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1080 Holistic Health Assessment > Week 1-6 > Flashcards

Week 1-6 Flashcards

(60 cards)

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1
Q

definition of holistic health assessment

A

Acknowledges and addresses physiological, psychological, sociological, developmental, spiritual, and culture needs of patient

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2
Q

what does a health assessment include

A

history and physical assessment

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3
Q

when presenting health concerns we use what technique

A

OLDCARTSS

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4
Q

what does OLDCARTSS stand for

A

-onset
-location
-duration
-characteristic
-aggravating/alleviating factors
-radiation
-time
-severity
-social environment

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5
Q

what is included in health history

A

past medical history (diagnosis, surgeries)
-family history
-medications
-immunizations
-allergies
-lifestyle choices
-psychosocial (family, living situation, employment)
-impact on function (how is condition affecting daily life)

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6
Q

what is the purpose of a physical assessment

A

-obtain baseline data
-supplementing/confirming data obtained in health history
-help establish diagnosis and plan of care
-evaluating physiological outcomes of care and health status

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7
Q

physical assessment techniques (IPPA)

A

-inspection (using senses)
-palpation (touching and feeling)
-percussion (tapping for sound)
-auscultation (listening to breath, heart, vascular using stethoscope)

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8
Q

what is included in the head to toe exam

A

-general health survey
-vital signs
-skin/dermatological
-HEENT (head, eyes, ears, nose, throat)
-respiratory system
-cardiovascular system
-peripheral vascular system (veins, arteries not in chest/abdomen)
-gastrointestinal system
-genito-urinary system
-sexual/reproductive health
-neurological system
-mental health
-cognition
-nutritional/fluid balance

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9
Q

what is clinical judgement

A
  • Interpretation/conclusion about clients needs, concerns, health problems
  • Decision to take action
  • Use standard approaches OR improvise new ones to benefit patient response
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10
Q

what is the clinical judgement model (CJM)

A
  • Framework for nurses’ decision making
  • Noticing all aspects of client situation
  • Critical thinking
  • # 1 faze is noticing
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11
Q

what is the basis of the general survey for mental health

A

noticing mental state and behaviors of initial encounter

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12
Q

parts of the general mental health survey (ASEPTIC)

A
  • Appearance & behavior
  • Speech
  • Emotion
  • Perception
  • Thought process
  • Insight
  • Cognition
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13
Q

what is family and community in context of health

A
  • Set of relationships that influence each other’s lives
  • Future obligations & care giving functions
  • Any combination of 2+ people bound together overtime
  • Family is whoever patient says
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14
Q

what are the characteristics of family

A
  • Connect need for stability with need for growth and change
  • Flexible structure
  • Cohesive unit
  • Influence on environment
  • Hardiness & resiliency in coping
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15
Q

what is community

A
  • People, residents
  • Place, physical/geographical location
  • Function, aims/interests/activities
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16
Q

what are healthy community components

A
  • Collective relationships to create supportive living environment
  • Collective capacity to solve problems
  • Adequate housing conditions
  • Safe environment
  • Sustainable resources (employment, health care, education)
  • Meets basic needs of residents
  • Diverse, innovative & sustainable economy
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17
Q

what is the premise of infection prevention and control routine practices

A
  • everyone is potentially infectious
  • Same safe standards for every patient encounter
  • Prevent exposure & spread of microorganisms
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18
Q

what is the chain of infection

A
  • Infectious agent (pathogens that cause disease/infection)
  • Reservoir (agents pathogens live in & multiply)
  • Portal of exit, body openings/artificial openings (how pathogens leave human body)
  • Mode of transmission direct/indirect contact (transmission of pathogens)
  • Portal of entry (entry of pathogens)
  • Susceptible host (factors that cause vulnerability to pathogens)
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19
Q

how can you interrupt the chain of infection

A
  • Optimizing patient health
  • Protective gear
  • Hand hygiene
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20
Q

what are the moments of hand hygiene

A
  • Before initial patient contact
  • Before aseptic procedure
  • After bodily fluid exposure risk
  • After final patient contact
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21
Q

types of communication

A
  • Essential component in building patient/family relationship
  • Complex, ongoing interactive process
  • Verbal, active listening (words, feelings, essence)
  • Non-verbal, body language, gestures, expression
  • Ineffective, poor patient outcomes & negative patient experience
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22
Q

what is the purpose of therapeutic interviewing

A
  • Obtain health history
  • Identify health needs & risk factors
  • Determine specific changes in wellness & pattern of living
  • Relate client’s interpretation & understanding of conditions
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23
Q

what are the types and sources of data gathering

A
  • Subjective data, stated by client/family
  • Objective data, observed by heath care provider
  • Primary source, patient/interpreter
  • Secondary source, charts/family members
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24
Q

what are the three types of interviews

A
  • Comprehensive (everything birth-present)
  • Focused (presenting symptom only)
  • Emergent (impacts on right now care)
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25
what are the phases of interviewing
- Pre-interactive phase (before client is present) - Beginning phase (setting the tone) - Working phase (open & close ended questions - Closing phase (wrap up, next steps, questions)
26
what is the purpose of health history
- Collect relevant subjective data - Ask right questions to find answers
27
what is privacy
- Unique definition for everyone - Information privacy, client’s control of their health information (collected, used, disclosed)
28
what is confidentiality
- Duty to protect information - Intimate/private knowledge
29
what is personal health information
- Any identifying client information (verbal, written, electronic)
30
what is the role of the CNO in privacy and confidentiality
- Practice standards on privacy & confidentiality
31
what are hard situations related to privacy and confidentiality
- Violence - Illicit drug use - Police (no automatic access to patient information & chart) - Driving concerns
32
what is information gathering documentation
- Communication of client’s health status & needs - Communication to other member of circle of care - Legal record
33
what are the expectations of information gathering documentation
- Factual, accurate, relevant - Organized & complete - Proper grammar, spelling, language, punctuation
34
what are the important parts of written documentation for information gathering documentation
- No erasing/white out - Legible writing in PEN - No blank spaces - Pertinent specific facts (avoid generalized information) - ORGANIZE thoughts - Begin each entry with date and time (24 hour) - End with signature & designation (WFN-1)
35
what are the styles of assessment documentation
SOAP - Subjective (from patient history) - Objective (physical) - Assessment - Plan SBAR - Situation - Background (relevant health history) - Assessment - Recommendation
36
what is cognitive development
- Uses experiences to move through stages (birth- adulthood) - Thinking becomes more sophisticated & complex
37
how does cognition change with age
- Process, remember, consider information becomes slower - Learning takes longer - Slightly decreased short term memory - Long term memory & decision making remains intact
38
what are atypical changes of cognition
- Unusual changes for cognitive deterioration - Memory loss of recent events - Tangentiality (changes ideas while speaking)
39
what is delirium
- Abrupt onset, usually brief duration - Impaired attention - Altered levels of consciousness - Incoherent speech - Often symptom of different issue - Assessment, confusion assessment method CAM & IWATCHDEATH
40
what is dementia
Dementia - Slow development, progressive deterioration of brain - Does not remit - Normal attention & consciousness - Ordered speech - Must have change in function & memory impairment - Instrumental activities of daily living (IADL) deteriorate first - Activities of daily living (ADL) deteriorate last - Includes Alzheimer’s, Parkinson’s, Lewy Body - Assessment, clock drawing test, RUDAS, functional dementia scale
41
what is depression
- 15-20% develop late life depression - Reversible, frequently diagnosed as dementia (incorrect treatment given) - Physical/social limitations - Low energy - Assessment, Cornell Scale for Depression, Geriatric Depression Scale (GDS), suicide risk
42
assessment of cognition
- Medical history (head injuries) - ADL’s & IADL’s - Cognitive screening & advanced physical exam - Imaging (head CT/MRI)
43
what is the modified cognitive approach
- Slow down - Sit directly in front - Ensure all aids are provided - Simple instructions (redirect wandering thoughts) - Limit environment stimulus - Repetition & prompting
44
factors of cognition prognosis
- Onset (sudden/gradual) - Mood/behavior changes - Course of decline - Current level of function (IADL’s & ADL’s) - History of confusion
45
what is the MMSE
- Mini mental state exam - 30 questions used to assess cognition - Screen for dementia, memory, orientation
46
what is the RUDAS
- Rowland university dementia assessment scale - Planning, sequencing & organizing - Minimizes effects of education level, language, cultural background
47
driving and cognition
- Dementia increases risk of accident - Driving capacity depends on cognition, function, medications, behavior, physical abilites
48
what is the mental health assessment continuum
- Mental health is not linear - Mental health & mental illness are not the same thing - Not static
49
what are mental health positive reinforcements
- Individual - Family - Community - Society
50
what is mental health promotion
- Strategies to improve population mental health - Activities, available resources - Campaigns
51
what is positive mental health
- Interpret reality accurately - Healthy self-concept - Relate to others - Sense of meaning - Creativity/productivity - Behavioral control - Cope/adapt with change & conflict
52
what is the DSM-V
- Diagnostic & statistical manual of mental disorders - Standardize assessment data & outcomes - Prevent indiscriminate outcomes - Used to get broad understanding of client - Not client conforming to diagnosis
53
what are mental health domains
- Biological, theories that explain neurobiological changes in relation to mental disorders - Psychological, process of thoughts, feelings, behaviors influence cognition & emotion - Social, influence of social forces - Spiritual, connections between individual & universe
54
components of mental health history
- Medical & family history - Medications - Violence/trauma - Substance abuse - Suicidal/homicidal - Hallucinations/delusions
55
What is the mental health physical exam (ASEPTIC)
- Appearance - Speech - Emotion/affect - Perception - Though process/content - Insight/judgment - Cognition
56
patients seek mental health treatment when
- Intolerably painful - Life crisis - Crime - Unmanageable - Interrupt daily function
57
what is the stigma surrounding mental health
- Negative stereotype & discrimination - Limits access to life opportunities - Criminalization of illness behaviors - Limits access to healthcare
58
what is STOP criteria
- identify stigmatizing behaviours & advocate for inclusive attitudes - Stereotype people with mental health conditions - Trivializes/belittles people with mental health conditions - Offends people with mental health conditions - Patronizes (treats them as less) with mental health conditions
59
what is recovery oriented care
- Focuses on pursuing recovery, not achieving it - Shared decision making - Concentrates on wellness - Self-expectations have strong influence on behavior & outcomes
60
what are the pillars of recovery
- Choice, public funded services & different models of care - Community, connection to recovery community - Integration, manageable tasks

1080 Holistic Health Assessment (5 decks)

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