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Nurs 220 - Holistic Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Biographical data includes…

A

Name, address, age, birth, gender, race, languages, occupation, religion….etc

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2
Q

sources of patient history

A

patient or relative/friend
- judge the reliability of the informant
-reliable when same answer after same question asked

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3
Q

What will the patient say when the reason for seeking care?

A

Brief spontaneous statement in persons own words

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4
Q

COLDSPA

A
  • Character
  • onset
  • location
  • duration
  • severity
  • pattern
  • associated factors
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5
Q

Character

A

how does it feel, look, smell, sound, etc.?

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6
Q

Onset

A

When did it begin; is it better, worse, or the same since it began?

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7
Q

Location

A

Where is it, does the pain radiate?

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8
Q

Duration

A

How long does it last? Does it Recur?

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9
Q

Severity

A

How bad on a scale 1-10; what is the patients perception of this?

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10
Q

Pattern from COLDSPA

A

What makes it better? (aka alleviating factors)
- What makes it worse? (aka precipitating/aggravating factors)

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11
Q

Associated factors

A

What other symptoms do you have with it?
- will you be able to continue doing your work or other activities (leisure or exercise?)

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12
Q

Past Health topics?

A
  • Problems such as birth
  • Childhood illnesses
  • immunizations to date
  • Adult illnesses (physical, emotional, mental)
  • Surgieries
  • Accidents or injuries
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13
Q

Family history topics

A
  • Age & health or cause of death of relatives
  • family history of various conditions such as “heart disease, high BP, stroke, diabetes, etc.”
  • Family tree
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14
Q

Review of systems

A

SHEEM TBH
- skin, hair, nails
- Head/neck
- Ears
- Eyes
- Mouth, Throat, nose, sinyses
- Thorax and lungs
- Breasts, and lymphatics
- Heart & neck vessels

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15
Q

Lifestyle question (simple)

A

Description of a typical day/activities on a typical day

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16
Q

evidence based practice

A

combo of scientific evidence, nurse’s experience and expertise, and client’s preferences

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17
Q

first step interviewing

A

asking patients name and birth to foster trust

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18
Q

alter interview based on..

A

patients age and experiences in life

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19
Q

laundry list of discriptors

A

examples used in coldspa

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20
Q

First question to ask when talking about diet?

A

What did you eat in the last 24 hrs?

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21
Q

Types of social activities

A

Recreation/relaxation
- Societal contributions

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22
Q

Types of relationships (3 things)

A
  • Family
  • Sig. others
  • Pets
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23
Q

Neonate years

A

1st 4 weeks of life

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24
Q

Infant years

A

1 month to 1 yr

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25
Q

toddler years

A

1-3 yrs

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26
Q

Pre-school child years

A

3-5 yrs

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27
Q

School-aged child years

A

6-12 yrs

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28
Q

Adolescent years

A

13-18 yrs

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29
Q

Young Adult years

A

19-40 yrs

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30
Q

middle age adult yrs

A

41-65 yrs

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31
Q

Older adult years

A

over 65 yrs

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32
Q

Functional assessment includes…

A

(SSDRACS)
- Self-esteem, self-concept
- sleep/rest
- diet
- relationships
- activity/exercise
- coping/stress management
- spiritual resources

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33
Q

Pediatric patient assessment questions

A

mom and dad will play a role in the interview
- birth history is important
- Developmental milestones
- Denver II Screening tool

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34
Q

Pregnant patient assessment

A
  • chief complaints w/ duration
  • History of everything medically
  • Socio-economic history
  • Contraceptive history
  • History of allergy
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35
Q

Older adult patients assessment questions to ask

A

same format for functional assessment but with additional questions
- important to recognize positive health measures
- affirm things they are doing right

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36
Q

Older person may..

A

shrug off symptoms
- take time to figure out why they came for examination
- have many chronic problems

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37
Q

Past health questions for older patients

A

General health in the past 5 yrs
- Accidents or injuries, serious or chronic illnesses, hospitalizations, operations
- last exam
- obstetric status

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38
Q

older patient “family history” questions

A
  • not useful for predicting family diseases
  • helps to know which diseases family member had
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39
Q

What is a health risk

A

The chance or likelihood that something will harm or otherwise affect your health

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40
Q

What is a risk factor

A

Any attribute that increases the likelihood of developing a disease or injury

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41
Q

Identify patients early enough to…

A

provide treatment & avoid/reduce symptoms & other consequences, improving health outcomes
(Ex: age, sex, family health history, lifestyle, genes, ethnicity…)

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42
Q

Components of ROS (review of systems)

A

(MM SHEF)
- Male genital System
- Musculoskeletal system
- Sexual health
- Hematologic system
- Edocrine system
- Female genital system

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43
Q

If the client answers in the affirmative to a PREVIOUS symptom/problem, you…

A

Document the following information:
- When did it occur/ when were they diagnosed?
- (if injury/trauma), what was the nature of the injury?
- How was it treated?
- How did the recovery go?
- Any lingering effects?

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44
Q

If the client answers in the affirmative to a CURRENT symptom/problem, you…

A

document the following information:
- COLDSPA

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45
Q

ROS: General Overall Health State

A
  • Present weight (history of weight), fatigue, weakness or malaise, fever, chills, sweats or night sweats
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46
Q

ROS: Skin

A
  • History of skin disease (eczema, psoriasis, hives), - - pigment or color change
  • change in mole
  • excessive dryness or moisture
  • excessive bruising
  • rash or lesion
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47
Q

ROS: Hair/Nails

A

Hair: Recent loss/change in texture

Nails: Change in shape, color, or brittleness

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48
Q

ROS: Health Promotion for skin/oral

A
  • amount of sun exposure; method of self-care for skin & hair
  • Pattern of daily dental care, use of dentures, bridge & last dental checkup
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49
Q

ROS: Nose & Sinuses

A
  • Discharge & its characteristics
  • any unusually frequent or severe colds, sinus pains, nasal obstructions, nosebleeds, allergies, or hay fever, or change in sense of smell
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50
Q

ROS: Mouth & Throat

A
  • Mouth pain
  • frequent sore throat
  • bleeding gums
  • toothache
  • lesion in mouth or tongue
  • dysphagia
  • hoarseness of voice
  • tonsillectomy
  • altered taste
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51
Q

ROS: Neck

A
  • Pain, limitation of motion,
  • lumps or swelling
  • enlarged, tender nodes
  • goiter
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52
Q

ROS: Breast

A
  • pain
  • lump
  • nipple discharge
  • history of breast disease
  • Any surgery on breasts
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53
Q

ROS: Health promotion on Breast

A
  • Perform Breast self-examination, including its frequency & method used; last mammogram
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54
Q

ROS: Axilla

A
  • Tenderness, lump, swelling or rash
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55
Q

ROS: Respiratory System

A
  • History of lung disease (asthma, bronchitis, pneumonia, etc)
  • Chest pain w/breathing
  • wheezing
  • noisy breathing
  • SOB
  • cough
  • sputum
  • pollution exposure
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56
Q

ROS: Health promotion for Resp. system

A
  • Last chest x-ray study, TB skin test
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57
Q

ROS: Cardiovascular

A
  • Chest pain
  • Pressure
  • Tightness
  • Palpitation
  • Cyanosis
  • Dyspnea on exertion
  • Edema
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58
Q

ROS: Health Promotion for Cardiovascular

A
  • Date of last ECG or other heart tests; cholesterol screening
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59
Q

ROS: Peripheral Vascular

A
  • Coldness
  • Numbness/ tingling
  • swelling of legs
  • Discoloration in hands or feet
  • varicose veins
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60
Q

ROS: Health Promotion for peripheral vascular

A
  • Does work involve long-term sitting/standing? Avoid crossing legs at knees
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61
Q

ROS: Gastrointestinal

A
  • Appetite
  • Food intolerance
  • heartburn
  • Indigestion
  • vomiting

MANY MORE

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62
Q

ROS: Health Promotion for Gastrointestinal

A

Use of antacids or laxatives

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63
Q

ROS: Urinary system

A
  • Frequency
  • Urgency
  • Nocturia
  • Dysuria
  • Color
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64
Q

ROS: Health Promotion for Urinary System

A

Measures to avoid or treat UTI, use of legal exercises after childbirth

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65
Q

ROS: Male genital system

A
  • Penis or testicular pain
  • Sores or lesions
  • Penile discharge
  • Lumps
  • Hernia
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66
Q

ROS: Health Promotion for Male genital system

A

Perform testicular self-examination? How frequently?

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67
Q

ROS: Female genital system

A
  • Menstrual history
  • Vaginal itching
  • Discharge & its characteristics
  • Age at menopause
  • Postmenstrual bleeding
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68
Q

ROS: Health Promotion of Female Genital system

A

Last gynecologic checkup & last pap test

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69
Q

Sexual relationship questions to ask

A

Are you having sex?
- How many partners?
- Condoms?
- Erection issues?
- Any STD contact?

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70
Q

ROS: Musculoskeletal System (joints, muscles, and back included)

A
  • History of arthritis/ gout

In joints: Pain, stiffness, swelling

In muscles: pain, cramps, weaknesses?

In the back: Any pain, stiffness, limitation of motion?

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71
Q

ROS: Health Promotion for Musculoskeletal system

A
  • How much walking per day?
  • what are the effects of limited ROM on ADLs (grooming, feeding, toileting?)
  • Any mobility aids used?
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72
Q

ROS: Neurologic System (Motor, sensory, and mental status included)

A
  • History of seizure, stroke, fainting, blackouts?
  • Motor function: Weakness, tic or tremor, paralysis, or coordination problems?
    Sensory function: Numbness/tingling?
    Cognitive function: Memory disorder
    Mental status: Any nervousness, mood change, depression, or history of mental heath dysfunction or hallucinations?
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73
Q

ROS: Health Promotion for Neurological System

A

Data about interpersonal relationships & coping patterns

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74
Q

ROS: Hematologic Systems

A
  • Bleeding tendency of skin or mucous membranes
  • excessive bruising,
  • lymph node swelling
  • exposure to toxic agents or radiation
  • blood transfusion & reactions
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75
Q

ROS: Endocrine System

A

History of diabetes
- Diabetic symptoms
- History of thyroid disease
- intolerance to heat/cold
- change in skin
- excessive sweating

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76
Q

What should you record when documenting

A

Record the presence/absence of ALL symptoms so that it is very clear what Q’s you asked

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77
Q

The ROS (Review of systems) is only used for what?

A

Subjective Data

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78
Q

Objective assessment techniques/alternative words

A

inspection: Looking
Palpation: touching
Percussion: Tapping
Auscultation: Listening

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79
Q

What is comfort?

A

a person’s sense of psychosocial, emotional, and physical well-being

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80
Q

What is pain according to a patient?

A

Pain is whatever the experiencing person says it is

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81
Q

What is Nociceptive Pain

A

Nerve fibers in PNS & CNS are functioning & intact
- Begins outside the NS from actual or potential tissue damage

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82
Q

Four phases of Nociceptive pain

A

Transduction, Transmission, Perception, and Modulation

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83
Q

What is neuropathic pain

A

Abnormal processing d/t injury of nerve fibers
- not predictable processes & phases

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84
Q

Sources of pain (4 things)

A
  • Visceral pain
  • Deep somatic pain
  • Cutaneous pain
  • Referred pain
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85
Q

What are the 7 Dimensions of Pain

A
  • physical
  • sensory ( ex. 7 out of 10)
  • behavioral
  • sociocultural
  • cognitive (beliefs, attitudes)
  • affective (feelings/emotions to pain)
  • spiritual (meaning & purpose to pain)
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86
Q

pain assessment questions to ask

A

Coldspa

86
Q

Does the patient self-report?

A

Yes and always

87
Q

Pain elicits a stress response in the human body that triggers the…

A

SNS resulting in physiologic responses such as:
- Anxiety
- focus on pain
- Inc. resp. rate
- Dec. urinary output

88
Q

Physical exam: Joints

A

note:
- size
- contour
- circumference
- AROM/PROM

89
Q

Physical exam: Abdomen

A
  • inspect/auscultate/palpate
  • Contours/symmetry
  • Guarding/organ size
90
Q

Physical exam: Muscles/skin

A

inspect:
- color/swelling
- masses/deformity
- sensation changes

91
Q

Is pain a normal part of the aging process?

A

NO, it is not

92
Q

What is mental status:

A

A person’s emotional & cognitive functioning
- it is inferred indirectly through the assessment of behavior

93
Q

Assessed behaviors for MENTAL STATUS include:

A
  • LOC
  • language
  • Mood & affect
  • orientation
  • attention
  • memory
  • perceptions
94
Q

What is cognition?

A

it is the brain’s ability to process, retain, & use info
- this includes reasoning, judgment, perception, attention, comprehension, & memory

95
Q

What are the components of a mental status exam?

A

(ABCT)
- Appearance
- Behavior
- Cognition
- Thought Process

96
Q

A full mental status exam when initial screening suggests what?

A
  • Depression
  • Anxiety
  • Brain lesions (trauma)
  • Symptoms of psychiatric illness
97
Q

Contributions from health history for mental status exam?

A
  • Alcoholism
  • Medications that may cause confusion or depression
  • Changes in sleep pattern. social interactions, or drug use
98
Q

the “A” in ABCT

A

appearance
- posture
- body movements
- dress
- grooming & hygiene

99
Q

the “B” in ABCT

A

Behavior
- LOC
- Facial expressions (mood & affect)
- Speech

100
Q

the “C” in ABCT

A

Cognitive Functions
- Orientation: time, place, person
- Concentration
- Recent memory
- Judgement

101
Q

the “T” in ABCT

A

Thought Process
- thought content (self explanatory)
- screen for anxiety, depression, suicidal thoughts

102
Q

Mini-mental status exam only looks at what?

A

Cognitive functioning, not mood or thought process

103
Q

mini-mental status exam avg score is

A

27

104
Q

For mini-mental status exam, between what scores show no cognitive impairment?

A

24-30

105
Q

the mini-mental status exam is useful for detecting what?

A

organic diseases
- dementia, delirium

106
Q

What is the mini-cognitive exam for?

A
  • Tests executive function
  • People with NO cognitive impairment should be able to successfully complete
107
Q

What is a mental disorder?

A

A behavioral pattern associated w/ distress, impaired functioning, and risk of disability

108
Q

What is an organic disorder?

A

a Brain disease of specific organic origin - Dementia, delirium, intoxication

109
Q

Psychiatric mental illness is what?

A

an organic etiology not yet established - Anxiety disorder, schizophrenia

110
Q

Developmental considerations for Psychosocial assessment

A
  • Can take older patients longer to respond, but should still be logical.
111
Q

What is culture?

A

Culture is the patterns of behavior & thinking that people living in social groups learn, develop, and share

112
Q

Cultural groups is categorized around…

A

racial, ethnic, religious, or socially common practice patterns

113
Q

What is subcultural?

A

People within a culture whose practices or beliefs are separate from the dominant culture

114
Q

What is multiculturalism?

A

Cultures and subcultures coexist within a given society in which no one culture dominates

115
Q

What are ethnic groups?

A
  • Common characteristics
  • Nationality, language, values, customs, share a cultural heritage
116
Q

When asking a patient “With what culture do you identify?” the areas of assessment are?

A
  • use of traditional healing practices
  • preferences for care
  • health benefits
  • religious or cultural practices at specific times
117
Q

risks related to cultural assessment

A
  • powerlessness
  • fear
  • anxiety
  • hopelessness
  • inadequate family coping skills
118
Q

What is spirituality?

A
  • It is personal but a universal human experience
  • connects to something bigger than self
  • may have elements of religion
119
Q

Spirituality is a search for:

A

peace, purpose, transcendence, connection w/others or nature

120
Q

What is religion

A

it is an organized framework of believers with similar beliefs, moral values, & spiritual practices to express faith & worship of god or a higher power

121
Q

Risks related to spiritual assessment

A
  • Expressing fear of dying
  • depression or withdrawal
  • changes in eating or sleeping patterns
  • expressing anger, bitterness, shame, & hopelessness
122
Q

What triggers stress in one person might…

A

not cause stress in another

123
Q

What is a Stressor?

A

An external influence that threatens to disrupt equilibrium that is needed ti maintain homeostasis

124
Q

Stressors may be what?

A
  • May be physical, mental, or emotional
  • May be positive/negative, depending on perception
    - additional sources of stressors include:
    – Work & financial disruptions, discrimination, elections.
125
Q

What are Biogenic stressors

A

Directly trigger stress response without any cognitive process
- Ex. caffeine, amphetamines, extreme temperature

126
Q

psychosocial stressors

A

Environmental events, either real or imagined
- Facilitate activation of stress response rather than directly triggering it
- Depends on how person perceives stressor

127
Q

What are the 4 categories of stressors?

A
  • Acute, time-limited
  • sequence events following the initial stressor
  • chronic intermittent
  • chronic permanent
128
Q

Internal stressors consist of what?

A

internal environment

129
Q

Internal environment definition

A

Person’s physical, spiritual, cognitive, emotional, and psychologic well-being

130
Q

External environment stressors:

A

Triggers outside the individual that require change or disrupt homeostasis
- Positive stressors cause eustress
- Negative stressors cause distress

131
Q

What are the physiologic indicators of stress?

A
  • Stimulation of sympathetic, neuroendocrine systems
    - Perception of potential stressor triggers physiologic manifestations
    - prolonged exposure to perceived stressors can lead to disease, and may even be fatal
132
Q

What are the Psychologic indicators

A

Fear
- The perceived threat to safety or well-being

Anxiety
- Apprehension, dread, mental uneasiness, & a sense of helplessness in response to an actual or perceived threat to the well-being

Anger
- Subjective sense of intense displeasure, & irritation

Depression
- Persistent, abnormally low mood characterized by feelings of emptiness, hopelessness, sadness, or despair

133
Q

What are the cognitive indicators?

A

Changes in mental processes
- problem-solving
- cognitive structuring
- manifestations of impairments in cognitive abilities
- suppression
- self-control
- fantasizing

134
Q

What is coping?

A

individual applies cognitive & behavioral measures to handle internal & external demands that the individual perceives as exceeding available resources

  • Integration of environmental cognitive measures to mitigate or diminish the stress response
135
Q

Stress Management Techniques: Cognitive strategies (1 thing)

A

Cognitive refraining

136
Q

Stress Management Techniques: Behavioral strategies

A
  • Physical exercise
  • Journaling
  • Mindfulness
137
Q

What is mindfulness?

A

A stress management technique (adaptive coping strategy)
- Being aware of surrounding & senses at the point in time

138
Q

What are examples of Maladaptive coping?

A
  • Withdrawing from social gatherings
  • Frenzied social life
  • malnutrition
  • excessive sleeping
  • excessive drinking
139
Q

What is nutrition?

A

Nutrition is the study of the nutrients & how they are handled by the body, as well as the impact of human behavior & environment on the process of nourishment

140
Q

What is nutritional Health?

A
  • Physical result of balance of nutrient intake & nutritional requirements
    - poor nutritional health may be from over or undernutrition
141
Q

What are the factors that affect food choice?

A
  • taste
  • smell
  • habits
  • availability
142
Q

What is the purpose of a nutritional assessment?

A

To identify individuals malnourished or at risk of developing malnutrition
- provide data to develop a nutrition plan
- See the effectiveness of nutritional care

143
Q

What is the purpose of a nutritional screening

A
  • to identify those at nutritional risk or to establish a baseline (similar to nutritional assessment)
144
Q

What is part of the Nutritional Health History

A
  • Previous medical problems
  • current medications
  • Surgical history
  • Allergies
  • Alcohol/tobacco use
145
Q

Types of nutritional-related complaints

A
  • Weight loss/gain
  • Changes in energy level
  • change in appetite/taste
146
Q

What is dysphagia

A

difficulty swallowing

147
Q

What is undernutrition

A

occurs when nutritional reserves are depleted or when nutrient intke is inadequate to meet day-to-day needs

148
Q

vulnerable groups

A

infants, children, pregnant, immigrants, low-income peeps

149
Q

Risk factors for obesity

A

lack of sleep
- genetics
- culture
- oversized food portions

150
Q

signs of malnutrition: skin

A

dry
- flaky
- scaly
- cracks
- lesions

151
Q

signs of malnutrition: hair

A
  • dry
  • sparse
  • corkscrew hair
152
Q

signs of malnutrition: eyes

A
  • foamy plaques
  • dryness
  • pale red
153
Q

signs of malnutrition: lips and tongue and gums

A

lips: cheilosis (cracked lips), ulcers

Tongue: Red, pale, atropic

Gums: Bleeding

154
Q

signs of malnutrition: nails and musculoskeletal

A

nails: brittle, ridged, spoon-shaped

musculoskeletal: pain in calves, thighs, joint pain, muscle wasting

155
Q

Culture considerations for nutrition

A
  • understand differences in food intake
  • socioeconomic status
  • work schedule
  • religion
  • food traditions
156
Q

older adults nutrition SUBJ DATA and OBJ DATA

A
  • adequate intake?
  • physiological changes
  • socioeconomic changes
  • psychosocial changes

OBJ DATA
- Height
- TSF and skin elasticity

157
Q

What is the circadian rhythm

A
  • A Biological rhythm that have daily cycles
  • light & darkness
  • awake is when body temp is highest and vice versa
158
Q

Non REM cycle (NREM) stages

A

stage N1: very lightsleep, last few minutes
Stage N2: light sleep (50% of sleep)
Stage N3:/N4: deep sleep
- Sleeper difficult to wake
- eyes dont move

159
Q

REM sleep desc

A
  • occurs 70-90 min after sleep begins
  • most dreams occur (2 hrs a night)
  • body and brain highly active( brain may be learning)
160
Q

Functions of sleep and psychologic effects of inadequate sleep

A

Physiological effects
- Restores normal levels of activity
- Necessary for protein synthesis

psychologic effects
- irritability
- poor concentration
- difficulty making decisions

161
Q

Factors affecting sleep

A
  • sleep quality
  • quantity of sleep
  • daytime exercise
  • emotional stress/physical pain or illness
  • diet
  • motivation
  • environment
  • regular sleep schedule
  • bedtime hygiene habits
  • substance use
  • medications
  • environment
162
Q

Sleep assessment questions

A
  • Ask about sleep patterns, history, and any recent changes
  • identify usual sleep requirements
  • ask about sleep problems
  • 0-10 sleep scale
163
Q

Lifespan considerations: Infants for sleep

A
  • irregular schedule
  • SIDS (sleep on back)
164
Q

Lifespan considerations: Children

A
  • Need consistent sleep schedule
  • Nightmares
165
Q

Lifespan considerations: Adolescents

A
  • Shift in sleep-wake patterns
  • ## Nocturnal emissions
166
Q

Lifespan considerations: Pregnant individuals for sleep

A
  • inc. need for sleep during first trimester
  • comfort!
167
Q

Lifespan considerations: Older adults

A
  • earlier sleep and wake times
  • inc. in disturbed sleep
168
Q

Insomnia assessment findings

A
  • Inability to attain an adequate amount of sleep and feel rested
  • difficulty falling and staying asleep
  • waking up too early
  • waking up tired
  • acute insomnia - Lasts a few days possibly due to personal or situational stressors
  • Chronic insomnia - Lasts a month or more
169
Q

Any discrepancy with family should be…

A

DOCUMENTED!

170
Q

Purpose of family assessment

A

To examine relationships that can potentially impact a clients health
- identifying strengths, problems, and areas of opportunity

171
Q

Why do nurses perform a family assessment?

A
  • family members and illness intertwine
  • To analyze opportunity, problems, and strengths
172
Q

the 3 components of the family assessment

A
  • Structure
  • Development
  • Other environmental components
173
Q

the 3 family structures

A
  • Internal structure ( family comp. gender, Rank order, Subsystems, boundaries, power structure)
  • external structure
  • context
174
Q

Internal structure: composition

A

who makes up the family?
Can be depicted graphically a a genogram

175
Q

Family assessment: Gender

A

Can determine role and behavior in the family

176
Q

Family assessment: Rank order

A

Sibling rank of each family member

177
Q

Family assessment: subsystem

A

Gender, generational, or interest-based subsystem

178
Q

Family assessment: Boundaries (function equals?)

A

Functional = clear boundaries, good connections

179
Q

Family assessment: Dysfunctional

A

rigid boundaries, poor connections

180
Q

Family assessment: Differentiation of self

A

Balance btw feeling & thinking

181
Q

Family assessment: Distribution of Power

A
  • Power Hierarchy
  • Shared Power
182
Q

What is the Family attachment diagram used for?

A

Can be used to assess the Internal Structure!

183
Q

Family assessment: External Structure and External Systems

A
  • Extended structure
    • Doesn’t reside in the home but can provide support
    • The “cut off” family member

External Systems
- Significant people (co-workers, neighbors, church, classmates)

184
Q

What is an Ecomap?

A

Used to assess EXTERNAL structure “E to E”

185
Q

Family Assessment: Context

A

(This is where culture plays a role)
- Race &/or ethnicity
- Social Class
- Religion
- Environment

186
Q

Achieving various stages of development is important to the…

A

health of the family and its individuals

187
Q

A static family is considered…

A

dysfunctional

188
Q

The 4 family functions

A
  • Instrumental function
  • Affective function
  • Expressive Function
  • Health Care function
189
Q

Instrumental function

A
  • Is family meeting the routine daily living needs of its members
  • ADL’s = activities of daily living
    (bathing, toileting, grooming, ambulating, positioning, feeding)
190
Q

Affective Function

A

Are family members providing mutual support to one another?
- Is each individual family member allowed to attain emotional maturity through self-differentiation?
- Is healthy socialization occurring?
- What subgroups exist within the family & what function do they serve?
- Do boundaries exist within the family? are they rigid or permeable?

191
Q

Expressive Function
How are ______ expressed?
How are ___ conveyed?
How do the ___ members _____ __ one another?
What is the ____-______ communication like?

A
  • How are emotions expressed
  • How are needs conveyed?
  • How do the firm members listen to one another
  • What is the non-verbal communication like?
192
Q

Health Care function

A

How does the family view illnesses?
- How does the family respond to/cope with illness?
- What are the family’s health promotion practices?

193
Q

What is ethnicity? (Includes family)

A
  • Subgroups with a common ancestry, history, and cultural identity
    - Family coping
    - Family stress
    - Family communication

MANY OF THESE ARE IMPACTED BY CULTURE

194
Q

Family Assessment: Analyze the data

A

Identify patterns
- highlights strengths (deliver “ commodities”)
- Cluster data to reveal abnormal findings

195
Q

Family assessment: Multigenerational families

Effective functioning families often demonstrate….

If there is a multigenerational pattern of maladaptive behaviors, this can make interventions…

A
  • patterns of positive behaviors

-more difficult to implement

196
Q

What is assessment?

A
  • gathering data on individual health status
  • identify concerns and needs
197
Q

Nursing assessment: The nurse documents for individual’s potential for:

A
  • inc. risk
  • Current health promotional activities
  • Relevant physical, psychological, social, cultural and environmental factors
198
Q

Holistic nursing assessment def

A

Collects holistic subj. and obj. data to determine a client’s function to make a professional clinical judgment

199
Q

Physical medical Assessment Focuses primarily on

A

The client’s physiologic development status

200
Q

Mind, body, and spirit are _____ and _____ as a whole

A

interdependent and function as a whole
- Multifaceted basis of disease

201
Q

What forms the core of nursing?

A

Health promotion and disease prevention

202
Q

What 2 things are considered open systems?

A

individual and human environment

203
Q

Collection data is done by these three methods:

A
  • Observation
  • Interview
  • Examination
    (these three methods are interwoven in practice)
204
Q

Primary data source for collecting data and secondary data sources?

A

Primary: Patient

Secondary:
- family membesrs
- friends
- lab tests
- Medical records

205
Q

4 types of health assessment

A
  • initial/comprehensive (or baseline) assessment
  • Problem-focused (or system-focused) assessment
  • Time-lapsed reassessment/ongoing assessment (monitoring)
  • Emergency assessment
206
Q

What is constant data?

A

Facts that do not change over time
ex: birth date/blood type

207
Q

What is variable data?

A

Data that can change over time
(can be quick, slow, frequent, or rare)

208
Q

4 types of databases

A
  • complete (total health) database
  • Focused or Problem-centered database
  • Follow-up database
  • Emergency Database
209
Q

Complete (total health) database description

A
  • includes a complete health history and a full physical exam.
  • Describes current and past health state and forms a baseline to measure all future changes
  • Yields first diagnoses (for initial/comprehensive Assessment)
210
Q

Focused or Problem-Centered Database

A
  • For limited or short-term problems
  • Collect “mini” database, smaller scope and more focused than complete database
  • Concerns mainly one problem, or one body system
  • History and examination follow the direction of presenting concern (for problem/system focused assessment)
211
Q

Follow-up database

A

The status of all identified problems should be evaluated at regular and appropriate intervals
- Note changes that have occurred
- Evaluate whether the problem is getting better or worse
- Identify coping strategies being used (for time-lapsed/ongoing assessment)

212
Q

Emergency database

A
  • Rapid collection of data, often compiled concurrently with lifesaving measures
  • Diagnosis must be rapid and comprehensive in nature (for emergency assessment)
213
Q
A

Nurs 220 - Holistic Assessment (5 decks)

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