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71 Cards in this Set
- Front
- Back
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Subjective data |
What the person says about himself during history taking |
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Objective data |
What you as the health professional observed by inspecting,percussing,palpating, and auscultating during the physical examination |
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Diagnostic reasoning |
The process of analyzing health data and trying to conclusions to identify diagnosis The four steps are one-attending to initially available cues to-formulating diagnostic hypotheses three-gathering data relative to the tentative hypothesis for-evaluating each hypothesis with new data collected five-arriving at a final diagnosis |
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Evidence |
A body of clinical information that is used to validate a particular assessment |
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Nursing process |
Six phases are included assessment, diagnosis, outcome identification, planning, implementation, and evaluation |
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Principal of setting priorities |
Step one: make a complete list of current medications, medical problems, allergies, and reasons for seeking care. Step two: determine the relationships among the problems. Assign priority to first level priority problems remember the ABC's plus V the airway problems, breathing problems, cardiac and circulation problems, vital signs concerns the only exception would be during CPR then the order is C A B |
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EBP |
Evidence-based practice. It is a systematic approach to practice that emphasizes the use of the best evidence in combination with the clinicians experience as well as the patients preference and values to make decisions about care and treatment |
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Four types of databases |
Complete, focused or problem centered, follow up, and emergency |
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Holistic health |
Help use that include the mind body and spirit as inter-dependents and functioning as a whole within the environment |
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Direct, closed questions |
Used for specific information. Calls for short one to two word answers. Elicit cold facts. Limits for poor and leaves interaction neutral. Example are your headaches on one side or both? |
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Open ended questions |
They are used for narrative information. Calls for long paragraph answers. Elicit feelings, opinions, ideas. Builds and enhance his report. Example tell me all about your headaches. |
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PQRSTU |
P-provocative or palliative. What brings it on? What were you doing when you first noticed it? What makes it better? What makes it worse? Q-quality or quantity.how does it look, feel, sound, how intense/severe is it? R-region or radiation. Where is it? Does it spread anywhere? S-severity scale. How bad is it on a scale of 1 to 10? Is it getting better, worse, staying the same? T-timing. Onset-exactly when did it first occur? Duration-how long did it last? Frequency-how often does it occur? U-understand patient's perception of the problem. What do you think it means? |
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Wellness |
A dynamic process and view of health; a move toward optimal functioning |
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Prevention |
Any action directed toward promoting health and preventing the occurrence of Disease |
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Holistic health |
The view that the mind, body, and spirit are interdependent and function as a whole within the environment |
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Diaphoretic |
Inducing perspiration if it's a drug. Of a person it equals two sweating heavily |
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Abstract reasoning |
Pondering a deeper meaning beyond the concrete and literal |
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Consciousness |
Being aware of one's own existence, feelings, and thoughts and being aware of the environment |
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Consciousness |
Being aware of one's own existence, feelings, and thoughts and being aware of the environment |
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Delirium |
An acute confusional change or loss of consciousness and perceptual disturbance that may accompany acute illnesses; usually resolves when the underlying causes treated |
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Dementia |
A gradual progress of process, causing decreased cognitive function even though the person is fully conscious and awake; not reversible |
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Memory |
Ability to lay down and store experiences and perceptions for later recall |
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Mood |
Pro long display of a person's feelings |
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Orientation |
Awareness of the objective world in relation to the self |
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Orientation Affect |
Awareness of the objective world in relation to the self |
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Perceptions |
Awareness of objects through any of the five senses |
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Thought content |
What the person thinks-specific ideas, beliefs, the use of words |
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Thought process |
The way a person thinks, the logical train of thought |
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Organic disorders |
Caused by brain disease of known specific organic cause e.g., delirium, dementia, alcohol and drug intoxication, and withdraw |
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Psychiatric mental disorders |
In which an organic at etiology has not yet been established E.g., anxiety disorder or schizophrenia |
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Affect |
A temporary expression of feelings or state of mind or mood is more durable A prolonged Display of feeling that color the whole emotional life |
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Attention |
The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli |
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Attention |
The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli |
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Mental disorder |
Is a clinically significant behavioral, emotional, or cognitive syndrome that is associated with significant distress a painful symptoms, or disability involving social occupational or key activities |
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Mental status |
Is a person's emotional (feeling),and cognitive (knowing)function |
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A, B, C, T |
The four main headings of mental status assessment: appearance, behavior, cognition, and thought processes |
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Aphasia |
The impairment of language ability secondary to brain damage. A mental status examination SS his language dysfunction and any emotional problems associated with that such as depression or agitation. |
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Anhedonia |
Little interest or pleasure in doing things |
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Dysphonia |
Disorder of voice. Difficulty or discomfort and talking, with abnormal patch or volume, caused by laryngeal disease. Voice sounds hoarse or whispered the articulation and language are intact |
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Dysarthria |
Articulation. Distorted speech sounds; speech may sound unintelligible; basic language-word choice, grammar, comprehension-intact |
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Aphasia |
Language comprehension and production secondary to brain damage. True language disturbance; defect and word choice and grammar or defect and comprehension; defect is in higher integrative language processing |
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Global aphasia |
Severe form. Spontaneous speech is absent or reduced to a few stereotype words or sounds. Comprehension is absent or reduced to only the person's own name and if you select words repetition, reading, and writing are severely impaired |
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Broca aphasia |
Expressive a facia. The person can understand language but cannot express himself or herself using language. The speech is mostly nouns and verbs with you grammatic fillers repetition reading aloud so impaired. Auditory and reading comprehension are surprisingly it's intact |
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Broca aphasia |
Expressive a facia. The person can understand language but cannot express himself or herself using language. The speech is mostly nouns and verbs with you grammatic fillers repetition reading aloud so impaired. Auditory and reading comprehension are surprisingly it's intact |
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Wernicke aphasia |
The person can hear sounds and words cannot relate them to previous experiences. Speech is fluent, effortless and well articulated and often lacks substance of words. Speech can be incomprehensible. |
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The four skills required for the physical examination are |
inspection, palpation, percussion, and auscultation |
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Amplitude |
How loud or soft they sound is (the intensity) |
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Duration |
The length of time a note lingers |
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Pitch |
The number of vibrations or cycles per second Of a note- the frequency |
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Quality |
A subjective difference in a sound as a result of the sounds distinctive overtones-timbre |
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Hyperthermia |
Increase temperature fever |
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Hyperthermia |
Increase temperature fever |
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Hypo thermae |
Decreased temperature usually caused by accident so prolonged exposure to cold |
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Pulse |
The amounts of blood the heart pumps into the aorta the stroke volume. when assessing Pauls you want to include the rate the rhythm and the force. The rate should be anywhere from 60 to 100 beats per minutes. The rhythm should have a regular even tempo. The rate shows the strength of the heart stroke volume. The scale is zero-absent 1+-weak, thready 2+-normal 3+-full, bounding |
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Bradycardia |
A heart rate less than 50 beats per minutes |
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Tachycardia |
A rapid heart rate to find us over 95 beats per minutes or over 100 beats per minutes |
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Tachycardia |
A rapid heart rate to find us over 95 beats per minutes or over 100 beats per minutes |
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Sinus arrhythmia |
The heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. This is commonly found in children and young adults |
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Breaths per minute-respirations |
Neonate =30-40 1 yr = 20-40 2 yr = 25-32 8-10 yr =20-26 12-14 yr = 18-22 16 yr = 12-20 Adult = 12-20 |
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Systolic pressure |
The pressure is the max maximum felt on the artery during left ventricular contraction or Systole |
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Systolic pressure |
The pressure is the max maximum felt on the artery during left ventricular contraction or Systole |
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Diastolic |
The pressure is the elastic recoil are resting pressure but the blood exerts constantly between each contraction |
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Pulse pressure |
The difference between the systolic and diastolic pressures are reflects the stroke volume |
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What can cause variations of blood pressure |
Age, sex, race, weight, exercise, emotions, stress, and diurnal rhythm |
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What are the five factors that determine the blood pressure |
Cardiac output-if the heart pumps more blood into the blood vessels the pressure on the walls increases. Peripheral vascular resistance-is the opposition to bloodflow through the arteries. When the constricted vessels become smaller The pressure needed to push the contents becomes greater causing vasodilation which means the vessels become larger less pressure is needed. Volume of circulating blood how tightly the blood is packed into the arteries. Viscosity the thickness of blood the contents are thicker the pressure increases. Elasticity of vessel walls when the walls are stiff and rigid the pressure needed to push the contents increases. |
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Auscultatory gap |
The period when korotkoff sounds disappeared during auscultation |
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Korotkoff sounds |
1- Tapping, followed by auscultatory gap 2- swooshing 3- knocking 4- abrupt muffling 5- silence |
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Hypotension |
Abnormally low BP |
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Hypotension |
Abnormally low BP |
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Hypertension |
Abnormally high BP |
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What are the five vital signs |
Temperature, pulse, respirations, blood pressure, pulse ox,pain |
