Health Assessment mid-term: Course Introduction, Interviewing, Health History,

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Health Assessment mid-term: Course Introduction, Interviewing, Health History,
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2013-03-05 20:40:29
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Health Assessment mid term Course Introduction Interviewing History
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Health Assessment mid-term: Course Introduction, Interviewing, Health History,
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  1. what standard precautions should we consider and why?
    • we should wash our hands and wear gloves when dealing and preventing the transmission of blood and body fluids
    • - by not taking this precautions we run the risk of spreading nosicomial infections to patients
  2. health assessment is what?
    is a systematic way of collecting data about a client/patient for the purpose of determining client's health status
  3. the nursing process consist of what
    • - assessment 
    • - diagnosis 
    • - goal setting
    • - plan 
    • - implement
    • - evaluate
  4. the nursing process serves for what?
    it serves in the clinical process that we use
  5. assessment of a patients involves what three main components?
    • - patients interview
    • - physical exam
    • - lab/diagnostic
  6. patient interview is about collecting what type of data?
    its about collecting subjective data
  7. if the patient is unable to speak for themselves during the interview, who would we talk to next to gather information?
    we would go to the parent or spouse
  8. physical exams is about collecting what type of information?
    - its about collecting subjective and objective information
  9. lab/diagnostic testing is about collecting what type of information?
    it is about taking objective information
  10. what is subjective information
    what the person says about himself or herself
  11. what is objective information
    what you observe through measurement, inspection, palpation, percussion, and auscultation
  12. what are the basic concepts of communication ?
    • there is a
    • - sender
    • - receiver
    • - message
    • - feedback
    • - context
  13. situational context
    can be where it is actually happening. it is a wellness visit at a nurse practitioner's office or is it a crisis situation in the emergency room
  14. historical context
    is this a new occurrence or is this a reoccurring issues for the patient?
  15. what is communication
    • - it is not just the use of words, it is a dynamic process that includes
    • - behaviors
    • - verbal and nonverbal 
    • - intended or perceived
  16. communication: what should we look for in behavior?
    watch for the congruence of what their saying and how they are behaving
  17. what is more accurate, the words the patient is saying or their behavior?
    the behavior of the patient is more important
  18. what are some personal variables that may affect communication?
    • - age
    • - gender
    • - language
    • - preferences
    • - experiences
    • - personality 
    • - self concept
    • - values, attitude
    • - cultural background
    • - religious/spiritual beliefs
  19. how can age affect communication?
    • the pateints may be older so asking personal questions may make them feel uncomfortable.
    • - the patients may perceive you a certain way because of your age
    • - be aware of generation differences
  20. how can gender affect communication?
    sometimes the opposite sex may not want to give intimate information b/c of the difference in gender
  21. how can language affect communication
    a language barrier can prevent you from assessing the patient to the best of your ability
  22. when is comes to communication  nurses must have a high what in order to communicate effectively with the patient.
    the nurse must have a high EQ (emotional intelligence) b/c sometimes we have to stake a step back and try to understand that the patient may not be lashing out on you b/c of personal reasons but instead b/c that is how they respond to a crisis
  23. communication can be impacted by what?
    • - visual (whether they are able to see you)
    • - hearing (can they hear you or are having difficulty hearing you?)
    • - tactile (extremities missing)
  24. what are some aspects to consider in a message?
    • - what is in the mind of the sender?
    • - what did the sender chose to send
    • - how is the message sent?
    • - what is received by the receiver?
    • - what does the message bring to mind in the receiver
  25. what are the goals of effective communication?
    • - to send CLEAR, HEALPFUL messages to our patients
    • - INTERPRET ACCURATELY what our patients are communicating
  26. verbal communication
    are the words you speak, vocalizations, the tone of voice
  27. verbal communication includes what two categories?
    • - denotation
    • - connotation
  28. what is denotation?
    it is the concrete definition of a word
  29. what is connotation?
    it is the personal interpretation on what means to the person
  30. how should we use vocabulary when communicating to a patient. what words should we avoid using when speaking to them?
    • using medical jargon can confuse and lose the patient 
    • - auscultation
    • - CAT scan
    • - Stool 
    • - Void
    • - Colon
  31. how can we PACE our communication with the pateints
    • speed or rate at which the message is delivered
    • - which includes the pauses between important ideas or concepts
    • - clarity
    • - timing and relevance
    • - para-language
  32. therapeutic communication is what?
    • - goal focused
    • - deliberate
    • - has different perspectives
  33. how should social communication be?
    • - spontaneous 
    • - needs both
    • - mutual sharing
    • - both parties express naturally 
    • - reciprocal approval 
    • - terminates spontaneously
  34. how should therapeutic communication be
    • - planning
    • - needs of the pateints 
    • - focus on problem solving
    • - encourage patient to express feelings, concerns
    • - nurse not seeking personal approval 
    • - nurses terminates
  35. critical elements of communication
    • - genuineness
    • - respect
    • - empathy
  36. during communication, we respect the patient by?
    • addressing them by name. dont make the assumption that you can call the patient by their first name unless they say so 
    • - also by your tone of voice
  37. during communication, we show empathy by?
    recognizing what the patient is going through and allowing yourself to acknowledge what the patient is going through
  38. what elements should be involved in a patients interview ?
    • - it should be based on a trusting relationship 
    • - privacy
    • - confidentiality 
    • - nonjudgmental
    • - document
  39. how should we be in position to the patient during an interview?
    • - there is eye contact
    • - are at the same level 
    • - there is a closeness that doesn't invade personal space
  40. what are the three stages of on interview?
    • - stage I: introduction 
    • - stage II: working 
    • - stage III: closing
  41. stage I - introduction
    identify name , role, and purpose/ intentions
  42. stage II - working
    collection of patient data
  43. stage III - closing
    thanking and acknowledging the person. also summarizing and what the information will be used for
  44. what are some effective verbal interviewing techniques
    • - open-ended questions
    • - closed questions
    • - facilitation
    • - silence
    • - reflection
    • - empathy 
    • - clarification
    • - confrontation 
    • - interpretation 
    • - explanation 
    • - summary
  45. verbal techniques: open-ended questions
    • gives patient permission to give you their story in their own word
    • - how can I help you?
    • - what brings you here today?
  46. verbal techniques: closed questions
    • very often yes, no questions
    • - are you having pain?
  47. verbal techniques: facilitation
    done through para-language - your body position or through the nodding of your head allows the patients to tell you more
  48. verbal techniques: silence
    allows patient to process the question and formulate an anwer
  49. verbal techniques: reflection
    picking up on a word that he patient said regarding the information and reflect on it allowing the patient to share more information
  50. verbal techniques: interpretation
    telling the patient what we understand allows the patients to clarify any misunderstanding
  51. what are some effective nonverbal techniques
    • - professional appearance 
    • - posture
    • - gestures and facial expression 
    • - eye contact
    • - voice
    • - touch
  52. what are some non-therapeutic techniques
    • - requesting an explanation - why?
    • - probing
    • - offering false reassurance 
    • - giving false reassurance
    • - giving approval/disapproval 
    • - defending
    • - advising
  53. how would you document an unanswered question?
    never leave the question blank, write that the patient refused to offer this type of information
  54. in which ways can questions a patient become problematic?
    • - posing leading questions
    • - interrupting the patient
    • - engaging in talkativeness
    • - using multiple questions
    • - using medical jargon 
    • - being authorative
  55. what are some tips for using an interpreter
    • - use trained medical interpreter - not family or significant other
    • - allow time for the patient and interpreter to converse prior to interview
    • - request sentence by sentence translation 
    • - allow extra time
    • - use brief questions
    • - maintain eye contact with the patient 
    • - observe patient's nonverbal response
    • - use preprinted questions if available
  56. health history serves as what?
    as a basis for planning care
  57. health history is what ?
    • subjective information of health status including 
    • - social 
    • - emotional 
    • - physical 
    • - cultural 
    • - well-being
  58. what are the types of health history's ?
    • - complete
    • - episodic
    • - interval or follow-up
    • - emergency
  59. episodic health history
    • focuses on the problem the patient has been experiencing 
    • - focused on the problem on hand
  60. interval or follow-up history
    checking if the treatment worked or failed stood the same
  61. emergency history
    • - essential information only
    • - are they on any medications? have any allergies?
  62. name the components of a health history
    • - biographical information 
    • - informant
    • - reason for seeking health care - "chief complaint"
  63. characteristics of chief complaints include what?
    • - location
    • - radiation
    • - quality 
    • - quantity 
    • - associated symptoms
    • - aggravating factors
    • - alleviating factors
    • - setting
    • - timing
    • - meaning/impact
  64. chief complaint: location
    - where is the pain located?
  65. chief complaint: radiation
    does the pain move from the main site to other parts of the body?
  66. chief complaint: quality
    • whats does the pain feel like?
    • - dull
    • - burning
    • - sharp
    • - itchy
  67. chief complaint: quantity (severity)
    on a scale of 0-10, jow much pain are you feeling right now?
  68. chief complaint: associated symptoms
    are you experiencing any other symptoms?
  69. chief complaint: aggravating and alleviating factors
    what makes the pain worse? what makes the pain better?
  70. chief complaint: setting
    • Where was the person or what was the person doing when the symptom started? 
    • - for example: were they shoveling snow?
  71. chief complaint: timing
    • onset, duration, frequency 
    • - when did the symptom first appear?
    • - how long did the symptom last?
    • - was it steady(constant)? or did it come and go(intermittent)?
  72. chief complaint: meaning/impact
    • how it affect daily activities 
    • - how has this affect you?
    • - is there anything you can't do now that you could before?
  73. PQRSTU
    • P: provokes/palliative
    • Q: quality/quantity 
    • R: region and radiation
    • S: severity 
    • T: timing
    • U: understanding patient's perception
  74. COLDSPAM
    • C: character - how does it look, feel, sound, smell
    • O: onset
    • L: location - where, ? radiation
    • D: duration
    • S: severity
    • P: pattern - what makes it worse/better
    • A: associated manifestations
    • M:what meaning does this have to you
  75. components of a past history
    • - medical history 
    • - surgical history 
    • - psych/mental health history 
    • - medications: prescribed, over the counter
    • - communicable diseases 
    • - allergies 
    • - injuries/accidents
    • - childhood diseases 
    • - immunization history
  76. components of a family health history
    • - identify genetic patterns 
    • - immediate blood relative
    • - genogram
  77. components of social history
    • - alcohol use: type, amount, frequency, CAGE
    • - drug use: type, amount, frequency 
    • - tobacco use: pack yr history 
    • - sexual practices
    • - travel history: military history 
    • - education 
    • - roles and responsibilities (any support at home?)
    • - domestic violence
  78. CAGE
    • C: Have you ever thought you should Cut down your drinking?
    • A: Have you ever been Annoyed by criticism of your drinking?
    • G: Have you ever felt Guilty about your drinking? 
    • E: Do you drink in the morning? (i.e., an Eye opener?)
  79. violence (domestic) leads to what
    chronic health problems
  80. should domestic violence screening be done with every patient?
    yes, every patient
  81. components of health maintenance
    • - sleep
    • - diet
    • - exercise (FIT)
    • - stress management 
    • - safety devices 
    • - health check-ups: traditional and alternative
  82. FIT
    • F: frequency of exercise 
    • I: intensity of exercise 
    • T: how many time a week
  83. what is Review of Systems
    • subjective responses to series of body system questions
    • - this is not the physical assessment 
    • - ask questions such as: do you have these symptoms? (helps guide physical exam)
  84. what is the purpose of a physical assessment?
    • - screening of general well-being
    • - validation of complaints that caused the patient to seek health care
    • - monitoring of current health problems
    • - formulation of diagnosis and treatments
  85. types of assessment techniques
    • - inspection (I)
    • - palpation (P)
    • - percussion (P)
    • - auscultation (A)
    • you usually follow the order IPPA, expect for the abdomen which is IAPP
  86. inspection
    • inspecting the 
    • - sense of smell
    • - sense of sight
  87. palpation
    • is the ac of touching the patient in a therapeutic manner. it includes
    • - light palpation 
    • - moderate palpation
    • - deep palpation
  88. light palpation
    • - superficial, delicate, gentle 
    • - uses finger pads or the back of your hand

    provides information on skin texture, moisture, temperature, superficial pulsations and tenderness
  89. moderate palpation
    • - superficial, delicate, gentle 
    • - uses finger pads
    • - depress 1 cm below surface

    provides information on skin texture, moisture, masses, fluid, muscle guarding  pulsations, and tenderness
  90. deep palpation
    provides information about the position of organs, masses, their size, shape, mobility and consistency 

    • - uses hands
    • - depress 4 to 5 cm below skin surface
    • - most commonly used for assessing abdominal and reproductive structures
  91. palpation tips
    • - wash hands before and after the exam
    • - waer gloves if indicated
    • - warm hands
    • - fingernails short and clean
    • - inform the patient when, where, and how the touch will occur 
  92. percussion
    • - striking one object against another to cause vibrations that produce sound 
    • - analyze sounds by intensity, duration, pitch 
    • - any part of the body can be percussed 
    • - most commonly used for abdomen and thorax
  93. percussion: quality of sounds include?
    • - flatness
    • - dullness
    • - resonance
    • - hyperresonance
    • - tympany
  94. percussion: flatness
    When no air is present, over thigh muscles, bone, or over tumor
  95. percussion: dullness
    fluid filled areas, Relatively dense organ, as liver or spleen
  96. percussion: resonance
    over norma/healthyl lung tissue
  97. percussion: hyperresonance
    • - Normal over child's lung
    • - Abnormal in the adult, over lungs with increased amount of air (over inflated lungs), as in emphysema
  98. percussion: tympany
    Over air-filled viscus (e.g., the stomach, the intestine)
  99. percussion techniques
    • - immediate or direct
    • - mediate or indirect
    • - direct fist
    • - indirect fist
  100. auscultation
    • - clean earpieces
    • - point earpieces towards the nose
    • - quiet room 
    • - diaphragm - with pressure
    • - bell - without pressure
  101. the diaphragm picks up what type of sounds?
    high pitched sound
  102. the bell picks up what type of sounds?
    • picks up low pitched sounds
    • - you don't want to press on the skin, only lightly place it

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