Health assessment study guide Exam 1

Subjective vs objective data Subjective/symptom - What patient says about themselves Objective/sign – observed when inspecting, percussing, palpating and auscultating patient during physical exam Diagnostic reasoning ...

Subjective vs objective data Subjective/symptom - What patient says about themselves Objective/sign – observed when inspecting, percussing, palpating and auscultating patient during physical exam Diagnostic reasoning Attend to initially available cues Formulate diagnostic hypotheses Gather data relative to tentative hypotheses Evaluate each hypothesis with new data collect to arrive at final diagnosis Nursing process ADOPIE Assessment, diagnosis, outcome identification, planning, implementation and evaluation Critical thinking skills Identifying assumptions, organized approach, validation, normal and abnormal, inferences or drawing valid conclusions, clustering related cues, relevance, inconsistencies, identify patters, missing information, health promotion, risk diagnosis, set priorities, collaborative problems, outcomes, interventions, evaluation and corrective thinking, comprehensive plan of care. 4 types of data collecting Episodic or problem centered data base Follow up data base Emergency data base Complete and total health data base Health and illness Health is a balance of a person is a complex interlaced phenomenon, within physical, mental and spiritual nature Illness is a loss of that person’s balance Difference between culture, norms, social learning, religion, ethnicity and spirituality. Cross culture model of health care is a holistic model. Hot and cold theory of illness vs yin/yang theory. Naturalistic – forces of nature must be kept in balance. Yin and yang, hot and cold. Transcultural expression of pain. Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation and other factors unique to the person. Purpose of health history Biographical data Source of history Reason for seeking care Present health or history of present illness Past health Family health Review of systems Function assessment including activities of daily living (ADL) PQRSTU Provocative or palliative Quality or quantity Region or radiation Severity scale 1-10 Timing or onset Understand patient’s perception of problem Purpose of the CAGE test Cut, annoyed, guilty and eye opener 4 questions in regards to alcohol addiction Purpose of functional assessment Self-esteem, self-concept Activity and exercise Sleep and rest Nutrition and elimination Interpersonal relationships Coping and stress management Personal habits Illicit or street drugs Environment and work hazards Intimate partner violence Occupational health Review of systems contains what type of info General overall health state, skin, hair, eyes, ears, nose and sinuses, mouth and throat, neck breast, axilla, respiratory system, cardiovascular, peripheral vascular, gastrointestinal, unitary, male and female genital system, sexual health, skeletal muscle, neurologic, hematologic and endocrine system. Health promotion practices across the life span General health in past 5 years Accidents or injuries, serious or chronic illnesses, hospitalizations, operations Last examination Obstetric status Verbal vs nonverbal behavior Verbal Empathy Clarification Confrontation Interpretation Explanation Summary Nonverbal Vocal cues: pitch, tone, and quality of voice, including moaning, crying, and groaning Action cues: posture, facial expression, and gestures Object cues: clothing, jewelry, and hairstyles Personal space: interpersonal transactions and care of belongings Touch: involves use of personal space and action Physical environment of interview Is a external factor, that makes patients feel more comfortable if they have privacy. Techniques of communication Communication is behavior, conscious and unconscious, verbal and nonverbal All behavior has meaning Body language: posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair Open ended vs closed ended questions Open ended Ask for narrative responses State topic only in general terms Use them in the following situations: To begin interview To introduce a new section of questions Whenever the patient introduces a new topic Closed ended Ask for specific information Elicit short one- or two-word answers, a yes or no answer, or a forced choice Use them in the following situations: After opening narrative to fill in details person may have left out When you need many specific facts about past health problems or during review of systems To move the interview along People with special needs Hearing impaired Acutely ill Under influence of street drugs or alcohol Those who must be asked personal questions