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153 Cards in this Set
- Front
- Back
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Name the objectives of Healthy People 2020
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Physical Activity, Nutrition, Tobacco Use, Alcohol and Substance Abuse, Sexual and Reproductive Health, Mental Health, Injury and Violence Prevention, Occupational Safety and Health, Enviromental Health, Oral Health, Emerging Issues, Preventive Services
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Define Health
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A state of complete Physical, Mental, and Social well being
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A systemic method of collecting data about a client for the purpose of determining the clients health, predicting risks, and identifying health-promoting activities
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Health Assessment
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This enables a nurse to clarify points, and obtain missing info while still watching for verbal and nonverbal cues.
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Focused Interview
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Information that the client experiences and communicates to the nurse. Includes perceptions of nausea, dizziness, or itching sensations
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Subjective data
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A legal document used to plan care or to communicate information between and among health care providers
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Client Record
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What does SOAP stand for
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S-Subjective data
O-Objective data A-Assessment P-Planning |
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What does APIE
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A-Assessment
P-Problem I-Intervention E-Evaluation |
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Refers to the exchange of information, feelings, or ideas
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Communication
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Considering more than just the physiological health of a patient and incorporating all aspects of the patient
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Holism
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A hands on Examination of the client that includes a general survey and examination of body systems
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Physical Assessment
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Data that can be measured by the professional nurse. This data can be known as overt data or signs
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Objective Data
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What are the different forms of Documentation
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1. Narrative Notes
2.Problem Oriented Charting 3.Flow Sheets 4.Focus Documentation 5.Charting by Exception 6.Computer Documentation |
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How does The Developmental Level of patient affect the approach to care?
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Different levels of intellectual ability decide how well a patient can give the appropriate information. This varies with age. In children parents are the primary information source.
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What is the Nursing Process
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The Nursing Process is a systematic, rational, and dynamic approach used to plan and provide care for a client
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What are the stages of the Nursing Process
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1.Assessment
2.Diagnosis 3.Planning 4.Implementation 5.Evaluation |
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True or False.
The Nursing Process is a ongoing and every evolving process of care for a client. |
True.
Refer to page 12 in D'Amico to see figure |
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1st step of the nursing process where data is collected and organized. The data is both subjective and objective. This step begins the second a patient comes into contact with a client
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Assessment
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After data is collected, using knowledge both scientific and belonging to other disciplines a nurse formulates a judgement based on clustered and like information
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Diagonsis
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Priorities are set and client goals are stated. Interventions and strategies are dealt in order to provide the best health status for the patient
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Planning
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Implementation?
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Step 4 of the Nursing Process where the plan designed in step 3 is put into action and a ongoing assessment continues to observe the client
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What is Evaluation
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The nurse compares the present client status to what achievement of the stated goals or outcomes. If necessary steps can be taken to re initiate the process if goals are not met.
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Teaching used to explain a question or a procedure. Can be used to reduce anxiety.
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Informal Teaching
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These responses are designed to a need of a individual, group, or community
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Formal Teaching
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A state of life that personally satisfying and balanced
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Wellness
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What are the 3 Levels of prevention
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Primary
Secondary Tertiary |
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What is Primary Prevention?
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Health promoting strategies that imply a high level of health should already exist
EX:Health education or immunizations |
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What is Secondary Prevention?
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secondary prevention emphasises on resolving health issues and preventing serious consequences.
Ex: Health Screenings, Treatment of illness, and examinations across the lifespan |
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What is Tertiary Prevention?
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Aimed at restoring the individual to the highest level of health
Ex: Rehabilitation services |
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Behavior that is motivated by the desire to increase well-being and actualize human potential
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Health Promotion
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Being mentally, emotionally, socially, and spiritually well
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Psychosocial Health
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What are the Internal Factors of psychosocial health
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Genetics, Physical Health, and Physical Fitness
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What are Genetics?
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Genes that are passed down through parents to offspring. They affect can possibly affect the likelihood of a person inheriting a certain condition
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What are the external factors of psychosocial health
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Family, Culture, Geography, and Economic status
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How do external factors effect psychosocial health?
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These factors influence the morals and values a person has growing up and can for better or worse greatly affect a persons psychosocial well being
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What is Self-Concept
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The beliefs and feelings one holds about oneself.
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An individuals capacity to identify and fulfill the social expectations related to the variety of roles assumed in a lifetime
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Role Development
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Relations in which the individual establishes bonds with others based on trust. They show mutual reliance and support among individuals
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Interdependent Relationships
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What are the physical signs of Stress?
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Increased HR
Decreased Blood Clot Time Increased RR and Depth Dilated Pupils Elevated glucose levels Dilated Blood Vessels Elevated BP Increased BV |
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What is H.O.P.E
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H-What helps during hard times
O-Organized Religion P-Personal Spirituality E-Effects on Care |
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Skill of observing the client in a deliberate and systematic manner. Begins when nurse meets the client
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Inspection
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Skill of assessing the client through the sense of touch to determine specific characteristics
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Palpation
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Vibratory tremors felt through the chest wall. Can be vocal, when client speaks, or during coughing. Best perceived using the base of the fingers.
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Fremitus
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Temperature is best felt on this part of the hand
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Dorsal surface also known as the back of the hand
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What are the 3 forms of palpation
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Light
Moderate Deep |
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What is Light Palpation
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Use of finger pads of dominant hand. Used to assess skin texture, pulse, or tender inflamed areas near skin surface. Depth of only 1cm is reached in the formation of circles
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What is Moderate Palpation
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Used to assess structures. Moderate pressure using palmar surface of fingers on dominant hand downward 1 to 2 cm rotating in circular motion
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What is Deep Palpation
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Used to palpate organs deep in cavity. Uses palmar surface of dominant hand while pushing down on dominant hands dorsal surface with palmar surface of non dominant hand to a level of 2 to 4cm
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The striking or tapping of body producing a wave of sound
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Precussion
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What are the different forms of percussion
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Direct
Blunt Indirect |
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What is Direct Percussion
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Tapping of the body with finger tips of dominant hand. Used to examine the thorax of infants and the sinuses of an adult.
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What is Blunt percussion
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The placing of the palm of non dominant hand flat against the body and striking non dominant dorsal surface with dominant hand in a closed fist.
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What is Indirect Percussion
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The most used form. The hyper extended middle finger of non dominant hand is placed over the area examined. Using dominant index finger to strike the top of the middle finger to cause a sound to be produced
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What do the sounds made by percussion sound like
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1.Typany- Loud/High pitched
2.Resonance- Loud/Low pitched 3.Hyperresonance- Loud/low long duration 4.Dullness-High pitched/short 5.Flatness- High/soft/very short |
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Where are the sounds normally heard when percussing
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1.Tympany-Found over air filled organ
2. Resonance-Normal over lungs 3.Hyperresonance- Air trapped in lungs 4.Dullness- Heard over solid organs 5. Flatness- Solid tissue such as muscle or bone. |
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The skill of listening to the sounds of body. Done using a stethoscope
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Auscultation
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What is the normal Equipment used by a nurse and for what?
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1.Stethoscope-Auscultation
2.Doppler-Auscultation when stethoscope is not enough 3.Opthalmoscope- Inspection of Inner eye 4.Otoscope- Used to inspect external ear |
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Information that hint to the possibility of a health problems
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Cues
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What are the major components of the General Survey
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Physical Appearance, Mental Status, and Mobility
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What are considered Vital Signs
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Temperature
Pulse Respiratory Blood Pressure Pain |
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What is normal Temperature
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98.6 F or 37 C
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What factors influence body temperature and how?
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1.Age- Infants are higher. Core temp stabilizes with age
2.Diurnal Variations- Temp highest at 8 pm and lowest between 4-6AM 3.Exercise 4.Hormones 5.Stress 6.Illness |
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What are the routes for measuring temperature and where are they taken
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1.Oral- Sublingual Pocket
2.Tympanic-Exernal ear canal 3.Rectal-anus towards umbilicus and 1cm in infants and 1.5 cm otherwise 4.Axillary-Central Axila 5. Temporal-Scan across forehead ending at temple |
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What are the different pulse points
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1.Temple
2.Carotid 3.Brachial 4.Radial 5.Femoral 6.Popiteal 7.Posterior Tibial 8.Dorsalis Pedis |
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What factors effect pulse
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1.Age-Infants and children higher till 16.
2.Gender- Males are slower 3.Exercise-Increase 4.Stress-Increases 5.Fever-Increases 6.Blood loss- Increases 7.Meds- Increase or Decrease 8.Position Changes-Decrease |
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The pressure of the blood as the ventricle contracts
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Systolic Pressure
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Pressure between ventricle contractions when heart is at rest
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Diastolic Pressure
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The saturation of oxygen on hemoglobin the body.
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Oxygen saturation
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This history includes a collection of data that tells the intensity, quality, pattern, and precipitating factors
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Pain History
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Observation and gathering of data while the client is performing common place or routine activities
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Functional Assessment
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What are some factors that influence pain
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1.Age
2.Gender 3.Culture 4.Previous Experiences |
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What is the name for the pain receptors
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Nociceptors
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What is Transduction in the pain process
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Stimuli trigger release of biochemical mediators. Ions cross cell membranes. Medications work to block the release of these mediators
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What is Transmission in the pain process
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Impulses from stimuli travel to the peripheral never fibers in the spine. The impulse travels up the spinothalamatic tract to the brain and thalamus. The signal then goes from the thalamus to the SSC where pain is processed
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What is Perception in the pain process
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Patient becomes conscious of the pain.
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What is Modulation in the Pain Process
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Brain sends a signal back down to the dorsal horn of the spinal cord. The fibers release various substances that reduce pain.
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Acute pain
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Pain that lasts less than 6 months and usually last only as long as the healing process takes
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Chronic Pain
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Pain that lasts longer than 6 months and interferes with daily functioning.
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Cutaneous pain
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Pain that originates from within the subcutaneous tissue
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Deep Somatic Pain
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Pain that arises from ligaments, bones, blood vessels, and nerves
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Visceral Pain
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Pain that results from the stimulation of pain reception in the abdominal cavity, cranium, and thorax. Appears as aching or feeling of pressure
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Radiating Pain
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Pain perceived as the source of pain that extends to nearby tissues.
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Referred Pain
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Pain felt in a part of the body that is considerably removed from the tissues causing the pain
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Intractable Pain
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Pain that is highly resistible to relief. Pain that from advanced malignancy normally
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Neuropathic pain
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Results from current or past damage to the peripheral or central nervous system. Does not need a stimulus for the pain to start.
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The amount of pain stimulation the person requires to feel pain
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Pain threshold
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An excessive sensitivity to pain
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Hyperalgesia
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Pain Sensation
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Considered to be the same as pain threshold
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The ANS and the behavioral responses to pain
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Pain Reaction
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Pain Tolerance
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Maximum amount and duration of pain that an individual is willing to endure.
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What is included in a Pain Assessment
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1.Onset
2.Duration 3.Characteristics 4.Aggravating Factors 5.Relief 6.Treatment 7.Impact of pain on life 8.Coping 9.Emotional Response |
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An exchange of information between individuals
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Communication
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The process of formulating a message for transmission to another person
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Encoding
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Actions that are used during the encoding/decoding process to obtain and disseminate information, develop relationships, and promoting understanding
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Interactional Skills
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Listening
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Paying undivided attention to what the client says and does.
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Attending
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Giving full attention to verbal and nonverbal message.
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Paraphrasing
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Clarification, through the restating of basic messages
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Used to encourage open communication. Most effective when starting an interaction or when trying to get the client to discuss specific health concerns
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Leading
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A very direct way of speaking with clients to obtain subjective data for decision making and planning care
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Questioning
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Repeating the clients verbal or nonverbal message for the clients benefit
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Reflecting
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The process of gathering the ideas, feelings, and themes that the client has discussed throughout the interview and restating through several general statements
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Summarizing
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What are the Barriers to Effective Client Interaction
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1.False Reassurance
2.Interrupting or changing the subject 3.Passing Judgement 4.Cross Examination 5.Technical Terms 6.Sensitive Issues |
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what are the factors of the influence of culture on nurse-client interactions
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1.Diversity
2.Body Language 3.Language Differences |
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Positive Regard
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The ability to appreciate and respect another persons worth and dignity with a non judgmental attitude
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Empathy
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The capacity to respond to another s feelings and experiences as if they were your own
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Genuineness
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The ability to present oneself honestly and spontaneously. Down to earth and real.
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Concreteness
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Speaking to the client in specific terms rather than vague generalities
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The best source of information for the health history assessment interview
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Primary Source
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Secondary Source
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A person or record that provides additional information about a client
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What are the phases of a Health Assessment Interview
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1.Perinteraction
2.The Initial Interview 3.The Focused Interview |
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What happens in the Preinteraction phase of a Health Assessment
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A nurse collects data from the medical record, previous health patterns, screening, and other information gained from professionals
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What happens in the initial interview phase of a Health Assessment
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This is planned meeting in which the nurse gathers information form the client directly. Data is gathered on every facet of the clients life.
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What happens in the Focused Interview phase of Health Assessment
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The focused interview is used to clarify previously obtained information and to update current information. It is also done to hone in on a specific health issues.
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What is OLD CART
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O-Onset
L-Location D-Duration C-Characteristics A-Aggravating Factors R-Relieving Factors T-Treatment |
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What is ICE
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I-Impact on ADL's
C-Coping Strategies E-Emotional Response |
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What are the components of a Health History
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1.Biographical Data
2.Present Health or Illness 3.Past History 4.Family History 5.Psychosocial History 6.Review of Body Systems |
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What does Biographical Data contain
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Name, Adress, Age, DOB, Birthplace, Gender, Marital Status, Race, Ethnic Identity, Religion, Occupation, Health Insurance, Source of Information, Reliability
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What does Present Health and Illness contain
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Reason for care
Health beliefs and practices Health Patterns Medications, prescriptions,and OCD |
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What does Past History contain
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Medical, surgical, hospitalization, outpatient care, childhood illnessess, immunizations, mental and emotional health, allergies, substance abuse
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What does Family History contain
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Immediate family
Extended family Genogram |
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What does Psychosocial History contain
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Occupational history
Education Finances Roles and relationships Family Social structure Self-concept |
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What does Body Systems contain
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Skin, Hair, Nails
Head, Neck, Lymph Eyes Ears, Nose, Mouth, Throat Respiratory, Breasts, Axillary Cardiovascular Peripheral Vascular Abdomen Urinary Male/Female Repo Neuro Muscloskeletal |
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What are the 3 phases of decision making
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1.Identify the problem
2.Determine the alternatives 3.Select the most appropriate alternative |
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What are the 11 Functional Health Patterns
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Health Perception, Activity, Metabolism, Elimination, Sleep, Cognition, Self-Concept, Role-Relationships, Coping, Sexual Activity, Values/Beleifs
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What is the Clinical health Model
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Health Model that interprets health as the absence of disease or injury, therefore a person is sick if they have any illness no matter how small
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What is the Host-Agent-Environment Model
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A model that helps identifying the cause of a illness and depends on the interaction between the host, agent, and the environment these exist in
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What is the Health Belief Model
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This model show that a relation exists between a person beliefs and their actions. If a person believes they are sick they will be and vice versa.
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What is the High-Level Wellness Model
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This model recognizes health as an ongoing process towards a persons highest potential of functioning
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What is the Holistic Health Model
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This model acknowledges the interaction between mind, body, and spirit.
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First knowing then caring for oneself
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Self-Awareness
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What does it mean to make informed choices
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This means being an active participant in ones life and actively benefiting ones self-concept
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What is disease?
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A state of disharmony of the mind, body, and spirit.
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A product of the disharmonious interaction among mind, body, emotions, and spirit
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Illness
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The balance of the body
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Homeostatsis
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Normal Body Temps for Infant, Children, Adults, and Elderly
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Infant-99.4-99.7
Children-98.0-98.6 Adult-97-99 Elderly-95-99 |
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Normal Pulse for Infant, Children, Adults, and Elderly
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Infant-80-160
Children75-100 Adult-60-100 Elderly-60-100 |
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Normal RR for Infant, Children, Adults, and Elderly
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Infant-30-60
Children-18-30 Adults-12-20 Elderly-12-20 |
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Normal BP for Infant, Children, Adults, and Elderly
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Infant-74-100/50-70
Children-84-120/54-80 Adult-90-120/60-80 Elderly-90-120/60-80 |
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The difference between the apical pulse and the peripheral pulses
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Pulse Deficit
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The amount of air that moves in and out of the lungs every breath
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Tidal Volume
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A pulse rate above 100
A pulse rate below 60 |
Tachycardia
Bradycardia |
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RR above 20
RR below 12 |
Tachypnea
Bradypnea |
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The absence of respirations
A normal respiratory rhythm and depth Difficulty breathing |
Apnea
Eupnea Dyspnea |
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The mathematical differences between the Systolic and Diastolic pressures
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Pulse Pressure
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An exaggerated decrease in systolic blood pressure with inspiration
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paradoxical blood pressure
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Sound made when blood flow returns which can be heard with a stethoscope during the measurement of blood pressure
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Korotkoff sounds
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The absence of kortokoff sounds between phases 1 and 2.
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Auscultatory Gap
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A condition which blood pressure is chronically elevated above the normal measurements
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Hypertension which is above 140/90
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Prehypertension
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A blood pressure that is between 120/80 and 139/89 mm HG
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A blood pressure that is below 100/60
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Hypotension
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Inadequate reflex compensation upon position change that cause a imbalance in cerebral perfusion
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Orthostatic Hypotension
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Lifespan considerations for vitals for Newborn/Infants and Toddlers and preschoolers
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Newborn/Infants- RR, BP, and pulse fluctuate rapidly due to immature mechanisms
Toddlers/Preschoolers-Vitals begin to stabilize. Monitoring becomes more of a concern that stabilizing |
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Life Span Considerations for vitals in School-Age/Adolescent and Adult/Older Adults
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School-Age/Adolescent-High variability in vitals as RR,BP, and pulse decrease.
Adult/Older Adult- Stable Vitals, disease prevention becomes more of worry than maintaining proper vitals. |
