NURS11000 Holistic Assessment – Flashcards
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Capillary refill
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Time talen for colour to retunr to external capillary bed after pressure applied
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Cyanosis
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Bluish coloured skin due to poor oxygenation
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Angina
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Severe chest pain due to inadequate blood supply to heart
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Glasgow coma Scale
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Scale to record responsiveness verbally, motor response, opening eyes & dilation of pupils to light
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Hypoglycaemia
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Low glucose in blood <3.5mmoL
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Hyperglycaemia
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High glucose in blood >6mmoL
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Percussion
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Act of taping surface of body part to hear sound to learn condition
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Auscultation
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Listening to pulse of heart with stethescope
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Palpation
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Process of using hands to examine body & diagnose/perceive
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Holism
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Understanding health in terms of wholes instead of parts
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DETECT
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Acronym for detection & evaluation process
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ABCDEFG
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Acronym for what to assess in assessment process
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Define Holism
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holistic medicine integrates western medicine with complimentary & psychological therapies to treat the whole person. Consider all parts of the person to make up their health & care
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What are the dimensions of the whole person?
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1. Physical & developmental 2. Emotional 3. Intellectual-psychological 4. Scio-cultural 5. Spiritual
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What is person centred care?
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recognises individuality, care is individuality to that person & their circumstances
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How does holism apply to person centred care?
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By considering the whole person you can understand their individual needs
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What is patient assessment?
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The 1st phase of the nursing process, involving collection of subjective & objective data & organising, validation & documenting that data
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What is the purpose of health assessment
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to determine overall health i.e. all aspect physical, spiritual, etc
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How does holistic nursing relate to patient assessment?
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health assessment determines a patients over all health by looking at all aspects - therefore holistic
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Components of assessment
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DR ABCDEFG Physical spiritual psychosocial
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How to prepare patients for assessment
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Explain process & need for assess Obtain equipment Ensure private, comfortable room Be sensitive Assess all needs/areas
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How does holistic patient assessment maintain patient safety?
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By ensuring all areas are assessed, any potential changes or abnormalities can be detected
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What communication skills are needed for patient assessment?
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Open questions Body language - open Listening skills Clarifying answers/understanding
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List/describe the components of patient assessment
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Biographical data Reason seeking health care History of present concern Previous health/family history Current lifestyle habits Medication
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What does DETECT stand for?
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Deterioration Evaluate Treatment Escalate Communicate Teamwork
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How does DETECT recognise & manage patient deterioration?
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It includes all components of assessment incorporating all avenues of support to help the patient
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What is "between the flags"
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A system of colour coded charts where patient assessment data is recorded & identifies when a patient is deteriorating.
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How do you manage patients using the "between the flags" tool?
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Anything in yellow zone = initiate treatment & communicate to nurse in charge Red Zone = rapid response team is called with immediate treatment
