302 Exam 1 Blueprint Chapter 2-6

What happens during the pre-interaction phase of the interview?

Compiling existing data and preparing for the patient interview using existing medical records

What happens during the beginning phase of the interview?

Introduction and stating the purpose of the interview

What two question types are used in the working phase?

Close-ended (direct) questions and open-ended questions

What is a close-ended (direct) question used for?

To gather specific information

What is an open-ended question used for?

To gather broad answers in the patient's own words

What happens during the closing phase of the interview?

Summarizing and stating the two to three most important problems or patterns; reporting any legally required information

What is restatement?

A communication technique that relates to the content of the communication

What is reflection?

Summarizing the main themes of communication

What is elaboration (facilitation)?

Assisting the patient to more completely describe difficulties

What is silence (as a technique)?

Purposefully allowing the patient time to gather thoughts and provide accurate answers

What is focusing (as a technique)?

Redirecting the patient to the pertinent topic being discussed

What is clarification (as a technique)?

Asking questions to determine the patient's meaning when word choice or ideas are unclear

What is summarizing (as a technique)?

Reviewing and condensing information into the two or three most important findings

What is the primary data source in a health history?

The patient (subjective data)

What are secondary data sources?

Medical records and family members

What is an emergency health history used for?

Gathering information about the immediate problem

What is a focused health history used for?

Gathering information about the current situation, including onset and related past medical history

What is a comprehensive health history?

Gathering all medical information about the patient

What does CC stand for?

Chief Complaint

What is the Chief Complaint (CC)?

The reason the patient is seeking care, e.g. shortness of breath

What does HPI stand for?

History of Present Illness

What mnemonic is used to remember the components of HPI/symptom analysis?

OLD CARTS

What does the O in OLD CARTS stand for?

Onset - when it started

What does the L in OLD CARTS stand for?

Location - where it's happening

What does the D in OLD CARTS stand for?

Duration - constant or intermittent

What does the C in OLD CARTS stand for?

Character - description of the pain/problem

What does the first A in OLD CARTS stand for?

Aggravating factors - what makes it worse

What does the R in OLD CARTS stand for?

Relieving factors - what makes it better

What does the T in OLD CARTS stand for?

Timing - specific time of day or activity it occurs

What does the S in OLD CARTS stand for?

Severity - intensity of the problem

What does PMH stand for?

Past Medical History

What are components of Past Medical History (PMH)?

Illnesses, childhood illness, immunizations, surgical history, obstetric history, health screenings, current medications, allergies, family history

What does gravida mean in obstetric history?

Number of times a person has been pregnant

What does para mean in obstetric history?

Number of deliveries after 20 weeks

What should be recorded about allergies in the health history?

What the patient is allergic to and how they react

What does ROS stand for?

Review of Systems

What is included in the Review of Systems (ROS)?

General health state and a review of each body system to determine signs, symptoms, or illness

Is Review of Systems (ROS) data subjective or objective?

Subjective

What is the most important strategy for preventing infection transmission?

Hand hygiene

Which organization recommends hand hygiene implementation?

WHO (World Health Organization)

What are the 5 moments of hand hygiene?

Before touching a patient, before an aseptic procedure, after body fluid exposure, after touching a patient, after touching patient surroundings

What is inspection (assessment technique)?

Observing the patient for general appearance or specific details

Which assessment technique is used for every body part/system?

Inspection

What is an overall observation during inspection called?

General survey

What does inspection provide?

Objective physical data leading to accurate diagnosis and treatment

What characteristics are noted during inspection?

Physical characteristics/odors, behaviors, age, gender, level of alertness, body size/shape, skin color, edema, hygiene, posture, level of comfort/anxiety

What is palpation?

Clinical touching of specific body areas to assess characteristics using touch

What part of the hand is used for fine discrimination in palpation?

The finger pads

What part of the hand is used to assess the abdomen in palpation?

The palmar surface

What part of the hand is used to assess temperature in palpation?

The dorsal surface of the hand

What is light palpation appropriate for?

Assessing surface characteristics

What is moderate/deep palpation used for?

Assessing abdominal organ characteristics, using both hands and the palmar surface of the fingers

What is percussion?

A tapping technique with the hands used to determine the condition of solid or air-filled body areas

What is the purpose of percussion?

To produce sound or elicit tenderness in order to assess density

What is direct percussion?

Tapping fingers directly on the skin

What is indirect percussion?

Using the nondominant hand as a barrier and tapping strongly on it

What percussion tone is heard over bone?

Flat

What percussion tone is heard over the liver?

Dull

What percussion tone is heard over healthy lung tissue?

Resonant

What percussion tone is heard over the abdomen (gas bubble/stomach)?

Tympany

What is auscultation?

Using a stethoscope to assess the movement of air or fluid within specific body systems

What are the common foci of auscultation?

Lung sounds, heart sounds, bowel sounds

What descriptors are used in auscultation?

Intensity (soft/loud), pitch (high/low), location

What is the correct order of physical assessment?

Inspection, palpation, percussion, auscultation

What accommodation should be made for older adults who get cold easily?

Offer a blanket or drape

When should the most important assessments be performed on an older adult, and why?

At the beginning, because older adults may fatigue quickly

How can breathing be made easier for an older adult during assessment?

Slightly elevate the head of the bed or examination table

How should you enter the room for a pediatric assessment?

Slowly enter and introduce yourself to the child and family

When does assessment begin during a pediatric exam?

As soon as you enter the room

What is an important rule about touching a pediatric patient?

Always look before you touch

How should you position yourself relative to a child during assessment?

Get on eye level with the child when possible

What assessment approach should be used with children?

Approach the child developmentally, assessing verbal and non-verbal cues

What tools can help explain procedures to a child?

Dolls, puppets, or drawings

What should be done at the end of a pediatric assessment?

Save the most invasive or painful assessments/procedures for last

What are vital signs important indicators of?

The patient's physiological response to the environment

What five measurements are included in vital signs?

Temperature, pulse, respirations, blood pressure, oxygen saturation

What other measurements are taken as part of the general survey?

Height and weight (used to calculate BMI)

What does vital signs measurement reflect about a patient?

Health status, including cardiopulmonary and overall body function

Why might vital signs need to be assessed related to medications?

To evaluate the effect or need for patient medications (e.g., before giving a medication for elevated temperature)

What do vital signs provide that helps track a patient's condition over time?

Baseline measurements

What indicates an urgent situation during assessment?

Extreme anxiety, acute distress, pallor, cyanosis, mental status change

What should happen if urgent indicators are found during assessment?

Interventions begin while continuing the assessment

What might prompt a rapid response team to be called?

Acute change in mental status/agitation/restlessness, new-onset chest pain, labored breathing, tachypnea/bradypnea, tachycardia/bradycardia, hypotension/hypertension

What equipment is needed for vital signs/general survey?

Scale, height bar, stethoscope, thermometer, watch with second hand, sphygmomanometer, pulse oximeter, tape measure (for infants)

What is the expected oral temperature range?

96.8-100.4°F (average 98.6°F)

How do rectal temperatures compare to oral/tympanic temperatures?

Usually about 1 degree higher

How do axillary temperatures compare to oral/tympanic temperatures?

Usually about 1 degree lower

How do temporal temperatures compare to oral and axillary temperatures?

About 1 degree higher than oral and about 2 degrees higher than axillary

What are the thermometer types listed?

Electronic, disposable probes, tympanic, temporal, oral/axillary, rectal

How do you take an oral temperature?

Place the probe with cover under the tongue

Who is an oral temperature suitable for?

Patients 3-4 years and older, if cooperative

What can interfere with an accurate oral temperature reading?

Recent food or fluid intake

When should an oral temperature NOT be taken?

If the patient has trauma or recent surgery to the face or mouth

What is the expected pediatric oral temperature range?

97.9-99°F

How do you take an axillary temperature?

Place the probe with cover in the center of the clean, dry axilla, then lower the arm over it

What is the expected pediatric axillary temperature range?

97.9-99.5°F

Who is the axillary route appropriate for?

All ages; used in older children when an oral temperature can't be obtained

How do you take a rectal temperature in an adult?

Insert the lubricated rectal probe with cover into the anus 1-1.5 inches

What should you do if resistance is encountered during a rectal temperature?

Remove the probe immediately

When should rectal temperatures NOT be obtained?

In clients with diarrhea, on bleeding precautions (low platelets), or with rectal disorders/deformities