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73 Cards in this Set
- Front
- Back
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What is the Nurse Practioner Approach?
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NPs incorporate all the concepts of health and therefore must collect data based on the use of an holistic wellness model, as well as the biomedical model.What is the Problem Oriented Approach?
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What is the Problem Oriented Approach?
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the preferred method of organizing clinical info: SOAP
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What does SOAP stand for?
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S:Subjective (what the patient or family tells you)
O: Objective (What you observe, Physical Exam and Labs) A: Assessment (What you think is going on) P: Plan( What you intend to do, 5 steps) |
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What are Signs? What are Symptoms?
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Signs: Objective Data: What the healthcare provider observes by inspecting , percussing, palpating and ausculatating during the physical exam and lab studies.
Symptoms: Subjective Data: What the person says about him or herself during the history taking. |
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What percentage of the diagnosis can be made with a history? With the history plus physical exam?
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History alone: 70% plus physical 90%
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What are internal factors of communication?
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Liking others, empathy, ability to listen
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what are external factors of communication?
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Ensure privacy, refuse interruptions, physical environment, dress, note taking (do as little as possible), don't tape record or video
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What are the non verbal skills of communication?
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Physcial Appearance, Posture, gestures, facial expression, eye contact, voice and touch (don't touch a lot)
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List 9 responses of nursing communication
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Facilitation, Silence, Reflection, Empathy, Clarification, Confrontation, Interpretation, Explanation, summary
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What are the 10 TRAPS of interviewing?
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providing false assurance
giving unwanted advice using authority using avoidance language engaging in distancing using professional jargon using leading or biased questions talking too much interrupting using "why" questions. |
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what is the lifespan of men and women?
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men: 74 women: 79
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what percentage of seniors live in long-term care facilities?
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only 5%
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What should you remember when interviewing a child?
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Children are not small adults! You have 2 patients, always introduce yourself to both, explain the plan each time you meet, allow child to play with toy, read a book, never lie or promise something that you can't deliver.
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what are the stages of development?
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newborn (birth)
infancy (0 to 12 months) early childhood (1 to 4) Middle childhood (5 to 10) Adolescence (11 to 20) |
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What are the types of Data Collection?
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Complete (Traditional H & P) Data Base : comprehensive
Episodic: more problem centered Follow-up: more problem centered Emergency: ABC's |
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what is a complete Data Base - H & P
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combo of subj and obj info along with relevant diagnostic studies. Others will refer to your docs (including the history).
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What is important In an H & P?
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to be complete, accurate, and clear.
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List the 9 aspects of a Classic H & P
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Intro Info
Chief Complaint (CC) History of Present Illness (HPI) Past medical history (PMH) Current Health History Social Occupational Family History Functional Assessment Review of Systems (ROS) Physical Exam (PE) |
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Define Chief Complaint
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Primary reason for the patient seeking medical attention, usually stated in the patient's own words. Not a diagnostic statement
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What is the history of present illness
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For the sick person it will be a detailed, chronological account of their CC
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List the analysis of symptoms
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Location
Character or quality quantity or severity timing setting aggravating or relieving factors associated factor clien't perception of the symptoms |
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What does PQRSTU stand for?
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they are critical charactersitics of symptoms.
P: Provocative or Palliative Q: Quality or Quantity R: Region or Radiation S: Severity Scale T: Timing U: Understand patient's perception |
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What is included in the past medical history?
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General Health
Childhood diseases Adult medical illness OB/Contraceptive history Hospitalizations/Operations Psychiatric History Accidents or Injuries |
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what are the 10 aspects of Social History?
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Home situations, marital status, vocation, relationships, finances, travel, military, Typical Day, Religious Beliefs, Transportaion issues
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What are the 10 factors included in the current Health Status?
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Current Meds, Allergies, Habits, Screening Tests, Immunizations, Sleep Patterns, Exercise/Liesure Activities, Diet, Environment hazards, Use of Safety measures
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List the 7 preventative Measures to discuss
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Alcohol, drug and tobacco counseling, cancer screening, infectious disease prevention, methods of stress reduction, injury prevention, environmental and occupational hazards
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List the 6 activities of daily life
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transfer
toileting continence bathing, dressing feeding |
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List the 7 instruments of activities of daily life
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using telephone, traveling, shopping, preparing meal, doing housework, manage medications, manage money
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What are the 2 forms of documentation for a family history?
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Genogram and write out the whole history
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What are the assessment techniques of a physical exam?
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Inspection, palpation, percussion, auscultation
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Describe inspection
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concentrated and active looking. *Least mechanical but yields the most phsycial signs.
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What is the purpose of palpation?
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to confirm points you noticed during inspection
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What does palpation assess?
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texture
moisture temp organ location and size masses vibrations or pulsations crepitus thrills presence of tenderness |
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what are the 2 types of palpation?
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light or deep
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what area of the hands are used for palpation?
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tips of fingers, dorsa of hands, palmar aspect of mcp joints or ulnar surface
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why percuss?
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to locate organs and determine size
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what are the 2 types of percussion?
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1: Direct: 1 finger for sinuses or childs chest.
2: Indirect: hyperextend middle finger of non dom hand and tap with dom middle finger |
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what sounds can be heard during percussion?
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timpany-air in abdomen
resonance-hair filled lung hyperresonance-emphysema dullness-over dense organ (liver or spleen) flatness- over a bone |
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what is the diaphragm of a stethescope?
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large side used for high pitched noises
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what is the bell of a stethescope?
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small side use for low pitched sounds
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List the Vital Sign
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Height/weight/head circumference in babies
temperature pulse respirations blood pressure |
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When should height and weight be taken?
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Anually for adults, every visit for children (plot on a growth chart)
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what is the equation for BMI?
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weight (kg)/height (m)
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what age should you continue to measure head circumference?
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2
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what influences temperature?
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diurnal cycle, menstral cycle, excersize, age
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Route of temp measurement
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oral, electronic, axillary, rectal, tympanic membrance
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what should you do when trying to auscultate a harry chest?
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wet it. Dry hair will give a sound of fluid in the lungs.
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how does rectal, tympanic and axillary temp measurements differ from oral?
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Rectal and tympanic are slightly higher than oral, axillary is slightly lower.
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how old should you continue to use rectal temp measuring
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2 months
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define stroke volume
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the amount of blood that is pumped through the heart in one beat 70ml
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define Pulse
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force that flairs arteries and in certain places in the body the flair can be palpated
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What is a normal range for HR
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adults (60-100)
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define bradycardia
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when HR is below 60bpm
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define tachycarida
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when HR is over 100bpm
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what is the normal HR for newborns
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70-190bpm
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List the grading scale for HR force
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2+ is normal, 1+ is weak, 3+ is bounding
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what is meant by the elasticity of the pulse?
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refers to the quality of the arterys, are they springy.
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where and how long should you take a pediatric pulse
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Brachially in children under 4. Count for 1 full minute
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how does an infance RR differ from and adult?
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Infants are higher than adults
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what is the normal RR for adults and infants?
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Infants: 30-40 Adults: 10-20
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what kind of breathers are infants?
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diaphragmatic breathers
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define systolic BP
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max pressure during systole: contraction of the ventricle
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define diastolic pressure
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recoil, resting pressure in vessels.
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describe the factors that influence BP
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Age, Race, Weight, Excerise, Gender, Emotions, Stress
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what are some physiological factors that can effect BP
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Peripheral vascular resistance and elasticity, Volume and viscosity of circulating blood, cardiac output
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what is the normal range for adult BP
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120/80
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do newborns have a higher or lower BP than adults?
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much lower: 65-85/45-55
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describe the auscultatory gap
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a silent interval that may be present between systolic and diastolic pressures: the sound disappears and then reappears.
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describe orthostatic blood pressure
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take BP readings laying, sitting and standing. See if a drop in systolic of more than 20 mmHg and or pulse increases of 20 bpm or more.
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why would you conduct an orthostatic bp test?
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if you suspect volume depletion, hypertensive or taking hypertensive meds, or pt reports fainting.
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list the general survey questions
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weight loss, weight gain, fatigue, chills, night sweats, overall general health
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list some optimal conditions for taking BP
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no caffeine for 30 mins before, calm environment, seated comfortably, arm is free of clothes (but thin shirt ok)
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What are some general survey observations?
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physical appearance, body structure, mobility and behavior
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