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203 Cards in this Set
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- Back
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admission orders |
instructions that say I want X, Y, Z done. |
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discharge summary |
especially useful for provider who will see pt after hospital |
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operative note |
tells us what happened in the OR |
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operative report |
much more thorough |
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preoperative orders |
written in advance of the surgery so the staff know what you want them to do |
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what is the order the objective PE is documented in? |
VS general HEENT neck chest respiratory abdomen extremities NS pelvic/rectal |
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Plan has 3 parts |
diagnostic tests treatments/therapeutics patient education |
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what info must be included for each medication? |
name strength dose route frequency duration |
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what is strength? what is dose? |
strength is the mg per pill dose is how many pills they take at a time |
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is this S or O? pain scale |
S |
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S or O? patient is unconscious |
all O S from family or bystanders |
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S or O? patient tells you results of previous testing |
S |
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what is the purpose of an Admit Note? |
summarize the Admission H&P if it isn't available in the chart yet |
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mnemonic for Admit orders? |
AD CAVA DIMPLS |
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AD CAVA DIMPLS stands for? |
Admitting physician Diagnosis Condition Activity VS Allergies Diet Interventions Medications Procedures Labs Special instructions |
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what is A for admit entail? |
attending physician and hospital unit |
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what does Condition entail? |
one word - stable, unstable, critical, comatose |
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what does Activity entail? |
activity allowed is based on condition and mental alertness depends on factors like intubated? on narcotics? |
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what are examples of Procedures? |
wound care, dressing changes |
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who completes the Operative Report? how is it different from Operative Note? |
surgeon completes operative note and gives full details. Operative Note is brief and hand-written, available immediately after the surgery |
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when is a Procedure Note used? |
procedure is done but not in the OR |
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how is a Delivery Note different than the others? |
it focuses on baby features and is written in paragraph form. |
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what are the key features of a Discharge Summary? |
required for any stay longer than 24 hrs must be completed before hospital submits for payment - within 30 days |
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what is the main section of a Discharge Summary? |
hospital course - briefly summarize the eval, treatment, and progress during hospitalization |
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if a patient elopes... |
document date and time you were informed complete the discharge summary, in disposition state the pt eloped |
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define culture |
learned beliefs and behaviors that are shared among groups |
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define ethnicity |
social groups with a shared history, sense of identity, cultural roots |
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define stereotype |
generalizations about a group of people attributing a set of characteristics to the group |
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define prejudice |
irrational attitude of hostility directed against a group or their supposed characteristics |
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define discrimination |
unfair treatment of a person on the basis of prejudice |
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define values |
standards we use to measure beliefs and behaviors beliefs with an emotional investment - for/against |
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define bias |
favoring one side rather than remaining neutral attitudes we attach to perceived differences |
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3 skills of cultural communication? |
CER Curiosity Empathy Respect |
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what does curiosity entail? |
elicit core values about health corroborate your preconceptions about a culture's approach to health understand pt as a whole person elicit pt's explanatory model of illness |
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what is the patient's explanatory model of illness? |
meaning that the pt attaches to illness causes/fears/hopes about illness |
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4 Es to interview patients from underserved areas |
Empathic Enlist Explain Empower |
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what does Enlist their help mean? |
frame the medical problem in language they can understand. validate pt priorities. inform pt of the problem's importance and the value of addressing it. |
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what does Explain mean? |
avoid medical jargon give specific, concrete instructions provide low literacy instructional materials |
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what does Empower mean? |
give positive feedback on pt success elicit pt concerns about cooperating with treatment seek pt's personal commitment to participate |
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what are cultural considerations needed within the deaf community? |
touch and vision important
extended goodbyes ASL is native language |
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define CAM |
group of diverse medical and healthcare practices that are not generally considered part of conventional medicine |
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CAM describes these 3 types of therapies |
integrative complementary alternative |
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what is integrative therapy? |
use both conventional and outside of the norm approaches |
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ex of energy therapy? |
reiki magnets qigong |
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ex of alternative medical systems? |
homeopathy naturopathy ayurveda |
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ex of biologically based approaches |
diets herbs vitamins |
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ex of manipulative and body based therapy |
massage chiropractic osteopathy |
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ex of mind-body interventions |
yoga spirituality relaxation |
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what are the most common CAM therapies? |
natural products deep breathing meditation chiropractic |
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who uses CAM? |
higher socioeconomic group avoid toxicity dissatisfaction with conventional medicine holistic health philosophy transformational experience |
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what diseases if CAM most frequently used for? |
back pain neck pain joint pain |
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explain Western medical model |
mechanistic the body is a machine, malfunctions and needs tune ups or replacements |
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Western medical model differs from others by |
they view illness as imbalance of forces chinese yin-yang hispanic hot-cold |
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how do you ask about a pt's explanatory model? |
start with statement of respect "I know different people have very different ways of understanding illness.... please help me understand how you see things." |
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visual learners need |
visual aids like maps, diagrams, graphs sit in the front of classroom can visualize objects in head |
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aural learners need |
info that is "heard or spoken" learn best from lectures, group discussion likes to work things out with sound and music |
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read/write learners need |
info displayed in words powerpoint, lists, quotes print freak |
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kinesthetic learners need |
experience and practice active learning demonstrations, videos, case studies |
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describe adult learners |
problem oriented results oriented self-directed |
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describe youth learners |
subject oriented - want to complete the course future oriented dependent on adults for direction |
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patient education has 4 parts |
convey info check for understanding enhance memory negotiate |
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what does it mean to enhance memory? |
write down the instructions provide other instructional material refer them to websites |
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define health literacy |
constellation of skills, including ability to do basic reading and numerical tasks required to function in the healthcare environment |
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most adults read at what level? how many adults can understand pre-printed healthcare material? |
8th-9th grade 50% |
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poor health literacy causes |
skipping follow up appts difficulty controlling chronic illnesses less likely to understand disease prevention |
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what test is used to assess health literacy? |
REALM Rapid Estimate of Adult Literacy in Medicine |
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how does REALM work? |
it is not a test of comprehension. it is word recognition. |
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what is REALM-revised and how is it scored? |
assesses 8 words. 11 are read but the first three are not scored. score of 6 or less IDs patients at risk for poor literacy. |
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6 steps to enhance understanding |
slow down use living room language show pictures limited amount of info given "teach back" approach be respectful, caring, and sensitive |
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define counseling |
advice from a knowledgeable person as to a decision or course of action |
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list models of change |
health belief model theory of reasoned action social cognitive commitment to change |
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how do you initiate discussion about a problem health behavior? |
ask opened ended questions use 5 As |
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the 5 As are |
ask assess advise assist arrange |
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what is Ask? |
ask patient at every visit! "do you smoke?" |
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assessing readiness to change involves |
assess: current state of change conviction confidence |
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what is the Stages of Change model? |
6 stages - people move through them in making a change in behavior. they may relapse and enter back into any of these stages. |
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list Stages of Change |
pre-contemplation contemplation preparation action maintenance relapse |
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describe contemplation stage. |
aware of problem and seriously considering it pros and cons thinking of changing in the next 6 months*** |
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when does preparation stage occur? |
intends to take action in the next month |
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what is the action stage? |
has altered behavior for 1 day to 6 months |
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what is conviction? |
what pt believes about important of taking action |
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what is confidence? |
what pt believes about their ability to change a behavior despite obstacles |
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what is your goal as a PA when pt is in pre-contemplation stage? |
get pt to begin thinking about change get pt to visualize himself after the change "if you were to quit, what would be some advantages?" |
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goal in contemplation stage? |
get pt to examine pros and cons to change, possible solutions |
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in 5As, what is "arrange"? |
arrange follow up visits appointments for consultants, education classes |
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motivational interviewing emphasizes these clinician characteristics |
empathy curiosity pt's self-determination acceptance |
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some clinicians use the 5Rs to counsel patients in changing behaviors. these are |
relevance risk rewards roadblocks repetition |
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what is relevance? |
make it personal
relate change to family, age, health concerns |
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what is rewards? |
health save money appearance self-esteem feel better overall |
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what is repetition? |
if at first you don't succeed, try try again! |
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what are the new words you should use for "supportive language"? |
commitment
consider choose what works for you eating style activity style healthy BMI |
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why use warm water when hand washing? |
cold water not as effective, hot water is drying to skin |
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hand sanitizer must be |
60% alcohol |
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general appearance includes |
state of health ease of breathing build sexual development posture motor activity dress/grooming |
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normal range for T |
97.8-99.1 F |
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average respirations/min |
12-18 |
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average pulse |
60-100 bmp |
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considerations when obtaining VS |
no alcohol/tobacco/caffeine/exercise within 30 mins of exam seated with both feet on ground and back supported |
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average body T is 98.6F, what is this in C |
37C |
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fever is medically significant above |
100.4F 38C |
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what temperatures are life-threatening? |
+/- 4 degrees |
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know the clinical equivalents for these. 35C 36C 37C 38C |
95 96.8 98.6 100.4 |
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contraindications for oral T? |
unconscious restless unable to close mouth |
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how do you take a rectal T? when is it used? |
pt on side with hips flexed insert lubricated probe 3-4cm aim toward umbilicus use on infants, unconscious, and when accurate T are needed |
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what T is most accurate? least? |
rectal T the best axillary least |
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how does tympanic membrane T work? |
assure no cerumen infrared beam aimed at membrane takes 2-3 sec to measure core T |
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tympanic membrane T is usually |
higher than oral by +0.8C |
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how do you describe pulse rhythm? |
regular - evenly spaced beats regularly irregular - pattern with skipped beats irregularly irregular - no pattern, chaos |
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adults breath 12--18 breaths/min. newborns do |
44 breaths/min |
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what is tachypnea |
rapid shallow breaths |
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what is hyperpnea |
hyperventilation rapid deep breaths |
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how much does BP have to rise for increased risk? |
20mm rise in systolic 10 mm rise in diastolic over 115/75 |
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this increase in BP increases the risk for |
stroke renal failure eye disease heart disease doubles |
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to get an accurate BP measurement, it must be the proper cuff size. explain |
width of bladder 40% of upper arm circumference length of bladder 80% of upper arm circumference |
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explain BP technique |
center bladder over brachial artery cuff 2.5 cm above antecubital crease slightly flex elbow support arm above heart level |
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what is an auscultatory gap? |
silent interval between systolic and diastolic pressures |
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describe how to measure BP |
use bell of stethoscope pump cuff 20-30 mm above palpable systolic P release P by 2-3 mm per second and listen for karotkoff sounds |
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what causes auscultatory gap? |
arterial stiffness, atherosclerotic disease |
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normal BP is between |
100/60 and 140/90 |
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to be normal, BP must be |
Systolic < 120 Diastolic <80 |
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pre-hypertension is |
systolic 120-139 OR diastolic 80-89 |
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stage 1 HTN is |
systolic 140-159 OR diastolic 90-99 |
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stage 2 HTN is |
systolic equal to or greater than 160 OR diastolic equal to or greater than 100 |
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what is JNC 8 |
2014 evidence based guidelines for the management of HTN in adults |
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how is BMI calculated |
weight (kg)/ height (m^2) |
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what waist circumference measurements are concerning? |
women > 35 inches men > 40 inches |
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what are the clinical skills of interviewing? (5) |
objectivity
precision sensitivity specificity reliability |
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sensitivity is |
test's ability to "pick up" real cases of disease in question |
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specificity is |
test's ability to "rule out" disease in normal people |
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define health |
complete physical, mental, and social well-being not merely the absence of disease |
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define disease |
diagnosed by demonstration of pathologic features |
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define illness |
meaning of the disease for the pt how it impacts his life |
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define curing |
restoring health; recovery from disease |
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define healing |
to make whole personal experience |
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define respect |
unconditional positive regard |
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define genuineness |
congruence ability to be yourself in professional role |
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define empathy |
ID and understand patient's experiences, feelings, and motives |
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core qualities of a therapeutic relationship? |
REG respect empathy genuine |
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levels of responding to pt? |
ignoring minimizing interchangeable additive |
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6 Cs of medical documentation |
clear contemporaneous concise complete comprehensible correct mistakes transparently |
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Fortin's 5 Steps |
set the stage elicit CC & set agenda use non-focusing skills to help pt express himself use focusing skills to learn 3 stories transition to clinician centered phase |
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what are the 3 stories? |
symptom story (OLD CHARTS) personal story (what do you think it is?) emotional story (how are you handling this?) |
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examples of constitutional symptoms? |
fever, chills, night sweats, weight loss |
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CAGE stands for |
ever felt need to Cut down on drinking? ever been Annoyed by criticism of your drinking? ever felt Guilty about drinking? Eye-opener to steady nerves or get rid of hangover? |
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pack years equations |
PPD * years 2 packs per day * 10 years = 20 pack years |
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SAFE questions used for |
screening for intimate partner violence |
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SAFE stands for |
Stress/safety afraid/abuse friends/family emergency plan |
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FICA stands for |
Faith Influence Community Address |
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what FICA questions should you ask? |
do you consider yourself a person of faith? are you part of a faith community? is there anything I should know about your faith that impacts how I take care of you? |
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skin ROS |
ecchymosis erythema rashes itching, dryness |
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neck ROS |
swollen glands lumps pain or stiffness |
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HEENT ROS |
changes in vision changes in hearing runny nose bloody nose trouble swallowing |
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CV ROS |
chest pain
fainting HTN trouble breathing on exertion |
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respiratory ROS |
SOB cough sputum production frequent respiratory infections |
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GI ROS |
indigestion (dyspepsia) abdominal pain history of ulcers change in bowel movements |
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urinary ROS |
dysuria hematuria increase in frequency/urgency urinary infections |
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reproductive ROS |
discharge from genitals STIs high risk sexual behavior birth control methods |
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reproductive ROS - female specific |
heavy flow (menorrhagia) menopause breast masses or tenderness |
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Msk ROS |
muscle or joint pain arthritis swelling, redness, pain |
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psychiatric ROS |
nervous tension mood depression memory changes suicide thoughts |
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neurologic ROS |
changes in mood changes in memory headache, dizziness, blackouts tingling "pins and needles" |
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hematologic ROS |
anemia easy bruising or bleeding past transfusions |
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endocrine ROS |
thyroid trouble heat or cold intolerance excessive sweating excessive thirst or hunger |
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goals of HIPAA |
combat fraud and abuse make health insurance more affordable and accessible uniform standards protect medical records |
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what is the opening statement of the HPI? |
age, race, gender, state of health, chief concern, onset ex: Mrs. Smith is a 25 year old Caucasian woman who presents with sore throat that began 1 week ago. |
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list all info needed for meds |
name, strength, dose, route, frequency, why? |
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in difficult patients, what are examples of process problems? |
dementia, language barrier |
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what are examples of style impairments? |
reticent, rambling, vague pt |
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examples of topical problems? |
sexual history domestic violence drug use +ROS |
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what to do with demanding/dependent pts? |
be clear set limits and expectations set follow up appts emphasize pt responsibility |
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what to do with orderly, controlled pts? |
take orderly approach to interview, exam, and treatment
explain everything in detail summarize frequently admit when you don't know |
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what do do with dramatic pt? |
listen and observe
remain calm and firm understand your boundaries summarize to regain control stay focused |
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what to do with long suffering, masochistic pts?
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accept their pessimism
enlist their help |
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what to do with guarded, paranoid pts?
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remain friendly
clearly explain your strategy identify your role and its limitations openly acknowledge the pt's suspicious attitudes |
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how to handle superior pt? |
acknowledge pt POV do your job well don't argue |
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define somatization |
experiencing emotional discomfort or psychological distress in the language of physical symptoms |
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when to consider somatization? |
symptom description is vague or inconsistent symptoms persist despite adequate medical therapy illness began in psychologically meaningful setting pt has engaged in poly-doctoring hysteric personality style pt attributes idiosyncratic meaning to symptoms |
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list ex of syndrome of unknown etiology |
fibromyalgia chronic fatigue syndrome |
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diseases with subtle, multi system manifestations |
lupus MS polymyalgia rheumatica |
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5 barriers to telling bad news |
DCDKD |
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DCDKD stands for |
denying defeat
confusion destroying hope keeping distance disappearing |
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when you tell the patient bad news, their response can be (4) |
affective cognitive spiritual (why me?) visceral (numb, fight or flight) |
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6 step protocol to giving bad news |
SPIKES |
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SPIKES stands for |
set the stage assess patient's perception invitation for information give knowledge address emotion with empathy strategy and summary |
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describe how geriatric pt have multiple impairments |
50% have hearing loss vision problems physical deficits - problems with posture or mobility cognitive deficits |
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3 main causes of vision problems in elderly |
refractive error cataracts macular degeneration |
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name 6 IADLs |
manage money use phone shopping preparing food housekeeping taking meds |
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what is the mini-cog test |
3 word recall and clock draw test |
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a false positive on a memory test is from |
depression, anxiety |
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a false negative on a memory test is from |
high intelligence |
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when to start colonoscopies? |
q 10 years starting at age 50 |
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what is different in a ped interview? |
rely more on objective data |
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when can you begin to obtain some history from the child? |
preschool (3-5 years) |
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define anticipatory guidance |
specific topics that should be discussed with parents at age appropriate levels |
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after birth, when are well visits? |
newborn 2 weeks 1 mo, 2, 4, 6, 9, 12, 15, 18, 2-5 yearly |
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how do you obtain adolescent social hx? |
HEEEADSSS |
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HEEEADSSS stands for |
home education employment eating activities drugs sexuality suicide and depression safety |
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mnemonic for safety concerns? |
FISTS |
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FISTS stands for |
fighting injuries sex threats self-defense |
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what technique is used to approach challenging patient scenarios? |
BATHE |
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BATHE stands for |
Background situation patient's Affect most Troubling problem for pt how pt is Handling the problem Empathy |
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what mnemonic is used for angry patients? |
HEART |
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HEART stands for |
hear empathy apologize respond thank them for sharing |
