HA- Test 1

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155 Terms
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Therapeutic communication
professional communication with clients/patients; building a trusting patient-nurse relationship
moments of silence from the nurse to allow the patient to continue talking and explaining
repeating what the patient said in order to get more specific information; “I feel alone” ... “you feel alone?” ... “yes, I feel alone since my wife died”
using phrases such as “please continue” and “go on” to encourage a patient to continue their explanation
ensures that the nurse and the patient are on the same track and that the collected information is accurate and complete
Non-therapeutic communication
words, phrases, actions, and tones that make a patient feel uncomfortable, increase their stress, and worsen their mental and physical wellbeing
“Ten traps” of interviewing
false assurance, unwanted advice, using authority, avoidance language, distancing, professional jargon, leading or biased questions, talking too much, interrupting, using “why” questions
Verbal communication
the words spoken and the tone used in a conversation, includes written words as well
Non-verbal communication
body language, facial expressions, gestures, eye contact, etc
ability to understand the personal experience of the patient without bonding with them; keeps a professional relationship while also calming the patients anxiety about their situation
not good because it focuses on the nurses’ feelings rather than the patients’
Physical environment
sit equal to the patients’ level so that they do not feel intimidated when being interviewed, provide the patient with adequate privacy, minimize distractions
while interviewing, keep note-taking to a minimum in order to offer full, focused attention
Purpose of health assessment
gain an understanding of the patients’ beliefs, concerns, and perception of their health state
Can compile subjective and objective data
physical appearance, posture, ability to carry on a conversation, and demeanor
Phases of an interview
introduction, working phase, and conclusion
keep it short and formal; introduce yourself, position, and the purpose of the interview
Working phase
used to collect data, verbal skills are assessed, physical health is noted
a set of beliefs, attitudes, and practices shared by a group of people or community that is followed, accepted, and passed down to other members of the group
a broad term to describe one’s existence and a belief in transcendence
an organized system of beliefs as a shared experience
Sexual orientation
a person’s physical and emotional interest in others (LGBTQIA+)
Gender identity
a person’s inner sensibility that they are a man, a woman, neither, etc
Gender expression
outward demonstration of gender in relation to societal norms; dress, hairstyle, mannerisms, etc
older adults need to be addressed respectfully, may take longer to interview because they have a “longer” story to tell, and may use therapeutic tough to provide empathy
can affect the interview because communication may not be fully received
a communication disorder due to brain damage; sudden on-set often from stroke or head injury; impairs expression and language understanding
Broca’s Aphasia
expressive and can become easily frustrated when forming simple words/sentences; damage to area responsible for speech production
Wernicke’s Aphasia
receptive; do not understand when you speak to them; damage to the part of the brain that controls language and ability and can be very frustrating
Cultural humility
recognizing there is diversity within every culture and within every person
assuming a person has attributes, traits, beliefs, and values of a cultural group because they are apart of said group
belief that one’s culture (race, ethnicity, or country) is better than others
unfair and different treatment of another person/group; denying another group opportunities and rights to participate fully in society
unfavorable prejudgement or preconceived idea about a person or group of people
attitude, opinion or inclination (can be positive or negative) towards a group of people; can be a conscious attitude (explicit) or an unconscious attitude (implicit)
Birth to 12 months
12 to 36 months
3 to 6 years
7 to 12 years
Beginning to puberty
Health Insurance Portability and Accountability Act
standardized communication
brief description of pertinent patient variables, demographics, clinical diagnosis, and location
pertinent history as it directly relates to patient’s current health status
pertinent assessment findings obtained with interpretation of data
what you need or want for the patient in terms of medical treatment and/or assistance
how to prioritize care/interventions
is the airway open; is the patient choking
respiratory rate; oxygen saturation
pulse rate and rhythm, skin color, pain, paresthesia
level of consciousness; alert and oriented?
safety, hygiene, cause of injury
Recognize Cues
identify findings that may be abnormal; document them and report to the doctor/charge nurse
Analyze Cues
relate the abnormal findings to pathophysiology; make sense of the data
Prioritize Hypothesis
what is the problem; what is causing the problem; what is the most important problem to solve
Generate Solutions
what solutions/nursing interventions/tasks/medical/management/patient education can be established
Take Action
identify what needs to be done to help the patient
Evaluate Outcomes
did the patient’s condition improve? Worsen? Unchanged?
Effective/Indicated Care
actions that are adequate to produce the intended result and help the patient
Ineffective Care
actions that are not adequate to produce the intended result; do not help the patient
Unrelated/Non-Essential Interventions
actions that will not help the patient (not better nor worse)
Contraindicated Interventions
actions that can cause more harm to the patient
First-level of Priority Care
problems/issues that reflect critical findings, clinical deterioration and/or are life-threatening; require URGENT action
Second-level of Priority Care
problems/issues that may lead to clinical deterioration and may become life-threatening without intervention; require prompt (quick) action
Third-level of Priority Care
problems/issues that are focused on functional health, client education, and counseling; should be addressed but not urgent; is not acute in nature but required to support ADLs, knowledge level, and mental health; what may be a priority to the nurse is not always a priority to the patient
Listen to your patient
this is a collection of subjective data
are what the patient describes/explains is wrong
Look (inspection), Feel (palpation and percussion), Listen (auscultate)
identifies the objective data that can potentially explain the patient’s symptoms
are what can be measured (vital signs, physical exam, etc)
Confirm/Validate data
use laboratory data (blood results) or other diagnostic tools (x-ray, MRI, etc)
use an Electronic Health Record (EHR)
rapid, life-threatening (choking, drowning, cardiac arrest)
new patient, past and present history, life-style, obtain baseline VS
existing information, specific health concern, does not cover non-related areas
annual exams, mini-assessment of previous finding, improvement of previous problem
Reason for Seeking Care
the chief complaint of the patient, why they are there (nausea/vomiting, loss of appetite, insomnia, gout, swollen ankle, etc); use the PQRSTU
what were you doing when the pain started? What makes it better/worse? What triggers it? What relieves it? What aggravates it?
what does it feel like? Sharp? Dull? Stabbing? Burning? Crushing? Throbbing? Shooting? Stretching?
where is the pain located? Does the pain radiate/where to? Does the pain travel? Did it begin somewhere else?
on a scale of 0-10, what is the pain? Are certain activities limited due to the pain? How bad is it at its worst? Does the pain come in waves? Do you have to stop, sit down, lie down?
when did it start? How long does it last? How often does it occur? What were you doing when it first occurred? Does it wake you up at night? Seasonal? While eating/after eating? Specific time of the day?
do you understand why the pain occurs? Do you understand what causes it? Do you understand how to help the pain go away?
greet patient by documented name, eye contact, smile, acknowledge any guests
Introduce yourself
state name, role, and reason for visiting the patient's room
estimate the time it will take to complete all tasks with the patient
Hand Hygiene
always clean hands by washing with soap and water or with alcohol-based spray/gel
Functional health
the patient’s physical and mental capacity to participate in ADLS; provides the nurse with a holistic view of a patient’s human response to illness and life conditions
daily basic tasks that are fundamental to everyday function; walking, brushing teeth, feeding self, etc
Instrumental ADLs
more complex tasks that allow patients to function independently; managing finances, paying bills, purchasing/preparing meals, taking medications, facilitating transportation, etc
Initial screening
can show anxiety disorder or depression
Behavioral changes
memory loss, inappropriate social interactions
Brain lesions
trauma, tumor, stroke, cerebrovascular accident
impairment of language ability; secondary to brain damage
person is awake, alert, aware of stimuli from environment and within self; responds appropriately and quickly to stimuli
Facial expressions
appropriate and changes with topic; comfortable eye contact unless not used due to culture
quality, sounds are effortless, appropriate conversation
body language and facial expressions; mood appropriate to place and condition; person should be willing to cooperate
erect and position relaxed
Body Movements
voluntary, deliberate, coordinated, smooth and even
appropriate to setting, season, age, gender, and group
Attention Span
ability to concentrate; completes thoughts without wandering; can be impaired by people who are anxious, fatigued, or intoxicated
Recent Memory
interview question for within the past 24 hours; what one had for lunch, when they arrived at the facility; ask questions that you will know the answer to in order to match any discrepancies
Remote Memory
verifiable past events; past health, past jobs, birthday, anniversary
Immediate Recall
highly sensitive and valid memory test; pick four words and ask the patient to remember them, ask for the patient to recall the words at 5, 10, and 30 minutes - patients younger than 60 should be able to recall the four words with ease
Thought Processes
person should think logically, goal directed, coherent, and relevant; thoughts should be complete
compare and evaluate alternatives and reach an appropriate course of action
Abstract Reasoning
use a situation in which the patient would have to apply or interpret a statement; problem solving and interpretation of analogies; applied verbally and graphically
looks stated age
development for gender/age
alert and oriented
Skin color
even tone and pigmentation
Facial features
symmetric with movement
Overall appearance
presence or absence of distress
standing, sitting, slumped, etc
coordinated and balanced
Facial Expressions
eye contact, appropriate to situation
appropriate to environment; Varies based on age and disabilities
Dress and hygiene
appropriate for environment, body odors, style,
Mood and affect
comfortable and cooperative with examiner
facial expressions, eye contact, what they do and what they say
outward display of one’s emotional state
ability to form words; clear and understandable; appropriate word choice to situation and culture; clear ideas
Family dynamics
hierarchy, roles, values, behaviors
physical, emotional, mental, verbal, sexual, economic, financial
Diurnal cycle
lowest in the morning and highest in late afternoon
increased body temperature
Stress and anxiety
increased temp due to stimulation of sympathetic nervous system and increase of epi and norepi
Menstrual cycle
causes variations due to fluctuations in hormones
Pulse Adolescent and Adult
Resp. Adolescent and Adult
BP Adult
low bp; caused by dehydration, bleeding, cardiac conditions, side effects of medications
high bp
Orthostatic Hypotension
drop in bp when moving from lying/seated position to standing; decrease in bp by at least 20mmHg systolic or 10mmHg diastolic within three minutes of standing; Can feel faint, dizzy, and lightheaded
hypotension, tachycardia, restlessness and apprehension, skin is cold, moist, pal, cyanotic, decrease in o2 sat
Nociceptive pain
develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
Neuropathic pain
implies an abnormal processing of pain message that is difficult to assess and treat; perceived long after site of injury heals
originates from larger interior organs
Deep Somatic
blood vessels, joints, tendons, muscles, and bone; Aching, throbbing, localized
skin surface and subcutaneous tissues; Superficial with a sharp, burning sensation
felt at particular site but originates from another location
short-term and self-limiting
diagnosed when pain continues for six months or longer
spike in pain levels with moderate to severe intensity in an otherwise controlled pain syndrome
postoperative pain; examines physiological and behavioral changes on 3 point scale
nonverbal tool used to infants and children up to age 3
5 behaviors of pain
facial expressions, leg movements, activity levels, cry, and consolability