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Health Assessment > History taking/Interview/Hand Washing/Vital Signs Lecture (unit 1) > Flashcards

History taking/Interview/Hand Washing/Vital Signs Lecture (unit 1) Flashcards

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1
Q

health

A
  • absence of disease
  • having good quality of life
  • disease prevention
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2
Q

biomedical model of health

A

•absence of disease

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3
Q

wellness model of health

A
  • dynamic process

* move toward optimal functioning

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4
Q

holistic health

A

•mind, body, spirit, and environment interdependent

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5
Q

health history

A
  • asking pt/family ???

* past medical records

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6
Q

physical assessment

A

•using systematic, organized head-toe exam

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7
Q

components of health assessment

A

•health history
•physical assessment
•collecting data
*basis for developing a nursing plan of care for pt

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8
Q

nursing process in HA

A
  • assessment
  • nursing diagnosis
  • planning/intervention
  • evaluation
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9
Q

assessment

A

•collect pt data and think critically

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10
Q

nursing diagnosis

A

•name/prioritize issues

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11
Q

planning/intervention

A

•develop a plan for each issue

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12
Q

evaluation

A

•reassess effectiveness of interventions

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13
Q

health history interview

A
  • gives subjective data- what pt says

* first and most important part of HA

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14
Q

phases of interview

A
  1. ) pre-interview
  2. ) introduction
  3. ) working phase
  4. ) termination
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15
Q

pre-interview

A
  • review pt record/bedside report
  • adjust environment for pt comfort (privacy)
  • assessment of your own behavior/appearance
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16
Q

introduction

A
  • greet patient/establish rapport

* establish agenda- purpose for visit

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17
Q

working phase

A
  • invite patient’s story- listen
  • identify/respond to pt emotional cues
  • expand/clarify pt story
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18
Q

termination

A
  • summarize important points

* discuss plan

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19
Q

establishing agenda

A
  • ask about chief complaints

* use open-ended questions

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20
Q

expanding/clarifying story

A
  • guide pt to focus on chief issue
  • have pt elaborate on significant issues
  • use 7 attributes of a symptom
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21
Q

therapeutic communication

A
  • exchange of info that conveys meaning
  • listen w/o interrupting
  • show empathy
  • eye contact
  • take brief notes- keep attention on pt
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22
Q

interviewing acutely ill

A
  • ask abbreviated ??? (what hurts?)
  • determine cause of visit
  • prioritize
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23
Q

interviewing someone under the influence

A
  • simple direct ???s
  • avoid confrontation
  • determine last use of drug
  • get full history when sober
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24
Q

interviewing sexually aggressive pts

A
  • make clear that you are health care professional

* be assertive and don’t tolerate inappropriate behaviors

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25
how to avoid personal questions
* provide brief info if appropriate | * direct ??? back to pt
26
interviewing angry pts
* don't personalize the anger | * address the pts anger first with open ended ???s
27
interviewing pts with anxiety
* normal response to illness | * be empathetic and compassionate
28
interviewing hearing impaired
* ask preferred method of comm. | * get interpreter if necessary
29
interviewing crying person
* let them express feelings * offer tissue * wait for crying to subside to talk
30
interviewing elderly
* always use last name- Mr. last name * don't rush them * give longer response time * consider physical limitations * touch is very important
31
responses to open ended question response
* facilitation * silence * reflection * empathy * clarification * confrontation * interpretation- inference * explanation- facts * summary
32
facilitation
* encourages person to say more * nodding * "yes", "go on"
33
reflection
•echoing pts words
34
empathy
•recognize feeling and put it in words
35
clarification
•"tell me what you mean by that"
36
confrontation
•"you tell me you don't hurt, but when I touch here, you flinch"
37
traps of interviewing (10)
1. ) false assurance/reassurance 2. ) giving unwanted advice 3. ) using authority 4. ) using avoidance language 5. ) engaging in distancing 6. ) using professional jargon 7. ) using leading/biased ???s 8. ) talking too much 9. ) interrupting 10. ) asking "why" ???s
38
avoiding false reassurance
* "you seem worried about ___" | * offer to listen to anxieties/sit for moment
39
avoiding using authority
* don't say dr. knows best * state there are risks/benefits * remide pt that decision is ultimately theirs
40
avoiding using avoidance language
* don't step around the truth | * state facts
41
aspects of nonverbal communication
* appearance * gestures * posture * facial expressions * eye contact * voice * touch
42
health history
* pt provides subjective info about their past/present health * primary data source * key is reliability- pt give same responses later?
43
secondary data source
* charts | * family
44
categories of health history
* biographical data * reason for seeking care * history of present condition * past history * family history * review of symptoms * health patterns
45
biographical data
•name, age, occupation, DOB, phone #, religion, ethnicity, etc
46
reason for seeking care
* describes reason for visit * record 1-2 symptoms and duration * use quotes
47
sign
•objective
48
symptom
* subjective | * written in ""
49
history for present illness
•complete description of present illness
50
OLD CART
``` Onset Location Duration Characteristic symptoms Associated manifestations Relieving/exacerbating factors Treatments ```
51
provocative/palliative
* what brings it on | * what makes it better
52
quality
•how intense
53
region
* where | * does it spread
54
severity
•pain skill
55
past history
* allergies/what happens? * medication (rx and over counter) * childhood/adult documented illness * surgeries * OB history * health maintenance behaviors
56
health maintenance behaviors
* immunizations * screenings * safety measures * risk factors
57
review of symptoms
* history of each symptom from head to toe * record symptoms as present/absent/"denies" * only subjective data * recorded in medical terminology (denies frequency, nocturia, dysuria)
58
health patterns
* values/beliefs * sleep * exercise * nutrition * relationships * stress * family violence * sensitive topics
59
functional assessment
•measures self care ability related to - activities of daily living (ADLs) - activities needed for independent living - personal habits (drugs/alcohol-ETOH/tobacco-PPD/exercise)
60
activities of daily living (ADLs)
* bathing * dressing * eating * walking
61
activities needed for independent living
* housekeeping * cooking/cleaning * finances
62
standard precautions
•set of principles assuming that all blood, body fluids, secretions, excretions, non-intact skin, and mucus membranes can possibly transmit pathogens
63
most important way to prevent spread of infection
•hand washing
64
nosocomial infection
* infection that has been acquired in a health care setting | * HAI- hospital acquired infection
65
when to wash hands with soap
* if visibly soiled or exposed to C. diff * before/after physical contact w/ pt * after moving from contaminated to clean * after removing gloves * after contact w/ secretions, objects, and blood * before/after entering pt rooms
66
when to perform physical assessment
* on admission * ongoing basis * accepting responsibility for pt * pt status changes * evaluating effectiveness of interventions
67
preparing for an exam (5)
1. ) reflect on you approach 2. ) adjust environment 3. ) make pt comfortable 4. ) gather equipment 5. ) choose systematic head to toe sequence
68
reflecting on approach
* ID self as student * remind them it may take you a little longer (learning) * don't interpret findings (if hear lung crackle, don't assume it's pneumonia) * eye contact
69
adjust the environment
* avoid awkward positions- adjust bed height * good lighting * close curtain * quiet (turn tv down)
70
make pt comfortable
* keep informed * privacy * draping to visualize one area at a time * pay attention to facial expressions
71
order of examination (except abdomen)
* inspection * palpation * percussion * auscultation
72
order of examination abdomen
* inspection * auscultation * percussion * palpation
73
inspection
•concentrated watching •always comes first •look for symmetry *most important part of exam
74
palpation
* touching pt to assess | * applying tactile pressure from palmar fingers to assess
75
palpation w/ fingertips
•texture, swelling, pulsation, masses
76
grasping palpation
•position, shape, consistency, attachment
77
dorsal surface of hand palpation
•temperature
78
ball of hand/base of fingers palpation
•vibrations
79
light palpation of abdomen
* slow * systematic * detects surface/muscle characteristics * be gentle w/ warm hangings
80
deep (bimanual) palpation
* using both hands * getting at deeper organs beneath muscle * liver, kidney
81
perpendicular lighting
* light source directly over area | * light on bed over pt
82
tangental lighting
•lighting that comes from the side •shows shadows that can tell abnormal elevation/indentation •utilized when examining jugular vein *best type of lighting
83
percussion
* Use of finger (third) to deliver rapid tap or blow against distal finger laid against a surface of chest or abdomen * evokes a sound wave to determine location, size, density of organs
84
purpose of percussion
* helps determine if increased density of tissue * helps determine increased/decreased air beneath surface * helps detect air, fluid, or solid mass
85
how to percuss
* place middle finger on area w/ other fingers raised | * use middle finger of other hand to do a wrist-flick strike on stationary middle finger
86
more dense the organ
•the duller the sound
87
resonant sound
* air filled | * Ex: lungs
88
tympany
* hollow organ sound | * Ex: stomach
89
dull sound
* over denser organs | * Ex: liver
90
flat sound
* no air | * Ex: bone
91
auscultation
* Detect characteristics of heart, lung, bowel sounds, and turbulent blood flow * don't listen through clothing * avoid touching tubing * avoid friction/wet hair
92
diaphragm of stethoscope
* High pitched * Breath, bowel, normal heart sounds * Held firmly: leave a slight ring
93
bell of stethoscope
* Soft, low pitched sounds * Extra heart sounds, murmurs * Held lightly
94
using stethoscope
* keep tubing steady * slope ear pieces toward nose * make sure snug in ears- blocks extraneous noise * make sure chest piece turned to bell/diaphragm side
95
head to toe sequence (10)
1. ) general survey 2. ) vital signs 3. ) skin 4. ) HEENT- head, neck, eyes, ears, nose, throat 5. ) posterior/anterior thorax/lungs 6. ) breasts, axillae 7. ) cardiovascular 8. ) abdomen 9. ) lower extremities and circulation 10. ) nervous and musculoskeletal
96
general survey
* objective observation of pt | * all data gathered at first encounter and continues throughout interaction
97
data you should gather through general survey (5)
1. ) physical appearance 2. ) state of health 3. ) grooming 4. ) mobility 5. ) behavior
98
apparent state of health
* look age * look ill * skin color * odor * facial expressions * posture * speech * mood * symmetry * motor activity * signs of distress
99
level of consciousness
* LOC | * awake/alert
100
measurement during general survey
•weight and height
101
influences on temperature
``` *hypothalamus controls •diurnal cycle (highest 8pm-12am) •menstrual cycle •exercise •age •stress •illness ```
102
normal resting temp
* 37 C | * 98.6 F
103
normal rage of temp
* 35.8-37.3 C | * 96.4-99.1 F
104
oral temp
•under tongue on side in posterior pockets •delay 10-15 min if just ate/drank/smoked *most common
105
rectal temp
* insert 3-4 cm in anal canal toward umbilicus | * not used often b/c of health risks
106
tympanic temp
•less accurate measurement
107
apical pulse
* central pulse located over apex of heart | * reflects HR
108
peripheral pulse
* rhythmic expansion of an artery that is palpated | * reflects HR and adequacy of circulation to extremity
109
pulse deficit
* difference b/t apical and peripheral pulse rate | * apical-radial
110
stroke volume
* amount of blood that exits LV during each ctx | * pressure wave in arteries
111
cardiac output
* volume of blood pumped from heart in one min | * SVxHR
112
heart rate
* bpm * decreases with age- newborn 120 bpm * affected by age, gender, circadian rhythm, blood volume, body temp, exercise, stress, meds, etc
113
Tachycardia
•more than 100 bpm
114
Bradycardia
•less than 60 bpm
115
when to take apical pulse
* when you are measuring vital signs and you palpate radial pulse * if radial pulse is irregular * take apical for full min * compare the two- find pulse deficit
116
heart rhythm
* regularity of beats | * how even is the tempo
117
Sinus arrhythmia
•during inspiration HR increases
118
hypervolemia
* high blood volume * pulse full; bounding * HR may increase * Ex: too many fluids
119
hypovolemia
* low blood volume * pulse weak or thready * rade increases to transport more O2 * Ex: bleeding inside
120
HR increases when...
•blood volume decreases
121
0 force
•absent pulse
122
1+ force
•weak/thready pulse
123
2+ force
•normal pulse
124
3+/4+ force
•full; bounding
125
artery elasticity
•feels springy when taking pulse
126
taking pulse in child under 2
* take apical | * record for min
127
taking pulse in child > 2
•radial x 1 min
128
taking adult pulse
* radial x 30 sec (unless abnormal) | * if irregular, determine pulse deficit- RECORD FOR MIN
129
what to pay attention to when taking pulse (3)
1. ) rate 2. ) rhythm 3. ) force/elasticity
130
recording respirations
* do secretly- finish counting pulse but pretend still counting while counting resp. rate * count for 30 sec unless irregular
131
normal respiratory rate infant
•30-80 bpm
132
normal respiratory rate adult
•12-20 bpm
133
blood pressure
* force of blood against arterial wall | * normal is 120/80
134
systolic pressure
•max on ctx of L ventricle
135
diastolic (DP)
•pressure during resting phase of cardiac cycle
136
pulse pressure (PP)
* SP-DP | * tends to increase w/ age
137
mean arterial pressure
* pressure average in arteries | * pressure forcing blood into tissues
138
BP range
•90/60-139/89
139
physiologic factors controlling BP
* cardiac output * peripheral vascular resistance * vol. circulating blood * viscosity * elasticity
140
peripheral vascular resistance
* how much resistance heart has to push against during contraction * BP = CO x PVR * higher if have narrow arteries
141
what influences blood viscosity
* # RBCs | * glucose levels
142
sphygmomanometer measurement
* W = 40% arm circumference | * L = 80% arm circumference
143
using too small BP cuff
•false high reading
144
using too large BP cuff
•false low reading
145
positioning pt for BP reading
* allow rest 5 min to be relaxed * put cuff on bare arm * arm at heart level * back against chair, feet flat on ground * bladder of cuff centered over brachial art. 2.5 cm above antecubital crease * secure cuff snugly
146
steps of taking BP
1. ) palpate brachial artery and place bell over 2. ) rapidly inflate until pulse is obliterated 3. ) slowly deflate 2 mmHg/beat 4. ) listen for Korotkoff's sounds 5. ) read gauge at first sound- systolic 6. ) read gauge at last sound- diastolic 7. ) document systolic/diastolic and position of pt
147
osculatory gap
• the period during which Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point •responsible for errors made in recording falsely low systolic blood pressure *to avoid estimate systolic first and if pump cuff 30 mmHg past normal
148
estimating systolic pressure
1. ) palpate radial artery 2. ) blow cuff until can't palpate anymore * blow cuff 20-30 mmHg higher than estimated systolic
149
Korotkoff sound I
•systolic pressure
150
Korotkoff IV sound
•muffling of sounds
151
Korotkoff V sound
•when sounds disappear •diastolic pressure *listen little longer to be sure
152
acute pain
* short term, sudden onset | * dissipates after injury heals
153
chronic pain
* continues for 6 months or longer | * doesn't stop when injury heals
154
stomatic pain
* ligaments | * bones
155
cutaneous pain
•lacerations
156
visceral pain
* abdomen | * thorax
157
radiating pain
•left arm pain w/ heart attack
158
referred pain
* liver pain in shoulder | * same nerve
159
intractable pain
* severe, constant pain that is not curable by any known means and which causes a bed or house-bound state and early death if not adequately treated * treated with opioids and/or interventional procedures
160
neuropathic pain
•PNS or CNS
161
phantom pain
•missing body part
162
what to observe when inspecting pain
* guarding * facial grimacing * restlessness * changes in vital signs
163
guarding
•trying to protect area
164
what to look for when palpating pain
* crepitation | * swelling

Health Assessment (8 decks)

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