Health Assessment Nursing Process, Communication, Pain

Front 1

What are the steps in the Nursing Process?

Back 1

Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation
(ADPIE)

Front 2

What are parts of assessment?

Back 2

Data collection, review clinical record, interview, health history, physical exam, functional assessment, consultation, review of literature

Front 3

Name the characteristics of the nursing process.

Back 3

Dynamic and cyclic, patient centered, goal directed, flexible, problem oriented, cognitive, action oriented, interpersonal, holistic, systematic

Front 4

What is included in the diagnosis portion of the nursing process?

Back 4

Interpret data, identify clusters of cues, make inferences, compare clusters of cues with definitions and defining characteristics, identify related factors, document diagnosis

Front 5

Define nursing diagnosis.

Back 5

Nurses clinical judgment about the client's response to actual or potential health conditions or needs.

Front 6

What is included in the planning portion of the nursing process?

Back 6

Establish priorities, develop outcomes, set time frames for outcomes, identify interventions, document plan of care. Based on assessment and diagnosis.

Front 7

What is included in the implementation portion of the nursing process?

Back 7

Implementation of treatments, procedures, protocols. Review planned interventions, schedule and coordinate total health care, collaborate with other team members, supervise implementation of care plan/according to care plan. Counsel person and significant others, involve person in health care, refer for continuing care, document care provided.

Front 8

What is included in the evaluation portion of the nursing process?

Back 8

Evaluate patient condition, response to treatment, overall plan of care. Refer to established outcomes, evaluate individual's condition and compare actual outcomes with expected outcomes. Take corrective action to modify plan of care. Document evaluation in plan of care.

Front 9

What is the Kleinman model?

Back 9

Explanatory model of illness that is designed to elicit the patient's perspective of illness.

Front 10

Name the 8 questions of the Kleinman model.

Back 10

What do you call your illness? What name does it have? What do you think has caused the illness? Why and when did it start? What do you think the illness does? How does it work? How severe is it? Will it have a short or long course? What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment? What are the chief problems the illness has caused? What do you fear most about the illness?

Front 11

Affirmation/Facilitation

Back 11

to say more, "aha, go on, tell me more

Front 12

Silence

Back 12

Difficult to maintain, allow gathering of thoughts before responding

Front 13

Clarifying

Back 13

If unsure or confused, rephrase what was said and ask for clarification. "Let me see if I have this right..."

Front 14

Restating/Paraphrasing

Back 14

Patient's main idea. "I heard you say... So you are saying..."

Front 15

Reflection of feeling

Back 15

Focus on feelings, "you seem to be feeling..."

Front 16

Validating

Back 16

Value what speaker is saying. "I see what you are saying..."

Front 17

Informing

Back 17

Giving information encourages involvement in healthcare decisions.

Front 18

Redirecting

Back 18

Get back on track again, "getting back to what brought you to the office..."

Front 19

Focusing

Back 19

Inquire about specific are, "you said your mother and father have HTN, have you gotten your BP"

Front 20

Sharing perceptions/confrontation

Back 20

bringing up inconsistencies, "you say it doesn't bother you, but you look angry and annoyed.

Front 21

Identifying themes

Back 21

Recurrent themes make connection and focus on major theme, "from what you've told me, you have problems at home without your medicines"

Front 22

Sequencing events

Back 22

Trouble sequencing events help place events in order. "What happened before the problem started? What happened next? How did it end?

Front 23

Suggesting

Back 23

Present alternative ideas, provides options. "Have you tried slow abdominal breathing when you have anxiety?"

Front 24

Presenting reality

Back 24

when exaggerated or contradicting facts, helps be more realistic

Front 25

Summarizing

Back 25

Final review of what you understand has been said, "let me summarize what you've told me...So you main point is..."

Front 26

Methods of effective communication

Back 26

Genuineness: open, honest, sincere
Respect: Everyone should be respected as a person of worth and value, be nonjudgmental in your approach
Empathy: knowing what your patient means and understanding how s/he feels. Acknowledges patients feelings, shows acceptance, care and concern, fosters open communication. "This must be very difficult for you.."

Front 27

What is Assessment?

Back 27

Systematic process, continuous collection of data about health status. Nurse responsible for data collection. Identifies strengths and limitations. Collecting, validating, and clustering data.

Front 28

Purpose of Assessment

Back 28

Collect pertinent patient health status data. Identify abnormal findings, identify patients strengths and coping resources. Identify actual problems. Identify risk factors.

Front 29

Divergent thinking

Back 29

Analyzing various viewpoints, differentiating relevant/irrelevant data, making inferences (conclusions).

Front 30

Reasoning

Back 30

Ability to differentiate fact (truth) from assumptions (beliefs)

Front 31

Deductive reasoning

Back 31

Start from general rule to specific

Front 32

Inductive reasoning

Back 32

Start from specific and derive general rule.

Front 33

Reflection

Back 33

Allows to step back and think, consider "if...then" possibilities. Experience and new evidence may change opinions

Front 34

Four techniques of physical assessment:

Back 34

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Front 35

Levels of Preventive Care

Back 35

Primary: Focus on health promotion and illness prevention
Secondary: Focus on early detection, prompt intervention, and health maintenance
Tertiary: Focus on rehabilitation and extended care

Front 36

Subjective assessment data

Back 36

Covert, not measurable symptoms. What is stated.

Front 37

Objective assessment data

Back 37

Overt, measurable symptoms. What is observed.

Front 38

Name the phases of the interview:

Back 38

Introductory
Working
Termination

Front 39

What happens during the introductory phase of the interview?

Back 39

Introduce self, put patient at ease, explain purpose of interview, explain time frame

Front 40

What happens during the working phase of the interview?

Back 40

Data collection, structured, longest phase.

Front 41

What happens during the termination phase of the interview?

Back 41

End of interview. Summarize and restate findings.

Front 42

Maslow's hierarchy of needs

Back 42

Patient basic needs: Physiological, safety, love and belonging, self-esteem, self-actualization

Front 43

Roy's adaptation theory

Back 43

Patient adaptation to physiological, self-concept, social role, interdependence demands,

Front 44

Gordon's Functional health patterns

Back 44

11 functional groups. Health perception, nutrition, elimination, exercise, cognitive, sleep, self concept, relationship, sexuality, coping, values

Front 45

NANDA-Unitary person framework

Back 45

constant interaction with environment. 9 human response. Exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, feeling.

Front 46

Transduction

Back 46

Response to noxious (painful) stimulus results in tissue injury. Peripheral release chemicals (histamine, prostaglandins, serotonin, bradykinin) propagate pain message. Noxious stimulus (Mechanical, Thermal, or Chemical) converted into nerve impulse by nocioreceptors (found in skin, SQ, joints, walls of arteries.)

Front 47

Transmission

Back 47

to spinal cord and brain. Primary afferent nerve fibers C-fibers and A-delta fibers.

Front 48

C-fibers

Back 48

slow constant pain (mechanical, thermal, and chemical stimuli)

Front 49

A-delta fibers

Back 49

fast intermittent pain (mechanical stimuli)

Front 50

Perception

Back 50

Conscious awareness of pain via cortical structures such as limbic system.

Front 51

Modulation

Back 51

pain message inhibited inhibited through descending pathways slow down or impede pain impulse (serotonin, norepinephrine, GABA, endogenous endorphins)

Front 52

Sensitization

Back 52

prolonged exposure to noxious stimuli; acts as protective mechanism during healing, but if persist, chronic pain can develop.

Front 53

Hyperalgesia

Back 53

increase response to painful stimuli lower threshold of pain

Front 54

Allodenia

Back 54

painful response to nonpainful stimuli

Front 55

Central sensitization

Back 55

Spinal neuron hyperexcitability results in hyperalgesia and allodynia. As well as persistent pain and referred pain.

Front 56

Acute pain

Back 56

severe and lasts a relatively short time

Front 57

Chronic Pain

Back 57

Continues for >=6 months

Front 58

Nociceptive pain

Back 58

exposure to noxious stimuli

Front 59

Visceral pain

Back 59

results in deep internal organ injury or stretching. Presents with autonomic response of N&V, pallor, diaphoresis.

Front 60

Poorly localized pain

Back 60

cramping

Front 61

Neuropathic pain

Back 61

Injury to peripheral or CNS; burning, shooting, and tingling

Front 62

Mono/polyneuropathies

Back 62

Damage peripheral nerves from metabolic disorders, toxins, infections, trauma, compression, autoimmune and heredity diseases; continuous deep, burning, aching or bruised, paraoxysmal shocklike or abnormal skin sensitivity

Front 63

Deafferentation

Back 63

loss of afferent input from damage to peripheral nerve, ganglion, plexus or CNS (phantom pain and postmastectomy pain). Burning, cramping, crushing, aching, stabbing, shooting

Front 64

Hyperalegia

Back 64

Excessive sensitivity to pain

Front 65

Hyperpathia

Back 65

Hypersensitivity to sensory stimuli

Front 66

Dysesthesia

Back 66

Abnormal sensations of skin numbness, tingling, burning, or cutting.

Front 67

Sympathetically Maintained Pain

Back 67

results from sympathetic nervous stimulation from peripheral nerve damage, sympathetic efferent innervation, or circulating catecholamines

Front 68

Central Pain

Back 68

primary lesions or dysfunction of CNS (CVA, tumors, trauma, demyelination (MS), burning, numbing, tingling to shooting sensation.

Front 69

Evaluation tool for children

Back 69

QUESTT:
Question child
Use pain rating scale
Evaluate behavioral and physiological changes
Secure parent's involvement
Take cause of pain into account
Take action and evaluate results

Front 70

Health History

Back 70

Biographical data
Current health status (PQRSTU)
Past health history
Family history
Review of systems
Psychosocial history

Front 71

PQRSTU (P)

Back 71

P= Precipitating/palliative, identify factors that make symptom worse or better; any previous self-treatment or prescribed treatment and response.

Front 72

PQRSTU (Q)

Back 72

Q= Quality/quantity, identify rating of symptoms (pain 1-10) and descriptors (numbness, burning, stabbing)

Front 73

PQRSTU (R)

Back 73

R= Region/radiation/related symptoms, identify exact location of symptom and area of radiation.

Front 74

PQRSTU (S)

Back 74

S= Severity
Identify symptoms severity (how bad at its worst) any associated symptoms (presence or absence of N/V associated w/CP

Front 75

PQRSTU (T)

Back 75

T = Timing. Identify first noticed; how it has changed/progressed; acute or chronic; constant, intermittent or recurrent.

Front 76

PQRSTU (U)

Back 76

U = Understanding of cause of pain

Front 77

Symptom Analysis (OLDCARTS)

Back 77

Onset, Location, Duration, Character, Aggravating/Associated, Radiation/Relieving, Treatment/Timing, Severity

Front 78

Physiologic effects of pain

Back 78

Cardiac: Increased BP, cardiac O2 demand, CO

Pulmonary: Hypoventilation, hypoxia, decreased cough, atelactasis (collapse of lung)

GI: N&V, ileus

Renal: Oliguria (diminshed UO), urinary retention

MS: spasm, joint stiffness

Endo: Increased adrenergic activity

CNS: Fear, anxiety, fatigue

Immune: Impaired cellular immunity, wound healing

Front 79

Pulse: Stroke Volume

Back 79

SV = EDV − ESV

the volume of blood pumped from one ventricle of the heart with each beat.

Front 80

Regular Sinus Rhythm

Back 80

15-30sec, start "0"

Front 81

Irregular rhythm

Back 81

apical HR greater than 1 min.

Front 82

Length of Inspiration/Expiration cycle

Back 82

30sec-1min

Front 83

Ratio of HR to RR

Back 83

HR:RR=4:1

Front 84

Systolic Blood Pressure

Back 84

max pressure on artery during L ventricular contraction

Front 85

Diastolic blood pressure

Back 85

elastic recoil or resting pressure between contractions.

Front 86

Pulse pressure

Back 86

Difference between systole and diastole. Reflects stroke volume.

Front 87

Freud Developmental Theory

Back 87

Psychosexual: Biological drives influences development

Front 88

Erikson Developmental Theory

Back 88

Psychosocial: 8 developmental stages with crisis to be resolved

Front 89

Piaget Developmental Theory

Back 89

Cognitive development: Knowledge comes from interaction between genetic potential and environmental experiences

Front 90

Kohlberg Developmental Theory

Back 90

Moral Development: Cognitive development and emotional growth affect individuals ability to make autonomous decisions.

Front 91

Havighurst Developmental Theory

Back 91

Activity during aging: elderly stay active and maintain or substitute activities, more satisfied with life. Diminished activities equated with social isolation and accelerated physical decline.

Front 92

I-SBAR-R

Back 92

A form of communication to providers
Identification: self as nursing student and patient use 2 identifiers

Situation: concise statement of problem

Front 93

What is the diaphragm of the stethoscope good for?

Back 93

High pitched sounds. Eg. breath, bowel, normal HB

Front 94

How should the diaphragm be held

Back 94

Tightly

Front 95

How should the bell of the stethoscope be held?

Back 95

Loosely

Front 96

What is the bell of the stethoscope good for?

Back 96

Low pitched sounds, such as murmurs