NR 509 SOLVED MIDTERM EXAM TEST PREP (UPDATED 2021)

NR 509 SOLVED MIDTERM EXAM TEST PREP (UPDATED 2021) ◇Most frequently asked questions collected for exam preparations ● Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unne ...

NR 509 SOLVED MIDTERM EXAM TEST PREP (UPDATED 2021) ◇Most frequently asked questions collected for exam preparations ● Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes in 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. ● ● patient ● ● Is appropriate for new patients in the office or hospital Provides fundamental and personalized knowledge about the 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 lifestyleCapture 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, oritching, 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 methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho-therapy, or psychiatric admissions. Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, orjudgment; headache, dizziness, vertigo, fainting, black-outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”. Subjective vs Objective Data Subjective- symptoms or what the patient tells you. Apparent only to the person affected; includes client’s perceptions, feelings, thoughts, and expectations. Cannot be directly observed and can be discovered only asking questions. Examples: low back pain, fatigue, immunizations, weight gain, stomach cramps. Objective- signs or what you observe. Detectable by an observer or can be tested against acceptable standard; tangible; observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam. Examples: blood pressure, heart rate, wound appearance, lung sounds, ambulation description. Subjective Data (symptoms) What the patient tells you Patients history, from Chief Complaint through Review of Systems Objective Data (signs) What is observed during physical examination Laboratory information, test data Documentation- Documentation needs to be CLEAR, CONCISE, COMPREHENSIVE. -think order and readability, amount of detail. - Record: history, PE, and lab findings - describe what's observed not what was done -SOAP (subjective, objective, assessment, & plan) note is used for providers of various backgrounds/specialties to communicate with each other Chapter 2 Clinical Decision Making ashley Clinical decision making should be evidence based. The FNP should draw on a full range of knowledge and experience, and read widely. Clinical decision making is when the reading about diseases and abnormalities is most useful. By consulting the clinical literature, you are embarking on evidence-based decision making and clinical practice. There are five steps to generating a clinical hypotheses 1. Select the most specific and critical findings to support your hypothesis2. Match findings against all the conditions that can produce them. 3. Eliminate the diagnostic possibilities that fail to explain findings. 4. Weigh the competing possibilities and select the most likely diagnosis 5. Give special attention to potentially life-threatening conditions Once the hypothesis is made it should be tested, this may include further history taking, testing or physical examination. The next step is to establish a working diagnosis such as “bacterial meningitis, pneumococcal”. The final step is developing a plan. The plan should make reference to diagnosis, treatment and patient education. It is important to discuss your assessment with the patient prior to finalizing the plan to ensure the patient is onboard. Critical Thinking and Reasoning Critical thinking- the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action. The main critical thinking skills in which nursing students should be exercised during their studies are critical analysis, introductory and concluding justification, valid conclusion, distinguish between facts and opinions, evaluation the credibility of information sources, clarification of concepts and recognition of conditions. Critical thinking is an essential process for the safe, efficient and skillful nursing practice. The nursing education programs should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning. Critical thinking is the disciplined, intellectual process of applying skillful reasoning as a guide to belief or action. In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care. Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision- making. Differential Diagnoses (obtained from book and week 1 review) - A list with potential causes of patient specific problem/CC -A chief complaint must be identified first. -Includes all medical diseases that may possibly explain problem/ CC. -The differential diagnosis list should begin with the most likely explanation or etiology for the problem/CC. EX: C/O vomiting blood: 1. Peptic ulcer 2.Cirrhosis with bleeding esophageal varices 3. Acute hemorrhagic gastritis -Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. The differential diagnosis list is similar to, but different from, the problem list. -The differential diagnosis includes all of the medical diseases that may possibly explain the patient’s chief complaint or principal problem -A differential diagnosis list is focused on providing an explanation for a specific complaint.-In order to develop a differential list versus a problem list, you must first identify the chief complaint. Each differential diagnosis should offer an explanation or etiology for the same chief complaint. Pathological and Physiological Processes Pathologic Process- patient complaints often stem from a pathologic process involving diseases of a body system or structure. Common Classified: congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic. Example: Possible pathological causes of a headache include- sinus infection, concussion from trauma, subarachnoid hemorrhage, or brain tumor. Problem List -After you complete the clinical record, it is good clinical practice to generate a problem list that summarizes the patient’s problems that can be placed in the front of the office or hospital chart. -List the most active and serious problems first and record their date of onset. - Helps to individualize the patient’s care. On follow-up visits, provides a quick summary of the patient’s clinical history and a reminder to review the status of problems the patient may not mention. -An accurate Problem List allows better population management of patients, by using EHRs to track patients with specific problems, recall patients who are behind on appointments, and follow up on specific issues. -Allows other members of the health care team to learn about the patient’s health status at a glance. For example, in a patient who is vomiting blood and is known to have migraines and to be diabetic, the problem list might read: 1. Hematemesis 2. Diabetes Mellitus 3. Migraine 4. Recent divorce 5. Poverty Prioritization Generate problem list with all problems noted, differential diagnoses should cover all possible causes of chief complaint. Prioritize which complaints/problems are highest priority (urgent) for this visit. (i.e., Tina has diabetes, htn, and a slew of other issues, but utmost importance is her foot wound and ankle pain) Chapter 3 **Interpretation and Analysis (Area is lacking information) Heather and StacyThe clinician must focus on the patient to elicit the full story of the patient's symptoms, but the clinician must also interpret key information to reach an assessment and plan. Patient-centered interviews recognize the importance of patients' expressions of personal concerns, feelings, and emotions and evoke the personal context of the patient's symptoms and disease Sensitivity- true positive. The probability that a person with disease as a + test. Specificity- True negative. SnNOUT- a sensitive test with a negative result rule OUT disease SpPIN- a specific test with a positive result rules IN disease Bayes Theorem- one way to use likelihood ratios to revise probabilities for disease Natural frequencies- represents the joint frequency of two events, such as the number of patients with disease and the number who have a positive test result. Kappa score- reproductivity. Measures the amount of agreement that occurs beyond chance. Precision-reproductivity. Being able to apply the same test to the same unchanged person and obtain the same results. Logical Sequence pg 73 In general, an interview moves through several stages. Throughout this sequence, as the clinician you must remain attuned to the patient’s feelings, help the patient express them, respond to their content, and validate their significance. As a student, you will concentrate primarily on eliciting the patient’s story and creating a shared understanding of the patient’s concerns. Later on, as a practicing clinician, reaching an agreement on a plan for further evaluation and treatment becomes more important. Whether the interview is comprehensive or focused, pay close attention to the patient’s feelings and affect, always working on strengthening the relationship as you move through the typical sequence that follows. Including the patient’s feelings, ideas, and expectations leads to therapeutic interventions best suited to the patient’s needs, coping skills, and life circumstances. 1. Greeting the patient and establishing rapport. The initial moments of your encounter lay the foundation for your ongoing relationship. If this is the first contact, explain your role, your status as a student, and how you will be involved In the patient’s care. Use a formal title to address the patient. Avoid first names until you have permission, except with children and adolescents. Don’t be afraid to clarify how to pronounce a patient’s name. Acknowledge any visitors in the room and inquire about their names and relationship to the patient. Whenever visitors are present, YOU ARE OBLIGATED TO MAINTAIN THE PATIENT'S CONFIDENTIALITY. Let the patient decide if the visitors can stay in the room. ALWAYS BE ATTUNED TO THE PATIENT'S COMFORT. Consider the best way to arrange the room and how close you should be to the patient. Give the patient your undivided attention. 2. Taking Note As a novice, you may need to write down much of what you learn during the interview. Experienced clinicians usually recall much of the interview without any notes. Jot down short phrases, specific dates, or words, but do not let note taking or the laptop screen distract you from the patient. Maintain good eye contact. If the patient is talking about disturbing material, put your pen down and look away from thecomputer. Face the patient directly as you elicit the patient’s story, observing non-verbal behaviors. Look up from the computer as often as possible, readjusting your position as needed. 3. Establishing the Agenda=chief complaint Once you have established rapport, you are ready to pursue the patient’s reason for seeking care, traditionally called the chief complaint. In the ambulatory setting, where there are often three or four reasons for the visit, the phrase presenting problem(s) may be preferable. One benefit to this phrase is that it does not characterize the patient as a complainer. Begin with open-ended questions that allow full freedom of response: “What are your special concerns today?”, “How can I help you?”, or “Are there specific concerns that prompted your appointment today?” These questions encourage the patient to talk about any kinds of concerns, not just clinical ones. Note that the first problem the patient mentions may not be the one that is most important. Often, patients give one reason for the visit to the nurse and another to you. For some visits, patients do not have a specific concern and only “want a check-up”. Identifying all concerns allows you and the patient to decide which ones are most pressing and which can be postponed to another visit. Using questions such as, “Is there anything else?”, “Have we got everything?”, or “Is there anything we missed?”, can help to uncover the patient’s full agenda and “the real reason” for the visit. Identifying the full agenda protects time for the most important issues. Even negotiating the agenda at the outset doesn’t avert “oh by the way” concerns that suddenly emerge at the end of the visit. 4. Inviting the Patient’s story Once you have prioritized the agenda, invite the patient’s story by asking about the foremost concern, “Tell me more about...” Encourage patients to tell their stories in their own words, using an open-ended approach. Avoid biasing the patient’s story—do not inject new information or interrupt. Instead, use active listening skills: lean forward as you listen; add continuers such as nodding your head and phrases like “uh huh,” “go on,” or “I see.” Train yourself to follow the patient’s leads. If you ask specific questions prematurely, you risk suppressing details in the patient’s own words. Studies show that clinicians wait only 18 seconds before they interrupt.28 Once interrupted, patients usually do not resume their stories. After the patient’s initial description, explore the patient’s story in more depth. Ask, “How would you describe the pain?”, “What happened next?”, or “What else did you notice?” so that the patient enriches important details. 5. Exploring the Patient’s perspective The disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient. Disease is the explanation that the clinician uses to organize the symptoms that leads to a clinical diagnosis. Illness is a construct that explains how the patient experiences the disease, including its effects on relationships , function , and sense of well-being. FIFE The Patient’s Feelings, including fears or concerns, about the problem The patients Ideas about the nature and cause of the problem The effect of the problem on the patients’ life and Function The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences. 6. Identifying and Responding to the Patient’s emotional Cues. Illness is often accompanied by emotional distress; 30% to 40% of patients have anxiety and depression in primary care practices. Visits tend to be longer when clinicians miss emotional clues. Clues to the patients’ perspective on illnessDirect statement by the patient of explanations, emotions, expectations, and effects of the illness Expression of feelings about the illness without naming the illness Attempts to explain or understand symptoms Speech clues (e.g., repetition, prolonged reflective pauses) Sharing a personal story Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. A mnemonic for responding to emotional cues is NURSE: Name- “that sounds like a scary experience for you”; Understand or legitimize- “It’s understandable that you feel that way”; Respect- “you’ve done better than most people would with this”; Support- “I will continue to work with you on this”; and Explore- “How else were you feeling about it”. 7. Generating and Testing Diagnostic Hypotheses As you gain experience listening to patient concerns, you will deepen your skills of clinical reasoning. You will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generate the differential diagnosis. It is important to fully flesh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to errors in diagnosis. It is helpful to visualize the process of evoking a full description of each symptom as “the cone” First, open-ended questions to hear “the story of the symptom” in the patient’s own words Then more specific questions to elicit “the seven features of every symptom” Finally, the yes-no questions or “pertinent positives and negatives” from the relevant section of the review of systems Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the written record. Questions about clusters of symptoms in common clinical entities are also found in “The Health History” section of each of the regional physical examination chapters. The interview is your primary source of evidence for and against various diagnostic possibilities. The challenge is to avoid a clinician- centered agenda, letting focused questions take over that obscure the patient’s perspective and limit your opportunity to create an empathic therapeutic connection. 9. Sharing the treatment plan Learning about the disease and conceptualizing the illness allow you and the patient to create a shared picture of the patient’s problems. This multifaceted picture then forms the basis for planning further evaluation (e.g., physical examination, laboratory tests, consultations) and negotiating a treatment plan. Shared decision-making has been called the pinnacle of patient-centered care.36 Experts recommend a three-step process: introducing choices and describing options using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time, if needed. 10. Behavior change and Motivational Interviewing. Many of your patient visits will close with a discussion of behavior changes needed to optimize health or treat illness. These could include a change in diet, exercise habits, cessation of smoking or drinking, adherence to medication regimens, or self-management strategies, among others.38 Advanced techniques such as motivational interviewing and the therapeutic use of the clinician–patient relationship are beyondthe scope of this book. Nonetheless, it is worthwhile to introduce the principles of motivational interviewing, a set of well-documented techniques that improve health outcomes, especially for patients with substance abuse.39 Motivational interviewing helps patients “to say why and how they might change, and is based on the use of a guiding style” of inter- viewing, rather than direct advice. It engages patients to express the pros and cons of a given behavior.40 Motivational interviewing makes the assumption that many patients already know what is best for them and helps them con- front their ambivalence to change.41 Using three core skills empowers the patient to provide ideas, solutions, and a timetable for change. The Guide Style of Motivational Interviewing: 1. “Ask” open-ended questions—invite the patient to consider how and why they might change. 2. “Listen” to understand your patient’s experience—“capture” their account with brief summaries or reflective listening statements such as “quitting smoking feels beyond you at the moment”; these express empathy, encourage the patient to elaborate, and are often the best way to respond to resistance. 3. “Inform”—by asking permission to provide information, and then asking what the implications might be for the patient. 11. Closing the Interview and the Visit. You may find that ending the health history interview, and later concluding the visit, are difficult. Patients often have many questions, and if you have done your job well, they feel engaged and affirmed as they talk with you. Let the patient know that the end of the interview or the visit is approaching to allow time for any final questions. Make sure the patient understands the mutual plans you have developed. For example, before gathering your papers or standing to leave the room, you can say, “We need to stop now. Do you have any questions about what we’ve covered?” As you close, summarizing plans for future evaluation, treatments, and follow-up is helpful. A useful technique to assess the patient’s understanding is to “teach back,” whereby you invite the patient to tell you, in his or her own words, the plan of care. An example would be: “Could you please tell me what you understand is our plan of care?” The patient should have a chance to ask any final questions, but the last few minutes are not a good time to bring up new topics. If this happens and the concern is not life threatening, simply assure the patient of your interest and make plans to address the problem at a future time. “That knee pain sounds concerning. Why don’t you make an appointment for next week so we can dis- cuss it?” Reaffirming your ongoing commitment to the patient’s health shows your involvement and esteem. 12. Taking Time for Self-Reflection The role of self-reflection, or mindfulness, in developing clinical empathy cannot be overemphasized. Mindfulness refers to the state of being “purposefully and nonjudgmentally attentive to [one’s] own experience, thoughts, and feelings.”44 As you encounter people of diverse ages, gender identities, social class, race, and ethnicity, being consistently respectful and open to individual differences is an ongoing challenge of clinical care. Because we bring our own values, assumptions, and biases to every encounter, we must look inward to see how our own expectations and reactions affect what we hear and how we behave. Self-reflection is a continual part of professional development in clinical work. It brings a deepening personal awareness to our work with patients. This personal awareness is one of the most rewarding aspects of patient care. Associated Symptoms OLD CARTS Seven Attributes of a Symptom 1.Location 2.Quality 3.Quantity or severity 4.Timing, including onset, duration, and frequency 5.The setting in which it occurs 6.Factors that have aggravated or relieved the symptoms 7. Associated manifestationsAdaptive Questioning Guided Questioning: 1.Moving from open-ended to focused questions 2.Using questioning that elicits a graded response 3.Asking a series of questions, one at a time 4.Offering multiple choices for answers 5. Clarifying what the patient means 6.Encouraging with continuers 7.Using echoing Challenging Patients -Silent -Blind -Confusing -With impaired capacity -Talkative -Angry or disruptive -With a language barrier -With low literacy or low health literacy -With hearing impairment -With limited intelligence -Seeking personal advice -Seductive Chapter 4 General Approach to the Physical Examination Use open-ended questions-helps to encourage the patient to describe what they are experiencing Listen and ask common-sense questions Follow a thorough and systematic sequence to history taking and physical examination Keep an open mind toward both the patient and the clinical data Always include "the worst-case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely eliminated Analyze any mistakes in data collection or interpretation Confer with colleagues and review the pertinent clinical literature to clarify uncertainties Apply the principles of evaluating clinical evidence to patient information and testing As you talk with and examine the patient, heighten your focus on the patient’s mood, build, and behavior ○ 1. Reflect on your approach to the patient: When greeting the patient identify yourself as a student, beginners spend more time in certain areas and that is ok but just warn the patient that you may want to listen to their heart a little longer but that does not mean anything is wrong ■ Avoid interpreting your findings, you are not the patients primary care provider ■ Avoid negative reactions or showing distaste when finding abnormalities○ 2. Adjust the lighting and the environment: set the stage so that both you and the patient are comfortable; good lighting and a quiet environment enhance what you see and hear however may be hard to arrange ○ 3. Check your equipment: The following equipment is needed: ■ An ophthalmoscope and an otoscope. If you are examining children, the otoscope could allow pneumatic otoscopy. ■ ●A flashlight or penlight ■ ■ ■ ■ ■ ■ ■ ● Tongue depressors A ruler and a flexible tape measure, preferably marked in centimeters ●Often a thermometer ●A watch with a second hand ●A sphygmomanometer ●A stethoscope with the following characteristics: ●Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the proper size, align the ear pieces with the angle of your ear canals, and adjust the spring of the connecting metal band to a comfortable tightness. ■ ●Thick-walled tubing as short as feasible to maximize the transmission of sound: ∼30 cm (12 inches), if possible, and no longer than 38 cm (15 inches) ■ ●A bell and a diaphragm with a good changeover mechanism ■ ■ ■ ■ ●A visual acuity card ●A reflex hammer ●Tuning forks, both 128 Hz and 51 Cotton swabs, safety pins, or other disposable objects for testing sensation and two-point discrimination ■ ●Cotton for testing the sense of light touch ■ ■ ■ studies ■ ●Two test tubes (optional) for testing temperature sensation ●Gloves and lubricant for oral, vaginal, and rectal examinations ● Vaginal specula and equipment for cytologic and bacteriologic ●Paper and pen or pencil, or desktop or laptop computer ○ 4. Make the patient comfortable. Show sensitivity to privacy and patient modesty; this conveys respect for the patients vulnerability ○ 5. Observe standard and universal precautions. ○ 6. Choose the sequence, scope, and positioning of examination **Interview Facilitation Vital Signs pg. 123: Blood pressure, heart rate, RR, and temperature Begin by measuring the blood pressure and heart rate. Count the heart rate for one minute by palpating the radial pulse with your fingers, or by listening for the apical pulse with stethoscope at the cardiac apex. Count respirations at this time to avoid the patient becoming alerted=change in pattern.Blood Pressure pg 124 Ambulatory and Home blood pressure monitoring are more predictive of cardiovascular disease and end organ damage than manual and automated measurements in the office Reference standard for confirming elevated office blood pressures- Measure blood pressure at preset intervals over 24 to 48 hours, usually every 15-20 minutes during the day and 30 to 60 minutes during the night. Gold Standard: Ambulatory blood pressure monitoring: automated. Provides 24 hour average blood pressures. Shows nocturnal blood pressure “dips” (normal) or stays elevated (Cardiovascular disease risk factor). Expensive and may not be covered by insurance. Types of hypertension: 1.White coat hypertension (isolated clinic hypertension) > 140/90 in medical settings and mean awake ambulatory readings <135/85 2. Masked hypertension office blood pressure <140/90, but elevated daytime blood pressure >135/85. 3.Nocturnal hypertension- “dipping occurs” in most patients at night as they shift from wakefulness to sleep. Selecting the Correct Size Cuff: Cuff too small= readings HIGH. Cuff too large= readings LOW Brachial Artery: brachial artery below heart= BP readings HIGHER. Brachial artery above heart level= BP readings LOW. Definitions of Hypertension ● Make sure patients understand all the steps needed to ensure accurate readings at home, as detailed in this section. Office manual or automated blood pressure based on the average of two readings on two separate occasions: ≥140/90 Classification of Hypertension Normal <120 systolic <80 diastolic Prehypertension 120-139 systolic 80-89 diastolic Stage 1 ages 18-60; diabetes or renal disease 140-159 systolic 90-99 diastolic Ages > 60 years 150-159 systolic >100 Stage 2 >160 systolic >100 diastolic Steps to Ensure Accurate Blood Pressure Measurement 1. The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement. 2. The examining room should be quiet and comfortably warm. 3. The patient should sit quietly for 5 minutes in a chair with feet on the floor, rather than on the examining table. 4. The arm selected should be free of clothing, fistulas for dialysis, scars from brachial artery cutdowns, or lymphedema from axillary node dissection or radiation therapy. 5. Palpate the brachial artery to confirm a viable pulse and position the arm so that the brachial artery, at the antecubital crease, is at heart level—roughly level with the fourth interspace at its junction with the sternum. 6. If the patient is seated, rest the arm on a table a little above the patient’s waist; if standing, try to support the patient’s arm at the mid-chest level Estimate the Systolic Pressure and Add 30 mm Hg : To decide how high to raise the cuff pressure, first estimate the systolic pressure by palpation. As you palpate the radial artery with the fingers of one hand, rapidly inflate the cuff until the radial pulse disappears. Read this pressure on the manometer and add 30 mm Hg. Using this sum for subsequent inflations prevents discomfort from unnecessarily high cuff pressures. It also avoids the occasional errorcaused by an auscultatory gap—a silent interval that may be present between the systolic and diastolic pressures (Fig. 4-5). Deflate the cuff promptly and completely and wait for 15 to 30 second Identify the Systolic Blood Pressure Inflate the cuff again rapidly to the target level, and then deflate the cuff slowly at a rate of about 2 to 3 mm Hg per second. Note the level when you hear the sounds of at least two consecutive beats. Identify the Diastolic Blood Pressure Continue to deflate the cuff slowly until the sounds become muffled and disappear. To confirm the disappearance point, listen as the pressure falls another 10 to 20 mm Hg. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mm Hg below the muffling point, provides the best estimate of diastolic pressure Average Two or More Readings Read both the systolic and diastolic levels to the nearest 2 mm Hg. Wait 2 or more minutes and repeat. Average your readings. If the first two readings differ by more than 5 mm Hg, take additional readings. When using an aneroid instrument, hold the dial so that it faces you directly. Avoid slow or repetitive inflations of the cuff because the resulting venous congestion can cause false readings Measure Blood Pressure in Both Arms At Least Once. Normally, there may be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg. Subsequent readings should be made on the arm with the higher pressure. **A pressure difference of more than 10 to 15 mm Hg occurs in subclavian steal syndrome, supravalvular aortic stenosis, and aortic dissection, and should be investigated. Orthostatic Hypotension If indicated, assess orthostatic hypotension, common in older adults. Measure blood pressure and heart rate in two positions—supine after the patient is resting from 3 to 10 minutes, then within 3 minutes once the patient stands up. Normally, as the patient rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, whereas diastolic pressure rises slightly. Orthostatic hypotension is a drop in systolic blood pressure of at least 20 mm Hg or drop in diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing. Causes of orthostatic hypotension include drugs, moderate or severe blood loss, prolonged bed rest, and diseases of the autonomic nervous system. The Hypertensive Patient with Systolic Blood Pressure Higher in the Arms than in the Legs Compare blood pressure in the arms and the legs and assess “femoral delay” at least once in every hypertensive patient.