NR 509 Mid-Term Exam (updated 2020) – Chamberlain College of Nursing | NR 509 Mid-Term Exam (updated 2020)

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NR 509 Mid-Term Exam (updated 2020) – Chamberlain College of Nursing ● Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes i... n position, enhance clinical efficiency, move head to toe, examine the patient from their right side Active listening, empathic responses, guided questioning, nonverbal communication, validation, reassurance, partnering, summarization, transitions, empowering the patient 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. Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Guided Questioning- show your sustained interest in the patient’s feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient’s own words, without interruption. Non-verbal- includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed, neutral, or open. Validation- helps to affirm the legitimacy of the patient’s emotional experience. Reassurance- an appropriate way to help the patient feel that problems have been fully understood and are being addressed. Partnering- building rapport with patients, express your commitment to an ongoing relationship. Summarization- giving a capsule summary of the patient’s story during the course of the interview to communicate that you have been listening carefully. Transitions- inform your patient when you are changing directions during the interview. Empowering the Patient- empower the patient to ask questions, express their concerns, and probe your recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take medications as prescribed. Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5 Comprehensive: Used for patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. A source fundamental and personalized knowledge about the patient, strengthens the clinician-patient relationship. ● Is appropriate for new patients in the office or hospital ● Provides fundamental and personalized knowledge about the patient ● Strengthens the clinician–patient relationship ● Helps identify or rule out physical causes related to patient concerns ● Provides a baseline for future assessments ● Creates a platform for health promotion through education and counseling ● Develops proficiency in the essential skills of physical examination Flexible Focused or problem-oriented assessment: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. ● Is appropriate for established patients, especially during routine or urgent care visits ● Addresses focused concerns or symptoms ● Assesses symptoms restricted to a specific body system ● Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible Tangential lighting: JVD, thyroid gland, and apical impulse of heart. Components of the Health History Jenna/Ashley Initial information Identifying data and source of the history; reliability Identifying data- age, gender, occupation, marital status Source of history- usually patient. Can be: a family member or friend, letter of referral, or clinical record. Reliability- Varies according to the patient’s memory, trust, and mood. Chief Complaint Chief Complaint- Make every attempt to quote the patient’s own words. Present Illness Complete, clear and chronological description of the problem prompting the patient visit Onset, setting in which it occurred, manifestations and any treatments Should include 7 attributes of a symptom: ● Location ● Quality ● Quantity or severity ● Timing, onset, duration, frequency ● Setting in which it occurs ● Aggravating or relieving factors ● Associated manifestations -Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives” when doing Review of Systems that are relevant to the chief complaint. A list of potential causes for the patients problems. -Present illness should reveal patient’s responses to his or her symptoms and what effect this has on their life. -Each symptom needs its own paragraph and a full description. -Medication should be documented, name, dose, route, and frequency. Home remedies, non-prescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed medications. -Allergies-foods, insects, or environmental, including specific reaction Tobacco use, including the type. If someone has quit, note for how long -Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness. Past history -Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also include any chronic childhood illness -Adult illnesses: Provide information in each of the 4 areas: ● Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitalizations; number and gender of sexual partners; and risk taking sexual practices. ● Surgical: dates, indications, and types of operations ● Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function. ● Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments. -Health Maintenance: Find out if they are up to date on immunizations and screening tests. Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy, cholesterol levels etc.. Family history Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, and symptoms reported by patient. Ask about history of breast, ovarian, colon, or prostate cancer Ask about Genetically transmitted diseases Personal or social history Describes educational level, occupation, family of origin, current household, personal interests, and lifestyle Capture the patients personality and interests, sources of support, coping style, strengths, and concerns Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety measures, sexual practices, and use of alcohol, drugs, and tobacco Expanded personal and social history personalizes your relationship with the patient and builds a rapport Review of systems pg 11-13 Documents presence or absence of common symptoms related to each of the major body systems Understanding and using Review of Systems questions may seem challenging at first. These “yes-no” questions should come at the end of the inter- view. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.” Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians include diseases like pneumonia or tuberculosis. Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help clarify the diagnosis. For example, after a full description of chest pain, you may ask, “Do you have any history of high blood pressure . . . palpitations . . . shortness of breath . . . swelling in your ankles or feet?” or even move to questions from the Respiratory or Gastrointestinal Review of Systems The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the Present Illness. Significant health events, such as past surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration. Keep your technique flexible. Remember that major health events discovered during the Review of Systems should be moved to the Present Illness Past History in your write-up. Some experienced clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and examination, and necessary note taking becomes awkward The Review of Systems: Pg. 12-13 ROS Chart Copied from online book General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices. Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Cardiovascular: “Heart Trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move-ments, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Palpation. Palpate the olecranon process and press over the epicondyles for tenderness. Palpate the grooves between the epicondyles and the olecranon process, where the synovium is most easily examined. Normally the synovium and olecranon bursae are not palpable. The sensitive ulnar nerve can be palpated posteriorly between the olecranon process and the medial epicondyle. Palpate the epicondyles. Note any displacement of the olecranon process. Abnormal Findings: Elbow Range of Motion: Flexion: Biceps brachii, brachialis, brachioradialis. “Bend your elbow” Extension: Triceps brachii, anconeus. “Straighten your elbow”. Supination: Biceps brachii, supinator. “Turn your palms up, as if carrying a bowl” Pronation: Pronator teres, pronator quadratus. “Turn your palms down.” *After injury, preservation of active range of motion and full elbow extension makes fracture highly unlikely. Tenderness over the radial head, olecranon, or medial epicondyle and bruising, plus absent elbow extension, may improve these test characteristics. Full elbow extension also makes intra-articular effusion or hemarthrosis unlikely. Rheumatoid arthritis Joints affected polyarticular and symmetrical. Assess for subcutaneous nodules. Muscle atrophy and weakness present. Process: Chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone, and damage to ligaments and tendons Common Locations: Hands—initially small joints (PIP and MCP joints), feet (MTP joints), wrists, knees, elbows, ankle Pattern of Spread: Symmetrically additive: progresses to other joints while persisting in initial joints Onset: Usually insidious; human leukocyte antigen (HLA) and non-HLA genes account for >50% of risk of disease; involves proinflammatory cytokine Progression and Duration: Often chronic (in >50%), with remissions and exacerbations Acute RA: Tender, painful, stiff joints in RA, usually with symmetric involvement on both sides of the body. The distal interphalangeal (DIP), metacarpophalangeal (MCP), and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease. Chronic RA: In chronic disease, note the swelling and thickening of the MCP and PIP joints. Range of motion becomes limited, and fingers may deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show “swan neck” deformities (hyperextension of the PIP joints with fixed flexion of the distal interphalangeal [DIP] joints). Less common is a boutonnière deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). Rheumatoid nodules are seen in the acute or the chronic stage. Chapter 17 Neurological Assessment and Modification for Age Normal vs Abnormal Findings and Interpretation Subarachnoid hemorrhage- the worst headache of my life, with instantaneous onset Meningitis- stiff neck and severe headache Brain tumors or abscess- dull headache increased by coughing and sneezing, especially when reoccurring in the same location Migraine- an aura or prodrome. Five pound feature: pulsatile or throbbing, one day duration or at least 4 to 72 hours if untreated, Unilateral; Nausea or vomiting; Disabling or intensity causing interruption of daily activity. Guillain-Barre syndrome- progressive subacute onset of lower extremity weakness. Delirium- a multifactorial syndrome, an acute confusion state marked by sudden onset, fluctuating course, inattention, and at tome changing levels of consciousness. Dementia- declines in memory and cognitive ability that interfere with activities of daily living. Most common Alzheimer (>65 years old). CN 1- olfactory: sense of smell by presenting the patient with familiar non-irrigating odors. Loss of smell occurs=head trauma, smoking, aging, use of cocaine, and Parkinson disease CN 2- optic: test visual activity. Inspect optic fundi, paying close attention to the optic disc. Inspect each disc carefully for bulging and blurred margins (papilledema), pallor (optic atrophy), and cup enlargement (glaucoma). - Test visual fields by confrontation: test each eye separately and then together CN II and III- Inspect size and shape of the pupils, and compare one side with the other. Anisocoria= a difference of >0.4 mm in the diameter of one pupil compared to the other. - Intracranial aneurysm: large pupil reacts poorly to light or aniscoria worsens in light, the large pupil has abnormal pupillary constriction, and ptosis and ophthalmoplegia are also present and if the patient is awake. - Horner syndrome=if both pupils react to light and anisocoria worsens in darkness, the small pupil has abnormal pupillary dilation. CN III, IV, VI- Oculomotor, Trochlear, and Abducens: test the extraocular movements in the six cardinal directions of gaze and look for loss of conjugate movements in the aby the six directions, which causes diplopia CN V- trigeminal- palpate the temporal muscles and masseter muscles and check sensory CN VII- Facial, inspect the face both at rest and during conversation with the patient for symmetry. Ask the patient: raise eyebrows, frown, smile, close both eyes, show both upper and lower teeth, smile, puff out both cheeks. CN VII- Acoustic and Vestibula. Whisper test, Weber, and Rinne. -Vertigo and hearing loss= Meniere disease CN XI- Spinal accessory= stand behind the patient, look for atrophy or fasciculations in the trapezius muscles, and compare one side with the other. Ask patient to shrug both shoulders upward against hands. -Fasciculations= fine flickering irregular movements in small groups of muscle fibers. -Peripheral nerve disorder= trapezius weakness with atrophy and fasciculations points, the shoulder droops, and the scapular is displaced downward and laterally. CNXII- Listen to the articulation of the patient’s words, inspect the tongue as it lies on the floor of the mouth. Look for any atrophy or fasciculations. Some coarser restless movements are normal. Then with the patient’s tongue protruded, look for asymmetry, atrophy, or deviation from the midline. As the patient to move the tongue from side to side, and note symmetry of the movement. Romberg Test- test for position sense. The patient stand fairly well with eyes open but loses balance when they are closed= positive test (Ataxia) Babinski Reponses (Abnormal)- Dorsiflexion of the big toe. Arising from a CNS lesion affecting the corticospinal tract, can be positive in unconscious states from drug or alcohol. Occasionally accompanied by reflex flexion at hip and knee. Unconscious states from alcohol and drugs or seizures. Brudzinski Sign- Flexion of both the hip and knees is positive sign. As you flex the neck, watch the hips and knees in reaction to maneuver. Normally they should remain relaxed and motionless. Kernig sign- pain and increased resistance to knee extension are positive. Flex the patients leg at both the hip and the knee, and the slowly extend the leg and straighten the knee, discomfort behind the knee during full extension is normal but should not produce pain. Lumbosacral radiculopathy- pain radiating into the ipsilateral leg is positive straight leg test. Asterixis- metabolic encephalopathy in patients whose mental functions are impaired. Caused by abnormal function of the diencephalic motor centers that regulate agonist and antagonist muscle tone and maintain posture. Test by asking patient to “stop traffic”, observe for 1 to 2 minutes. Intention tremors- cerebellar disorders Oral-facial dyskinesias- bizarre movements of face= late complications of psychotropic drugs, psychoses, elderly, and edentulous Tics- brief and repetitive= Tourette syndrome and phenothiazines Athetosis- slower and twisting, writhing than choreifrom movements, larger amplitude= cerebral palsy Dystonia- similar to ahetoid movements, often involve large parts of the body. Grotesque, twisted postures. Caused by phenothiazines, torsion dystonia, and spasmodic torticollis. Chorea- brief, rapid, jerky, irregular movements, and unpredictable. Causes= sydenham chorea (with rheumatic fever) and Huntington disease. Aphonia- loss of voice that accompanies disease affecting the larynx or its never supply Dysarthria- defect in muscular control of the speech apparatus. Words may be nasal, slurred, or indistinct Aphasia- disorder in producing or understanding language -Wernicke a fluent receptive aphasia. Sentences lack meaning and words are malformed or invented. Speech may be totally incomprehensible. -Broca Aphasia non-fluent or expressive aphasia. Slow with words and laborious effort. Inflection and articulation are impaired but words are meaningful, with nouns, transitive verbs, and important adjectives. Small grammatical words are dropped. Seizure Disorder pg 724, 780, 781Jessica – patient reports “spells” or fainting - A sudden excessive electrical discharge from cortical neurons. - Symptomatic with an identifiable cause or idiopathic - Epilepsy: two or more seizures that are not provoked by other illnesses or circumstances. Does not always involve loss of consciousness, depends on type. Usually classified as generalized or partial, based on location in the cortex of the initial seizure focus. More common in infants and older adults, the baseline neurological exam is frequently normal. - Generalized epilepsy syndromes- usually begin in childhood or adolescence. - Tonic-clonic motor activity, bladder or bowel incontinence, and postictal state. Tongue biting or bruising of limbs may occur. Loses consciousness, and the body stiffness into tonic extensor rigidity. Breathing stops and patient becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. Breathing resumes and is often noisy, with excessive salvation. - Partial- usually adult-onset seizures - Myclonic (drop attack) - sudden loss of consciousness with falling but no movements. - Absence- a sudden brief lapse of consciousness, with momentary blinking, starting, or movements of the lips and hands but no falling. Typical <10 sec. Atypical > 10 sec. Syncope pg 724 Jessica -Determine if consciousness was lost, external noise or voices throughout the episode, felt light-headed, or weak -Syncope= sudden but temporary loss of consciousness and postural tone from transient global hypoperfusion of the brain - Causes= seizures, vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope, orthostatic hypotension, cardiac disease causes arrythmias. Stroke and subarachnoid hemorrhage are unlikely unless both hemispheres are affected. -Vasovagal Syncope- Most common cause: prodrome nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event, then vagally mediated hypotension, often with slow onset and offset. -Syncope from arrythmias- onset and offset are sudden, reflecting loss and recovery of cerebral perfusion -Micturition syncope: vasovagal response, sudden hypotension. Precipitating= emptying the bladder after getting out of bed. [Show More]

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