Phys Assess #1 Flashcards
(423 cards)
1
Q
Learn to develop a trusting relationship with the patients, they will be in a vulnerable state if they are __
A
ill
2
Q
Important to be self aware and knowledgeable of our own ___
A
differences
3
Q
It is important to be self-aware and knowledgeable about one’s own culture-
A
it shows how we care for people
4
Q
Awareness is an interactive and ongoing process-
A
it could change
5
Q
is an integral part of becoming culturally competent
A
Cultural self assessment
6
Q
US Demographics: Total population passed 321 million in
A
2015
7
Q
US Demographics: 61.6% of the population identified as
A
non-Hispanic and whites
8
Q
US Demographics: Largest and fastest growing group
A
Hispanics
9
Q
US Demographics: Remember the US has a lot of
A
immigrants
10
Q
US Demographics: Minority is
A
increasing
11
Q
Emerging Minority Group Trends: Differences noted in
A
age, poverty level, and household composition
12
Q
Emerging Minority Group Trends: All ethnic and racial minority groups exceed the national poverty level
A
they are living in poverty, related to lower levels of education, income, and correlated with higher levels of disability
13
Q
Emerging Minority Group Trends: Low educational attainment and lower income are correlated with __
A
likelihood of disability.
14
Q
Emerging Minority Group Trends: Family size and multigenerational families are more evident in ___
A
minority groups
15
Q
They have little to no understanding to the US health care system-
A
immigrants
16
Q
HC addresses the needs to this specific population if they ___
A
do not understand
17
Q
Immigration and Health Care Concerns: Status of immigrants entering the health care system:
A
In 2014, 13.2% of population were foreign born individuals.
Expected population to double by the year 2065
18
Q
Immigration and Health Care Concerns: Minimal understanding of the following:
A
US health care system
Medical practice interventions
19
Q
Immigration and Health Care Concerns: Communication is an essential component:
A
Need for an interpreter
Provide materials that are based on health literacy principles
20
Q
Immigration and Health Care Concerns: Limited understanding of the HC system, medical practice interventions, may stay away from __
A
health care and become sicker
21
Q
Determinants of Health and Health care Disparities: Social Determinants of Health (SDOH)-
A
helps identify vulnerable patients that need the most help. They face social, economic and environmental disadvantages.
22
Q
Constellation of related factors
Affect a person from preconception to death
EBP indicates that poverty has greatest influence on health status.
A
Social Determinants of Health (SDOH)-
23
Q
Patients may have lower
A
ability to read and write or not at all
24
Q
Require the greatest assistance or interventions for
A
racial minorities, people with disabilities, or members of the LGBTQ population
25
Neighborhood and built environment, Health and health care, Social and community context, Education, Economic stability
Social Determinants of Health (SDOH)-
26
Healthcare Disparities: Our goal to Identify, define, and recognize vulnerable populations.
“A particular type of health difference that is closely linked with social, economic, or environmental disadvantage.”
27
Healthcare Disparities: Work toward eliminating by utilizing available resources.
Us dept of health and human services: Goal of Healthy People- program of nation wide health promotion and disease.
28
Healthcare Disparities: Promotion of health care frameworks-
providing Accessible, culturally and linguistically competent delivery of health care to promote quality of life for all patients
29
The goal for healthy people is to eliminate ___
health disparity
30
Can see increased disparities in specific populations, greater obstacles in obtaining HC due to ___
racial or ethnic characteristics
31
Even though we want to decrease disparities, There has not been any change to ____
access of care or health care disparities
32
National Standards for Culturally and Linguistically Appropriate Services in Health Care
Set of 15 standards
They provide a blueprint to improve quality of care for diverse populations to eliminate health disparities
33
Civil Rights Act 1964- support individuals with LEP
LEP- limited English proficiency
Assisting with communication utilizing resources such as interpreters to make sure the pts are understanding the care they receive
34
Language barriers can decrease quality of care if they __
do not understand
35
Culture-Related Concepts
4 Basic Characteristics of culture
Terminology
36
4 Basic Characteristics of culture
Learned, Shared, Adapted, Dynamic
37
Learned –
Culture is learned from birth through a process of language acquisition and socialization.
38
Shared-
Shared by all members of the same cultural group.
39
Adapted-
Adapted to specific conditions that related to environmental and technical factors in the context of available resources.
40
Dynamic-
Culture Is dynamic. Very hard to define.
Not biologically or genetically determined and subcultures are going to occur when groups function within a larger culture but they break off into smaller cultures based on gender differences, age, occupation, or ethnicity
41
Ethnicity:
Social group with shared traits
42
Ethnic identity:
Self-identification with a particular ethnic group
43
Assimilation:
Process of adopting culture and behaviors of a major culture. Includes pt adopting practices such as dress and diet.
44
Biculturalism and integration:
Allow for reciprocating and maintaining ethnic identity. Allows patient to be apart of both cultures
45
Acculturative stress:
Based on the input from the environment include social, interpersonal, and societal factors
46
Spirituality:
broad encompasses something larger than one’s own existence with a belief in transcendence. Helps individuals to find a purpose and a meaning to life.
47
Religion:
organized system of beliefs as a shared experience that can assist in meeting one’s individual spiritual needs
48
Two concepts that can be interrelated but do not have to exist simultaneously
Spirituality and Religion
49
They help individuals define their feelings and beliefs.
Spirituality and Religion
50
Cultural interview-
it is very important gathering info about health related beliefs
51
If a patient is wearing a charm or amulet. Ask __
what is it and what is represents
52
Disease Causation Theories:
Biomedical or scientific- basis of western medicine
Naturalistic or holistic
Magico religious
53
Biomedical or scientific- basis of western medicine
Cause and effect that can provide physical and psychological illnesses—e.g., germ theory.
Does state that microorganisms such as bacteria or viruses are responsible for disease
54
Naturalistic or holistic-
Belief in the forces of nature that there is balance in the universe—e.g., yin/yang theory
55
yin/yang theory- Yin
Female or negative forces- emptiness darkness and cold.
Cold foods are going to be eaten during hot illness.
56
yin/yang theory- Yang
Male forces or positive forces that emit warmth and fullness, hot foods are going to be eaten during a cold illness.
57
Example of Cold diseases:
ear ache, chest cramps, paralysis or GI discomfort, rheumatoid arthritis, or TB.
58
Example of Hot illness:
abscess, sore throat, rash, and kidney disorders
59
Magicoreligious-
Supernatural forces dominate resulting in good versus evil—e.g., voodoo or faith healing
60
Each culture has its own healers- speak in their __
native tongue
61
Use of alternative, complementary, or traditional therapies based on __
belief system
62
Hispanic Tongue:
curandero, espiritualista, yerbo, or sabedor
63
Black Tongue:
Ougan, spiritualist, old lady
64
American Indian Tongue:
shaman, medicine woman, medicine man
65
____ states that the healing is not complete unless the body and mind are both healed
The Medicine man
66
Asian Tongue:
herbalists, acupuncturists, bone setters
67
Amish Tongue:
braucher
68
Always maintain cultural sensitivity, offer to call priest of spiritual specialist
If unsure ask
69
Ask if they had attempted other remedies at home, ask if they ___
have been seen
70
OTC meds are readily available for patients they might try it before ___
coming to see the doctor
71
Awareness of beliefs across the life cycle can impact perception of health care delivery and treatments
Developmental Competence
72
Parenteral and childs perceptions of illness
Consider the patients beliefs
Cultural taboos
73
Cultural taboos-
Avoided by both children and adults from the religion.
Specific to cultures not consuming pork or caffeine.
Jehovah witness: blood refusal
Providing care to an older adult, assess the role of the family, may not know about health promotion or programs available
74
Values held by dominant culture influence perception of older adults
Independence, self-reliance, and productivity
Care-dependent versus caregivers- role switch
Culture shock- coming from a different country
75
Older generation- the ability to care for themselves has ___
changed
76
Transcultural expression of pain: Remember that Expectations, manifestations, and management of pain are all embedded in a ___
cultural context.
77
Transcultural expression of pain: Pain is highly personal, depending on cultural learning, the meaning of the situation, and other factors unique to ___
the person.
78
Transcultural expression of pain: Considers the situation, what is causing the pain which effects how they express the paint, and ___
other unique factors related to pt
79
Transcultural expression of pain: Culture affects perceives, responds, and ___
manages the pain
80
Providing care- will see different variations of expression of pain. May turn to their social environment for ___
validation and comparison
81
Becoming a Culturally Competent Practitioner
Culturally sensitive, appropriate, competent, and cultural care
82
Culturally sensitive
Caregivers possess basic knowledge and understanding.
83
Culturally appropriate
Caregivers apply knowledge to improve health outcomes.
84
Culturally competent
Caregivers apply a universal concept of understanding to all contextual aspects of care.
85
Cultural care
Provision of health care across cultural boundaries in consideration of context
86
Care may not always align, ask questions that are not ___
too complex
87
When touching patient's, use touch within _____
cultural boundaries
88
Pace questions through out the ____
assessment
89
Treat personal items with ____
care and respect
90
Cultural Self-Assessment: Explore your own personal history to develop cultural sensibility.
Use thoughtful reasoning.
Responsiveness
Discrete interactions
91
Cultural Self-Assessment: Think about the components of culture that you experience in your own daily life.
Purposely action to gain better understanding to help others
Only when we acknowledge our own values and beliefs are we able to fully help others.
Helps us greater understand and help our patients
When acknowledging values and beliefs we can fully take care of them
92
Ask about their influences, family traditions, where they are from to ___
gain info
93
Cultural Assessment: There is no one universally accepted tool that addresses ___
all variables.
94
Cultural Assessment: Do not apply stereotypes-
listen and learn.
95
Cultural Assessment: Recommended list of domains of interest that may be included:
Heritage, health practices and communication
Family roles and social orientation, nutrition and pregnancy, birth/childrearing
Spirituality/religion, death, and health providers
96
To gain a better understanding of our patient
After a pt recognizes a symptom they will seek self treatment- OTC
Cultural Assessment
97
Spiritual Assessment: Use open-ended questions to start the conversation
“Do you have any religious or spiritual preferences that we can support”?- answers spiritual portion
98
Spiritual Assessment: Variety of tools available
FICA—Faith, importance/influence, community and address/action
Brief R-COPE—examines patient’s coping mechanisms
99
Unmet spiritual needs lead to ___
decreased outcomes
100
Important in gather info regarding our ____
patient
101
Best chance what the patient perceives their ___
health state to be
102
First opportunity to gather information about patient's beliefs, concerns, and perception of their individual health state
Interview Purpose
103
Allows for compilation of subjective data and awareness of objective data
Interview Purpose
104
Gather subjective data in the interview
What the patient says includes chest pain, heart burn, itching
105
Objective data- what we observe through our ___
Physical assessment
106
Successful Interview Characteristics
Gather, Establish, Teach, Build, Discuss
107
Gather ___
complete and accurate data about person’s health state including description and chronology of any symptoms.
108
Establish ___
trust to foster acceptance and allow for data sharing.
109
Teach ___
the person about their individual health state. Ways the manage health or promote
110
Build ___
rapport to continue therapeutic relationship.
111
Discuss ___
health promotion and disease prevention.
112
Gather info about ___
current health state, when the symptoms start, what are they, when did it change
113
Contract between you and the client
Interview
114
The mutual goal of the interview is
optimal health
115
Process of Communication: Sending
Verbal communication
Nonverbal communication
116
Verbal communication
Words you speak—vocalization
Tone used in conversation
117
Nonverbal communication
Body language helps to provide cues which may be correlated with truer feelings.
Recognize importance of unconscious messages that body language portrays
118
Change in demeanor or posture-
note It
Can be related to be forced to make difficult decision, make sure to educate them
119
Internal Factors:
Liking others, Empathy, Ability to listen, Self-awareness
120
Liking others—
using a “genuine” approach
121
Empathy—
develop an understanding and sensitivity for others feeling’s
122
Ability to listen—
make sure to use an “active” process
123
Self-awareness—
be aware of “implicit bias”, own belief systems. Different things as the HC team member to maximize skills
124
Process of Communication: External Factors
Ensure privacy, Avoid interruptions, Physical environment, Dress, Note-taking, Electronic Health Record (EHR)
125
Ensure privacy—
aim for “geographic” privacy but ensure “psychological” privacy
126
Avoid interruptions—
minimize and/or refuse
127
Physical environment—
“equal status” seating- same level, 4-5 ft apart for comfort and communication
128
Dress—
appearance and comfort
129
Note-taking—
keep to a minimum, offer “focused” attention so that it is not a barrier
130
Electronic Health Record (EHR)-
make sure the computer screen is not in between you and the client
If interviewing the team, can ask parents to leave for a moment
131
Turn off the TV to
minimize distractions
132
Techniques of Communication
Introducing the interview, Working phase,
133
Introducing the interview-
What it is for
134
Working phase-
Data-gathering phase
Verbal skills include questions to patient and your responses to what is said.
135
Two types of questions: Open-ended-
Broad range, narrative information. States the topic discussed in general terms. To begin the interview. “How has your health been since the last visit”- allows pt to elaborate
136
Two types of questions: Closed-
ask for specific information that leads to a forced choice. Yes or No.
137
Each has a different place and function in interview.
Open and closed ended questions
138
Verbal Responses: Assisting the Narrative
Facilitation, Silence, Reflection, Empathy, Clarification, Confrontation, Interpretation, Explanation, Summary
139
Facilitation—
Encourage to share more info
140
Silence—
Providing directed attentiveness, Paying attention
141
Reflection—
Echo or help express meaning
142
Empathy—
Name a feeling and allow for its expression
143
Clarification—
Wanting to conform info. Can be used if the patient’s word choice is confusing. Can be used to summarize the patients words or to better understand them
144
Confrontation—
Clarifying inconsistent information
145
Interpretation—
Making associations in order to identify a cause of conclusion
146
Explanation—
Inform the person by sharing factual and objective information
147
Summary—
Provide the conclusion based on verifying the info receives and verified that the interview process is ending.
148
Ten Traps of Interviewing to avoid
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using why questions
149
Gives patients a false sense of provided comfort-
false assurance or reassurance
150
Nonverbal Skills—Congruency
When verbal and nonverbal messages are congruent, the verbal message is reinforced.
151
Nonverbal Skills— Incongruent
When they are incongruent, nonverbal message is viewed as the truer one as it is under unconscious control.
152
Make sure the nonverbal and verbal skills are __
matched
153
Nonverbal Modes of Communication
Physical appearance, Posture, Gestures, Facial expression, Eye contact, Voice, Touch
154
Physical appearance-
Take note of the image as an initial perception (First impression)
155
Posture-
Interpretation of body language and how it effects engagement
156
Gestures-
Can send messages
157
Facial expression-
Can reflect emotion and culture
158
Eye contact-
Differ from culture to culture, if able and culturally appropriate maintain eye contact. Be mindful of cultural diversity
159
Voice-
Aware of the tone, intensity, and rate
160
Touch-
Use caution when talking about eye contact and touch
161
Be cautious, interpreting by
age, gender, cultural background, pt past experiences, specific cultural setting,
162
Ending should be gradual thereby allowing for adequate closure to allow for final expression.
Closing the Interview
163
No new topics introduced
Closing the Interview
164
Summary provided as final statement- understand what the patient said
Closing the Interview
165
Not abrupt or awkward
Closing the Interview
166
Make sure to give patient the opportunity to include any last input
Closing the Interview
167
Communicating with Different Ages: Use “Stages of cognitive development” as a guideline to ___
facilitate communication.
168
Communicating with Different Ages: Consider the ___ and ___ level of the child.
maturity and developmental
169
Communicating with Different Ages: Consider that a health care crisis can lead to ___ as a common response.
regression
170
Communicating with Different Ages: Be aware of ___ to maintain engagement.
nonverbal behaviors
171
Communicating with Different Ages: Primary method of communication with infants
Nonverbal
172
Communicating with Different Ages: One direction at a time, keep simple, and give warnings before transitions.
Make sure they know what's going on, mentally prepared.
May need to stoop down to their level and connect with an inanimate object
Toddlers
173
Communicating with Different Ages: Interviewing parent of child or children- include __
child and parent
174
Communicating with Different Ages: Address child by name to build ___
rapport with the child
175
Stages of Cognitive Development
Infants- Birth to 12 months
Toddlers- 12 to 36 months
Preschoolers- 3 to 6 years
School-age- 7 to 12 years
Adolescents- Starts with puberty
176
Infants- Birth to 12 months
Gentle handling with quiet calm voice
177
Toddlers- 12 to 36 months
Give one direction at a time and provide simple explanations
178
Preschoolers- 3 to 6 years
Short directions with concrete explanation
179
School-age- 7 to 12 years
Ask questions to gather data and be nonjudgmental
180
Adolescents- Starts with puberty
Respectful, honest attitude with focused on the individual
181
May speak 1 to 2 words-
toddlers
182
World revolves around them –
preschoolers
183
Objective and realistic-
School age
184
Drastic change to their self concept, communicate so they are aware-
adolescents
185
Developmental task of finding purpose and evaluating existence
The Older Adult
186
Address respectfully
The Older Adult
187
Typically, the interview process will take longer.
The Older Adult
188
Use therapeutic touch to provide empathy.
The Older Adult
189
May need increased response time- time to interpret, process and answer the questions
The Older Adult
190
May have a lot more information to provide, may take longer
The Older Adult
191
Hard of hearing- facing patient and make sure they can see our mouth
The Older Adult
192
Include questions that are related to aging
The Older Adult
193
Consider appropriate pacing
Physical limitations
Typically, the interview process will take longer.
194
Interviewing People with Special Needs: Consider key elements that will address vulnerable populations.
Acutely ill, drug/alcohol abuse, sexually aggressive, emotionally distraught (crying), angry and/or threatening violence and anxious
195
Interviewing People with Special Needs: Use appropriate resources as they relate to the context of the situation.
Social worker, aid
196
Interviewing People with Special Needs: Be alert to “personal question” queries as they may indicate ulterior motives:
Provide appropriate response based on personal ethics.
197
Interviewing People with Special Needs: Alcoholism and drug abuse-
educating the drug interactions
198
Interviewing People with Special Needs: Disease processes worse, can interact with all medications-
alcohol
199
Interviewing People with Special Needs: Common admitted to the hospital-
Alcohol and drugs
200
Being aware of maintaining cultural
Maintaining privacy and modesty
Being aware of maintaining cultural
Maintaining privacy and modesty
201
Be mindful of your communication patterns
Being aware of your own personal bias and baggage
Sexual orientation
202
Interpreter services may be necessary
Communication
203
Use appropriate language
Consider verbal and nonverbal ques
Culture and Genetics Considerations
204
Involves understanding and following directionsA patient may be literate (read) but not have health literacy (Educational level).
that lead to effective communication between the patient and the health care provider.
Health Literacy
205
A patient may be literate (read) but not have health literacy (Educational level).
Health Literacy
206
Provide simple and easy to use directions, use layman's terms
Health Literacy
207
Written materal make sure its based on standard education levels
Health Literacy
208
Provide education in different method, videos, if they cannot read or write
Health Literacy
209
Use 12 pt font, don’t use all capitalizations
Health Literacy
210
Teach back for verification and clarification
Health Literacy
211
Standardized Communication—SBAR
Situation, Background, Assessment, Recommendation or Request
212
Situation
Provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location
213
Backgrounds
Provide pertinent history as it directly relates to patient's current health status
214
Assessment
State pertinent assessment findings obtained with interpretation of data
215
Recommendation or Request
State what you need or want for the patient in terms of medical treatment and/or assistance
216
Communicate with other professions
Standardized Communication—SBAR
217
Maintain standard of communication, promote effective interpersonal communication
Standardized Communication—SBAR
218
Creates environment of respect and enhance collaboration
Standardized Communication—SBAR
219
Maintain open lines of communication providing timely updates in an organized manner
Standardized Communication—SBAR
220
Decrease or get rid of communication within the healthcare setting- main goal
Standardized Communication—SBAR
221
Collect subjective data to combine with objective data from physical exam and labs to form the database for our patient
Purpose of Health History
222
Provides a complete picture of patient’s past and present health status
Purpose of Health History
223
Can be used as a screening tool for detection of abnormalities or find trends
Purpose of Health History
224
Depending on what the pt is seen for the focus may differ in terms of clinical practice setting and/or nature of complaint.
Purpose of Health History
225
Describes the individual as a whole and how they interact with the environment
Purpose of Health History
226
Dealing w a pt who is ill, gather symptoms in chronological order,
Purpose of Health History
227
Objective data, labs and health history=
database
228
The Health History Sequence
Biographic data, Source of history, Reason for seeking care, Present health or history of present illness, Past health, Family history, Review of systems, Functional assessment including activities of daily living (ADLs)
229
When performing the health history do it in an
orderly fashion
230
The Health History Areas of focus may differ slightly in terms of
individual patient concerns.- issued reported
developmental considerations- delays in development
presence of health problem
no detection of health problems.
concerns r/t aging.
identification of vulnerable population.
identified barriers to communication.
231
Subjective data
Determine if they have access to care or needs resources
The Health History
232
Name, address, and phone number
Biographic Data
233
Age, birth date, and birthplace
Biographic Data
234
Gender (identification) and relationship status
Biographic Data
235
Race and ethnic origin
Biographic Data
236
Occupation: usual and present, changed occupations due to health or illness
Biographic Data
237
Primary language- Language-concordant provider or medical interpreter
Biographic Data
238
Includes patients information
Basic info that makes up the patient
Biographic Data
239
If they had lost a job due to illness, know
what kind of job they lost and why they had to change the profession
240
Record who furnishes information, usually the person, although source may be relative or friend.
Source of History
241
Judge reliability of informant and how willing he or she is to communicate.
Source of History
242
Reliability leads to consistency of information.
Source of History
243
Note any special circumstances, such as use of interpreter.
Source of History
244
Think critically about who is reliable
Source of History
245
This info goes into the patient medical record
Source of History
246
Drug reconciliation
Source of History
247
Ill patient, sleepy, under the influence- not reliable info to gather
Source of History
248
Brief spontaneous statement in (pts) person’s own words describing reason for visit
Reason for Seeking Care
249
Document reported findings
Reason for Seeking Care
250
Subjective sensation person feels from disorder documented in quotes
Symptom:
251
Objective abnormality that can be detected on physical examination or in laboratory reports
Sign:
252
Reason for care is not a diagnostic statement.- document exactly what the patient says they are there
Reason for Seeking Care
253
Focus on patient’s prioritized reasons for seeking care.- ask the patient why they came to seek help.
Reason for Seeking Care
254
Present Health or History of Present Illness (HPI): Collect all provided data and identify eight critical characteristics (Pain or injury, discomfort)
Location, character(quality), quantity(severity), timing, setting, aggravating or relieving factors, associated factors and patient’s perception
255
Present Health or History of Present Illness (HPI): Make sure that collected data are precise and accurate.
Use measurable standards and/or patient’s own words as qualifiers.
256
Present Health or History of Present Illness (HPI): Use standardized indicators to document findings
Reliability and validity of reported results (Pain scale)
257
Go over pts past health and present illness
Present Health or History of Present Illness (HPI):
258
Gather pts perception to try to identify what they feel is going on
Present Health or History of Present Illness (HPI):
259
Each of the identified areas can have residual impact on present (as well as future) health status. (ex: Stroke)
Past Medical History
260
Focus on obtaining specific pertinent information relative to each of the identified categories.
Past Medical History
261
More accurate and detailed information obtained will lead to better clinical decision making.
Past Medical History
262
Will provide cues as to how patient’s cope with illness and/or health concerns. Identify how they cope, what they use, how much they use.
Past Medical History
263
Patients can become emotional when talking about the past, stop and comfort them
Past Medical History
264
Ask them if they had any changes within the past year
Past Medical History
265
Past Medical History: Childhood illnesses
Experienced or exposed to presence or absence of complications. Document actual diagnoses
266
Past Medical History: Accidents or injuries
Type and nature of event, acute and/or residual deficit noted. (serious injuries)
267
Past Medical History: Serious or chronic illnesses
Presence of comorbidities has pronounced effect. (Ex: COPD)
268
Past Medical History: Hospitalizations
Types based on clinical indications, interventions used as therapy, and length of stay along with dates of occurrences
269
Past Medical History: Operations
Facility, procedure, date
270
Past Medical History: Obstetric History
Relevant data r/t childbearing inclusive of GPAL, labor/delivery experience, condition of infant, and postpartum course.
271
Past Medical History: Immunizations
Correlate with CDC Guidelines. If they are up to date or if they have them.
272
Past Medical History: Last Examination Date
Obtain last data set for commonly occurring labs/diagnostics (blood work, ECG, chest x-ray, occult blood and gender-specific testing—PAP/PSA).
273
Past Medical History: Allergies
Note allergen and reaction. Sometimes people list the symptoms of the medication instead of the reaction. When it occurred.
274
Past Medical History: Current Medications
Perform medication reconciliation to determine the right meds and dose
Include prescribed and OTC medication and/or herbal therapy.
275
Highlights diseases or conditions that an individual may be at risk for as a result of genetics
Family History
276
Provides age and health or cause of death of relatives (immediate)
Family History
277
Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance
Family History
278
Pedigree or genogram used as standardized tool to organize data
Family History
279
Biographic data
Cross-Cultural Care Implications: Additional questions for new immigrants
280
Spiritual resource and religion: assess if certain procedures cannot be done
Cross-Cultural Care Implications: Additional questions for new immigrants
281
Past health: what immunizations, if any
Cross-Cultural Care Implications: Additional questions for new immigrants
282
Health perception- to begin relationship
Cross-Cultural Care Implications: Additional questions for new immigrants
283
How does person describe health and illness?
Cross-Cultural Care Implications: Additional questions for new immigrants
284
How does person see problems he or she is now experiencing?
Cross-Cultural Care Implications: Additional questions for new immigrants
285
Nutrition: taboo foods or food combinations that is important in their culture
Cross-Cultural Care Implications: Additional questions for new immigrants
286
Evaluate past and present state of each body system (surgeries that effects them)
Purpose of ROS
287
Assess that all pertinent data relative to each body system have been noted
Purpose of ROS
288
Evaluate health promotion practices- Vaccinations, breast exams, testicular exams
Purpose of ROS
289
Organized manner proceeding in a logical sequence
Cephalocaudal approach
290
If information obtained in HPI, then it doesn’t have to be re-assessed again.
Items within different systems may not be inclusive
291
Double check
Patients review of their own body
Make sure including questions that reflects normal process of aging
Review of Systems
292
Functional Assessment: ADLs- Determines ability that related to their functional status
Self-care activities of daily living as they relate to general health status
293
Functional Assessment: Objectively measure functional status
Monitor and assess for changes over time.
294
Functional Assessment: Relevant data related to lifestyle and type of living environment
May include “sensitive” topics r/t lifestyle behaviors and as such may require attention to privacy concerns
Different types of “screening tools” may provide more objective validation of information with regard to substance and/or alcohol abuse. (severity)
295
Maintain privacy when talking about ___
incontinence
296
Measure pts ability to provide self care in regard to ADLs, IADLs nutrition, social relationships, self concept, and coping. Healthy living environment
Functional Assessment
297
Learns how the pt handles day to day activities
Functional Assessment
298
Questions are asked at the end of the interview
Functional Assessment
299
Alcohol abuse or misuse- Cage assessment, older population may be more dependent and can drink more.
Cutting down?
Annoyed about criticism?
Guilty about drinking?
Drink in the morning as an eye opener?
If any says yes to 2 or more of the questions, suspect alcohol abuse. Perform more complete substance abuse questionnaire with this patient
300
Perception of Health- Ask questions such as the following:
How do you define health? Barriers? Focus on a subject?
How do you view your situation now?
What are your concerns?
What do you think will happen in the future?
What are your health goals?
What do you expect from us as nurses, physicians, or other health care providers? To work towards
301
Use open ended questions to gather as much info as possible
Ask how their health is after last visit
Perception of Health
302
Informant will not be the PT.
Developmental competence- child
303
Immunizations, Medications
Developmental competence- child
304
Past health history can have a residual impact on present (and future) health status
Developmental competence- child
305
Prenatal delivery and Postnatal period
Developmental competence- child
306
Most info may come from the parent
Always document the source of the information and the relationship to the child, and if used an interpreter
Determining if the child met their developmental growth or milestone
307
Development changes or issues
Developmental competence- child
308
Nutritional changes or issues (bottle or breastfed, nutritional supplements, special formula)
Developmental competence- child
309
Family History
Developmental competence- child
310
Review of Systems: CHILD: Same method of inquiry used with the adult patient can now be used with the child.
Use an organized approach.
Include at least “two” individuals—parent and/or child.
311
Review of Systems: CHILD: Tailor questions to the child's ___
age and level of development.
312
Review of Systems: Functional assessment-
focus on child's position within the family unit. Respect the relationship of the child and caregiver
313
Not ignoring the child- use inanimate objects
Review of Systems: CHILD
314
Know about past hospitalizations, allergies and reactions
Review of Systems: CHILD
315
IADL-
paying bills, laundry, shopping for groceries, effects the patients independence
316
Pts emotional functioning and cognitive functioning
Relative and dynamic (changes)
Mental status assessment
317
Mental status is a person’s
emotional and cognitive functioning.
318
Mental status cannot be scrutinized directly like the characteristics of
skin or heart sounds.
319
Its functioning is inferred through assessment of an individual’s behaviors:
LOC, Use of language, Mood/affect, Orientation, Ability to pay attention, Memory and abstract reasoning and Perception
320
When asking questions the pt may take longer to answer questions
Older Adults
321
The ability to answer questions not effected
Older Adults
322
As the patients age it will leave the patients mind mostly intact and their general knowledge may not decrease
Older Adults
323
Should not have any loss of vocabulary
Older Adults
324
Recent memory allow the thought process to take place
Older Adults
325
Remote memory should not be effected in older adults
Older Adults
326
Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities
Mental disorder
327
Due to brain disease of known specific organic cause
Organic disorders
328
Delirium or dementia or alcohol and drug use and use or abuse=
organic disorders
329
Organic etiology has not yet been established
Psychiatric mental illnesses
330
Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Psychiatric mental illnesses
331
Anxiety disorder and schizophrenia
Psychiatric mental illnesses
332
Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent.
Developmental Competence Infants and Children
333
Addressing concerns that parents or teachers have as developmental process associated with aging continues
Developmental Competence Infants and Children
334
Critical issues may be seen r/t substance abuse, suicide, and impact of mental health issues being diagnosed and/or individuals receiving treatment
Developmental Competence Infants and Children
335
Age-related changes in sensory perception can affect mental status along with chronicity of disease process (presence of comorbidity). (ex: COPD)
Developmental Competence Aging adults
336
Experienced more Grief and despair surrounding these losses can affect mental status and can result in disability, disorientation, or depression or sadness)
Developmental Competence Aging adults
337
Older adulthood contains more potential for losses.
Developmental Competence Aging adults
338
Aging alone should not impact their
mental health
339
Full mental status examination is a systematic check of emotional and cognitive functioning.
Components of the Mental Status Examination
340
Usually, mental status can be integrated within the context of the health history interview.
Components of the Mental Status Examination
341
Four main headings of mental status assessment: A-B-C-T
Appearance/Presentation
Behavior/not normal
Cognition
Thought processes/communication
342
Document and note
abnormalities
343
When a Full Mental Status Examination Is Necessary
Initial screenings, sudden behavioral changes, brain lesions, sudden aphasia, symptoms of psychiatric mental illness
344
Suggests an anxiety disorder or depression
Initial screening
345
Memory loss, inappropriate social interaction. May have family members reporting changes.
Sudden Behavioral changes
346
Trauma, tumor, cerebrovascular accident, or stroke
Brain lesions
347
Impairment of language ability secondary to brain damage. Determine the type. Expressive (cannot speak) or receptive(cannot understand)
Sudden Aphasia
348
Especially with acute onset
Symptoms of psychiatric mental illness
349
Enough info to identify any problems-coping skills-
full health history
350
Known illnesses or health problems
Factors That Could Affect Interpretation of Findings
351
Medications: Side effects, confusion, depression
Factors That Could Affect Interpretation of Findings
352
Educational and behavioral level: Level of understanding
Factors That Could Affect Interpretation of Findings
353
Stress responses observed in: social interactions, changes in sleep habits, stress responses, under the influence or withdrawing
Factors That Could Affect Interpretation of Findings
354
If any of these factors are present, note them
Factors That Could Affect Interpretation of Findings
355
Appearance, behavior, cognitive functions, and thought processes
Additional screenings as needed based on observations
Objective Data: Collection Addressing key areas:
356
Additional screenings as needed based on observations
Objective Data: Collection Addressing key areas:
357
Documentation of findings and what has changed since the last time seeing this pt
Objective Data: Collection Determination of normal versus abnormal findings
358
Obtaining baseline and then trending results upon ongoing assessment
Objective Data: Collection Determination of normal versus abnormal findings
359
Make sure to start with the basic functions first (Conscious) then
language barriers
360
Objective Data: Appearance
Posture, Body movements, Dress, Grooming and hygiene
361
Erect and position relaxed, comfortable
Posture
362
Voluntary, deliberate, coordinated, and smooth and even
Body movements
363
Appropriate for setting, season, age, gender, and social group
Dress
364
Congruence between grooming and age
Grooming and hygiene
365
Objective Data: Behavior
LOC, Facial expression, Speech, Mood and affect
366
Awake, Alert, Aware, respond appropriately and reasonably to stimuli
Level of consciousness
367
appropriate to the situation and that is changes appropriate with the topic
Facial expression
368
Quality of speech is appropriate, note slurring and effortlessly communicate
Speech
369
Assess body language and facial expressions
Mood and affect
370
Objective Data: Cognitive Functions
Orientation, Attention span, Recent memory, Remote memory
371
Discern orientation through course of interview, or use direct questioning to verify
Time:
Place:
Person:
Orientation
372
Appropriately pay attention
Attention span
373
Recent memory- 24 diet recall, when did you arrive at the agency. Dementia patients may make up responses
Recent memory
374
Birthday, Anniversaries, historical events relevant to the person.
Remote memory
375
____ is going to be lost when the cortical storage area for that memory is damaged.
Occurs in Alzheimer's disease and dementia or other diseases when the cerebral cortex is damages
Remote memory
376
Highly sensitive and valid memory test
The Four Unrelated Words Test
377
Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall
The Four Unrelated Words Test
378
Pick four words with semantic and phonetic diversity; ask person to remember the four words. Sound different and completely unrelated.
The Four Unrelated Words Test Assessment Process
379
To be sure person understood, have him or her repeat the words.
Ask for the recall of four words at 5, 10, and 30 minutes.
The Four Unrelated Words Test Assessment Process
380
Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.
The Four Unrelated Words Test Assessment Process
381
Memory recall test
Tests patients ability to make new memories
Ball, pillow, dog, letter
The Four Unrelated Words Test
382
____ are the two most common mental health disorders seen in individuals seeking health care.
Anxiety and depression
383
Generalized anxiety disorder scale (GAD-7)
Consists of 7 itemized scale
Higher the score, greater the likelihood.
First 2 questions relate to core anxiety.
Greater or equal than 3 indicates diagnosis.
384
Sudden onset of anxiety- lasting less than 10 mins-
panic attack
385
Irrational fear of a specific object-
Phobia
386
Generalized anxiety disorder, Social anxiety disorder, OCD and PTSD
most common
387
Series of tools that can be used in
clinical setting
388
Patient Health Questionnaire-2 (PHQ-2) complete assessment if positive
Asks 2 questions about depressed mood and anhedonia (lack of interest).
Little interest of pleasure of doing things, feelings of hopelessness. How bad are the symptoms. The higher the score the higher the diagnoses.
Serves as a screening tool to use full PHQ-9 tool
389
PHQ-9- Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms
Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.
390
Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief.
Screening for Suicidal Thoughts
391
Begin with more general questions and proceed if you hear affirmative answers.
It is very difficult to question people about possible suicidal wishes for fear of invading privacy.
Risk is far greater skipping these questions if you have the slightest clue that they are appropriate
For people who are ambivalent, you can buy time so the person can be helped to find an alternate remedy.
392
Share any concerns you have about a person’s suicide ideation with a mental health professional.
Screening for Suicidal Thoughts
393
Share with mental health professional to get more help
Screening for Suicidal Thoughts
394
Is the ability to compare and evaluate alternatives and reach an appropriate course of action
Judgment
395
____ about daily or long-term goals, likelihood of acting in response to hallucinations (sensory perception for which no external stimuli exists, can strike any sense) or delusions, and capacity for violent or suicidal behavior.
Test judgment
396
These plans should be realistic and rational.
Judgment
397
Determined patients family obligations, plans for the future and make sure health plans are appropriate considering their
health condition
398
Supplemental Mental Status Examination
Mini-Mental State Exam (MMSE) & Montreal Cognitive Assessment (MoCA)
399
Concentrates only on cognitive functioning
Mini-Mental State Exam (MMSE)
400
Standard set of 11 questions requires only 5 to 10 minutes to administer.
Mini-Mental State Exam (MMSE)
401
Useful for both initial and serial (follow up) measurement
Mini-Mental State Exam (MMSE)
402
Detect dementia and delirium and to differentiate these from psychiatric mental illness.
Mini-Mental State Exam (MMSE)
403
Normal mental status average 27; scores between 24 and 30 (highest score) indicate no cognitive impairment
Mini-Mental State Exam (MMSE)
404
Anything greater than or equal to 26 is considered normal
Mini-Mental State Exam (MMSE)
405
Looks at orientation, ability to pay attention, language
Mini-Mental State Exam (MMSE)
406
Patient must be able to read and write and able to see the examination
Mini-Mental State Exam (MMSE)
407
Low education levels or decreased intellectual abilities- be careful
Mini-Mental State Exam (MMSE)
408
Examines more cognitive domains, more sensitive to mild cognitive impairment
Montreal Cognitive Assessment (MoCA)
409
Make sure what they are saying is logical
Assess for dementia or delirium
Supplemental Mental Status Examination
409
Denver II screening test gives a chance to interact directly with child to assess mental status.
Infants and children Screening Tests
410
“Behavioral Checklist” for school-age children, ages 7 to 11, is tool given to parent along with the history.
Covers five major areas: mood, play, school, friends, and family relations
It is easy to administer and lasts about 5 minutes.
410
For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas.
An additional language test is the Denver Articulation Screening Examination.
Denver II screening test
411
Adolescents
Follow same A-B-C-T guidelines as for adults.
Appearance
Behavior
Cognition
Thought
412
Confusion is common and is easily misdiagnosed.
Presence of delirium can have serious affects.
Developmental Care of Aging Adults
413
Check sensory status, vision, and hearing before any aspect of mental status.
Developmental Care of Aging Adults
414
Delirium-
Acute confused state, potentially preventable especially dealing with hospitalized patients. Sudden onset of symptoms related to uti, infection, and impaired sleep. Can be paired with memory deficit
415
Dementia-
chronic and progressive loss of cognitive abilities. Lose intellectual functions and develop slowly and over time. Impaired judgement and memory
416
Depression-
long term depressed mood. Lack of pleasure, disturbed sleep, major depressive disorder- one or more major depressive episodes at least 2 weeks of the depressed state. At least 4 additional symptoms of depression
417
dysrhythmic disorder-
accompanied by 2 years of depressed mood for more days than not. Ask how long they have been depressed
418
Testing Aging Adults
Follow same A-B-C-T guidelines for the younger adult with these additional considerations.
Appearance
Behavior
Cognition
Though Process
419
LOC assessment especially if they are dealing with
confusion
420
If pt has been hospitalized for a significant amount of time they may not be able to tell specifically the
amount of time they have been there
420
Dementia pts- if asking again it does not
effect the ability to learn
