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NUR 518 – Exam 1
Study Guide
- Sequence of the Clinical Encounter a. Initiating the encounter i. Setting the stage/preparation ii. Greeting the patient and establishing initial report b. Gathering information i. Initiating information gathering ii. Exploring patient’s perspective of illness iii. Exploring biomedical perspective of disease including relevant back-ground and context c. Physical examination d. Explanation and planning i. Provide correct amount and type of information ii. Negotiate plan of action iii. Shared decision making e. Closing the encounter
- Exploring the patient’s perspective a. F-feelings i. Patients feelings, including fears/concerns about the problem b. I-Ideas i. Patients ideas about the nature and cause of the problem c. F-effect on function i. The effect of the problem on the patient’s life and function d. E-expectations i. The patient’s expectations of the disease, of the clinician, or of health care, often based on prior personal/family experiences
- Shared decision-making a. Introducing choices and describing options using patient decision supports tools when available b. Exploring patient preferences; and moving to a decision
c. Checking that the patient is ready to make a decision and offering more time if needed i. Shared decision making promotes optimal therapy, adherence to treatment, and patient satisfaction
- Social determinants of health a. Economic stability i. Employment, food insecurity, housing instability, poverty b. Education i. Early childhood education and development, enrollment in higher education, high school graduation, language and literacy c. Social and community context i. Civic participation, discrimination, incarceration, social cohesion d. Health and health care i. Access to health care, access to primary care, health literacy e. Neighborhood and built environment i. Access to foods that support health eating, patterns, crime and violence, environmental conditions, quality of housing
- Cultural humility a. Self-awareness i. Learn about your own biases; we all have them b. Respectful communication i. Work to eliminate assumptions about what is “normal”. Learn directly from your patients; they are the experts on their culture and illness. c. Collaborative partnerships i. Build your patient relationships on respect and mutually acceptable plans
- Core values of medical ethics a. Nonmaleficence i. “First do no harm” directive that health care professionals should avoid causing harm to patients and minimize the negative effects of treatment
i. Principle that clinicians must elicit patients voluntary and informed authorization to test or treat them for illness or injury. Because patients cannot consent to treatment without knowing what they are being treated for, this principal also encompasses the responsibility to inform patients of diagnoses, prognoses, and treatment alternatives. g. Truth telling i. Value that clinicians should disclose information beyond that required by informed consent that may be relevant to patients
- Number of similar procedures a physician has performed h. Justice i. Value that all patients with similar medical needs should receive similar medical treatment and should be treated fairly by clinicians
- Skilled interviewing techniques a. Active or attentive listening b. Guided questioning c. Empathic responses d. Summarization e. Transitions f. Partnering g. Validation h. Empowering the patient i. Reassurance j. Appropriate verbal communication k. Appropriate nonverbal communication
- Working with a medical interpreter a. Introductions i. Make sure to introduce all the individuals in the room. During the introduction, include information as to the role’s individuals will play. b. Note Goals
i. note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there by any follow- up? c. Transparency i. Let the patient know that everything said will be interpreted throughout the session
b. Talkative c. With confusing narrative d. With altered state or cognition e. With emotional lability f. Angry or aggressive g. Flirtatious h. Discriminatory
i. With hearing loss j. With low or impaired vision k. With limited intelligence l. Burdened by personal problems m. Nonadherent n. With low literacy o. With low health literacy p. With limited language proficiency q. With terminal illness or dying
- Health History and Assessment: Comprehensive or Focused a. Comprehensive: i. Is appropriate for new patients in the office or hospital ii. Provides fundamental and personalized knowledge about the patient iii. Strengths the clinician- patient relationship iv. Helps identify or rule out physical causes related to patient concerns v. Provides a baseline for future assessments vi. Creates a platform for health promotion through education and counseling vii. Develops proficiency in the essential skills of physical examination b. Focused: i. Is appropriate for established patients, especially during routine or urgent care visits ii. Addresses focused concerns or symptoms iii. Assess symptoms restricted to a specific body system iv. Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible
- Subjective vs Objective Data a. Subjective: i. Includes symptoms which are health concerns that the patient tells you ii. Examples of complaints of sore throat, headache, or pain iii. Also includes feelings, perceptions, and concerns obtained from the clinical interview iv. Clinical record from the chief complaint through the review of systems
- Components of the Comprehensive Adult Health History a. Initial information b. Chief complaint(s) c. History of present illness d. Past medical history e. Family history f. Personal and social history i. Alcohol use ii. Tobacco use iii. Illicit drug use iv. Sexual history v. Spiritual history g. Review of systems
- HPI documentation a. Elaboration of chief complaint with attention to chronology i. “JM is a 48-year old male with poorly controlled diabetes mellitus presenting with 3 days of fever” ii. RP is a 23-year old male with recent travel to Mexico presenting with 1 month of low-grade fever and night sweats” iii. Location:
- Area of body, bilateral, unilateral, left, right , anterior, posterior, upper, lower, diffuse or localized, fixed or migratory, radiating to other areas iv. Quality:
- Dull, sharp, throbbing, constant, intermittent, itching, stabbing, acute, chronic, improving or worsening, red or swollen, cramping, shooting, scratchy v. Quantity or severity:
- 8/10 pain, moderately dizzy, approximately half a cup of bloody urine vi. Timing including:
- Onset- this morning, last night, 6 hours ago
- Duration- since last night, for the past week, until today, lasted for 2 hours
- Frequency- every 6 hours, daily, comes and goes vii. Setting in which it occurs:
- Worse when standing, improved with sitting,
aggravated by eating, fell going down the stairs, during a football game viii. Modifying factors:
- Relieved with acetaminophen, no relief with ibuprofen, it felt better/worse when ix. Associated manifestations:
conditioning ii. Skin conditions such as petechiae or ecchymoses iii. Eye movements iv. Pharyngeal color v. Symmetry of thorax vi. Height of jugular venous pulsations vii. Abdominal contour viii. Lower extremity edema
ix. Gait b. Palpation: i. Tactile pressure from the palmar fingers or finger pads
- To assess areas of skin elevation, depression, warmth, or tenderness ii. Lymph nodes iii. Pulses iv. Contours and sizes of organs and masses v. Crepitus in the joints c. Percussion: i. Use of the striking or plexor finger (usually the third) to deliver a rapid tap or blow against the distal pleximeter finger (usually the distal third finger of the left hand) laid against the surface of the chest or abdomen
- To evoke a sound wave such as resonance or dullness from the underlying tissue or organs
- This sound wave also generates a tactile vibration against the pleximeter finger d. Auscultation: i. Use of the diaphragm and bell of the stethoscope to detect he characteristics of heart, lung, and bowel sounds
- Including location, timing, duration, pitch, and intensity ii. For the heart, this involves sounds from closure of the four valves, extra sounds from blood flow into the atria and ventricles, and murmurs iii. Auscultation also permits detection of bruits or turbulence over arterial vessels
- Sequence of Examination: General Goals a. Key to a thorough and accurate physical examination is developing a systematic sequence of examination b. Recommend examining the patient from the patient’s right side, moving to the opposite side i. Estimates of jugular venous pressure are more reliable ii. The palpating hand rests more comfortable on the apical pulse iii. Right kidney is more frequently palpable than the left iv. Examining tables are frequently positioned
- Note posture, motor activity, gait, dress, hygiene, body odors
- Watch patient’s facial expressions, note manner, affect, reactions to people/environment
- Listen to patient’s speech and note state of awareness or LOC ii. Vital signs
- Blood pressure, pulse, RR, temperature a. The patient is sitting on the edge of the bed or exam table iii. Skin
- Assess skin moisture, dryness, temperature
- Identify any lesions, noting their location, distribution, arrangement, type, and color
- Inspect and palpate the hair/nails
- Study both surfaces of patient’s hands iv. Head, eyes, ears, nose, throat
- Examine the hair, scalp, skull, and face
- Check visual acuity and screen visual fields
- Observe the eyelids and inspect the sclera and conjunctiva of each eye
- Inspect cornea, iris, and lens (with oblique lighting)
- Compare the pupils, test their reactions to light
- Assess the extraocular movements
- With an ophthalmoscope, inspect the ocular fundi
- Ears: a. inspect the auricles, canals, and drums b. check auditory acuity c. if acuity is diminished, check lateralization (Weber test) and compare air and bone conduction (Rinne test) i. Room should be darkened for ophthalmoscopic exam. This promotes pupillary dilation and improved visibility of the fundi
- Nose and sinuses: a. Examine the external nose; using a light and nasal speculum b. Inspect the nasal mucosa, septum,
and turbinate’s c. Palpate for tenderness of the frontal and maxillary sinuses
- Throat: a. Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx
- Inspect and palpate the carotid pulsations
- Listen for carotid bruits
- Inspect and palpate he precordium
- Note the location of the apical impulse; attempt to note its diameter, amplitude, duration
- Listen at each auscultatory area with the diaphragm of the stethoscope
- Listen at the apex and the lower sternal border with the bell a. if indicated, ask the patient to roll partly onto left side while you listen at the apex for an S3 (mitral stenosis). The patient should sit, lean forward, and exhale while you listen for the murmur of aortic regurgitation
- Listen for the first and second heart sounds and for physiological splitting of the second heart sound
- Listen for any abnormal heart sounds or murmurs a. Elevate HOB to 30 degrees, adjusting as necessary to see the jugular venous pulsations xi. Abdomen
- Inspect, auscultate, then percuss the abdomen
- Palpate lightly, then deeply
- Assess the liver and spleen by percussion and then palpitation
- Attempt to palpate the kidneys a. If you suspect inflammation of the kidneys from infection, percuss posteriorly over the costovertebral angles (CVAs)
- Try to palpate the aorta and its pulsations a. Lower HOB flat position. Patient should be supine xii. Lower extremities
- Examine the legs, assessing three systems while the patient is still supine
- Peripheral vascular system: a. Palpate the femoral pulses, popliteal pulses b. Palpate the inguinal lymph nodes c. Inspect for lower extremity edema, discoloration, ulcers d. Palpate for pitting edema e. Inspect for varicose veins
- Musculoskeletal system: a. Note any deformities or enlarged joints
