261 Exam 1

primary prevention

health promotion strategies (annual exams)

Secondary prevention

early screenings, detection, treatment of diseases and prevent future disability

tertiary prevention

restoration of health after illness or disease (rehab)

assessment

collect and analyze data about the whole patient

disgnosis

analyzing potential or actual health problems using subjective and objective data

planning/outcome

working with the patient as a copartner to meet short/long term goals

implementation

interventions of the patient or nurse actions with the plan of care

evaluation

ongoing process of seeing if the short or long term goals have been met or not

clinical reasoning

uses patients history, physical signs, symptoms, laboratory data and diagnostic imaging to get a diagnosis and treatment plan

clinical judgement

interpretation or understanding a patient’s needs, concerns or heath problems. Taking action or not to take action

intuitive thinking

inner sense about a clinical situation

inspectin

looking

percussion

tapping different areas

palpation

using your hands to feel

auscultation

listening

patient protection and affordable care act

provides higher quality, safer, more affordable and accessible care with health insurance increasing accessibility to health care

empathy and compassion

deep awareness and insight into the feelings, emotions and behavior of another person

unconditional regard

respecting and accepting a patient with unbias care

genuineness

being honest with the patient

respect

each patient is important and of value

caring

connotes responsiveness between the nurse and the patient

verbal communication

spoken language

nonverbal language

body language, gestures, facial expressions, body positions, tone of voice, eye contact

active listening

pay close attention and express willingness to listen

active observing

concentrate what you hear and see during the interview

broad opening questions e

allowing more information to be told

confrontation

give honest and respectful feedback about what you see or hear that is inconsistent

exploring

encourage the patient to give you more details

facilitation

use simple verbal statements or words to encourage more information

focusing

asking specific questions to collect and clarify data

reflecting

repeat the patient’s words specifically for elaboration

transitional statements

to redirect the interview

silence

gives the patient time to think about their feelings

aphasiac patients

patient with an impairment of language or inability to communicate through speech or writing due to brain dysfunction

cognitively impaired patients

difficulty thinking with loss of short or long term memory

introductory phase

introduce yourself, explain your role and purpose, estimate time frame and ask about comfort level

working phase

collect data, patient history, nonverbal ques, identify goals and problems and ask if there is questions

summarization phase

clarify and summarize patient’s self report, restate finding and confirm goals

comprehensive health history

whole patient (all body systems) and full history

focused/problem-based health history

focuses specifically on acute problem or symptoms

follow up history

after patient is seen and new data since last history

primary source

the pat

secondary source

family members, significant others or medical records

O (OLDCARTS)

onset

L (OLDCARTS)

location

D (OLDCARTS)

duration

C (OLDCARTS)

characteristics

A (OLDCARTS)

aggravating or alleviating factors

R (OLDCARTS)

related symptoms

T (OLDCARTS)

treatment

S (OLDCARTS)

severity

biographical data

name, address, DOB, religion and language

Medications

prescriptions, vitamins, supplements, OTC drugs, blood transfusions, immunizations

past medical history

childhood illnesses, adult illness, accidents, chronic illnesses, hospitalizations, surgeries and mental/emotional illnesses

Genogram

pictural diagram of family medical hist

acute

short term

chronic

long term

HYPER

above normal or high

HYPO

below normal or low

TACHY

fast

BRADY

slow

subjective data

information verbally given by the patient

ausculate

listening for sounds

palpation

using your hand to feel for surface characteristics

supine position

patient lies on their back with their face up

contraindication

a condition or symptom that makes treatment or a procedure unsafe or inadvisable

knee to chest

patient kneels and rest their chest on the surface and bring their hips up

lateral recumbent

lying horizontally on the patient’s side

objective data

measurable, observable, and verifiable information of a patient

dorsal recumbent

patient lies on their back and knees bent and feet flexed on the table

lithotomy position

patient lies on their back with their hips and knees flexed, and their legs elevated by stirrups or padded leg holders

prone position

patient lies on their chest and their face down

mini mental state exam

short assessment that test areas of cognitive function such as orientation, registration, attention and calculation, recall and language

normal pulse rate

60-100

normal oxygen

95-100

normal blood pressure

120/80

normal temperature

99.7 - 99.5

normal respirations

12-20

dietary recall

Patient recalls what they ate within a certain time frame and factors influencing their nutritional intake

normal BMI

18.5 - 24.9

underweight BMI

<18.5

Obese BMI

>25-29.9

Oral temp contraindication

Patient cannot keep mouth closed, breathes through their mouth, has decreased mentation or unable to follow directions

tympanic membrane temperature contraindications

Patient has ear pain, ear drainage, large amount of wax in ear

axillary temperature contraindictions

axillary skin problems, excessive sweating, inability to move arm

rectal temperature contraindications

Patient with rectal surgery, disease of rectum, low white blood cell count, blood clotting disorders, cardiac disease, diarrhea, hemorrhoids

Levels of LOC

person, place, time and situation

orthostatic hypotension

abnormal fall in blood pressure within three minutes of standing upright

psychogenic pain

mental and emotional pain that simulates pain mechanisms in the brain

radiating pain

starts in one area and spreads to another part of the body