Test 1 (modules 1-3) Flashcards
(113 cards)
1
Q
Purpose of health history
A
to collect past & current subjective & objective data about the patient
2
Q
Subjective data
A
What the patient tells you, describes – symptoms such as “my back hurts”; “I do not feel well”And – includes information from the review of systems
3
Q
Objective data
A
What you see, observe, palpate, etc. during the physical assessment
4
Q
health history sequence
A
Biographical data
Chief complaint (CC); reason for seeking care; being admitted into the hospital
Present health or history of present illness (HPI)
Allergies
Medications
Immunizations
Past history (PH)
Family history (FH)
Review of systems (ROS)
Others:
Functional assessment or activities of daily living (ADLs)
Health promotion – what is/has been done to enhance health
5
Q
Review of systems (ROS)
A
A review of each system of the body
Generally begin at the head & move down
Most will ask about symptoms or disorders the system + important chronic and common disorders
6
Q
Symptom of assessment: P
PQRSTU
A
Provoking or palliating factors
7
Q
Symptom of assessment: Q
PQRSTU
A
Quality or quantity
8
Q
Symptom of assessment: R
PQRSTU
A
region or radiation
9
Q
Symptom of assessment: S
PQRSTU
A
severity scale 1-10
10
Q
Symptom of assessment: T
PQRSTU
A
timing
11
Q
Symptom of assessment: U
PQRSTU
A
understanding pts. perception of the problem
12
Q
withdrawal symptoms of alcohol
A
- 2nd to 4-5th day:
Tremors; headache, anxiety, irritability, possible N&V, tachycardia
More severe – delirium tremens
Tachycardia, sweating, tremors, hallucinations, agitation; possible seizure activity
13
Q
Alcohol instruments: C
CAGE
A
Should CUT down on your drinking?
14
Q
Alcohol instruments: A
CAGE
A
ANNOYED by criticism of your drinking?
15
Q
Alcohol instruments: G
CAGE
A
Have you felt Guilty about you drinking?
16
Q
Alcohol instruments: E
CAGE
A
Need a drink ing the morning ( EYE-opener)
17
Q
Intimate partner violence
A
physical, sexual, psychologic/emotional between current or former spouses or partners.
18
Q
elder abuse
A
physical abuse or neglect; psychologic abuse or neglect, financial abuse or neglect; self-neglect
19
Q
child abuse
A
neglect, physical, sexual, emotional
20
Q
vulnerable abuse
A
physically &/or developmentally disabled
21
Q
First level of priorities
A
A = Airway problems
B = Breathing problems
C – Cardiac/circulation problems
V = Vital signs
22
Q
Second level of priorities
A
Mental status change Acute pain Acute urinary elimination problem Abnormal laboratory values Risks: infection, safety, security
23
Q
Third level of priorities
A
Lack of knowledge
Lack of activity
Lack of rest
Family coping problems
24
Q
Assessing height
A
With shoes off, and standing erect, measure the patient’s height using a wall-mounted measuring device or measuring pole
25
Assessing weight
Remove shoes and heavy outer clothing or heavy personal belonging
26
BMI underweight
BMI
27
BMI normal
BMI 18.5-24.9
28
BMI overweight
BMI 25.0-29.9
29
BMI obesity
BMI >30
30
Normal oral temperature
37 degrees C 98.6 degrees F
31
normal pulse rate
50-90 beats per minute
32
normal blood pressure
120/80
33
bradycardia
pulse rate of
34
tachycardia
pulse rate of >95
35
Atrial fibrillation
a contraction abnormality
36
Blood pressure
the force of the blood against arterial walls.
37
Systolic blood pressure
the highest point of pressure on arterial walls when the ventricles contract and push blood through the arteries at the beginning of systole.
38
Diastolic blood pressure
the lowest pressure present on arterial walls during diastole, which is ventricular relaxation.
39
prehypertension
120-139 80-89
40
hypertension stage 1
140-159 90-99
41
hypertension stage 2
>160 >100
42
Orthostatic hypotension
a decrease in systolic blood pressure of >= (greater than or = to) 20 mm Hg or pulse increases of 20 bpm or more when standing.
43
pulse oximeter
to assess arterial oxygen saturation (Spo2)Measures light absorbed by oxyhemoglobin (Hbo2) and unoxgenated hemoglobin (Hb) and converts this ratio into the percentage of oxygen saturation (%).
44
normal oxygen saturation
Spo2 97%-98%
45
Pain
an unpleasant sensory and emotional experience” associated with actual or potential tissue damage or described in terms of such damage. Pain is always subjective
46
Acute pain
short term and self-limiting
| Ex) surgery, trauma, and kidney stones
47
Chronic pain
diagnosed when the pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond.
48
Nociceptive pain
pain related to tissue damage that develops when functioning and intact nerve fibers in periphery and CNS are stimulated
49
Neuropathic pain
caused by a lesion or disease with an abnormal processing of the pain message. Most difficult to assess and treat
50
Visceral pain
pain that originates from the larger interior organs (i.e., kidney, stomach, intestine, gallbladder, pancreas)
51
somatic pain
pain that originates from musculoskeletal tissues or the body surface.
52
referred pain
pain that is felt in a particular site by originates from another location.
53
hyperalagesia
excessive sensitivity to a particular pain sensation
54
hypalgesia or hypoalgesia
decreased sensitivity to pain
55
optimal nutritional status
Sufficient nutrition, well-balanced, consumed to support the day-to-day needs and can adjust for increase in those needs (illness, growth, pregnancy, etc)
56
undernutrition
Depleted nutritional reserves or inadequate intake to support daily activities. The most vulnerable population are pregnancy, infants/children, poor, elderly and ill (acute/chronic)
57
over nutrition
Excess consumption of nutrients, calories, Na++ and fat, that is more than the body needs. Leading to increase for disease, and increase in BMI (66% of the US adults are overweight)
58
Hallucinations
sensory perceptions for which there are no stimuli
Ex: Hearing a baby cry when there is no baby present
Seeing an image that is not there
59
illusions
Misperception of an actual existing stimulus by any sense
| Ex: Spots on the walls are perceived as Spiders on the wall
60
Mini cog test
3-minute instrument screening cognitive impairment of the older adult in the primary care setting
61
Three-item recall test
Get patient’s attention and ask him or her to remember three unrelated words. Ask patient to repeat the words to ensure the learning was correct
62
Clock Drawing Test (CDT)
Ask patient to draw the face of a clock. After numbers are on the face, ask patient to draw hands to read 10 minutes after 11:00 (or 20 minutes after 8:00
63
alert
fully aware, responds appropriately
64
Lethargic or somnolent
drifts off to sleep, aroused to name
65
Obtunded
sleeps most of time, difficult to arouse
66
Stupor or Semi-coma
unconscious but responds to vigorous shake or pain – sternal rub
67
Coma
completely unconscious, no response to pain or stimuli e.g. suctioning ( deep coma = no motor response)
68
Delirium
( acute confusional state)….dulled cognition, impaired alertness, inattentive, incoherent, impaired recent memory, agitated, visual hallucinations, disoriented, confusion
69
Depression
sad, gloomy, dejected
70
Dementia
gradual, multiple cognitive deficits with memory impairment causing impairment in social or occupational functioning
71
Delirium
acute, disturbance of consciousness ( awareness of the environment) and change in cognition ( memory deficit, disorientation). Develops over hours to days---may be related to general medical condition or substance-induced
72
heritage consistency
Cultural, ethnic, & religious background and socialization experiences
73
Culture
Thoughts, communications, actions, beliefs, values
74
Ethnicity
Your social group , language, geography of your identity, traditions, food preferences, and shared values
75
Religion
The belief of a superhuman power /divine creator to obey and worship. Organized system
76
Holistic health
Absence of disease
| Mindy body spirt
77
Emergency database
Rapid collection of data
78
Episodic database
Limited for short term problems
79
Follow up database
Used to follow up short term or chronic health problems
80
the collection of data about and individuals health state
assessment
81
the Western European/North American tradition that views health as the absence of disease
biomedical model
82
a complete health history and full physical examination
complete database
83
simultaneously problem solving while self-improving ones own thinking ability
critical thinking
84
the total of all conditions and elements that make up the surroundings and influence the development of a person
environment
85
a systematic approach emphasizing the best research evidence, the clinicians experience, patient preference and values, physical examinations, and assessment
evidence based practice
86
used for a limited or short term problem concerns mainly one problem one cue complex, or one body system
focused database
87
used to evaluate the cause and etiology of disease, focus is on the function or malfunction of a specific organ system
medical diagnosis
88
used to evaluate the response of the whole person to actual or potential health problems
nursing diagnosis
89
any action directed toward promoting health and preventing the occurrence of disease
prevention
90
a dynamic process and view of health, a move toward optimal functioning
wellness
91
using a patients family member, friend, or child as interpreter for a patient with limited english proficiency
ad hoc interpreter
92
imagining that inanimate objects come alive and have human characteristics
animism
93
the use of euphemisms to avoid reality or to hide feelings
avoidance language
94
examiners response used when the patients word choice is ambiguous or confusing
clarification
95
questions that ask for specific information and elicit a short, one or two word answer, a yes or no, or a forced choice
closed question
96
response in which the examiner gives honest feedback about what he or she has seen or felt after observing a certain patient action, feeling, or statement
confrontation
97
the use of impersonal speech to put space between ones self and a threat
distancing
98
infantilizing and demeaning language used by a health professional when speaking to an older adult
elderspeak
99
direct computer entry of a patents health record while in the patients presence
electronic health recording
100
viewing the world from the other persons inner frame of reference while remaining yourself recognizing and accepting the other persons feelings without criticism
empathy
101
the tendency to view your own way of life as the most desirable acceptable or best and to act in a superior manner to another cultures way of life
ethnocentrism
102
examiners response that encourages the patient to sat more, to continue with the story
facilitation
103
private room or space with only the examiners and patient present
geographic privacy
104
examiners statement that is not based on direct observation, but is based on examiners interference or conclusion, links events, makes associations, or implies cause
interpretation
105
meeting between the examiner and patient with the goal of gathering a complete health history
interview
106
medical vocabulary used with a patient in an exclusionary and paternalistic way
jargon
107
a question that implies that answer would be better than another
leading question
108
message conveyed through body language, posture, gestures, facial expressions, eye contact, touch, and even where one places the chair
nonverbal communication
109
asks for longer narrative information, unbiased, leaves the person fee to answer in any way
open ended question
110
examiner response that echo's the patients word, repeats part of what the patient has just said
reflection
111
final review of what examiner understands patient has said, condenses facts and presents a survey of how the examiner perceives the health problem or need
summary
112
speech used by age 3 or 4 years in which three or four word sentences contain only the essential words
telegraphic speech
113
messages sent through spoken words, vocalizations, or tone of voice
verbal communication
