Unit 1- learning objectives Flashcards
Intent of health history
o provide a database of subjective information about the patient’s past and current health
b. Summarize the components of a health history.
Identifying data, -(name address etc)
chief complaints,(purpose for visit )present illness,
past history, family history
,personal and social history,
review of systems
c. Outline the techniques or effectively collect data during a health history.
Privacy
introduce interview
working phase-open ended and close ended questions
close interview
nonverbal
pqrstu
d. Consider how age, ethnic, and cultural variations effect data collection during a health history.
all of these can affect how you talk to the patient and how you administer treatment. Certain ages or cultures cannot receive certain types of treaments. You may talk to patients differently depending on their culture or age, so adjusting to each patient is critical, no two are the same
you must modify your actions based upon the clients culture (ex: eye contact is thought of as rude in some cultures)
e. Identify the source of data for the health history if the client is not able to participate.
If the cleint is unable to speak, then Charts and family members are considered secondary data sources. Primary data would be directly from the client. Subjective data are based on the signs and symptoms that the client reports; they may not be perceived by observers.
f. Recognize when data from a health history should be communicated to other health care providers.
to arrive at the correct diagnosis, some clincainans may communicate and share data among different providers
g. Consider how information from a health history can be used for patient teaching.
Using past information on health history, you can teach the patient how to do anything that might pertain to their well being. Making sure that the patient knows how to properly take care of themselves can lead to a betterment for their health
h. Explain how obtaining a health history is modified across the lifespan.
as one gets older and older, their health history gets added onto. Each time should be adjusted so that questions are asked about past health problems to make sure they are all fixed.
i. Differentiate between normal and abnormal findings.
normal findings is anything that is preveleant on the average human body
abnomral fidnings are most likely what the patient is in for, these are any findings that are differenet from the averag human. like different shape color temp etc
j. Identify the purpose of the general survey.
provides initial information about the client’s overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments.
k. Indicate typical sequence for a general survey.
provides initial information about the client’s overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments.
l. Summarize the components of a general survey of the client.
-physical appearance
-body structure
-mobility
-behavior
mental status
m. Contrast techniques of inspection, auscultation, palpation, and percussion.
inspection- sense of sight to identify specific chanracetidcs of individual
palpation- light 1-2cm, 3 fingers using finger pads (would use to assess swelling, crepitation, range of movement, injured joint)
Deep2.5cm depending on amount of abdominal fat, may be 5cm for obese. Usually performed as part of abdominal assessment.
Auscultation - Uses the sense of hearing to listen to body sounds
Percussion - Uses the sense of touch and hearing as examiner taps on an individual body to evaluate location and density of underlying structures.
n. Identify techniques to promote the physical and emotional comfort of the patient during the assessment.
Facilitation-mhmm-go on
silence-allows to speak
reflection- repeat patient
empathy-emotion in sentances
clarification-
interpretation-give judgment
explanation-detail
summary
o. Explain how to modify assessment techniques across the lifespan.
the way you speak changes to each individual as they get older. Addressing teenagers and up as Mr and Mrs promotes respect . not talking down and being respectful to each age
p. Define pertinent terminology used in general survey/physical assessment.
talk in human terms. Dont use any medical jargon. Speak in all language that everyoje will understandf
dont reassure.use authority,dustance,talk too much ot use why questions
q. Consider how age, ethnicity, and cultural variations may affect the general survey.
r. Discuss how teaching opportunities can be used during a general survey/physical assessment.
During general survey inform patient about normal range of vital signs for age and physical condition and normal weight for height and body frame
.
* If patient is on a therapeutic diet, discuss any problems that he or she has preparing a diet or selecting food. The best form of weight reduction is to achieve gradual weight loss by increasing exercise and decreasing caloric intake. Refer to clinical dietitian for specific information.
- Explain to patient any findings that need further examination.
s. Indicate processes of referral for clients with abnormal findings of general survey/physical assessment.
the registered nurse should then seek out resources, as well as utilize and employ different internal or external resources such as a physical therapist, a clergy member or a home health care agency in the community and external to the nurse’s healthcare agency.
These resources are tapped into and, when considered appropriate for the client and their needs.
t. Describe the concept of bloodborne pathogens.
cause disease and are present in blood. HIV,hep ABC HCV. Using all ppe to prevent infection spread. these are present in blood
u. Describe the principles of standard precautions.
everything is treated as if it is infectious. all body fluids are contaminated and are treated as if they are worst case scenario
v. Define medical and surgical asepsis.
Medical asepsis: practices that kill some microorganisms to prevent them from spreading.
Surgical asepsis (a.k.a. “sterile technique”): practices that completely kill and eliminate microorganisms.
w. Identify situations in which you would use clean versus sterile gloves/technique.
clean goes to clean–when the rest of procedures
sterile to sterile– when the integrity of the skin is accessed, impaired, or broken
x. Indicate techniques to maintain medical and surgical asepsis.
hand washing
cleaning clothes
sterilization
sterile gloves
sterile field
ppe
