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175 Cards in this Set

  • Front
  • Back
What is considered by Dr. Desjardens to be the most important part of seeing a patient?
The history section
Medical and nursing diagnoses are independent, but interrelated. What is the medical diagnosis primarily concerned with?
The medical diagnosis is primarily concerned with the ETIOLOGY of a disease and with CURING
What is the nursing diagnosis primarily concerned with?
The nursing diagnosis is concerned with impact on the individual and family and with caring
Nurse Practitioners incorporate all of the concepts of health and therefore must collect data based on the use of which models?
1. holistic wellness model
(Can the person afford meds?)
(Will the patient believe in my treatment plan?)

2. biomedical model
Which 6 factors must you expand upon during the assessment?
1. Growth and development
("Is my patient hitting the necessary milestones?")
2. Emotional status
3. Cultural, religious, and socioeconomic background
4. Performance of ADLs
("Does shortness of breath occur during ADLs?")
5. Patterns of coping
6. Client/patient perception of and satisfaction with his or her health status
What is the preferred method of organizing clinical information?
the problem oriented approach
Which acronym describes the information that you want to compile in your problem-oriented record?
SOAP
S in SOAP?
S: Subjective

What the patient (or family) tells you
O in SOAP?
O: Objective

What you observe (physical exams & labs)
A in Assessment?
A: Assessment

What you think is going on
P in SOAP?
P: Plan

What you intend to do (5 steps)
Describe the SUBJECTIVE DATA that is taken during a patient visit.
What the person says about him or herself during the history taking
Are SYMPTOMS subjective or objective?
subjective
Describe the OBJECTIVE DATA that is taken during a patient visit.
What the healthcare provider observes by inspecting, percussing, palpating, and ascultating during the physical exam and lab studies
Are SIGNS subjective or objective?
objective
What percentage of diagnoses can be made based on history alone?
70%
What percentage of diagnoses can be made when reviewing both the history and the physical exam?
90%
Which tests confirm what is found during the H&P?
Lab tests
What is the foundation of clinical practice?
The skills necessary to perform the H&P.
What is KEY to a successful interview?
communication
The process of communication is comprised of which 2 types of factors?
1. Internal factors
2. External factors
What are 3 internal factors in the process of communication?
1. Liking others
2. Empathy
3. Ability to listen
What are 6 external factors in the process of communication?
1. Ensure privacy
2. Refuse interruptions (i.e. from staff)
3. Physical environment
4. Dress
5. Note taking (try to do as little as possible)
6. Not taping/video recording without permission
List 6 nonverbal communication skills.
1. physical appearance
2. posture
3. gestures
4. facial expression
5. eye contact
6. voice and touch
What are 2 possibilities as to why someone will not look you in the eye?
1. Some cultures do not make eye contact
2. A person be be keeping something from you
Describe 9 responses that you can give during the communication process.
1. Facilitation ("Can you give me more information?)
2. Silence (listen to patient)
3. Reflection (show that you understand by echoing back what the patient has told you)
4. Empathy
5. Clarification (ask patient to explain "sugar" or "smiling on me Jesus")
6. Confrontation (watch the patient's face as you palpate)
7. Interpretation (people have physical symptoms for emotional problems)
8. Explanation
9. Summary (of what they told you)
What are 10 traps of interviewing? DON'T DO THESE!
1. Providing false assurance
2. Giving unwanted advice (instead, give pros and cons)
3. Using authority
4. Using avoidance language
("Joe died" not "Joe passed away")
5. Engaging in distancing ("where's the lump in YOUR breast"--not the breast)
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions
What is the age of a geriatric patient in NYC?
Anyone over 50 year old
How many older adults are currently in the US?
27 million
How many older adults are expected in 2050?
86 million
What is the lift span at birth for men and women?
Women: 79

Men: 74
In addition to increasing the life span, what is the demographic goal for the older population?
To increase the “health span”
Frailty is a common myth. What percentage of Americans over 65 live in the community?
95%
What percentage of Americans over 65 live in long-term care facilities?
5%
When communicating with an older adult, what should the environment be like?
Well-lit, moderately warm setting with minimal background noise
When communicating with an older adult, how should you speak?
Face the patient and speak in low tones
When communicating with an older adult, what should you make sure that the patient is using?
Glasses, hearing devices, and dentures if needed
When communicating with an older adult, how should you adjust the pace and content of the interview?
Adjust the interview according to the stamina of the patient; consider 2 visits for the initial evaluation if needed
When communicating with an older adult, should you allow for open ended questions and reminiscing?
Yes
When communicating with an older adult, should you include family and caretakers?
Yes, when needed, especially if the patient has cognitive impairment
When communicating with an older adult, which symptoms may give you clues for underlying disorders?
Fatigue
Loss of appetite
Dizziness
Pain
When communicating with an older adult, what should your demeanor convey?
Respect
Patience
Cultural awareness
When interviewing a child, how many patients do you have? What should you do at the beginning?
2+; Always introduce yourself to the patient and the parents
When interviewing a child, how often should you explain what you are going to do?
EACH time you meet
When interviewing a child, how should you stand?
Stoop down to the level of the child
When interviewing a child, what should you let the child do?
Play with a toy, read a book, etc.
When interviewing a child, never __
Lie or promise something you can’t deliver!
What are the first 5 stages of development and their corresponding ages?
1. Newborn (birth)
2. Infancy (0-12 months)
3. Early childhood (1-4 years)
4. Middle childhood (5-10 years)
5. Adolescence (11-20 years)
-Early, Middle, Late
What are 4 different approaches to data collection?
1. Complete (Traditional H & P) Data Base
-comprehensive
2. Episodic Data Base
-more problem centered
3. Follow-Up Data Base
-more problem centered
4. Emergency Data Base
-ABCs
What should you do at the very beginning of the interview? (2)
1. Greet the patient by name and introduce yourself (formal title)
2. Ensure confidentiality
What are 3 elements that contribute to the WORKING PHASE of the interview?
1. Open-ended questions
“What brings you here today?”
2. Closed or direct questions
(if you want a one word answer; don’t ask lots of these questions together)
3. Responses
What are 9 components of the “Classic” history and physical?
1. Introductory information
2. CC (chief complain)
3. HPI
4. PMH (past medical history)
5. Current health history
6. Social, occupational, family history
7. Functional assessment
8. ROS (review of systems)
9. PE (physical exam)
What kinds of identifying data should you attempt to acquire during the health history?
1. Name
2. Age
3. Gender
4. Race/ethnicity
5. Place of birth
6. Marital status
7. Occupation
What is the chief complaint?
The CC represents the primary reason for the patient seeking medical attention
How should you document the CC?
-By convention, it is stated in the patient’s own words and written in quotation marks
-It may include a short statement about duration
Is the CC a diagnostic statement?
No
How should you document the HPI for a well person?
Write a short statement about the patient’s general state of health
How should you document the HPI for an ill person?
-Write a detailed CHRONOLOGICAL account of the person’s CC
-Include analysis of the symptom information (8 points of info)
What is the purpose of analyzing a symptom?
It gives you a CHRONOLOGICAL look at the problem
What are the 8 steps in analysis of a symptom?
1. Location of the problem (ask to point)
2. Character or quality (Is it dull? Stabbing? Aching? Get patient to elaborate)
3. Quantity or severity (Get an idea of what is more than normal for the patient)
4. Timing (Beginning, duration)
5. Setting (Where were they when the symptoms started)
6. Aggravating or relieving factors (What helps?)
7. Associated factors
8. Client’s perception of the symptoms
What is another way to remember the 8 steps to analyzing a symptom for the HPI?
PQRSTU
P in PQRSTU?
Provocative or palliative (What makes it better/worse?)
Q in PQRSTU?
Quality or Quantity
R in PQRSTU?
Region or radiation
S in PQRSTU?
Severity Scale
T in PQRSTU?
Timing
U in PQRSTU?
Understand the patient’s perception
What are 7 pieces of information that you should include in the PMH portion of your history?
1. General health
2. Childhood illnesses
3. Adult medical illnesses
4. Obstetric/Contraceptive history
5. Hospitalizations/Operations
6. Psychiatric history
7. Accidents or injuries
What is Gravida (G)?
# of pregnancies
What is Para (P)?
# of live births
What is Abortion (AB)?
# of planned and/or spontaneous abortions
Interpret the meaning of G1P2Ab0?
1 pregnancy, 2 live births, 0 abortion.:.twins
What are 10 pieces of information that you should include in the current health status portion of your history?
1. Current medications
2. Allergies (NKDA? NKA?)
3. Habits (Alcohol? Drugs?)
4. Screening tests
5. Immunizations
6. Sleep patterns (naps? Hours/night? Falling/staying asleep?)
7. Exercise/Leisure activities
8. Diet (ask about eating habits?)
9. Environmental hazards
10. Use of safety measures (seatbelts? Sunscreen? Guns locked? CPR knowledge? Helmets?)
What are 7 preventative measures that you should discuss?
1. Alcohol, drug and tobacco counseling
2. Cancer screening
3. Infectious disease prevention
4. Proper diet and exercise
5. Methods of stress reduction
6. Injury prevention
7. Environmental and occupation hazards
What are 10 pieces of information that you should include in the social history during the history portion of your exam?
1. Home situation
2. Marital status
3. Vocation
4. Relationships
5. Finances
6. Travel
7. Military
8. Typical day
9. Religious beliefs
10. Transportation issues
When recording the family history, what are your 2 options of documentation?
1. Write out
2. Do a genogram
*Ideally do 3 generations, even if patient is adopted
What are 2 types of information that you should include in the functional assessment portion of your history?
1. ADLs
2. IADLs (Instrumental ADLs)
Give examples of ADLs.
1. Transfer
2. Toileting
3. Continence
4. Bathing
5. Dressing
6. Feeding
Give examples of IADLs.
1. Using telephone
2. Traveling
3. Shopping
4. Preparing meal
5. Doing housework
6. Manage medications
7. Manage money
What information ends the complete history of your patient?
ROS (review of systems)
What does the ROS do?
The ROS summarizes in terms of body systems all of the symptoms that the patient reports

*By reviewing in an orderly manner, you can specifically check each system and possibly uncover additional illnesses not previously discussed.
What does HEENT stand for?
H: head
E: Ears
E: Eyes
N: Nose
T: Throat
What should you ask your patient at the end of the health history?
“Is there anything more that you want to discuss that wasn’t covered?”
What type of data is acquired during the health history?
Subjective
After completing the health history, what should you begin?
The physical exam, in which you would collect objective data (the signs)
What skill is key to master while giving a physical exam?
Being a good observer and applying your observations to patient care
What are 4 types of assessment techniques?
1. Inspection
2. Palpation
3. Percussion
4. Ascultation
*Do all of these in the same order, except an abdominal exam
Describe Inspection.
Concentrated and active looking that provides an enormous amount of information
Which assessment technique yields the most physical signs?
Inspection (even though it is least mechanical)
What is the purpose of palpation?
To confirm the points you noticed during inspection
What should you use your sense of touch to assess?
1. texture
2. moisture
3. temperature
4. organ location and size
5. masses
6. vibrations or pulsations
7. crepitus
8. thrills
9. presence of tenderness
What parts of the hands could you use during palpation?
1. tips of fingers
2. dorsa of hands
3. palmar aspect of mcp joint or ulnar surface
What are 2 types of pressure that you could apply during palpation?
1. Light
2. Deep
How should you apply pressure during palpation?
Feel with dominant hand, push with nondominant hand
Which type of pressure palpation should you do first?
Light—once you touch a painful part too deep, the exam is over
What is percussion?
Tapping skin with sharp, short strokes
How deep can you realistically percuss?
~5 cm deep
How many fingers should you use in direct percussion?
1
When should you use direct percussion?
1. child’s chest
2. sinuses
How many fingers should you use in indirect percussion?
Use 2 fingers in your dominant hand to tap on your non-dominant middle finger
When using indirect percussion, what should you listen for?
1. tymphany: tap of air-filled area
2. resonance: air-filled lung
3. hyperresonance: too much air
4. dullness: over liver/spleen
5. flatness: percuss over bump
What instrument do you use for auscultation?
stethoscope
What type of sounds should you use your stethoscope diaphragm for?
High pitched sounds
What type of sounds should you use your stethoscope bell for?
Low pitched sounds
What body parts should you ascultate?
Heart, blood vessels, lungs, abdomen
What should you do when attempting to ascultate a hairy chest?
Wet the hair, otherwise it gives you the sound of fluid in the lungs
What does NAD mean?
No acute distress
What does utd mean?
Up to date
What is a VIS?
Vaccine information sheet
List 6 vital signs.
1. Height/weight measurement (head circumference)
2. Temperature
3. Pulse
4. Respirations
5. BP
6. Pain assessment
How often should you measure height/weight for adults?
Annually
How often should you measure height/weight for children? Why is this important?
Every visit, unless it’s a sick visit.

Plot the child’s height and weight on a graph or “growth chart” and follow the curve; 1 single measurement of ht and wt is not as important as the trends of these measurements
How do you calculate the body mass index?
BMI=weight (kg)/height(m)2
When can you stop measuring a patient’s head circumference?
Age 2
Birth weights __ by 6 months.
Double
What should you do when attempting to ascultate a hairy chest?
Wet the hair, otherwise it gives you the sound of fluid in the lungs
What does NAD mean?
No acute distress
What does utd mean?
Up to date
What is a VIS?
Vaccine information sheet
List 6 vital signs.
1. Height/weight measurement (head circumference)
2. Temperature
3. Pulse
4. Respirations
5. BP
6. Pain assessment
How often should you measure height/weight for adults?
Annually
How often should you measure height/weight for children? Why is this important?
Every visit, unless it’s a sick visit.

Plot the child’s height and weight on a graph or “growth chart” and follow the curve; 1 single measurement of ht and wt is not as important as the trends of these measurements
How do you calculate the body mass index?
BMI=weight (kg)/height(m)2
When can you stop measuring a patient’s head circumference?
Age 2
Birth weights __ by 6 months.
Double
Birth weights __ by 1 year.
Triple
How and how often should you measure a patient’s length?
Measure the length while supine until the patient is 3 years old
At 2 years of age, what is the child’s head circumference?
2/3 the adult size
Which body organ serves as a thermostat mechanism?
Hypothalamus
Which factors influence temperature?
1. diurnal cycle
2. menstrual cycle
3. exercise
4. age
What are 5 different routes that you can measure temperature?
1. oral
2. electronic
3. axillary
4. rectal
5. tympanic membrane
What is the average oral temperature?
37C or 98.6F
How do rectal, axillary, and tympanic temperatures compare to oral temperature?
1. rectal: .5C (1 F)> oral
2. axillary: .5 (1 F)> oral
3. tympanic: .8C (1.4F)>oral
What is a temperature diurnal variation?
35.8 C - 37.3 C
(96.4 F - 99.1 F)
Because of variations in temperature among rectal, oral, axillary, and ear sites, what is it necessary to do?
1. Chart the route along with the recorded temperature
2. Consistently use one route if possible
What type of temperature should you take if your patient is under 2 months?
Rectal
What type of temperature should you take if your patient was over 2 months?
Tympanic
What is the stroke volume?
Volume of blood pumped/ beat ~70 mL (cc)
What 4 elements should you assess the pulse for?
1. Rate
2. Rhythm
3. Force (is it bounding?)
4. Elasticity
What is the normal HR for a newborn?
70-190 bpm
What HR is considered bradycardia?
Below 60 bpm
What HR is considered tachycardia?
Above 100 bpm
In a normal adult, how should you take the HR?
30 sec x 2
*1st 30 sec, count pulse; 2nd 30 sec count respirations
In an abnormal adult, how should you take the HR?
60 sec
In an infant/kid, how should you take the HR?
60 sec
*due to possible irregularities in rhythm
When should you measure the apical rate of the child for the greatest accuracy?
While the child is asleep
In addition to the child’s HR, what else should you record?
Child’s behavior
To assess the HR in patients up to 4 years old, where should you take the pulse?
Brachially
What is the normal respiration rate for infants?
30-40
What is the normal respiration rate for adults?
10-20
*in general, the pulse is 4 x the respirations
How long should you count a pediatric respiratory rate?
1 full minute, especially in newborns and infants since rapid breathing (tachypnea) may not be detectable otherwise
What type of breathers are newborns?
Diaphragmatic breathers
How should you count the respiratory rate for an older child?
The same way as an adult (30 sec x 2)
What are 7 influences on BP?
1. age
2. gender (not different until puberty; estrogen decreases the BP until menopause)
3. race (blacks 2x higher rate)
4. emotions
5. weight
6. stress
7. exercise (should be normal after 5 min)
Define BP.
The pressure of blood against the wall
What is the systolic pressure?
The maximum pressure felt during systole (ventricular contraction)
What is diastolic pressure?
Resting pressure during diastole
What factors influence BP?
1. CO
2. Vascular resistance
3. Volume
4. Viscosity
5. Elasticity of vessel walls
What are optimal conditions for taking BP?
-avoid smoking/drinking 30 min before measurement
-ensure room is quiet and comfortably warm
-patient seated quietly in the chair with feet on floor for at least 5 min
-arm should be free of clothing (thin)
-palpate the brachial artery
-position the arm so that the brachial artery is at heart level
-rest the arm on a table a little above the patient’s waist, or support the patient’s arm with yoru own at the mid-chest level
What is a BP characteristic often found in older adults?
SYSTOLIC hypertension with widened pulse pressure
What is a HR and rhythm characteristic often found in older adults?
Pacemaker cells decline and affect response to physiologic stress
What is a RR (respiratory rate) characteristic often found in older adults?
not affected
What significance does an older adult's change in temperature regulation have on his/hear health?
susceptible to hypothermia
What is an ascultatory gap?
A silent interval that may be present between the systolic and diastolic BPs (ie the sound disappears for a while, then reappears)
In which populations does the ascultatory gap usually occur?
-elderly
-hypertension patients
When should you take serial measurements of pulse and BP?
1. if you suspect volume depletion
2. if patient is hypertensive or taking hypertensive meds
3. if patient reports fainting
4. patients with Parkinson's
How do you take orthostatic BP?
1. rest supine 2-3 minutes
2. take baseline BP and pulse
3. repeat with sitting, standing
What is orthostatic hypotension?
Drop in systolic pressure of more than 20 mm Hg and or pulse increase of 20 bpm or more
What are 4 categories that you should generally survey during the exam?
1. Physical appearance
2. Body structure
3. Mobility
4. Behavior
What are 6 history questions to ask during a general survey?
1. weight loss?
2. weight gain?
3. fatigue?
4. chills?
5. night sweats?
6. overall general health?
What are 2 causes of weight gain? Give examples
1. nutrition (eating too much)
2. medical causes (congestive heart failure--may lose 1 lb/day)
What are 2 causes of weight loss? Give examples
1. medical (cancer)
2. psychosocial (anorexia)
What is the most common complaint?
Fatigue!
What are 3 potential causes for fatigue and weakness?
1. medical
2. psychiatric
3. psychosocial
What might fever, chills, and night sweats indicate?
1. TB
2. Hodgkin's Lymphoma
3. Infectious disease
4. inflammation
5. neoplasm