Term
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Definition
| Data the patient tells us. |
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Term
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Definition
| What I observe with my own eyes. |
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Term
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Definition
| The purpose of assessment is to make a clinical judgement or diagnosis about the health patient's health state or response to actual or potential risks. |
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Term
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Definition
The starting point of every approach to clinical reasoning.
Information must be complete.
Helps form a picture of the patient. |
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Term
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Definition
Based of scientific method
Inital cues
Formulating, gathering data, evaluating, and validating a hypothesis. |
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Term
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Definition
ADOPIE
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation |
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Term
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Definition
Nursing process based on level of experience.
Novice, Competency, Proficient, and Expert. |
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Term
| NANDA - North American Nursing Diagnosis Association |
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Definition
Actual Diagnosis
Risk Diagnoses
Wellness Diagnoses (Knowledge, Spiritual) |
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Term
| Four types of data to collect |
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Definition
Complete-Yearly Physical
Episodic-Acute care (Only what you came in for)
Follow-up=To see if interventions are working
Emergency Data Base=ER visits |
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Term
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Definition
Two way process
Requires practice
Foundation for caring relationship |
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Term
| What are the two types of communication? |
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Definition
Verbal
(Spoken and written word)
Non-verbal
(Appearance, Facial Expression, Personal Space, and Touch) |
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Term
| External and Internal Factors |
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Definition
Liking others, Empathy, Ability to listen
Keep PT dressed
Don't take notes while interviewing if you can help it. |
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Term
| Skills for Therapuetic Communication |
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Definition
Do verbal and non-verbal cues match up
Non-judgemental attitude
Sensitive to PT cues |
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Term
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Definition
Allows PT to tell their story
Use when possible |
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Term
| Closed or direct questions |
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Definition
| You will get a yes or no response. |
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Term
| What are the nine responses when assisting a PT to express their feelings? |
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Definition
Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary |
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Term
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Definition
Providing false assurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distance
Using leading or biased questions
Talking too much
Interrupting
Using "Why" questions |
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Term
| How to ensure mutual understanding |
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Definition
Go with the non-verbal cues, over what the patient is saying, and ask them about what your observing.
Summarize
Validate |
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Term
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Definition
Most children will be interviewed with their parents.
School-aged and above can answer their own questions. |
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Term
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Definition
Different language
Hearing impaired
Sensory Loss
Acutely ill
Angry
Depressed
Sexually agressive |
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Term
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Definition
Professional Interactions
Etiquette
Space and distance
Gender
Sexual Orientation |
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Term
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Definition
Deescalation is necessary
Avoid Touch
Calm voice
Active listening, DO NOT ARGUE
Silence
Set limits |
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Term
| How to handle depressed PT's? |
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Definition
Provide brief, simple intro
Be honest and empathetic
Open-ended questions
Spend time w/ PT
Comfort Measures |
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Term
| Communicating with the elderly? |
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Definition
Encourage to wear glasses and hearing aids.
Face unaffected side
Lighting
Low tone
Do Not rush
Spend time to listen |
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Term
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Definition
Communicate for a specific purpose
Direct and open-ended technique |
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Term
| Information to obtain to provide for a plan of care? |
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Definition
Health-related concerns
Perception of health status
Prior problems
Effect of health on role and family
Influence on occupation |
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Term
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Definition
Biographical Data
Source of history
Reason for seeking care
Present health/history of present illness
Past Health
Family History
Review of Systems
Activities of Daily Living (ADL's) |
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Term
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Definition
Name, Address and phone number, age and birth date, Birthplace, Sex, Marital status, Race, Ethnicity, Occupation
Make sure you know your ethnic origin. |
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Term
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Definition
Who furnishes the information.
Are they reliable?
Test reliability by asking questions again in a different form later
Willingness to answer.
Note any special circumstances. |
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Term
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Definition
| Statement in person's own words, describing the reason for their visit. Symptoms-Subjective sensation Signs that we detect |
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Term
| Present Health or History of present Illness |
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Definition
Location
When, How long?, Better or worse?, Where?, and Pain?
Patient's Perception |
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Term
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Definition
P - Provokes - What causes it?
Q - Quality - How does it feel?
R - Region - Where does it hurt?
S - Severity Scale (1-10)- How bad?
T - Time - When did it happen?
U - Understand PT's perception |
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Term
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Definition
Childhood illnesses
Accidents/Injuries
Hospitalizations
Immunizations
Last Exam
Do not write, NO KNOWN ALLERGIES, NKA or NKDA |
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Term
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Definition
Age and health or cause for relative
Health of close family members
Family history of various conditions
Family tree (Genogram) |
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Term
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Definition
Additional ?'s for new immigrants
Religion
Health perception
Nutrition |
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Term
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Definition
Subjective data
General Overview
Skin, Hair, Head, Eyes, Ears, Nose, Mouth and throat, Neck, Breast, Axilla, Rspiratory, Cardiovascular, GI, Urinary, Genitalia, Sexual Health, Endocrine, Neurological, and muscular. |
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Term
| Functional Assessment and ADL's |
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Definition
Self-esteem
Activity and exercise
Sleep and rest
Nutrition and elimination
Relationships
Spiritual
Coping
Habits
Alcohol
CAGE Test for alcoholism |
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Term
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Definition
How do you define health?
How do you view your situation?
What are your concerns? |
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Term
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Definition
Health History to include information for age and developmental stage
Person giving info is reliable. |
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Term
| How do you assess pain in a child? |
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Definition
| Severity of pain Does it stop them from playing? Relation to activities or eating? Parent's senses? Parent's coping ability |
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Term
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Definition
Prenatal Care?
Labor and Delivery or C-section?
Problems?
Childhood illnesses
Accidents or injuries |
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Term
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Definition
Milestones
Denver II=developmental milestones |
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Term
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Definition
Physchological review
Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety |
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Term
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Definition
Major focus on ADL's
Reason for seeking care
Longer assessment time
Leave more time available |
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Term
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Definition
Past five years
Accidents or injuries
Last examination
Obstetric status |
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Term
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Definition
Current medications
May not know name or purpose
May not remember them all |
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Term
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Definition
| A person's response to emotional and cognitive function |
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Term
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Definition
Organic disorder
Psychiatric mental illness |
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Term
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Definition
Inferred through individuals behaviors
Consciousness
Language
Mood and Affect
Orientation
Attention
Memory - Abstract reasoning and thought process |
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Term
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Definition
Person, Place, and Time
Write it as A/O x 3
4th event may be event or situation
If only oriented w/one A/O x 1 |
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Term
| When to perform a full mental examination? |
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Definition
Behavior changes
If family is concerned
Loss of ability to speak or write coherently or understand speech.
Aphasia (caused by brain damage) |
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Term
| Contributions from Health History |
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Definition
Things that can affect a PT's response to mental status exam.
Known illnesses or health problems
Baseline education |
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Term
| Main Components of Mental Status Exam |
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Definition
A - Appearance
B - Behavior
C - Cognition
T - Though Process |
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Term
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Definition
Posture
Body Movements
Dress (appropriate for weather)
Grooming and Hygiene |
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Term
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Definition
Levels of Consciousness (Five)
Facial Expressions
Speech
Mood and affect |
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Term
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Definition
Orientation
Attention Span
Memory (Recent and Remote)
Four unrelated word test
Ability to lay down new memory
Four words and test at 5-,10-,15- minute intervals |
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Term
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Definition
Processess (Logical, Coherent, and relevant)
Constantly aware of reality
Perceptions
Screen for Suicide (Plan, Time, Way of doing it=need intervention) |
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Term
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Definition
Fact Test
Name ten things in each category and given a point system.
Short term memory =1st to go |
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Term
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Definition
| For Alzheimers PT's. Three words plus draw a clock with all numbers and give them a specific time to put. |
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Term
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Definition
Alert - Awake
Lethargic - Not fully alert, drift off to sleep
Obtunded - Sleeps most of the time, not easily aroused
Stupor/Semicoma - Respond to pain, unconscious, doesn't arouse easy
Coma - No response to stimuli
Delirium - Transient, will go away |
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Term
| Abnormal Findings with Mood and Affect |
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Definition
Flat affect (no expressions)
Depression
Depersonalization
Elation (Happiness)
Euphoria
Anxiety |
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Term
| What is the most basic function that should be tested first in an assessment of mental status? |
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Definition
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Term
| What is not a significant contributor to the assessment of mental status? |
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Definition
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Term
General Survey and Vital Signs
Chapter 8 & 9 |
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Definition
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Term
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Definition
Starts the minute you lay eyes on your PT.
"Look for rather than look at." |
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Term
| What to look for with general survey? |
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Definition
Physical appearance
Age, Gender, LOC, Skin Color
Facial Features, Body structure, Stature, Nutrition, Symmetry
Mobility, Posture, GAIT and ROM
Behavior, Facial expressions, Mood and affect, Speech, Dress, Hygiene |
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Term
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Definition
Follow health history and symptoms
PDRSTU
Collects objective data
Adapts to the PT's particular need |
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Term
| Systematic Approach to assessment |
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Definition
Explain steps to PT
Position PT to facilitate exam |
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Term
| General procedure for assessment |
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Definition
Cephalocaudal
External to internal
Normal to abnormal
Side to Side
From PT's right hand side
Done on one side should be done on the other. |
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Term
| Essential skills of physical assessment |
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Definition
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Term
| Inspection and Observation |
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Definition
CREEP!!!
Focus eyes on the person
Use lighting appropriately
Remember scents and odors |
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Term
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Definition
Fingertips: Texture, Swelling, Pulsation, and lumps
Dorsum (Back of hand): Temperature
Ulnar Surface and finger: Vibration
Thumbs: Shape and consistency of organs
Bi-manual Technique: Breast exam |
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Term
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Definition
Vibrate tissue to determine density
Thorax and Abdomen
Stationary Hand
Striking hand |
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Term
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Definition
Resonant: Low pitched over hallow tissue
Tympanic: High pitched like a drum
Dull: High pitched over dense organs (Liver)
Flat: High pitched over airless tissue
(Tumors, Bones) |
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Term
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Definition
To listen
Always listen on the skin
Diaphragm: High pitched sounds (Hold firmly against skin)
Bell: Low pitched sounds (Hold just enough to seal skin)
Turn off tv and radio
Warm the room and stethoscope |
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Term
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Definition
Close doors
Pull Curtains
Private Room |
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Term
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Definition
Field: Identify clean vs. unclean areas
Standard Precautions |
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Term
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Definition
Standing: Musculoskeletal
Sitting: Respiratory
Semifowler's: Cardiac
Dorsal Recumbant: Abdomen
Prone and Sim's: Rectal |
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Term
| Techniques for Assessment |
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Definition
Children: Adjust for age, Safety, Parent holds
Preschool/School-aged: Independent and curious
Teen and Older: Privacy and independence
Older Adult: Pace assessment and accomadate for physical abilities |
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Term
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Definition
Height, Weight, BMI Calculation
Waist Circumference:
Males <40 inches
Females <35 inches |
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Term
| Influences on Temperature |
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Definition
Diurnal cycle (Fluctuations throughout the day)
Menstrual Cycle (Middle of Cycle means increased temp)
Exercise
Age (Lower Temp) |
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Term
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Definition
Tympanic: Least contagious and most reliable
Auxillary temp will be 1 degree lower than core temp |
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Term
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Definition
Under tongue, leaps sealed
20 seconds for electronic
Not taken within 30 minutes of hot or cold food
Sublingual pocket in back of mouth |
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Term
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Definition
Deep into auxillary fold
Restrain arm at shoulder
Add 1 degree to temp for core |
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Term
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Definition
Gently place in ear canal
Pull ear up and back
Kids: Down and back |
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Term
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Definition
Not for newborns and children
Lubricated thermometer inserted 2-3 cm directed toward umbilicus.
Lay on left side |
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Term
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Definition
Assess HR
Rhythm (Regular or irregular)
Force (Strength)
0+ Absent
1+ Weak
2+ Normal
3+ Bounding |
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Term
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Definition
Upper Extremities: Brachial, Ulnar, Radial
Lower Extremities: Femoral, Popliteal, Dorsal Pedis, Posterior Tibal |
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Term
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Definition
Radial: Count for 30 seconds
Apical on Newborn
Apical pulse always for one minute |
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Term
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Definition
Adult: 60-100
Child: 80-120
Newborn: 120-160
Rhythm: Regular or Arythmia
Force: 2+ Normal |
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Term
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Definition
One breath is inhalation plus exhalation.
Observe effort and use of accessory muscles.
Abdominal breathing
Normal Rate:
Adult 12-20
Child 12-22
Newborn 30-60
Tachypnea and Bradypnea
Hyperventilation and Hypoventilation |
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Term
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Definition
Measure pressure in the arteries
Systolic pressure during contraction
Diastolic Pressure during rest |
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Term
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Definition
Seated in chair, arm supported at heart
Five minutes of rest
Bladder 80% of arm
Always validate |
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Term
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Definition
Prehypertension: >130/80 Asymptomatico
Hypertension: >140/90
Orthostatic Hypotension: Fall in BP and increase in Pulse (Difference of 10-20 from different positions)
Associated with position change
Hypotension: <90/60 |
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Term
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Definition
5th vital sign
Somatic
Visceral
PQRSTU
Alternative tools for children |
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Term
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Definition
Whatever the PT states it is
No way to measure
Very Complex |
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Term
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Definition
Transduction
Transmission
Perception
Modulation |
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Term
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Definition
Abnormal processing of pain
Most difficult to assess and treat
Pain recedes when injury heals |
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Term
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Definition
Visceral - Originates from organs (Tumors)
Deep Somatic Pain: Muscles, Bones, Tendons, and Trauma
Cutaneous Pain: Skin Surface (Cuts, Scrapes, and Burns)
Referred Pain: Pain felt in one spot but it orginates in another location. |
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Term
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Definition
Acute Pain: Short term, self-limiting, dissapates after injury heals
Chronic Pain: > 6 months and persistent
Malignant (Cancer related)
Does not stop when injury heals |
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Term
| Questions to ask for Pain |
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Definition
PQRSTU
Where, What, When, How much, Better or worse, Meaning? |
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Term
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Definition
Initial pain assessment
Brief pain inventory
Short form questionaire
Pain Rating Scales |
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Term
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Definition
Joints - Size/Contour/Circumference
Muscles/Skin - Color/Swelling, Masses, Sensation
Abdomen - Countour, symmetry,size |
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Term
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Definition
Nonverbal Cues
Acute or Chronic
Grimacing
Agitation
Diaphoresis
Changes in vitals |
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Term
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Definition
| A complete health history and full physical examination. |
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Term
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Definition
| Rapid collection of the database, often compiled with lifesaving measures. |
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Term
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Definition
| Western/European tradition that views health as the absence of disease |
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Term
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Definition
| Used to evaluate the cause and etiology of the disease |
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Term
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Definition
| Used to evaluate the response of the person to actual or potential health problems. |
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Term
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Definition
| Using a PT's family member, friend, or child as interpreter. |
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Term
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Definition
| Demeaning language used by health professionals when speaking to an older adult. |
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Term
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Definition
| Viewing the world from the other person's point of view. |
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Term
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Definition
| Examiner's response that encourages the PT to say more |
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Term
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Definition
| Pondering a deeper meaning beyond the concrete |
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Term
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Definition
| An acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness. |
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Term
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Definition
| Gradual, progressive process causing decreased cognitive function. |
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Term
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Definition
| How loud or soft a sound is |
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Term
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Definition
| an infection acquired during hospitalization |
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Term
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Definition
| illuminates the internal eye structure, which allows Dr. to look through pupil. |
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Term
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Definition
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Term
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Definition
| the number of vibrations per second of a note. |
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Term
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Definition
A brief period when sound disappears during auscultation
Common with hypertension |
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Term
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Definition
| Amount of blood pumped out of heart with each heartbeat. |
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Term
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Definition
| Pain restarts or escalates before next scheduled dose |
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Term
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Definition
| Pain originating from the surface of the skin |
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Term
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Definition
| Occurs predictably after specific movements. |
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Term
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Definition
| Abnormal processing of pain message, burning, shooting, in nature |
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Term
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Definition
| Specialized nerve endings that detect painful sensations. |
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Term
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Definition
| Pain felt at a particular site but orginates at another location |
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Term
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Definition
| Originating from the muscle, bone, joints, tendons, or blood vessels. |
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Term
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Definition
| First phase of nociception where pain stimulates into an action potential. |
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Term
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Definition
| Second phase where pain impulse moves from spinal cord to brain. |
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Term
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Definition
| Third Phase where you realize the pain is there. |
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Term
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Definition
| Neurons in brain release neurotransmitters that block the pain impulse. |
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Term
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Definition
| Originates from interior organs such as gallbladder or stomach |
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