health promotion and pt assessment outcomes

primary prevention

preventing diseases before occurrence (ie. immunizations, nutrition education)

secondary prevention

early detection and screening for health promblems and prompting treatment to prevent firther complications (ie. BP checks, mammograms, scoliosis, screening)

Tertiary Prevention

managing established disease to prevent further complications and promoting health to the highest level (DM care)

what does adipie stand for

assess, diagnose, identify outcomes, plan care, implement care, evaluate outcomes

what is an assessment

collecting info abt a pt's health status

subjective data

information the pt or guests of the pt tell you about their history

objective data

lab values, and other information that you yourself gathered

what are the two components of an assessment

health history (interview)

physical (hands-on) assessment

what are the 3 types of assessment

emergency and urgent, comprehensive, focused

what is a comprehensive exam

includes complete health history and physical assessment, and includes all body systems and areas (typically head-to-toe format)

- ie. school admission, first-time admit at a facility, sports physicals, annual exam

what is a focused exam?

specific to patient concerns and symptoms at the time of assessment

what is an emergency and urgent assessment

involves a life-threatening or unstable situation

determines level of urgency using ABCDE assessment

what does ABCDE stand for and during which assessment is it used

used during emergency and urgent assessment

Airway (with cervical spine protection if an injury is suspected)

Breathing: rate and depth, use of accessory muscles

Circulation: pulse rate and rhythm, skin color

Disability: level of consciousness, pupils, movement

Exposure

what is a functional assessment

A functional assessment focuses on functional patterns that all humans share. Nurses often use the functional patterns to collect subjective data.

what are some of the functional patterns measured in a functional assessment

health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

what is a head to toe assessment

Most organized system for gathering comprehensive physical data.

what is the body systems approach for health assessment

logical tool for organizing data that promotes critical thinking and allows you to analyze. basically clustering similar data gathered in head to toe and gunctional assessments, and reogranizing it in a way that allows you to draw conclusions.

what are some examples of demographic data

data on age, marital status, ssn, income, race, address, occupation and education

define therapeutic communication

purposeful communication used to develop a relationship with patients by exhibiting caring and empathy. this is important because building a relationship makes pt more likely to disclose info to u.

what are social determinants in health history

assessing environment, occupation, support systems, safety, accessibility to resources, and other things that can play a factor into a person's wellbeing

what is the AIDET method and when is it used

acknowledge, introduce self, duration, explanation, and thank you.

used to explain to pt what is about to happen before you do something. this includes before interviews

what are components of health history (6)

demographic data, reason for seeking care, past health history, allergies, family history, and health patterns

examples of health patterns

sleep, exercise, nutrition, and stress management

difference btwn primary and secondary health history sources

primary: the pt themself

secondary: family members or other guests providing info on behalf of the guest

DETERMINE WHETHER SOURCE IS RELIABLE OR NOT BY SEEING IF THEIR INFO IS CONSISTENT WITH EXISTING HEALTH RECORDS

what are the 4 basic physical assessment techniques, and what order should they be performed in

inspection, palpation, percussion, auscultation

what area is the only exception for four basic physical assessment technique order, and what order is it performed in instead

abdominal assessment; inspection, auscultation, palpation, and percussion

what is inspection (phys. assessment technique)

observation and concentrated watching of the pt including general appearance and performed on every body part. seek out cues for things that need immediate attention including odor, sounds (wheezing), aoppearance. can also have specific inspection data related to each body system

what is palpation (phys. assessment technique)

using touch to assess texture, temperature, firmness, and moisture

name and explain the 3 types of palpation technique and when they might be used

1. light: place finger pads of dominant hand on pt's skin, slowly move fingers in circular areas at a depth of 1cm

- always begin with this technique

- appropriate for surface characteristics such as texture, lesions, lumps, inflamed area of skin

2. moderate: same circular motion as light palpation, but using palmar surface of fingers (full fingers instead of fingertips) and use enough pressure to depress approximately 1-2cm

- used to assess size, shape, and consistency of abdominal organs

3. bimanual deep palpation: place the extended fingers of the nondominant hand over the dominant hand to use pressure of both hands, and use circulat motion to palpate 2-4 cm

- do not do this over areas that are at risk of being injured like enlarged spleen or inflamed appendix

how deep should each of the 3 palpation methods go

light: abt 1cm

moderate: 1-2cm

bimanual deep: 2-4cm

what is percussion (phys. assessment technique)

tapping motions to produce sounds that indicate solid or air-filled spaces over the lungs and other areas, or elicit tenderness

name and explain the 2 types of percussion

direct: tapping directly on the surface

indirect: tapping finger on another finger

what are the four different percussion tones in the body

resonant (and hyperresonant), tympanic, dull, flat

intensity, pitch, duration, quality, and location of hyperresonant percussion sound?

very loud, low, long, booming, emphysematous lungs

intensity, pitch, duration, quality, and location of resonant percussion sound?

loud, low, long, hollow, healthy lungs

intensity, pitch, duration, quality, and location of tympanic percussion sound?

loud, high, moderate, drumlike, gastric bubble (stomach)

intensity, pitch, duration, quality, and location of dull percussion sound?

moderate, high, moderate, thud, liver

intensity, pitch, duration, quality, and location of flat percussion sound?

soft, high, short, dull, bone

what is auscultation (phys. assessment technique)

listening to sounds produced by the body with stethoscope. movements of air or fluid from organs and tissues are heard over lungs, heart, and abdomen

what are some things assessed through auscultation

bp, lungs, heart ,and abdomen

what is measured during nutritonal assessments? (3)

weight/bmi, and waist-to-hip ratio, and interview

what are the value ranges for normal bmi

18.5-24.9

what are the bmi value ranges for underweight

<18.5

what are the bmi value ranges for overweight

25.0-29.9

what are the bmi value ranges for class 1 obesity

30.0-34.9

what are the bmi value ranges for class 2 obesity

35.0-39.9

what are the bmi value ranges for extreme obesity

40.0+

waist to hip ratio use, and values in males/females

used to assess body fat distribution as a health indicator

in males: >/= 1.0

in females: >0.8

things to think about during a nutritional assessment interview

- weight gain/loss intentionality

- change in fluid colume (can indicate issues with kidneys/heart, nutritional status)

- metabolic issues (hypothyroidism, type 2 diabetes)

- cardiac status (cardiovascular disease, hypertension)

what does OPQRSTU stand for in pain assessment

Onset: when the pain started, what was happening when pain started

Provocation/Palliation: what makes the pain worse (provocation) and better (palliation), including positions, movements, medications, or activities

Quality: how pain feels (sharp, dull, burning, throbbing, etc)

Region/Radiation: location, and whether it spreads to other areas

Severity: intensity of pain (1-10)

Timing: pain constant or intermittent, has it changed over time

Understanding: pt's understanding of what is causing the pain

what are the 2 different types of pain scales used

numeric pain intensity scale: 1-10)

wong-baker FACES scale (used for kids)