OSCE VIVA - Exam scripts for OSCES PDF

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Exam scripts for OSCES...

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OSCE VIVA      

In your OSCE VIVA you should be prepared to; Collaboratively receive information about a patient and decide upon 4 relevant assessments to gather data for that patient Personally justify 2 of those assessments to your assessor (why have you chosen to undertake those assessments) Personally describe how those assessments would be undertaken And interpret data from those assessments – explain why the patient is presenting this way by linking to the scenario notes Use that data to collaboratively identify 2 patient problems

Depth of explanation:   

Assessments with an * require a comprehensive explanation of how the assessment would be undertaken. These are assessments which you should already know or have learned so far this semester. Assessments with a # require less explanation of how the assessment would be undertaken but rather require comprehensive explanation of the data. Assessments with a % require both as these have been a particular focus of modules in these units.

OSCE 1: CNA 253

OSCE 2: CNA 255

Nervous system health and care:

Endocrine system health and care

General Assessments:  Vital signs  Pain assessment  Blood results (ABG and VBG)

General Assessments:  Vital signs  Pain assessment  Blood results (ABG and VBG)

Neurological Assessments  GCS  Limb strength  PERRLA  Acute spinal cord injury care

Diabetes Management  Urinalysis  Peripheral Blood Glucose Testing  Assessment of Suspected Hyperglycaemia (Neurological Assessment, Hydration Status Assessment)  Assessment of Suspected Hypoglycaemia (Neurological Assessment)  Diabetic Medication Management

Neurovascular Assessments  Neuro  Vascular Digestive system health and care: General Assessments:  Vital signs  Pain assessment  Blood results (ABG and VBG)  Hydration status assessment  Abdominal Assessment

Renal system health and care

Stoma   

Renal Management  Cannula Site Assessment  Hydration Status Assessment Associated with Dehydration  Urinalysis  Fluid Balance Associated with dehydration or fluid overload  Assessment of Suspected Fluid Overload (Hydration Status Assessment, Respiratory Assessment)

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Care Assessments: Dietary Considerations Stoma Output Assessment Peristomal Skin and Pain Assessment Stoma Assessments

Nasogastric Tube Management:  Post-Insertion Assessment  Pre-insertion Assessment

General Assessments:  Vital signs  Pain assessment  Blood results (ABG and VBG)

IDC Management  Post-Insertion Assessment  Urinalysis (Sample Acquisition when IDC in situ) (%)

OSCE 1: CNA 253 NERVOUS SYSTEM HEALTH AND CARE General Assessments: Vital Signs (#) Respiratory Rate

Provides clearest indication of brain function due to complex process of respiration involving different areas of the brain. Pattern, rate and depth of respirations give indications of damaged areas. Note: Cheyne-stokes, rapid, irregular, clustered, gasping, ataxic breathing & apnea.

Temperature

Alterations can indicate dysfunction of the hypothalamus or the brain stem. CNS function is altered by temps outside normal parameters. Hyperthermia: Possibly caused by infection & increases metabolic rate and therefore cerebral metabolism, increasing the brains need for glucose and oxygen. Hypothermia: Decreases the metabolic rate, decreasing cerebral blood flow and oxygen concentration of the brain.

Blood Pressure

Increases with intracranial pressure, as a compensatory mechanism. Increase in ICP exerts pressure on vessels in brain causing ischaemia.

Pulse Rate

Initially rise as a compensating mechanism and then slow in instances of increased ICP due to vagal stimulation from increased blood pressure.

Monitor every 15 minutes until stable, then hourly depending on condition of patient.

Pain Assessment (*) Provoking What were you doing when the pain started? What causes it? Interpret blood results including ABG or and VBG What (#): seems to trigger it? What factors What makes it better worse? relives it? What aggravates it? ABG and VBG Quality

PH: 7.35does - 7.45 What it feel like? Descriptors: sharp, dull, stabbing, C02: 25 - 45 burning, crushing, throbbing, nauseating, shooting, twisting, HCO2: 22-26 stretching.

Region, Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/ moves around? Is it localized to one spot?

Severity

How severe is the pain on a scale of one to ten, with 0 being no pain and 10 being the worst pain ever? How does it interfere with activities? How bad is it at its worst? How long does it last?

Temporal

When did the pain start? How long does it last? How often does it occur? Is it sudden or gradual? When do you usually experience it? Neurological Assessments:

Level of Consciousness

Glasgow Coma Scale (%) 4. Spontaneous 3. Verbal stimulus

2. Painful stimulus 1. Unresponsive Orientation

5. 4. 3. 2. 1.

Orientated Confused Inappropriate Incomprehensible None

Motor Response

6. 5. 4. 3. 2. 1.

Obeying Localizing Withdrawal Flexing Extending None

PERRLA (as per neuro assessment chart) (%) Pupil Shape Pupil strength Reactivity Motor scale

Limb Strength (%) Bring the Active light from from lateral persons 5. Normal power: limbthe against gravityside withoffull head towards the nose. Observe pupil constriction resistance be brisk) andresistance repeat, observing opposite pupil 4. Active(should movement against for constriction to indirect light (consensual 3. Active movement against gravity Repeat witheliminated other eye. 2. Activeconstriction). movement with gravity intracranial pressure: Pupils becoming 1. FlickerIncreasing of movement unequal or one pupil becomes more sluggish than the 0. None other.

Shoulder Abduction: Nerve root C5, deltoid  Make chicken Ask person to focus on distant object forout 30 to the wings, examiner places armsgaze against arms stretched seconds and look back at finger or pen held side and flexed at elbow approximately 10cm away. Note reaction and size of Elbow Flexion: Nerve root C6, C7, biceps brachii  Hold occurs to when pupils constrict and patientspupil, elbowaccommodation and wrist, ask patient pill towards their face converge to focus an object at close range. Elbow Extension: Nerve root C6, C7, C8, triceps)  Flex arm while examiner pulls against arm Extraocular Movement Assesses the oculomotor, trochlear and abducens (iii, iv, vi) cranial followto tipraise of light with Lower Limbs Hip flexion: L1, L2, nerves. iliopsoasAsk  patient Ask the to patient their eyes only, without moving their head. Hold light 25knee to chest with the knee at 90 against resistance from the 40cm in front of them and move light slowly up, down, examiner laterally Nerve and obliquely, watching pupil femoris movement as it Knee Extension: root L3, L4, quadriceps  Ask tracks light. Eye movement should be smooth and the patient to bend the knee to 90 while the examiner places hand at symmetrical. the knee and on the other ankle. Ask the patient to

Upper Limbs Assess for Accommodation

straighten their leg. Oculocephalic ReflexKnee Flexion: TestedNerve on unconscious if no spinal With root L5, S1,person hamstrings  Askinjury. the patient lying without a pillow, stand their to bend patient the knee andflat bring the heel toward theirbeside bottom, when hand on forehead and holding eyes the kneehead is 90with , the1examiner tries to straighten theboth leg while open. Quickly, but gently, turn their head from one side holding the knee. to another and watch their pupilanterior movements. reflex is Foot Dorsiflexion: Nerve root L5, tibialis  AskIfthe intact, their eyesback will move in the opposite to patient to pull the ankle and bring toes towarddirection the head. the which you turned their head. If person does Examiner toside pushtofeet down. not have reflexes, eyes will move  slowly Plantar Flexion of intact foot: Nerve roottheir S1, gastrocnemius Ask the from side to side downward or not at allwhile (will examiner move withpulls the head). patient to push feet/toes up.

Acute Spinal Cord Injury Care (#) Respiratory Assessment Loss of all or part of phrenic nerve (C3,4,5)  Artificial ventilation may be required  Additional loss of abdominal and thoracic muscles also reduces ventilatory efficiency  Increased risk of atelectasis and pneumonia (reduced cough) Skin Assessment

Loss of temperature regulation below lesion Loss of sensation below lesion

Reflex Assessment

There is a loss of reflexes below the lesion in the 7-10 days of spinal shock.

Sensory and Motor Assessment Association with spinal shock and indicators of spinal shock resolving

Loss of muscle, bowel and bladder tone Reappearance of reflex activity Initially hyperreflexia and spasticity  Reflex emptying of the bladder  Moderation of reflex activity  Flexor spasm and extensor spasm  Sabilisation of bowel and bladder reflexes  Risk of autonomic hypereflexia  Hypertension, headache, sweating, piloerection and bradycardia caused by sympathetic stimulation and vasoconstriction with reflex parasympathetic bradycardia

Neurovascular Assessments:

Paraesthesia (sensation) Paralysis (movement)

Neuro (%) All touchable/ visible surfaces should be checked for presence and type of sensation Where movement is restricted by a cast or dressing, digits should still be flexed and extended.

Vascular (%) Pain

1-10 scale and PQRST Normal: Moderate pain controlled with analgesia Compartment syndrome: Intense pain disproportionate to injury Circulatory compromise: Passive stretching of muscles and distal digits and elevation of the affected limb above heart level intensifying pain

Pallor

Normal: Colour should be healthy, well perfused pink Compartment syndrome: Can cause pallor, redness or cyanosis

Polar

Normal: Limb should be warm to the touch, or similar temperature to the unaffected limb Compartment syndrome: Affected limb may be cold or hot to touch

Pulses

Normal: Should be same rate and volume of the unaffected limb Compartment syndrome: Pulses and capillary refill may be absent or remain normal

Paraesthes ia

Normal: Sensation is assessed in the distal digits. Ask person about any alteration in sensation in the limb such as: Nerve compression: Numbness, pressure, tightness, tingling, or any other sensation. Then ask them to close their eyes and identify touches along different dermatomes. Paraesthesia is the earliest sign of neurological compromise

Paralysis

Ask person to move distal joints through full range of motion. Compartment syndrome: Muscle weakness or inability to flex or extend digits are late symptoms of compartment syndrome

Pressure

Oedema causes tenseness on distal limb and swelling may be visible . Tissue is firm.

Blood Loss

Check area for blood loss

DIGESTIVE SYSTEM HEALTH AND CARE General Assessments: Vital Signs (#) Heart Rate

Hypervolemia: Strong, rapid pulse rate Hypovolaemia: Compensatory systemic release of catecholamines promotes peripheral vasoconstriction, increases cardiac contractility and tachycardia. Tachycardia promotes increased myocardial oxygen demand that in conjunction with reduced tissue perfusion can result in myocardial failure.

Blood Pressure

Hypervolemia: High blood pressure caused by an increase in cardiac output Hypovolaemia: Low blood pressure due to decreased cardiac output caused by diminished preload

Respiratory Rate

Hypervolemia: Shortness of breath (dyspnoea), Increase in respiratory rate is indicative of pulmonary oedema secondary to fluid overload. Hypovolaemia: Deep, acidotic breathing is associated with severe dehydration

Temperature

Hypovolaemia: Extremities can become cold in the case of hypovolaemic shock.

Pain Assessment (*) Interpret bloodyou results ABGstarted? and VBG (#):causes it? Provoking What were doing including when the pain What Haematocrit The ratio of RBCs to total volume. If dehydrated factors What makes it better or blood worse? What seems to triggerhaematocrit it? What will increase due to decreasedit? blood volume. Ratio of plasma to relives it? What aggravates RBCs changes. CRP (CInflammatory Quality What does itmarker feel like? Descriptors: sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, stretching. reactive protein) Region, Potassium Radiation Bilirubin Severity Lipase Timing Amylase VBG and ABG Documentation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/ moves around? Is it localized to one spot? Bilirubin comes from the breakdown of RBCs, liver responsible for removing it from thepain blood putsof inone intoto bile. bilirubin How severe is the onand a scale ten,Elevated with 0 being no = itchy painskin and 10 being the worst pain ever? How does it interfere with When pancreas damaged it releases more lipase activities? Howisbad is it at or itsinflamed worst? How long does it last? resulting in a higher level in the blood When did the pain start? How long does it last? How often does it Can be normal occur? it sudden or gradual? When do you usually experience PH: 7.35 Is - 7.45 C02: it? 25 - 45 HCO2: 22-26

Hydration Status Assessment (%) Peripheral Pulses

Tachycardia may indicate hypovolaemia as

Peripheral Temperature and colour

Pallor may indicate hypovolaemia secondary to blood loss Cool temperature is indicative of hypovolaemia

Capillary Refill

Prolonged in hypovolaemia

Skin Turgor

Assess by gently pinching a fold in the skin of the hand and

releasing. Normal: Well hydrated skin should spring back to previous position instantaneously Dehydration: Skin will slowly return to normal, indicating decreased skin turgor Mucous Membranes

Visually assess Normal: Mucous membranes should be moist Dehydration: Mucous membranes dry and furrowed (could also be caused by anticholinergics)

Urine Output

Decreased in dehydration

Thirst

Increased in dehydration

Mental Status

Mild dehydration: Alert Moderate dehydration: Lethargic Severe dehydration: Obtund

Associated Vital Signs

See vital signs table

Gastrointestinal history

Abdominal Assessment (*) Medical: Nausea, vomiting, diarrhoea, constipation, abdominal distension, abdominal pain, increased eructation (burping), increased flatulence, dysuria, nocturia, urinary incontinence, anorexia, dysphagia, weight gain, weight loss, Surgical: Cholecystectomy, gastrectomy, ileostomy, colostomy, appendicectomy, pancreatectomy, nephrectomy, colectomy, ileal conduit, splenectomy, hernia repair, liver or renal transplant, bariatric surgery, gastric surgery. Medications: Histamine-2 antagonists, protein pump inhibitors, antibiotics, lactulose, antacids, vitamins, antiparasites, anticholinergics, tranquilisers, steroids, antidiarhhoeals, electrolytes, laxatives, stool softeners, insulin, antiemetics, antiflatulents. Family health history: Malignancies of the stomach, liver, pancreas or colon, peptic ulcer disease, diabetes mellitus, familial polyposis, inflammatory bowel disease, polycystic kidney disease, colitis, malabsorption syndromes, cystic fibrosis, food allergies and intolerances, eating disorders, obesity. Social history: Alcohol, tobacco and drug use, travel history, work and home environment, exercise, hobbies and leisure activities, education, economic status, religion, ethnic background.

Position patient supine and inspect abdomen

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Identify the anatomical landmarks: umbilicus, symphysis pubis and xiphoid process Observe contour and symmetry of abdomen; concave or convex. Look next to the patient and from the end of bed. Normal: the abdomen is flat or rounded and bilaterally

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Auscultate abdominal quadrants

symmetrical. Observe for smoothness, or protrusions, distension, pulsation, movement, peristalsis. Observing umbilicus for abnormalities: colour, contour, discharge, protuberance. Normal: midline and depressed beneath the abdominal surface. Pallor, perfusion and condition of the skin, abdominal muscles are relaxed or if the outlines are visible. Ask patient to raise their head to observe muscle contour changes and if any hernias or muscle separation is apparent. Scars, bruises, altered colour, lesions, rashes, scars, hair distribution, striae or fine veins, linea nigra. observing the abdominal movement during the respirations

This follows the line of the large intestine. I am making sure to listen over the ileocecal valve where bowel sounds should be audible. Bowel Sounds: High pitched, occurring 5-30 x min Abnormal: Absent, hypoactive, hyperactive. Hypoactive: Caused by decreased motility and possible obstruction. Hyperactive: increased motility, diarrhoea or gastroenteritis. Vascular sounds: Listen for bruit w/ bell of stethoscope (low pitched murmurs) in the epigastric region (aorta, renal arteries) and the lower quadrants (femoral arteries). Vascular sounds are generally abnormal and should be reported. 

Percuss abdomen

Percuss quadrants in the same systematic process as that for auscultation. If patient expresses pain in a particular quadrant, leave until last.  Listening for tympany (a musical drumming sound heard over hollow organs) over the stomach and intestines due to the gas in these organs and for dullness over solid organs (the liver, spleen or full bladder)  Dullness where tympany may be heard indicates possible mass, tumour, pregnancy, ascites or a full intestine.  A liver span of more than 12cm or less than 6cm or a liver descent of more than 2cm may indicate hepatomegaly or cirrhosis.  Spleen dullness may indicate >8cm line may indicate enlargement.  Costoverbal angle tenderness may indicate pyelonephritis. Ability to percuss a recently emptied bladder may indicate urinary retention. Solid organs: Liver, pancreas, spleen, kidneys and ovaries. Hollow organs: Stomach, small intestine, appendix, large intestine/colon, gallbladder, bladder, uterus, aorta, common bile duct, fallopian tubes.

Palpate Abdomen

Light palpation: presence of any distension, abnormal masses or tenderness. Note texture & consistency of underlying tissues. Use palmar surface of straight fingers horizontal to abdomen, indenting by 2cm. If patient

experiences pain, ask them to cough to determine the exact painful area and palpate the furthest quadrant from the pain first, palpating the tender quadrant last. Deep palpation: shape of deeper structures to determine size and consistency. I am going to place my hand on the persons RUQ just below their costal margin and instruct them to breathe deeply, pushing their liver against my hand. Normal livers are non-tender, have a regular and sharp lower edge and are solid to touch. Upper edge of liver can be located by percussing the right mid clavicular line of the chest downwards until the dullness of the liver is heard. Rebound tenderness indicates an inflamed peritoneum. An increase in pain when pressing slowly and deeply into the painful area and withdrawing confirms this. Tenderness on palpation: Inflammation, masses or enlarged organs Muscle Guarding on expiration: May indicate peritonitis Presence of masses, bulging and swel...