nursing process - ANSWER-ADPIE
subjective data - ANSWER-symptoms
objective data - ANSWER-observations
comprehensive assessment - ANSWER-complete health history and full physical
exam, medical records, and labs needed on admission to establish baseline
problem based/focused assessment - ANSWER-for limited or short term
patients focusing on one problem
episodic/follow up assessment - ANSWER-returning patient for same problem,
reevaluate treatment and coping skills
shift assessment - ANSWER-identify changes in a patient's condition from
baseline
,screening assessment/examination - ANSWER-short, focused exam for disease
detection and health promotion (ex. pap smear)
primary prevention - ANSWER-preventing disease (ex. immunizations)
secondary prevention - ANSWER-early detection/screening (ex. pap smears)
tertiary prevention - ANSWER-treatment/control (ex. diabetes management)
health history goals - ANSWER-gather data, create careplan, promote health
internal communication factors - ANSWER-linking others, non-judgement,
empathy, listening
external communication factors - ANSWER-privacy, reduce interruptions,
physical environment, dress, note taking
what type of questions are used at the beginning of an interview? - ANSWER-
open-ended
what type of questions are used to give more precise information? - ANSWER-
close-ended
, what type of questions lead patient to focus on one set of thoughts? - ANSWER-
directive
techniques of communication - ANSWER-active listening, facilitation,
clarification, restatement, reflection, confrontation, interpretation, summary
what type of data is in a health history? - ANSWER-subjective
health history sequence - ANSWER-biographical data, reason for seeking care,
present health or history of present illness, past health history, family history,
review of systems, personal and psychosocial history
what should biographical data not contain? - ANSWER-names
reason for seeking care - ANSWER-OLD CARTS: onset, location, duration,
characteristics, aggravating factors, related symptoms, treatment, severity
how should reason for seeking care be documented? - ANSWER-in patient
words and quotations
present health or history of present illness - ANSWER-chronic conditions (date
of diagnosis, impact on quality of life), allergies, medications (name, dose,
frequency, purpose), immunizations
past health history - ANSWER-name/type, date, and outcome