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Health Assesment-RN > Test 1 > Flashcards

Test 1 Flashcards

1
Q

Nursing process -steps

A

Assessment,

diagnosis,

outcome identification,

planning,

implementation,

evaluation

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2
Q

(*Perform the nursing actions identified in planning)- nursing process

Use community resources

Provide health teaching and health promotion

Document implementation and any modifications

Coordinate care delivery

Use evidence-based interventions

Implement in a safe and timely manner

A

Implement

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3
Q

Evaluate persons condition and compare actual outcomes with expected outcomes (progress toward outcomes)

Include patient and significant others

Ongoing assessment to revise plan or diagnoses

Communicate/inform results to patient and family

A

Evaluation

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4
Q

Review the clinical record

Health hx

Physical exam

Functional assessment

Cultural/spiritual assessment

Use evidence-based assessment techniques

A

Assessment

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5
Q

Compare clinical Findings of normal and abnormal variation in developmental events

Cluster associated data

Validate data

Confirm accuracy

Look for gaps

Interpret and Identify problem/data

Document the dx

A

Diagnosis

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6
Q

Identify expected outcomes

SMaRT components

Short term and long term goal measurement

Include a timeline

Cultural appropriate

Individualize to person

Realistic and measurable

A

Outcome identification

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7
Q

Establish priorities

Develop outcomes

Set timelines for outcomes

Identify interventions

Integrate evidence-based trends and research

Document plan of care

A

Planning

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8
Q

What are the components of evidence based decision making ?

A

Is there scientific evidence/research evidence

Patient preferences/values/circumstances

Clinicians experience and judgement

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9
Q

SMaRT components ?

A

Specific

Measurable

Attainable

Relevant

Time bound

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10
Q

Closed or open ?? Benefits of it

Tell me how you are feeling?

A

Open ended questions:

Narrative answers

Feelings and opinions

Develops rapport

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11
Q

Closed or open??

Do you have pain?

Benefits?

A

Closed ended questions

  • specific info
  • yes or no
  • limits rapport, neutral
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12
Q

Barriers to communication? Not to use

A

Providing false assurance or reassurance

Giving unwanted advice

Using authority (your dr knows best)

Avoidance language (they are in a better place)

Distancing (lump in “the breast”)

Adjust language to patient understanding

Leading questions (you don’t smoke do you?)

Interrupting

Don’t use why questions

Nonverbal skills (touch, voice,eye contact, gestures , facial expressions, posture , appearance

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13
Q

Reason for facilitation, cues, leads ?

Examples ?

A

Shows you are listening

Encourages to say more

  • nodding head yes
  • mmhmm
  • eye contact, shift forward
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14
Q

Gives the client time to think

A

Silence

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15
Q

Echos clients words to help patient identify feelings

“You have difficulty getting the day started?”

“It’s hard getting up in the morning”

A

Reflection

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16
Q

It must be difficult not being independent

A

Empathy

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17
Q

So you have difficulty lying down if you lie flat and you need pillows?

A

Clarification

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18
Q

Before you said you do not smoke but now you mentioned smoking with your friends?

A

Confrontation

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19
Q

I always take this blanket with me.

So this blanket must be very important to you

A

Interpretation

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20
Q

You cannot eat anything for 12 hours prior to surgery

A

Explanation

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21
Q

Condenses everything discussed allows plants to make corrections if needed

A

Summary

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22
Q

Lack of interest/attention

Door, curtain, computer, temp

Patient can not hear you

Safety- fear

Psychological barriers: Shocked, fear, embarrassed

Language Barrier

A

Barriers to communication

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23
Q

Types of pain

A 
Referred 
Phantom
Acute 
Chronic 
Breakthrough pain
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24
Q

Pain that is felt in a location other than where the pain originates

A

Referred pain

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25
Feeling like the limb is still there after amputated due to damaged remaining nerve endings
Phantom pain/ sensation
26
Short term pain which is self limiting Cause by ?Tissue damage Less than 6 months Mild moderate pain- sympathetic ns ? Severe pain- parasympathetic ns ?
Acute pain
27
Last longer than 6 months Intermittent or continuous Does not stop after injury heals Abnormal processing of pain fibers ?
Chronic pain
28
How to assess pain? Physical changes with pain ?
Posture/behavior Facial expression Sounds Palpation Vitals (increased BP, Pulse, resp) Pupil size dilation Sweating/increased temperature
29
Pain that occurs between doses of pain medication
Breakthrough pain
30
Pain that is acute and starts outside NS Results in actual or potential damage Responds to opiated and inflammatories
Nociceptive pain
31
Abnormal processing of pain from injury to nerve fibers or CNS Chronic Numbness, tingling,shooting, burning, poorly responsive to pain meds
Neuropathic pain
32
The point at which a person feels pain
Pain threshold
33
Duration or intensity of pain a person will endure before outwardly responding
Pain tolerance
34
What is pain ?
Whatever the patient says it is and whenever they say it is occurring
35
PQRST pain assessment
Precipitating or palliative Quality or quantity Region or radiation Severity scale Timing
36
What consists of substance abuse assessment ? Techniques to elicit (get) info from patient?
Learn terminology Tolerance Dependency vs addiction Watch for withdrawal symptoms such as nausea, vomiting, anxiety, headache, tremor ???
37
CAGE questionnaire ?
Cut down, annoyed, guilty, eye opener Questions to determine if your running is uncontrolled Cut down (should you cut down?) Are you annoyed of criticism you get about your drinking ) Have you ever felt guilty about your drinking? Do you drink in the morning ?
38
Alcohol use disorders identification test
AUDIT- questionnaires with ? Such as how often do you have a alcoholic beverage? Covers 3 domains: alcohol consumption, drinking behavior or dependence , and adverse consequences from alcohol
39
Frequency of use of alcohol, tobacco, rx, for non-medical use, illicit drugs
Quick assessment (substance abuse)
40
Who needs to be assessed for domestic violence ? When to report??
Everyone
41
What percent of women and men experience rape, physical violence and/or stalking ?
36% women and 29% men
42
Types of violence or abuse
``` Sexual Physical Threats Emotional Neglect Financial ```
43
How to asses intimate partner abuse IPV Scores?
Use your own words and be non- judgmental such as “domestic violence is so common I ask all my patient about abuse in the home.” ``` HITS H-hurt I- insult T-threaten S-scream ``` 1-5 never to frequent 10 or more indicates IPV
44
When to assess for IPV?
Assess at every visit Abuse assessment screen
45
S/s of abuse
Frequent UTIs Chronic pelvic pain STIs Anxiety/depression Back pain PTSD Failure to follow up Frequent healthcare visits
46
S/s of human trafficking
Injury/sign of abuse Malnourished Disoriented Lack of ID Few personal belongings Fearful, anxious, submissive Scared of the law Can not freely contact friends and family Avoids eye contact
47
What to do if you see signs of human trafficking?
Must report Call 911 if unsure Contact national human trafficking resource center
48
What are the characteristics and risks of human trafficking ?
Victims are usually white/black and US citizens Risk factor: ``` Age Poverty Unemployed Gender inequality Sexual abuse Mental or health problems ```
49
The degree of balance between nutritional intake and nutrient requirements Intake sufficient for basic needs
Nutritional status Optimal nutrition
50
Two are two primary components of this : Health history-subjective Physical examination-objective
Health assessment
51
Too much food energy or excess nutrients to the degree of causing disease or increasing risk of disease, a form of malnutrition (sedentary lifestyle) Related conditions: Heart disease Diabetes 2 Stroke Gallbladder disease
Overnutrition
52
What fraction of kids are overweight or obese? What ages?
1/3 Ages 6-19
53
Occurs when nutritional reserves or depleted or when nutrient intake is in adequate to meet day today needs or added metabolic demands - impaired growth - lowered resistance to disease - delayed wound healing
Undernutrition
54
How to asses food intake ? What methods??
24 hour recall Food diary (most comprehensive) Food frequency Typical food intake Direct observation
55
Difference between 24 hour food recall and food diary ??
Food diary may be more accurate - write down everything consumed for a certain period of time. Write down immediately after eating. 24hour recall- questionnaire to recall everything eaten within the last 24 hours. Can evoke Specific information about dietary intake.
56
Factors what can affect nutritional status?
Problem based hx: Weight loss, weight gain (when it started, intentionally ? Difficulty chewing or swallowing (Types of food you eat) Loss of appetite/nausea
57
Normal vs for an adult: Bp: P: R: O2: T:
Bp:systolic- 90-120 Diastolic- 60-80 P:radial, apical, carotid , brachial 60-100 bpm 3+ is full, bounding 2+ is normal 1+ is weak 0 is absent R:10-20 count for 30 sec x 2 T:98.6 O2:95-100%
58
How to take- pulse: Bp:
30 seconds and times by 2
59
What affects vital signs?
Stress, pain, drinking fluids, temperature, position, wrong cuff size ... ??
60
What can influence a normal body temp ? What is being assessed?
``` Drinking hot or cold fluids Exercise Stress Age Gender - mensuration in women Time of day Smoking Chewing gum ```
61
Characteristics assessed for pulse?
Pulse strength , Rhythm, BPM
62
R- What does a normal breathing pattern look Like?
relaxed, regular rhythm, quiet, 12-20 per minute
63
Temperature methods? Accuracy of them? Trouble shooting?
``` Tympanic ear - accurate Oral - most convenient and accurate Temporal- fast and accurate Rectal -most accurate to core temp Axillary- arm pit - kids ```
64
What do the bp numbers mean? Systolic ? Diastolic?
Bp is the force of blood pushing against the side of the vessel wall. (The strength charges with the event in the cardiac cycle) S-the maximum pressure felt in the artery during left ventricular contraction D-blood pressure flow when heart is relaxed or resting between each contraction
65
What is orthostatic bp?
A change in bp after standing up after laying down. Person may feel faint or dizzy
66
Types of assessments to screen for pt history?
Comprehensive health hx Complete total health Focused or problem- centered database Primary, secondary, and tertiary prevention General survey
67
Comprehensive health hx
A detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam. Also includes an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers.
68
Complete total health
Complete health hx and a full physical examination Yields the first diagnosis
69
Focused or problem- centered database
Limited or short term problem. Mainly one problem or one body system
70
Primary, secondary, and tertiary prevention
Primary- prevents health problems (safety glasses, vaccines, exercise) Secondary- screening, catch problems early Tertiary- cardiac rehab, support groups
71
General survey - what is it and what things to look for in patient?
A study of the whole person, covering the general health state and any obvious physical characteristics Age sex, loc, skin color Posture , body build Gait, ROM Facial expression, mood , speech, dress, hygiene Intro for the physical , objective parameters which apply to the whole person How the person stands at their name , so they look sick?, make eye contact? Smile, shake hand firmly? Health hx, measurements , vs **Physical appearance , body structure, mobility, and behavior
72
How and when to use tools/equipment? Oximeter ? Thermometers? Stethoscope ? Etc.
Have all equipment at easy reach and laid out in an organized fashion Make sure they care cleaned after using with sanitizer whipe
73
What are the 4 techniques of assessment? What information will each technique tell you?
1. inspection 2. palpation 3. percussion 4. Auscultation
74
Why to use assessment techniques?
to know your patient and identify their real needs Forms the basis of the care plan
75
Direct vs indirect percussion?
direct, which uses only one or two fingers, Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses) indirect, which uses the middle/flexor finger. striking a punch-like object with a hammer or percussor. Mediate Percussion; Involves 2 hands
76
Know medical terminology- from packet??
??
77
Know definitions in culture | From crossword-mod 3
Snsn
78
What are some cultural competence methods?
Explore patients beliefs , values, and needs to build effective relationships with them. Understand that each patient is unique
79
Causes/types of illness in culture?
Biomedical illness Naturalistic illness Magiocoreligious illness
80
What is a material vs non material cultural characteristic?
Material: dress, tools, art Non material: verbal, religion, customs, beliefs
81
What are the components of a mental assessment? ABCT:
Detailed mental status exam Assess through health hx Be aware of: Meds taken Hx of alcohol or drug use Stress levels Sleep disorders Appearance Behavior Cog function Thought process
82
What are expected age related changes? When it comes to memory/mind?
? Normal aging is associated with a decline in various memory abilities in many cognitive tasks; the phenomenon is known as age-related memory impairment (AMI) May need more time to learn new material or tasks
83
A condition which is Sudden onset, interrupting the bodies homeostasis Orientation: Altered consciousness Rapid mood swings/emotions Reversible
Delirium
84
delirium? What can affect it?
start of delirium is usually rapid — within hours or a few days. Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal
85
This condition has a slow gradual onset (organic) Orientation: Consciousness is not altered Flat, agitated Incoherent , slow, repetitive Not reversible
Dementia
86
What can affect dementia :
Can be caused by vascular disease, HIV, Alzheimer’s disease
87
how to Assess ones orientation?
Test attention span Recent memory Remote memory (long term) New learning
88
Components of the mental exam status ?
MMSE (mini-mental state examination Set of 11 questions that tests orientation to time and place , naming , reading, copying orientation , writing, and following three stage command. Can also test for dementia or mental illness
89
Performing mini-cog? What is it?
A newly developed, reliable , quick and easy available instrument to screen for cognitive impairment in healthy older adults Takes 3-5 minutes- ask adult to listen carefully to, then repeat the 3 words that you will say. (Short And unrelatedly words) Make sure there are no distractions. Have them do something else and then repeat again later.
90
Disease caused by bacteria, virus, etc
Biomedical illness
91
Illness caused when there is loss of natural balance Ting/yang Hot/cold
Naturalistic illnesses
92
Illness caused by supernatural forces Folk remedies
Magiocoreligious
93
What is normal gait?
Walk is smooth and even Balance with out assistance Movement of arm symmetry are present
94
WT and height in 80s and 90s ?
Prominent bony areas Muscle shrinkage and weight and height decreases- especially in males Fat loss from face , forearms, abd and hips (even with good nutrition)

Health Assesment-RN (7 decks)

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