- Intolerably painful
- Life crisis
- Crime
- Unmanageable
- Interrupt daily function
what is the stigma surrounding mental health
- Negative stereotype & discrimination
- Limits access to life opportunities
- Criminalization of illness behaviors
- Limits access to healthcare
what is STOP criteria
- 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
what is recovery oriented care
- Focuses on pursuing recovery, not achieving it
- Shared decision making
- Concentrates on wellness
- Self-expectations have strong influence on behavior & outcomes
what are the pillars of recovery
- Choice, public funded services & different models of care
- Community, connection to recovery community
- Integration, manageable tasks
