health ass exam 1 Flashcards
EBP encompasses (4)
research evidence clinical expertise clinical knowledge patient values and preferences (clinical decision making depends on all four factors bc pts deserve to be treated with the most current and best-practice techniques)
holistic health
incorporating external interpersonal environment of one’s mind and body
consideration of the whole person - views the mind, body, spirit as functioning as a whole within the environment
includes lifestyle behaviors, culture, values, family and social roles, self care behaviors, job-related stress, failures, etc.\
complete (total health) database
complete health history and full physical exam
describes current and past health state
forms a baseline against which all future changes can be measured
yields first diagnosis
focused or problem-centered database
for a limited or short-term problem
smaller in scope and more targeted than the complete database
concerns mainly one problem, one cue complex, one body system
follow-up database
status of any identified problems should be evaluated at regular and appropriate intervals, is used to follow up both short term- and chronic health problems
ex: what change has occurred? is the problem getting better or worse?
emergency database
an urgent, rapid collection of crucial information
often is compiled concurrently with lifesaving measures
diagnosis must be swift and sure
may be compiled by questioning the pt, but if pt is unresponsive health care providers may need to rely on fam and friends
once the person has stabilized, a complete database can be compiled
health promotion and disease prevention
preventative services, yearly checkup
culture and genetics
cultural health rights
emerging minority
subjective data
anecdotal information that comes from opinions, perceptions, experiences
what the person says abt themselves
objective data
physical data we can observe using out sense, come in either a measurement or direct observation
what you can obtain through physical examination
sending
verbal and nonverbal communication
receiver
interprets your words and behaviors based on past experiences, culture, and self-concept
listener’s bias or any preconceived notions can sabotage the message you are trying to communicate
patient-provider’s relationship is an emotionally charged professional relationship due to relationship being built on illness/vulnerabilities
internal factors
specific to you as the healthcare team member which can help you to maximize communication skills
liking, empathy, ability to listen, self awareness/bias
external factors
defining the environment so as to foster communication
ensure privacy, avoid interruptions, physical environment, dress, note-taking
electronic health record (EHR)
federal gov mandates so as to improve quality and safety
technology interface can affect communication in the provider-patient relationship
capture of biomedical, psychological, and emotional information may not always be captured
do not allow computer to become a barrier in communication process
open-ended questions
asks for narrative information
closed/direct questions
asks for specific information
1st step in interview
introduce interview, short and formal
second step in interview
data-gathering/working phase
open-ended/closed or direct questions
nine types of verbal response that full under pt perspective and interviewer perspective: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
closing interview
gradual thereby allowing for adequate closure to allow for final expression
no new topics
summary provided as final statement
verbal behaviors
the words you speak, vocalizations, and tone of voice
9 types of verbal responses: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
nonverbal behaviors
just as important as verbal
physical appearance, posture, eye contact, voice, gestures, touch, facial expression
congruency
when verbal and nonverbal messages are congruent, the verbal message is reinforced
can be viewed as either positive or negative thereby prompting the importance of self-awareness in order to promote communication
equal status seating
pt and nurse should be seated at eye level with no barriers in between
traps of interviewing
providing false assurance or reassurance giving unwanted advice using authority distancing using professional jargon using leading or biased questions talking too much interrupting using "why" questions using avoiding language
symptoms
subjective from pt
sign
objective abnormality detected on physical examination
OLDCART
onset (when)
location (where? point at it)
duration (how long does it last intermittent/continuous?)
character (pain scale 0-10? burning/stabbing/radiating?)
aggravation / associated s/s (swelling/redness/N/V? what makes it worse/better?)
response to treatment at home (positioning? medication?)
treatment
