NUR2180 Module 3 Quiz Focused Review Latest updated 2022
• Subjective vs objective data
o Subjective
▪ Health history
o Objective
▪ Physical
... [Show More] assessment
• Components of a health history
o Chief complaint
o Present health status
o Past health history
o Current lifestyle
o Psychosocial status
o Family history
o Review of symptoms
• Types of databases
o Complete total health database
▪ Includes complete health history and full physical examination
▪ Describes current and past health state and forms baseline to measure all future changes
▪ Yields first diagnoses
o Episodic or problem-centered database
▪ For limited or short-term problems
▪ Collect “mini” database, smaller scope and more focused than complete database.
▪ Concerns mainly one problem, one cue complex, or one body system
▪ History and examination follow direction of presenting concern
o Follow-up database (found in doctors office)
▪ Status of all identified problems should be evaluated at regular and appropriate intervals
▪ Note changes that have occurred
▪ Evaluate whether problem is getting better or worse
▪ Identify coping strategies being used
o Emergency database (usually ER or Trauma)
▪ Rapid collections of data, often compiled concurrently with lifesaving measures
▪ Diagnosis must be rapid and comprehensive in nature
• Therapeutic vs non-therapeutic communication
o Therapeutic
▪ Active listening
▪ Sharing observations
▪ Sharing empathy
▪ Sharing hope
▪ Sharing humor
▪ Sharing feelings
▪ Using touch
▪ Silence
▪ Providing Information
▪ Clarifying
▪ Focusing
▪ Paraphrasing
▪ Asking relevant questions
▪ Summarizing
▪ empathy
o Non-Therapeutic
▪ Asking personal questions
▪ Giving personal opinions
▪ Changing the subject
▪ Automatic responses
▪ False reassurance
▪ Self-Disclosure
▪ Confrontation
▪ Sympathy
▪ Asking for Explanations
▪ Approval or Disapproval
▪ Defensive Responses
▪ Passive or Aggressive Responses
▪ Arguing
• Characteristics of a culture
o Immigrants commonly maintain traditional eating customs long after language and manner of dress of adopted country become routine
o Newly arriving immigrants may be at higher nutritional risk
▪ Often coming from countries with poor resources and nutrition related problems
o Unfamiliar with foods, food preparation, food buying habits and food storage
o Standard tables for weight and height may not be appropriate
o Need to know food habits in regard to religion and culture
• Types of Nutritional assessments
o Anthropometric measurements
o Swallowing assessment prn
o Lab test
▪ Risk factors for a poor nutritional intake
▪ Questions re weight loss? Wt gain?
▪ How does age factor into nutritional intake?
▪ Food habits and customs
▪ Meal patterns
▪ Food beliefs and skills
▪ Supplement use
▪ Medical conditions affecting nutritional status
• Barriers to communication
o Lack of interest or attention/ lack of respect
o Physical barriers
▪ A curtain
▪ A door
▪ A computer
▪ A monitor
▪ Pain
▪ Room temperature
o The patients inability to hear you
▪ Hearing deficit
▪ Receptive aphasia
o Safety
▪ Fear
o Psychological barriers
▪ Embarrassment
▪ Disbelief
▪ Shock
▪ Fear
▪ Grief
▪ Fatigue
▪ Anger/hostility
o Language
▪ Using medical jargon
▪ Speaking above someone’s education level
• Types of pain- verbal and non verbal cues of pain
o Acute
▪ Short term, self limiting
▪ Tissue damage
▪ Self protective mechanism
▪ Mild
• Sympathetic nervous system response
▪ Severe
• Parasympathetic nervous system response
o Chronic
▪ Over 6 months in duration
▪ Adaptive responses
▪ Does not stop when injury heals
▪ Outlasts protective purpose
▪ Abnormal processing of pain fiber from peripheral and central sites
o Verbal
▪ Moaning
▪ Crying
o Non verbal
▪ Facial expression
▪ Cries
▪ Breathing
▪ Arms
▪ Legs
▪ alertness
• Assessment techniques and what we can learn from each one
o Inspection
▪ Looking for conditions you can observe with your eyes, ears, or nose.
• Skin color, lesions, bruises or rash
o Auscultation
▪ Abdominal assessment
• Bowel sounds
▪ Lung sounds
▪ Heart sounds
o Palpation
▪ Light
• Allows you to assess for texture, tenderness, temperature, moisture, pulsations, and masses
▪ Deep
• To assess for masses and internal organs
o Percussion
▪ Elicit tenderness
▪ sounds that may provide clues to underlying problems
• Review of systems in health history
o P
▪ Provoking factors
• What brought on the pain?
o Q
▪ Quality
• Stabbing, throbbing, burning
o R
▪ Radiation
• Does the pain radiate anywhere?
o S
▪ Severity/symptoms
• How bad is the pain?
o Scale 0-10
• Are there other symptoms with the pain?
o T
▪ Time
• Constant?
• What makes it better or worse? [Show Less]