Exam 1 Study Guide - Summary Advanced Health Assessment PDF

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Exam 1 Study Guide...

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Real world information/ application General information- review texts, ask your preceptor or clinical supervisor, if not found let us know. This is not all inclusive, nor is it a study guide as ALL content in the text is important. And all information in the book is “testable” content. The below information is to help you see areas/ content that are important to know and will frequently be used. As you read and study, it would be wise to consume the text so to speak. All of the words could be treated as a vocabulary list. That vocabulary list will help with definitions. Then, identify what are the assessments a person would see with those words. To help in the clinical assessment; what differentiates one dx from another. For example with a dx of URI….. what assessments (hx and subjective, and objective findings) discriminate between sinusitis, viral URI, bronchitis, influenza, copd, asthma, otitis media, strep throat, etc. 1. Differentiate Subjective vs Objective assessment (pg 6) a. Subjective data i. Symptoms, what the patient tells you b. Objective data i. Signs, what you observe Subjective data What the patient tells you The symptoms and history, from chief complaint through review of symptoms Mrs. G is a 54 year old hairdresser who reports pressure over her left chest “like an elephant sitting there”, which goes into her left neck and arm

Objective data What you detect during the examination, laboratory information, and test data All physical examination findings, or signs Mrs. G is an older, overweight, white female, who is pleasant and cooperative. Height 5’ 4”, weight 150lbs, BMI 26, BP 160/80, HR 96, and regular, respiratory rate 24, temperature 97.5F

2. Differentiate between Chief complaint, HPI, past hx, ROS etc (pgs 9-10) a. Chief complaint: one or more symptoms or concerns causing pt to seek care; make every attempt to quote the patients own words i. “my stomach hurts and I feel awful” ii. no specific complaints: “I have come for my regular check-up” b. HPI (History of present illness): Complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date; ROS “pertinent positives and negatives i. Components:

1. Each principle symptom should be well characterized 2. Risk factors for CAD 3. Reveal pt response to his or her symptoms and what effect the illness has had on the patients life 4. Each symptom merits its own paragraph and a full description 5. Medications should be noted, including name, dose, route and frequency of use 6. Allergies including specific reactions 7. Tobacco use, including the type 8. Alcohol and drug use c. Past history: i. Components: 1. Childhood illnesses 2. Adult illnesses a. Medical b. Surgical c. OBGYN d. Psychiatric 3. Health maintenance a. Immunizations b. Screening tests d. Family history: Outline or diagram the age and health, or age and cause of death, of each immediate relative including parents, grandparents, siblings, children, and grandchildren e. Personal and social history: captures the patient’s personality and interests, sources of support, coping style, strengths, and concerns i. Occupation ii. Last year of schooling iii. Home situation iv. Significant others v. Sources of stress vi. Life experiences vii. Leisure activities viii. Religious affiliation and spiritual beliefs ix. Exercise and diet x. Safety measures xi. Sexual orientation and practices xii. Drugs and alcohol 3. ******It is extremely important to know the difference between subjective and objective data placement in SOAP charting****

a. Subjective: client’s view of problems or progress noted, use client’s own words i. Subjective data b. Objective: nurses objective observations of the clients progress i. Objective data c. Assessment: nurses assessment of the client’s affect, mental status, and psychosocial i. Objective data d. Plan: plan for future treatment as it relates to progress noted 4. What are the 4 cardinal techniques of exam and in what order are they performed ( pg 18) a. Inspection b. Auscultation c. Percussion d. Palpation 5. Sequence of the exam (pg 19) a. Three general goals: i. Maximize the patient’s comfort ii. Avoid unnecessary changes in position iii. Enhance clinical efficiency b. Head to toe 6. Exam from the right side ( pg 20) a. Examine the patient from the patient’s right side, moving to the opposite side or foot of the bed or examining table as necessary b. Advantages: i. Estimates of jugular venous pressure are more reliable ii. The palpating hand rests more comfortably on the apical impulse iii. The right kidney is more frequently palpable than the left iv. Examining tables are frequently positioned to accommodate a righthanded approach 7. Review “assessment” and “plan” parts of the physical exam process (pg 24) a. Assessment: analysis and interpretation i. Select and cluster relevant pieces of information ii. Analyze their significance iii. Try to explain them logically using principles of biopsychosocial and bioclinical science b. Plan: incorporates patient education, changes in medications, needed tests, referrals to other clinical, and return visits for counseling and support

i. Includes the patient’s responses to the problems identified and to the diagnostic and therapeutic interventions that you recommend ii. Requires good interpersonal skills and sensitivity to the patient’s goals, economic means, competing responsibilities, and family structure and dynamics 8. Guidelines from experts, based on scientific data, should dictate our actions as an NP (pgs 59-63). There are multiple expert panels in areas such as gyn, family practice, cancer, etc. There can be conflicting recommendations such as frequency of paps, etc. a. GRADE: i. Grading of recommendations ii. Assessment iii. Development iv. Evaluation b. Primary goals: i. Clearly separate the quality of the evidence and the strength of the recommendations ii. Provide clear, pragmatic interpretations of strong versus weak recommendations c. Grade: i. A, B, C, D, I = highest to lowest 9. See the last paragraph on page 66 re listening. a. Lifelong commitment to masterful listening b. Sir William Osler, co founder of John’s Hopkins, “listen to your patient, he is telling you the diagnosis” and “the good physician treats the disease; the great physician treats the patient who has the disease” 10. Remember from psych 100 no use of the word “why”. 11. The techniques listed (pgs 69-73) are important. In our roles as nurses, in most cases, the patient is a captive audience (ie they can’t get away). However, in the role of the NP mostly the patient are not “captive”. a. Active listening: closely attending to what the patient is communicating, connecting to the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns b. Empathic responses: the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner i. To express empathy, you must first recognize the patient’s feelings, then actively move toward and elicit emotional content

ii. Examples: “how do you feel about that”, “that seems to trouble you, can you say more”, “you have lost your father. What has that been like for you”, “that sounds upsetting” iii. For a response to be empathic, it must convey that you feel what the patient is feeling c. Guided questioning: goal is to facilitate full communication, in the patient’s own words, without interruption i. Techniques: 1. Moving from open-ended to focused questions a. Questions flow from general to specific b. Start general: “how can I help” or “what brings you in today” c. Move to specific: “can you tell me more about what happened when you took the medication” then “did the new medicine cause any problems” d. Avoid leading questions that already contain an answer or suggested response like “has your pain been improving” 2. Using questioning that elicits a graded response a. Rather than a yes-no answer b. “how many steps can you climb before you get short of breath” 3. Asking a series of questions one at a time a. Ask one questions at a time b. “do you have any of the following problems” 4. Offering multiple choices for answers a. “which of the following words best describes your pain: acing, sharp, pressing, burning, shooting, or something else” 5. Clarifying what the patient means a. “tell me exactly what you mean by the flu” or “you said you were behaving just like your mother. What did you mean” 6. Encouraging with continuers a. Using gestures, posture, or words to encourage the patient to say more b. Pausing and nodding your head or remaining silent 7. Using echoing a. Simply repeating the patient’s last words encourages the patient to elaborate on details and feelings. d. Nonverbal communication: notice nonverbal behaviors and bring them to a conscious level

e.

f. g.

h.

i. j.

i. Match your patient’s position = increase rapport ii. Mirror patient’s paralanguage Validation: validate the legitimacy of his or her emotional experience i. Example: “your accident must have been very scary. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset” Reassurance: identify and acknowledge the patient’s feelings i. Example: “you seem upset today” Partnering: express your commitment to an ongoing relationship i. Make patients feel that no matter what happens, you will continue to provide their care Summarization: capsule summary of the patient’s story during the course of the interview i. Communicates that you have been listening carefully ii. Identifies what you know and what you don’t know iii. When to use: at times of transition Transitions: tell them when you are changing directions during the interview Empowering the patient: when you empower patients to ask questions, express their concerns, and probe your recommendations, they are most likely to adopt your advice, make lifestyle changes, or take medications as prescribed. i. Techniques for sharing power: 1. Evoke the patient’s perspective 2. Convey interest in the person, not just the problem 3. Follow the patient’s leads 4. Elicit and validate emotional content 5. Share information with the patient, especially at transition points during the visit 6. Make your clinical reasoning transparent to the patient 7. Reveal the limits of your knowledge

12. Consider asking a question re alcohol use as …How much alcohol do you drink in a day/week. Do not ask as…... do you drink alcohol. It seems to make it less judgmental if the question is posed as a given. 13. See page 75 regarding visitors. You must ask the question….. may we speak about you in front of your visitors/family. a. Acknowledge and greet visitors b. You are obligated to maintain the patients confidentiality c. Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them

14. Questions to discern info on the 7 attributes of a symptom are important (pg 79) a. Location: where is it? Does it radiate? b. Quality: what is it like? c. Severity: how bad is it (scale 1 to 10) d. Timing: when did (does) it start? How long does it last? How often does it come? e. Onset: include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness f. Remitting or exacerbating factors: is there anything that makes it better or worse? g. Associated manifestations: have your noticed anything else that accompanies it? 15. Page 85 has a statement that goes something like “What did you hope to get from this visit”. This is a good concept. Perhaps to say it in a slightly different way would be good. 16. Chapter 3 is wonderful. You will want to spend a good deal of time looking at this. As an NP you will be using all of these techniques and be exposed to a good deal of this. Though this chapter is not a system, ie GI, it is important. There are many things you already know and many things to learn. This chapter begins to build on how an RN and NP function differently.

17. What is a functional assessment?- describe a. continuous collaborative process that combine observing, asking meaningful questions, listening to family stories, and analyzing individual child skills and behaviors within naturally occurring everyday routines and activities across multiple situations and settings SKIN – CHAPTER 6 1. Please note the skin cancer pictures. It can be difficult to identify. Remember the ABCDE. Anything non- healing is suspect. Anything developing it’s own vascular supply is suspect. Review seborrheic keratosis and Cherry hemangiomas as you will see a lot of those. a. Skin: i. Color: normal skin color depends on the amount and type of melanin, but is also influenced by underlying vascular structures, changing hemodynamics, and changes in carotene and bilirubin 1. Look for increased pigmentation, loss of pigmentation 2. Look for redness, pallor, cyanosis, and yellowing a. Red color check fingertips, lips, and mucous membranes b. In dark skinned people, palms and soles

3. Abnormal: a. Pallor indicates anemia b. Cyanosis can indicate decreased oxygen in the blood or decreased blood flow in response to a cold environment – lips, oral mucosa, and tongue c. Jaundice results from increased bilirubin – sclera ii. Rashes: ask about itching = MOST IMPORTANT SYMPTOM 1. Find out what type of moisturizer or OTC products that have been applied 2. Encourage use of moisturizers to replace the lost moisture barrier 3. Abnormal: a. Causes of generalized itching, without apparent rash, include dry skin; pregnancy; uremia; jaundice; lymphomas; and leukemia; drug reactions; polycythemia vera; thyroid disease iii. Hair loss or nail changes 1. Hair loss: ask if there is hair thinning or hair shedding and if so where a. Perform a hair pull test by gently grasping 50 to 60 hairs with your thumb and index and middle fingers pulling firmly away from the scalp = TEST FOR SHEDDING b. Perform the tug test by holding a group of hairs in one hand, pulling along the hair shafts with the other = TEST FOR HAIR FRAGILITY c. Hair care practices  ask about shampoos, when they wash their hair, etc d. ***Most common cause of hair thinning: male and female pattern baldness*** e. Abnormal: i. Hair shedding at the root is common in telogen affluvium and alopecia 1. Alopecia can be diffuse, patchy, or total 2. Sparse hair is seen in hypothyroidism 3. Fine silky hair in hyperthyroidism ii. Possible internal causes of diffuse non-scarring hair shedding in young women are iron deficiency anemia and hyper/hypothyroidism 2. Nail changes a. Abnormal: onychomycosis, habit tic deformity, and melanonychia iv. Skin cancer: BCC most common, then SCC, and melanoma

1. Skin cancer prevention: a. SPF >30, broad spectrum, and water resistant 2. Screening: full body examinations for patients over age 50 or at high risk a. Patients who have a clinical skin examination within the 3 years prior to a melanoma diagnosis have thinner melanomas than those who did not have a clinical skin examination. b. Survival from melanoma strongly correlates with tumor thickness 3. Melanoma: most lethal due to its high rate of metastasis and high mortality at advanced stages a. Risk factors: i. Personal or family hx ii. >50 common moles iii. Atypical or large moles iv. Red or light hair v. Solar lentigines 1. On shoulders or upper back vi. Freckles vii. Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths viii. Light eye or skin color ix. Severe blistering sunburns in childhood x. Immunosuppression from HIV b. Describing skin findings: i. Primary lesion: primary lesions are flat or raised 1. Flat: you cannot palpate the lesion with your eyes closed a. Macule: lesion is flat and 1cm 2. Raised: you can palpate the lesion with eyes closed a. Papule: lesion is raised, 1cm, and filled with fluid 3. Other primary lesions include erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura ii. Number: lesions can be solitary or multiple. If multiple, record how many. Also consider estimating the total number of the type of lesion you are describing

iii. Size: measure with a ruler in mm or cm. for oval lesions, measure in the long axis, then perpendicular to the axis iv. Shape: circular, oval, annular, nummular, polygonal v. Color: use skin colored to describe a lesion that is the same shade as the patient’s skin vi. For red lesions or rashes, blanch the lesion 1. Blanching lesions are erythematous and suggest inflammation 2. Non-blanching lesions such as petechiae, purpura, and vascular structures (cherry angiomas, vascular malformations) are not erythematous, but rather bright red, purple, or violaceous vii. Texture: palpate the lesion to see if it is smooth, fleshy, verrucous or warty, or scaly 1. Scaling can be greasy, like seborrheic dermatitis or seborrheic keratosis 2. Dry and fine like tinea pedis 3. Hard and keratotic like actinic keratosis or SCC viii. Location: measure their distance from other landmarks ix. Configuration: describe patterns Systemic Diseases Addison’s disease

Acquired immune deficiency syndrome Chagas disease

Chronic renal disease CREST syndrome

Chron disease Cushing disease

Dermatomyositis

Associated findings or diagnosis Hyperpigmentation of oral mucosa as well as sun-exposed skin, sites of trauma, and creases of palms and soles Oral and anal SCC, severe psoriasis, severe seborrheic dermatitis, eosinophilic folliculitis Unilateral conjunctivitis and lid edema associated with preauricular lymphadenopathy Pallor, exerosis, uremic frost, pruritus, half and half nails, calciphylaxis Calcinosis, Raynaud phenomenon, sclerodactyly, matted telangiectasias of face and hands (palms) Erythema nodosum, pyoderma gangrenosum, enterocutaneous fistulas, aphthous ulcers Striae, atrophy, purpura, ecchymoses, telangiectasias, acne, moon facies, buffalo hump, hypertrichosis Violaceous erythema as macules, patches or papules in periocular region, on interphalangeal joints, and on upper back and shoulders

Diabetes

Disseminated intravascular coagulation Dyslipidemias Gonococcemia

Hemochromatosis Hypothyroidism

Hyperthyroidism

Infective endocarditis Kawasaki disease

Liver disease

Leukemia/lymphoma

Leukocytoclastic vasculitis Lymphogranuloma venereum Medium vessels vasculitides Meningococcemia

Neurofibromatosis 1 Pancreatic carcinoma Porphyria cutanea tarda Pyoderma gangrenosum

Pruritus, diavetic dermopathy, acanthosis nigricans, candidiasis, neuropathic ulcers, necrobiosis lipoidica, eruptive xanthomas Purpura, petechiae, hemorrhagic bullae, induration, necrosis Xanthomas, xanthelasma Purple to grey macules, papules or hemorrhagic pustules distributed over acral and periarticular surfaces Skin bronzing and hyperpigmentation Dry, rough, and pale skin; coarse and brittle hair; myxedema; alopecia; skin cool to touch; thin and brittle nails Warm, moist, soft, and velvety skin; thin and fine hair; alopecia; vitiligo; pretibial myxedema; hyperpigmentation Janeway lesion, osler nodes, splinter hemorrhages, petechiae Mucosal erythema, strawberry tongue, cherry red lips, polymorphous rash, erythema of palms and soles with later desquamation of fingertips Jaundice, spider angiomas and other telangiectasias, pamar erythema, terry nails, pruritis, purpura, caput medusa Pallor, exfoliative erythroderma, nodules, petechiae, ecchymoses, pruritus, vasculitis, pyoderma gangrenosum, bullous diseases Palpable purpura, purpuric wheals, hemorrhagic bullae in dependent area Lymphadenopathy above and below poupart ligament Livedo racemosa, purpuric nodules, ulcers Angular or stellate purpuric patches and plaques with gunmetal gray center. Progresses to ecchymoses, bullae, necrosis Neurofibromas, café-au-lait spots, freckling in axillae, plexiform neurofibroma Panniculitis, m...