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What person says about himself/herself during history
taking
Subjective data
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What u as a health professional observe by inspecting,
percussing, palpating, and ausculating during physical exam
Objective data
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Its made up of 6 phases: assessment, diagnosis,
outcome identification, planning, implementation, evaluation. It’s a dynamic
interactive process used in todays clinical setting u have to be able to move
back and forth through these steps
Nursing process
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Systematic approach to practice that emphasized the
use of best evidence in combination with the clinicians experience as well as
patient preferences and values to make decisions about care and treatment.
Evidence based practice
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Is the process of analyzing health data and drawing
conclusions to identify diagnosis
Diagnostic reasoning
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Guidelines to prevention emphasize link between health
and personal behavior. Health as absence of disease, health and disease are
opposite extremes on linear continuum, disease is caused by specific agents or
pathogens, a natural progression to health promotion and disease prevention
rounds out our concept of health.
Biomedical model
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Guidelines to prevention emphasize the link between
health and personal behavior. Prevention can be achieved primarily through
counseling from care providers designed to change people’s unhealthy behaviors
related to smoking, alcohol, poor nutrition, other drug use, lack of exercise.
Disease prevention
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Well person opinions are inconsistent about assessment
intervals. Advocates justify well person visits to the doctor just because of
some recommended preventative services and reduction of patient worry.
wellness
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The method from novice to becoming an expert
practicioner is through the use of critical thinking. During your career you
will need to sort through vast amounts of data and info in order to make the
sound judgements to manage patient care. Being able to do this well is critical
thinking.
Critical thinking
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1.identifying assumptions, 2. Identifying an organized
and comprehensive approach, 3. Validation, 4. Distinguishing normal from
abnormal, 5. Making inferences, 6. Clustering related clues, 7. Distinguisjing
relevant from irrelevant, 8. Recognizing inconsistencies, 9. Identifying
patterns, 10. Identifying missing info, 11. Promoting health, 12. Diagnosing
actual and potential problems
Critical thinking process
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Being aware when people with limited English
proficiency seek health care in healthcare settings such as hospitals, nursing
homes, clinics, day care centers, mental health care centers, services cannot
be denied because of their lack of English. Providing a translator or language
assisstence is appropriate.
Linguistic competence
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Implies that the caregivers attend to the total
context of immigration status, stress factors, and cultural similarities and
differences of the patient.
Cultural competence
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It is the provision of healthcare across cultural
boundaries and takes into account the context in which the patient lives as
well as the situations in which the patient’s health problems arise.
Cultural care nursing
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Culture is that of the thoughts, communications,
actions, values, and institutions of racial, ethnic, religious, or social
groups.
culture
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Pertains to a social group within the social system
that claims to posses variable traits such as common geographic orgin,
migratory status, religion, race, language, shared traditions, values, or
symbols and food preferances.
ethnicity
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When people have a condition that is culturally
defined. People of one group that are more likely to get a certain disease etc…
Culture bound syndrom
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The process of being raised within a culture and
acquiring the characteristics of that group.
socialization
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Refers to an organized system of beliefs concerning
the cause, nature, and purpose of the universe. Especially the belief in or
worship of God or Gods.
religion
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Attempt to study the degree to which a person’s
lifestyle reflects his or her traditional heritage.
Heritage consistency
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People from most traditional heritages tend to use
traditional healers from their own background. A folk healer is an
unlicensed person who practices the art of healing using traditional practices, herbal
remedies and even the power of suggestion. A folk healer may be a
highly trained person who pursues his specialties, learning by study,
observation and imitation.
Folk healers
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When people with limited English proficiency seek
health care in health care settings service cannot be denied to them.
Title of the civil rights act of 1984
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Ask for specific information, they elicit short or one
word answers such as yes or no.
Closed or direct questions
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Ask for specific information, they elicit short or one
word answers such as yes or no.
Closed or direct questions
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These responses encourage the patient to say more to
continue with the story ex mm-hmm, go on, these responses show the person you
are interested and will listen further.
facilitation
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Ethnocentrism is the tendency to believe that one's ethnic or
cultural group is centrally important, and that all other groups are measured
in relation to one's own. The ethnocentric individual will judge other groups
relative to his or her own particular ethnic group or culture, especially with
concern to language,
behavior, customs, and religion.
ethnocentrism
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A personal and/or cultural value is an absolute or relative ethical value, the assumption
of which can be the basis for ethical action. A value
system is a set of consistent values
and measures. A principle value is a foundation upon which
other values and measures of integrity are based.
value
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Direct computer recording of the patient health
record. Eliminates hand-written clinical data.
Electric health recording (EHR)
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Use this when the person’s word choice is ambiguous or
confusing. Clarification is also used to summarize the person’s words and make
them clear. You are asking for agreement on ur understanding of the patient’s
complaint the patient can either confirm or deny it.
clarification
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The frame of reference shifts from the patients
perspective to yours/ these responses now include your own thoughts and
feelings. Ex: you look sad when u mention ur mom passing away/ or you cringe
when I touch ur arm.
confrontation
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Viewing the world from the other person’s inner frame
of reference while remaining yourself. Recognizing and accepting the other
person’s feelings without criticism.
empathy
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With these statements you inform the patient/ you
share factual and objective info with them/ Ex: your dinner comes at 5:30 or
the reason you cannot eat or drink before your blood test is it will ruin the
results.
explanation
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It’s based on our inference or conclusion/ it links
events, makes associations, or implies cause/ ex: it seems like every time you
have that stomach pain you have some sort of stress in your life.
interpretation
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It is the use of impersonal language to put space
between a threat and the self. Ex: there is a lump in the left breast/ instead
of using lump in my left breast you say the left breast to distance yourself
from the problem.
distancing
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Using big medical words the the patient may not
understand/ use of jargon sounds exclusionary and paternalistic/ you need to
adjust your vocab to the person but avoid sounding condescending.
jargon
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Asking a patient questions that make one answer sound
better then the other. For Ex: asking a man you don’t smoke do you? You are
implying that smoking is bad and if he smokes he is bad. The man feels the need
to give you the right answer or guilty if he gives you the wrong answer.
Leading questions
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Think of yourself as a mirror reflecting the person’s
words or feelings. This helps the person elaborate on the problem. So you might
repeat certain significant details from the patient or reassure them.
reflection
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Asks for narrative information/ it states the topic to
be discussed but only in general terms/ use it to begin the interview and to
introduce a new section of questions/ use it also whenever the person
introduces a new topic/ Ex: tell me how can I help you? You mentioned shortness
of breath, tell me more about that?
Open ended question
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Keep the beginning
short/ address the patient his/her surname shake hands if possible/ introduce
urself state your role in the agency/ give the reason for the interview/ ask
open-ended questions/ let patient discuss their concern early/ the purpose of
the interview is to gather as much info as possible.
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interview
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Session should end gracefully/ abrupt or awkward
closing can destroy rapport and leave person with a negative impression of the
whole interview/ Ex: Is there anything else you would like to mention?
Closing interview
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The number of vibrations per second/ more rapid the
vibrations produce a high-pitched tone.
pitch
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Difference due to a sounds distinctive overtones.
Variations within a soundwave produce overtones.
quality
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Funnels light into the ear canal and onto the tympanic
membrane.
otoscope
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Illuminates the internal eye structures. It allows you
to look through the pupil at the fundus (background) of the eye.
opthalmoscope
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An infection acquired during
hospitalization/ an infection you get during a hospital stay.
Nosocomial infection
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An ad hoc interpreter is and
untrained person who is called upon to interpret, such as a family member
interpreting for her parents, a bilingual staff member pulled away from other
duties to interpret, a self-declared bilingual in a hospital waiting-room who
volunteers to interpret, or an advanced language student.
Ad hoc interpreter
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manner of communicating to older people using a slow rate of speaking, simplified syntax, vocabulary restrictions, and exaggerated prosody on the assumption
that their age makes them cognitively impaired
elderspeak
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