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35 Cards in this Set
- Front
- Back
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Identify verbal responces that focus on the perspective of the Health Care Provider
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Facilitation
Silence Reflection Confrontation Clarification Empathy Interpretation Explanation Summary |
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Facilitation
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Your Facilitative responce encourages the patient to say more, to continue with the story e.g."go on", "Continue", "uh,huh" or simpply nodding
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Silence
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Your silence communicates that the Pt has more time to think. Also gives you time to observe the client
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Reflection
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A reflective responce echoes the pt's own words. Repeat part of the statement. It focuses particular attention on a specific phrase and helps the conversation to continue. Pt "I'm here because my water is cutting off" you "your water is cutting off?"
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Confrontation
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You give your honest feedback about what you see or feel. e.g. "you say it doesnt hurt but when I touch you here you grimace"
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Empathy
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An empathetic responce recognizes a feeling and puts it into words. It names a feeling and allows expresion e.g. "Tell me what you mean by tired blood"
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Interpretation
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Based on your inferences or conclusion. Links events, makes associations, or implies cause. e.g. "It seems every time you complain of stomach pain you have a lot of stress in your life
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Explanation
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Share factual or objective information e.g. "Your dinner comes at 5 pm" or it may be to explain cause e.g. "The resaon you cannott eat or drink before your blood test is becasue food will change the test results
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Summary
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This is the final interview of what you understand the patient has said. It condences the facts and presents a survey of how you percieve the pts health problem of need.
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Objective
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What you as the health care profesional observe during the exam e.g Inspecting, Percussing, Palpation, Ausculation
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Subjective
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What the person says about himself during the history taking
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Historical
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Historical Data is a cluster of data information such as health history and family history
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Physical
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Physical data is the information that the nirse obtains during the physical assessment
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Documenting obstetric history
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# of pregnancies (gravada)
# of deliveries in which the fetus reached full term/preterm (para>20 wks) # of incomplete pregnancies # of living children For each complete pregnancy note the cource, labor and delivery, sex, wieght, condition of infant and postpartum course. For incomplete pregnacies, note the duration and weather it ended (S) spontaneously or (I) Induced(abortion) |
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Documenting Allergies
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Note both the drug and the reaction (rash, itching, etc)
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Important diseases or problems to assess for when taking a family history
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Heart disease
High Blood pressure Stroke Blood Disorders Cancer Sickle Cell Anemia Arthritis Allergies Obesity Alchoholism Mental Ilness Seizure disorder Kidney disease tuberculosis |
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What is the signifigance of the review of systems
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Evaluate the past and present health state of each body system
Double check i ncase any signifigant data were admitted in the present ilness section Evaluate Health promotion practices Order of body systems is roughly head to toe |
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What is the purpose of assessing functional assesment in a patient
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Measures a persons self care ability in the areas of general physical health or absence of illness; ADL's such as bathing, dressing, toileting, eating, walking, IADL's (instrumental) such as houskeeping shopping, cooking, laundry using telephone, managing finances. Nutrition: Social relationships and resources; Self concept and coping; and home environment.
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Techniques used in performing aphysical assessment
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Inspect
Palpation Percussion Ausculation |
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Inspect
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Concentrated watching
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Palpation
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Applies your sence of touch to assess texture, temp, moisture, organs location and size, swelling, vibration, pulsation, rigidity, spacticity, crepitation, lumps or masses
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Percussion
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Tapping the persons skin with short, sharp strokes to assess undelying structures
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Ausculation
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Listenig to sounds produced by the body such as heart, blood vessels, lungs, and abdomen using the stethescope
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What does physical growth indicate when assessing a child
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Poor weight gain or development delays would mean signs of a cardiac problem
Physical growth is the best index of a childs general Health |
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What is the signifigance of maintaining a patients core temperature
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Cellular metabolism requires a stable core temp of 37.2 C or 99F.The body regulates a steady temp through a thermostat or feedback mechanism, regulated in the hypothalamus of the brain. Core temp=oral or rectal or tempanic membrane
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Differentiate between various methods to obtain a Patients temperature
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Oral - accurate and convenient
Axillary - Under armpit, Safe and accurate for young children and infants when the environment is reasonably controlled Rectal - Use when other routes are unpractical like comatose, confused, shock, or access to mouth cant be gained e'g' facial dysfunction Tempanic Membrane - Ear, accurate measurement of the core temperature. |
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How do assess the quality of a patient's pulse?
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Rate
Rhythym Force |
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Rate of Pulse -
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Resting rate of the normal adult is 60 beats per minute
Count for 30 sec and double it |
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Rythym of Pulse
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Normal has an even tempo
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Force of Pulse
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Shows the strength of the stroke volume. Weak thready pulse denotes a decreased stroke volume. A full bounding pulse denotes an increased stroke volume
3+ = full bounding 2+ = normal 1+ = Weak and thready 0 = absent Elasticity = Normal = the artery feels springy, straight, resilient |
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What are the factors that influence a patients blood pressure
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Age, Gender, Race, Diurinal Rhythm (daily cycle of peak and trough), Weight, Excercise, Emotions, Stress
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Age related changes when assessing vital signs:
Temperature |
Newborns - Have a large surface to mass ration therefore they loose heat rapidly
Older Adults - Have a loss of subceutaneous fat resullting in a lower body temp. and feeling cold |
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Age related changes when assessing vital signs -
Pulse |
Infants - rate is 120-126 per min, this rate gradually decreases as child grows older
12-14 yr - 80-90 bpm - the strength and pulsation may weaken in an older adult client due to poor circulation or cardiac function and the peripheral pulse is then more diffucult to palpate |
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Age related changes when assessing vital signs -
Respirations |
Decrease w ith age - Newborns - 30-6- bpm
school age child - 20-30 adults 12-20 |
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Age related changes when assessing vital signs -
Blood Pressure |
Infants have low b/p increase with age
Older chlid + adolescence- Vary on body size, Larger child has higher b/p Older Adults - May have slightly elevated b/p due to decreased elasticity of blood vessels |
