correctly understanding findings to select appropriate plan of careinterpretingapplying clinical judgement to interpret or make conclusions regarding patient needs, concerns or health problemsunderstandingafter understanding the situation, the nurse responds by determining appropriate intervestionsresponding2 options: in action (during) or on-action (following)reflectingwhat are examples of health promotion?cardiac rehab, nutritional classes for diabeticswhat are examples of health protection?mammograms, colon screenings, eye examswhat are the three levels of health promotion?primary, secondary, tertiarywhat health promotion involves preventing disease from developing through preventing a healthy lifestyle?primarywhat health promotion involves screening efforts to promote early detection of disease?secondarywhat health promotion involves minimizing disability from acute and chronic illness or injury and allowing for most productive life within limitations?tertiaryobtaining a health history includes these 3 phases:Introduction
Discussion
SummaryThe introduction of health history includes:preparing the patient for what to expectthe discussion of health history includes:patient centered and directed questions
facilitating, collecting, and recording datathe summary of health history includes:the foundation for personalized & effective health care as well as the clarification and validation of understandingwhat is AIDET?acknowledge, introduce, duration, explanation, thank youwhen is AIDET used?during health historywhat type of question encourages a free-flowing response?open-ended question
example: how have you been feeling?what type of question yields precise date and leads the patient to focus on one set of thoughts?directive questions
example: what is your pain score?OLD CARTS:onset
location
duration
characteristics
aggravating and alleviating factors
related symptoms
treatment
severityCOLA?caring out loud alwayswhat percussion tone is loud, high-pitched and heard over the abdomen?tymphanywhat percussion sound is heard over normal lung tissue?resonancewhat percussion sound is heard in overinflated lungs, as in emphysema?hyperresonancewhat percussion sounds is heard over liver?dullnesswhat percussion sound is heard over bones and muscle?flatnessWhat is a stethoscope used for?Auscultation of pulse, heart, and respiratory soundswhat is a thermometer used for?temperatureWhat is the otoscope used for?a medical device which is used to look into the earsWhat is pulse oximetry?measure of the percentage of hemoglobin saturated by oxygenWhat is the snellen chart?an eye chart that can be used to measure visual acuitynormal heart rate for an infant100-160 beats/minnormal respiratory rate for an infant30-53 breants/minnormal blood pressure for an infant72-104/37-56heart rate for toddler98-140respiratory rate for toddler22-37BP for toddler86-106/42-63heart rate for school age child75-118respiratory rate for school age child18-25BP for school aged child97-115/57-76heart rate for adolescent and adult60-100respiratory rate for adolescent and adult12-20BP for adolescent110-131/64-83BP for adult<120-<80what should a temperature range from?96.4-99.1number of time in a minute a pulsation is feltrateregularity of pulsations or time between each beatrhythmwhat artery is used to find a pulse in infants?brachial arterywhat artery is located in the neck and used in CPR?carotidregularity of pulsations or time between each beatrhythmwhat is the maximum pressure exerted on arteries when ventricles eject blood from heart, its the first sound.systolicwhat represents minimum amount of pressure exerted on vessels when ventricles of heart relax?diastoliccultural desireThe motivation of a health care professional to "want to"—not "have to"—engage in the process of becoming culturally competentcultural awarenessThe self-examination and in-depth exploration of one's own beliefs and values as they influence behaviorcultural knowledgebegins when nurses learn about beliefs, religions, values, traditions, and customs of other cultural groupscultural skillability to perform a cultural assessment in a sensitive waycultural encountersprovide opportunities for nurses to interact with patients from culturally diverse backgroundsneuropathic painoccurs because of abnormal processing of sensory inputcancer is a example of what painneuropathicpain thresholdthe point at which a person feels painpain tolerancelevel of pain a person can endureanorexia nervosaAn eating disorder characterized by an obstinate and willful refusal to eat, a distorted body image, and an intense fear of being fatBulimia Nervosa (BN)An eating disorder characterized by repeated cycles of bingeing and purging.binge eating disorderan eating disorder in which people overeat compulsivelywhat is the most common symptom of skin disease?pruritis (itching)primary skin lesionmoles, freckles, patchessecondary skin lesionsexpected variation due to external factor - scarvascular skin lesionbruising, cherry angiomaMaculefreckle, flat, change in color of the skinPapuleelevated, firm, circumscribed area less than 1 cm in diameternodulesolid, round or oval elevated lesion 1 cm or more in diameter, like a papule but deeper in the dermistumorelevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diametervesicleelevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameterscaleeczema, keratinized cellspustuleraised spot on the skin containing pus; acne, impetigocystsac containing fluid; sebaceous cystpetechiaetiny, flat, reddish purple spotpurpuraFlat, reddish-purple, nonblanchable discoloration in the skin greater than 0.5 cm in diameterinflammation of hair folliclesWhat is folliculitis?abscess or boilfuruncleMost common skin cancerbasal cell carcinomamost serious skin cancermelanomapediculosis corporisbody licepediculosis pubispubic licealopecia areataan autoimmune disorder that attacks the hair follicles, causing well-defined bald areas on the scalp or elsewhere on the bodyhirsutismexcessive hair growth over the body that is usually related to the thyroid
