NSG 316 Exam 1 Guide. Questions and answers, Graded A+. Document Content and Description Below

NSG 316 Exam 1 Guide. Questions and answers, Graded A+. Document Content and Description Below NSG 316 Exam 1 Guide. Questions and answers, Graded A+. When does the general survey begin? - The moment you first encounter the person What does the general survey focus on/ c onsider? - physical appearance, body structure, mobility, behavior PBMB is PBMB subjective or objective? why? - Objective, because you are observing them and they are not verbally telling you. What do you look for in physical appearance? - age- appears to be stated age sex- appropriate developmental stage for age LOC- alert/ orients & responds to Questions Skin color- appropriate for genetic background facial features- symmetric no signs of acute distress What do you look for in Body Structure? - -stature- height in normal rage for age and heritage -nutrition- even body weight distribution -symmetry- body is bilateral -posture- stands comfortably and appropriate for age -position- sits comfortable in chair -body build/ contour: arms span equals height -Obvious deformities- congenital or squired defects What to look for in Mobility? - - gait -foot placement- agitate, smooth walking, well balanced -no involuntary movements What to look for in behavior? - -facial expression- and sign of pain / distress, expressions are appropriate tot he situation -mood & affect- comfortable and cooperative with examiner -speech- even tased, clear, articulate, communicates in the same language as the interviewee's - dress- appropriate for climate, clean -perosnal hygiene- well groomed and clean What is subjective data? - Data that only the subject or "patient" can feel and will tell you. during taking of history IS subjective data signs or symptoms? - symptoms What is objective data? - What you observe and can measure when inspecting, percussing, palpating, and ausculating during the physical Is objective data the signs or symptoms? - signs What is a data base? - subjective + objective + patient records + lab studies What is the Complete total health database - complete health history + full physical exam current + past health state for a base line What is the Episodic or problem centered database - "mini" database one body system/ one probable/ one cue complex hx and exam followed after for short term/ limited problems What is a follow-up database? - "after the fact" status of the problem being evaluated at a regular or appropriate time is problem getting better or worse id coping strategies What is Emergency database? - Fast collection of data usually only for lifesaving measures rapid and comprehensive - what did you take? How long ago? Who much? Nursing process - assessment, diagnosis, outcome identification, planning, implementation, evaluation Assessment: - review of record, interview, health hx, physical exam, functional exam, cultural/ spiritual exam, consultation, review of literature Diagnosis - interpreting data, comparing clusters of cue to make inference, validation on inference, identify related factors, document the diagnisis Outcome identification? - identifying the expected out acmes of the patent (individualized) ensuring realistic and measurable outcomes/goals short term and long term goal criteria Planning - establish goal based on patient care goal identify relevant intervention document the plan of care Implementation - determine patient readiness in health care process review intervention in a collaborative effort use delegation, mindfulness, supervision, and evaluation counsel person refer for contenting care document the care that was provided Evaluation - evaluate individuals condition and compare with expected outcoems summarize identify reasons for failure to achieve outcomes document evaluation in plan of care What is first level priority? - Emergent, life threatening, and immediate what is second level priority? - Next in urgency, requiring attention so as to avoid further deterioration What is third level priority? - Important to patient's health but can be addressed after more urgent problems are addressed evidence-based practice - clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences Why do you use age specific patient chats? - - focus on major risk factors for that age group based on lifestyle, health needs, and problems - positive approach to health aassessment What does HIPPA stand for and what did it implement? - HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT implemented patient confidentiality in written, verbal, or electronic communication What type of informaition is protected under HIPPA? - - any information that can be linked back tit he patient name, geographic, DOB, addmission, discharge, phone #'s. email, social, medical history, ID #, DL #, any age over 89, full face photo, Health plan beneficiary number Cultural sensitivity goals - caregiver possesses basic knowledge and understanding culturally appropriate goals - caregiver applies knowledge to improve health outcomes culturally competent goals - caregiver apply a universal concept of understanding to all ocntextual aspects of care cultural care goals - provision of health care across cultural boundaries in consideration of context What is health? - balance of a persons complex, interrelated phenomenon In ones being: physical, mental, spiritual outside world: natural, communal, metaphysical What is illness? - the loss of the person's balance, both within one's being and in the outside world Title 6 of the Civil Rights Act of 1964 - services can't be denied to people with limited English proficiency What is culture: - thoughts, communications, actions, beliefs, values, ans institutions of racial, ethnic, or social groups Characteristics of a culture - learned from birth shared by all members, adapted to specific conditions dynamic and chainging Ethnicity is grouped by? - -common geographical orgin -migratory status -religion -race -language -shared values, traditions, or symbols -food preferences What is religion? - belief in Devine or supernatural powers and and can be obeyed worshiped and beliefs that they are ruler and creator of universie involves practiec What is spirituality? - A "journey" that takes place over time and involves the accumulation of life experiences and understanding An attempt to find meaning, value, and purpose in life What is socialization - ebbing raised within a culture and having characteristics of that group Acculturation - process of adapting to and acquiring another culture assimilation - process of developing a new cultural identity and becoming members of domain culture biculturalism - dual pattern of identification and often of divided loyalty Biomedical causation theories - assume direct cause and effect body is a machine and can be divided into parts germ theory Maturalistic causation theories - forces of nature keep in balance ex. yin and yang, hot and cold Magicoreligious - Supernatural powers predominate in area of health and illness Examples include voodoo, witchcraft, and faith healing Healing and culture - seeking help from folk or religious healer and carried out in the body, mind and spirit Herritage consistency - degree to which a persons lifestyle reflects his or her traditional heritage Heritage consistent continumum - traditional: living within norms of traditional culture modern: acculturated to norms of dominant society Indicators of heritage conssitancy - extended family support of traditional activites family home within ethnic community to which they belong knowledge of language and culture orgin prince in herritage fequent cysts to old country/ neighborhood cultural competence steps? - - understand ones own values, beliefs, attitudes, and practices -identify meaning of health to patient -understand how health care system works -acquire knowledge about social backgrounds of patients -become familiar with language, interpretative services, community resources available to nurses and patients Successful interview characteristics? - -complete data bout person (health state, description and chronology of symptoms_ -rapport and trust -teach about health state -continue therapeutic realtionship -teach health promotion Elements of the interview process: - nonverbal skills, physical appearance, posture, gesture, facial expression, eye contact, voice, touch, closing interview Communication sending: - body language: verbal and nonverbal communication receiving: - words. gestures interpreted as interviewer seems fit what are open ended questions? - begins the interview with new topic or new question section what are close ended questions - They require a Yes or a No. These questions are intended to get the most relevant information in the shortest time possible moves the interview faster to know specific information about a health problem (past or present) Empathy - the ability to understand and share the feelings of another What is included in the health history? - - biographical data, -source of history -reason for seeking care -present health or present illness -past health -family history -review of systmes -functional assessment of daily livings Biographical data: - name, adress, phone #, age, DOB, birthplace, sex, marital status, race, wthinci organ, occupation Source: - usually the individual but can be a relative or friend wha qualifies someone as a reliable persons: - give the same answers when questions are rephrased or repeated letter int he interview Present Health or History of Present Illness - Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient's perception HPI for PAIN - PQRSTU p- provocative or pallpative Q- Quality or quantity R- Regior or radiation S- ona scale of 1-10 T- timing or onset U- understand the patient perception of the problem Past medical history: - Childhood Illnesses (big ones), Accidents or Injuries, Serious or Chronic Illnesses, Hospitalizations, Operations, Obstetric History, Immunizations, Last examination date, Allergies and reaction, Current Medications (prescribed, OTC, Herbal Review of systems: - HEAD TO TOE Family hostory - age. health, cause of death in realties, health of close family members, various conditions (Heart disease, high BP...) Functional assessment - ADL - activities of daily living IADL- instrumental activities of daily living AADLS- advanced activities of daily living self esteem sleep/ rest activities personal/ occupational habits perception of health - definition of health, view of situation now, concerns, and health goals what is the CAGE test - to test about alcohol consumption What does CAGE stand for? - C- Cut down A- annoyed by criticism G0 Guilty about drinking E- Eye opener Enviormental assessments of functional assessment - physical environment (