NR 509 Mid-Term Study Guide (updated 2020) – Chamberlain College of Nursing | NR509 Mid-Term Study Guide (updated 2020)

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NR 509 Mid-Term Study Guide (updated 2020) – Chamberlain College of Nursing ... NR 509 Midterm Study Guide Week 3 Ch. 1 ● Basic and Advanced Interviewing Techniques Basic Interviewing Techniques ● Active listening: Active listening means 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: Empathy has been described as the capacity to identify with the patient and feel the patient's pain as your own, then respond in a supportive manner. ● Guided questioning: Guided questions 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. ● Nonverbal communication: Nonverbal communication 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: Validation helps to affirm the legitimacy of the patient's emotional experience. ● Reassurance: Reassurance is an appropriate way to help the patient feel that problems have been fully understood and are being addressed. ● Partnering: When 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 patients 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 Interview Techniques ○ Determine scope of assessment: Focused vs. Comprehensive: ■ Comprehensive: Used 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. ● 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 ■ Focused: 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 prob- lems; 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 ○ Being aware of your reactions helps develop your clinical skills. ○ Your success in eliciting the history from different types of patients grows with experience, but take into account your own stressors, such as fatigue, mood, and overwork. ○ Self-care is also important in caring for others. Even if a patient is challenging, always remember the importance of listening to the patient and clarifying his or her concerns. ● Components of the Health History ● Initial information ■ Date and time of history-time is especially important in emergent situations ■ Identifying data-age, gender, marital status, occupation-identify source of history ie: family member, friend etc. ■ Reliability-usually documented at end of interview ie: “patient is vague when describing symptoms”. ○ Chief Complaint(s) ■ Try to quote the patients 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. 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, mineral 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; hospitaliations; 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. ○ 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 symtoms 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 ■ Documents presence or absence of common symptoms related to each of the major body systems ■ Understanding and using Review of Systems questions may seem challeng- ing 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 or 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 the examination, and necessary note taking becomes awkward 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 If onset was abrupt and without warning seizure should be considered. Interview witnesses that were present if possible. Vasovagal syncope is the most common cause of syncope and includes early symptoms of nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event, medicated hypotension, with a slow onset and offset. Other reasons for syncope include orthostatic hypotension, arrhythmias such a VT, and bradyarrhythmias. If both hemispheres are affected, stroke or subarachnoid hemorrhage can cause syncope. See table 17-3 for detailed description reasons/disorders of syncope, mechanism, factors and recovery. Types include: Vasovagal/Vasodepressor Orthostatic hypotension Cough Syncope Micturition Syncope Arrhythmias Aortic Stenosis and Hypertrophic Cardiomyopathy Syncope Hypocapnia due to hyperventilation Hypoglycemia Conversion Disorder with fainting Seizures were reclassified in 2010 as focal or generalized. Focal seizures- are conceptualized as originating within networks limited to one hemisphere. They are discretely localized or more widely distributed. They originate in subcortical structures. Focal seizures do not fall into any recognized set of natural causes. Ictal onset is consistent from one seizure to another. In some cases, more than one seizure type is seen, but each individual seizure type has a consistent site of onset. Focal seizures without impairment of consciousness include : Jacksonian- Tonic than clonic movements that start unilaterally in hand, foot, or face and spread to other body parts on the same side. Other Motor- Turning of the head and eyes to one side, or tonic and clonic movement of an arm or leg without the jacksonian spread. Autonomic symptoms- a funny feeling in the epigastrium, nausea, pallor, flushing, lightheadedness. With subjective sensory or psychic phenomena- numbness, tingling, auditory, hallucinations, olfactory symptoms. Focal seizures with impairment of consciousness- may or may not start with the autonomic and psychic symptoms described above, consciousness is impaired amd motor behaviors such as lip smacking, unbuttoning clothes and chewing are seen. Patient usually becomes amnesic to seizure afterwards, and has a headache. Generalized seizures- are conceptualized as originating at some point within, and rapidly engaging bilaterally distributed networks that include cortical and subcortical structures, but do not necessarily include the entire cortex. In generalized seizures the location and lateralization are not consistent from one seizure to another. They can be asymmetric. They usually begin with body movements, impaired consciousness, or both. If onset of tonic-clonic seizures begins after age 30 years, suspect a partial seizure that has become generalized or a generalized seizure caused by a toxic or metabolic disorder. Types of Generalized Seizures include: Tonic-clonic seizure-patient loses consciousness suddenly, sometimes with a cry, body stiffens 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 salivation. Injury, tongue biting, and urinary incontinence may occur. Absence seizure- A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. 2 types are seen: Typical: lasts <10 secs and stops abruptly, Atypical: lasts >10 secs. Myoclonic seizures- sudden, brief, rapid jerks, involving the trunk or limbs. Associated with a variety of disorders. Myoclonic Atonic-Sudden loss of consciousness with falling but no movements. Injury can occur. Pseudoseizures- mimics seizures but are due to conversion disorders. Do not usually follow a neuroanatomic pattern. ● Cranial Nerves ○ 12 cranial nerves ■ I-Olfactory-sense of smell ● To test: present familiar smell that is non irritating with eyes open and compressing each nare then have them close their eyes and test each nostril, by compressing each nare with different smells than the familiar ○ Loss of smell can occur in sinus conditions, head trauma, smoking, normal aging, Parkinson’s disease, and cocaine use ■ II-Optic-Vision ● To test visual acuity: have the patient stand 20 feet from Snellen eye chart, if they wear glasses for other than reading they should be wearing them, cover one eye with a card and not fingers to prevent being able to see through the fingers and have them read the smallest line they can-the vision is placed in a 2 number series such as 20/50, the first number indicates the distance of the patient from the chart and the second number is the distance at which a normal eye can see the same line ● To test pupils: will test reaction to light-dilation and constriction using a pen light ● Look into the pupil to look at the fundi for changes in arteries, papilledema, pallor, cup enlargement ■ III-Oculomotor-pupil constriction, opening the eyelid (elevation), most extraocular movements ■ IV-Trochlear-downward and internal rotation of the eye ■ V-Trigeminal ● Motor function: jaw clenching, lateral jaw movement ● Sensory function: this nerve has 3 divisions ○ Ophthalmic ○ Maxillary ○ Mandibular ■ To test: have the patient to clench teeth and note the strength and then have them move jaw side to side ■ Will test the sensory portion test sharp and soft feeling at the different areas of the face and forehead ● VI-Abducens-lateral deviation of the eye ○ Testing of III, IV, and VI with eye movement you have the patient follow your finger in the 6 cardinal directions looking for asymmetric movement ■ VII-Facial ● Motor: facial movements including expressions, closing the eye, and closing mouth ● Sensory-taste of salty, sweet, sour and bitter on anterior ⅔ of tongue and sensation from the ear ● To test: noting asymmetry in facial expressions, wrinkle forehead, close eyes so you can’t open, tense neck muscles, puff out cheeks ■ VIII-Acoustic-Hearing (cochlear division) Balance (vestibular) ● To test: whispered voice test ○ Conductive loss: air through ear transmission impairment ○ Sensorineural: damage to the cochlear branch ● Weber test at the top of the head with a tuning fork ● Renee test: test at the back of the head ■ IX-Glossopharyngeal ● Motor: pharynx ● Sensory:posterior portions of the eardrum and canal, pharynx, posterior tongue taste ■ X-Vagus ● Motor: palate, pharynx, and larynx ● Sensory-pharynx and larynx ○ To test IX and V have the patient say ahhh and observe the soft palate rise and fall as well as the uvula remaining centered and the pharynx moving laterally like a curtain-all of this should be simultaneous and symmetrical ○ Test the gag reflex ■ XI-Spinal Accessory: ● Motor: the sternocleidomastoid and the upper trapezius ● Sensory: none ○ To test motor: from behind ask patient to shrug shoulders against hands noting strength of the shrug; from in front of the patient have them turn their chin into your hand noting strength and observing the contraction of the opposite side of the sterno muscle ■ XII-Hypoglossal ● Motor: tongue ○ To test listen to the patient articulation of words, look for asymmetry of movement of tongue from talking and then sticking out the tongue and moving side to side ● Sensory: none ○ ● Intracranial Pressure Causes of increased intracranial pressure (ICP): Increase in brain volume Generalized swelling of the brain or cerebral edema from a variety of causes such as trauma, ischemia, hyperammonemia, uremic encephalopathy, and hyponatremia Mass effect ● Hematoma ● Tumor ● Abscess ● Blood clots Increase in cerebrospinal fluid ● Increased production of CSF ● Choroid plexus tumor Decreased re-absorption of CSF ● Obstructive hydrocephalus ● Meningeal inflammation or granulomas Increase in blood volume ● Increased cerebral blood flow during hypercarbia, aneurysms [Show More]

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