Test 1 - Clinical II PDF

Test One – Clinical II Week One – Clinical and Diagnostic Reasoning: The Nursing Process: - Provides a framework to identify client health status and help them meet health needs - Provides a guide for planning, implementing and evaluating care...

Test One – Clinical II Week One – Clinical and Diagnostic Reasoning: The Nursing Process: - Provides a framework to identify client health status and help them meet health needs - Provides a guide for planning, implementing and evaluating care - Written as a nursing care plan Characteristics o Dynamic and Cyclic o Client Centered o Flexible o Universally applicable o Patient status oriented 5 Steps: A ssessment D iagnosis P lanning I mplementation E valuation Nursing Assessment (CRITICAL PHASE): - Gain an understanding of the patient’s health - Identify strengths that promote health - Identify needs and nursing diagnosis to form interventions - Evaluate the effects of the plan - Establish a database for nursing intervention Characteristics: o First phase in nursing process o Systematic o Data is collected and used to identify health problems o Nurse collects, clusters and validates to organize data o Continuous process o CNO outlines accountability for assessment What is data? Information or facts about the patient used to identify health problems, plan nursing care and evaluate patient outcome Types of Data: Primary: subjective/objective data obtained from client (posture and statements) Secondary: Info obtained from sources other than client, clients record (ex. Xrays, family statement, verbal report) Types of Databases: Complete: includes complete health history and full physical exam Episodic/problem centered: short-term problem, mini database Follow up: evaluate identified problems at regular intervals Emergency: rapid collection complied concurrently with lifesaving measures Importance of critical thinking?  Assesment requires critical thinking skills and knowledge to decide what assessment to make, the info you need to know and how to get that information Critical thinking is recognizing that an issue exists, analyzing information, evaluating information and making conclusions. It is more than just cognitive skills, ability to ask questions, be well informed, honesty in facing personal biases, willing to reconsider and think clearly about issues. Steps of the Assessment Phase: 1. Collect data: observation, physical exam, interview 2. Validate Data with client and significant others: compare w obj data, validate conflicting data 3. Organize and Record Data: Initial assessment, ongoing assessment, special purpose assessments Interview: Contains purposeful structured communication, nurse questions client, initial assessment forms nursing history, nurse collects data about illnesses, clients ability to function and ability to cope. Components of a Nursing Health History: - Biographical information - Reasons for visit - History of current illness - Past health status - Review of systems - Social and family history - Lifestyles - Spiritual well-being - Psychological data - Patients perception of health status - Patients expectations General Survey – conscious use of physical senses to gather data from the client and environment, systematic so that no important information is missed Physical Exam – concerned with identifying strengths and deficits in functional abilities, provides objective data, data from general survey is used as a baseline for comparison I nspections: with instruments (otoscope, penlight, stethoscope) P alpation: uses fingerpads P ercussion: striking of body surface to create sound or vibration A uscultation: direct and done by unaided ear or indirect using stethoscope Validating Data: Verify data to ensure, complete, factual and accurate assessment, eliminate errors and biases and avoid jumping to faulty conclusions Should be validated if: - Subjective and objection do not agree - Client statements differ at different times in assessment - Data seems very abnormal  - Factors are present that interfere with accurate measurement Organize/ Cluster Data and Recording Data: After data is gathersed and validated, organize and put together related clues (what they say vs what you see, hear, feel, smell or measure), use a model to provide framework and interpret, use framework to find patterns. To record data: the nurse database is legal document, record accurate data not interpretation of data, record cues not inferences, avoid vague generalities Nursing Frameworks: Organizational tools to enable systematic collection of data, chosen because of philosophical orientation of nurse, facilitation of research, nursing needs or client population, what was learned in nursing school, what is used in health care institution Non-Nursing models: Head to toe, Maslow’s, body systems review model 1. Body systems Review: a. General appearance b. Measurements c. Skin, hair, eyes, ears, nose and sinuses d. Mouth, throat and neck e. Breast and axilla f. Respiratory system g. Cardiovascular system h. Peripheral system i. Gastrointestinal system j. Urinary system k. Female/male genital system l. Sexual health m. Musculoskeletal system n. Neurologic system o. Hematologic system p. Endocrine system 2. Jarvis Health Assessment Framework a. Health history and physical exam including all aspects of nursing history b. Focus is on the individual both in wellness and illness needs c. Health promotion d. Encourage discussion to promote health history e. Transcultural considerations f. Care based on developmental age and state of health Clinical Judgement: Recognizing cues, generating and weighing hypotheses, taking actions and evaluating Diagnostic Reasoning: occurs during second phase of nursing process (DIAGNOSIS), used to analyze data and draw conclusions about the clients health status, pivotal step in nursing process, diagnosis depends on assessment phase because of quality of data.  Assessment and Diagnosis phase overlap because nurses begin interpreting at the same time. The purpose is to identify the patients’ health status. Interpretation: complex process 1. Identify cues 2. Cluster cues and data gaps 3. Draw conclusions about present health status 4. Determine etiologies and categorize problems Cluster: grouping significant cues Etiology: most likely cause or contributing factor of the nursing diagnosis PRIORITIZE: ABC Concept map: tool used to organize cues and problem to find a connection Week Two – Interview and Complete Health History Interview Process: Subjective: what the patient says about themselves Gather complete and accurate data – represents client and addresses needs Establish report and trust Awareness of biases – based on own life experiences, reflect before on biases Share information with patient about health state Build report for a continuing therapeutic relationship Opportunities to engage in health promotion and illness prevention Address social determinants of health Ex. Homelessness/poverty high risk of exposure to trauma and violence, have a high level of stigma, don’t get treated well in health care Things to consider: Time and place  Introduction and explanation Purpose Length Expectations Presence of others Confidentiality Cost (address only if needed or asked) Ensure privacy Minimize interruptions Attention to environment Taking notes but still active listening Challenges of Note Taking Impedes eye contact Shifts attention away from patient Impedes observation of nonverbal behaviour Can be threating when discussing sensitive issues 10 Traps of Interviewing: 1. Providing false assurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Overusing medical jargon 7. Making assumptions or asking biased questions 8. Talking too much 9. Interrupting 10. Using “why” questions The Complete Health History: Biographical data Includes: name, age, address, phone number, health card, DOB, birthplace, gender, marital status, ethnocultural background, occupation, source of information Reason for seeking care Use quotes from patient, symptom = follow up with PQRSTU, sign (abnormality) Current health or history of current illness Characteristic of symptom, location, quality, severity, timing, setting, relieving factors, associated factors, patients perception/ understanding Past health General health in past 5-10 yrs, childhood illnesses, hospitalizations, obstetrical history (# full term preg, preterm, abortion, prenatal, postpartum), vaccines, allergies (marked in RED with stars), current meds Family History  Age and health or cause of death of relatives, health of close family members (BLOOD RELATED), family tree Review of Systems Quick but SUBJECTIVE, not objective or physical exam data Functional assessments and ADLS - Self-esteem - Sleep and rest - Coping and stress - Smoking history, alcohol, substance use (don’t judge just ask) Documentation for Complete Health History: - Who provided the information (spouse, client, significant other, family) - Use of interpreter - Patients’ orientation to Person, Time, Place, Situation (oriented x4) - Ability to communicate - What their preferred language is Cultural Considerations: when arrived in Canada and from where immigrant status, nutrition Know clients perception of Health: What it means to them, concerns, health goals, what to expect from health care providers Developmental Considerations for Adolescents: Home environment Education and employment Eating Activites Drug use Sexuality Suicide/ Depression Safety from injury and violence Skin, Hair and Nails Functions: Protection Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Production of vitamin D Older Adults: Slow atrophy of skin Loss of elasticity Thinning of stratum corneum  Decreased sweat Greater risk of heat stroke Senile Purpura Increased risk of skin disease Change of hair distribution Psychological impact of visible aging Subjective Data: - Previous Hx of skin disease - Change in pigmentation - Change in moles - Excessive dryness - Pruritis - Excessive bruising - Rash/lesions - Medication - Hair loss - Change in nails - Environemental hazards - Self-care behaviours Assessment (inspect and palpate, use back of hand for temp): - Colour - Pallor - Erythema - Cyanosis - Jaundice - Brown tan Edema: Fluid in legs, checked in legs 1+ mild pitting, no swelling 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, legs look swollen, indentation remains for a short time 4+ very deep pitting, very swollen, indentation lasts for a long time Objective Data of Physical Exam: Lesions: - Colour - Elevation - Pattern or shape - Size - Location and distribution - Exudate Types of Vascular Lesions Hemangioma Telangiectases Purpuric lesions Lesions caused by trauma or abuse Pot-wine stain Spider or star Petechiae Pattern injury Strawberry mark angioma Purpura Hematoma  Cavernous Venous lake Ecchymosis hemangioma Common Skin Lesions In children Common Diaper Dermatitis Primary contact dermatitis Intertrigo Allergy Impetigo Tinea corporis (ringworm of the body) Eczema Tinea pedis (ringworm of the foot) Measles (rubeola) Psoriasis German measles (rubella) Tinea versicolor Chickenpox (varicella) Herpes zoster (shingles) Erythema of Lyme Disease Malignant Skin Cancers Basal Cell Carcinoma Squamous Cell Carcinoma Malignant Melanoma  Metastatic Malignant Melanoma Mole Patrol: Asymmetry Border Color Diameter Evolution Abnormal Findings of the Skin: Circular Confluent Discrete Grouped Gyrate Target  Linear Polycyclic Zosteriform Pressure Wounds: Appear over bony prominence when circulation is impaired Assessed by stage (I-IV) depending on depth Stage 1: intact skin, appears red but unbroken Stage 2: partial thickness skin erosions, open blister Stage 3: full thickness, extends into sub-q tissue but no visible muscle or bone  Stage 4: extending into muscle, tendon, bone which may be exposed Hair: Look for signs of infestation Inspect and palpate Look at colour and note from pale blond to total black then grey, note if dyed Texture (smooth, thick, thin, straight, curly) Distribution Lesions (seborrhea = dandruff) Abnormal conditions: Seborrheic Dermatitis (cradle cap) Tinea Capitis (scalp ringworm) Alopecia Areata Toxic Alopecia Trichotillomania Pediculosis capitis (lice) Folliculitis (looks like pimples w hair coming out) Hirsutism Furuncle and abscess Nails: Inspect and palpate Look at shape and contour (normal = 160 degree or less) Consistency Colour: translucent nail plate and pink nail bed underneath Capillary refill within 3 seconds Abnormal conditions: Paronychia Beaus line Splinter hemorrhages Onycholysis Late clubbing Pitting Habit-tic Dystrophy Developmental Considerations: Infants: Mongolian Spot Café-au-lait spot Harlequin colour change Older Adults: Senile lentigines (liver spots) Skin Tags Thickened, brittle or yellow nails Common Foot Problems: Week Three – Head, Face and Neck, Including Regional Lymphatic System Anatomy and Physiology of Head and Face: Cranial Bones: frontal, parietal, occipital and temporal Sutures: coronal, sagittal and lambdoid Facial Bones: maxilla and mandible Salivary Glands: parotid (in cheeks), submandibular (jaw), sublingual (chin) C1 and C2 vertebrae = Atlas and Axis Abnormalities: Bulging Fontanel = hydrocephalus Sunken Fontanel = dehydration Anatomy and Physiology of Neck: Neck Muscles: sternocleidomastoid Anterior and posterior triangles Thyroid gland: wrapped around trachea Abnormalities: Deviated Trachea = BIG TROUBLE Impending obstruction of airway In pneumothorax the trachea deviates to the unaffected side Lymph Nodes: NOT PALPABLE, note size, tenderness and mobility Mnemonic: Please Put Our Small Snails Just Sitting Down, Playing Softly Preauricular (before ear) Posterior auricular (behind ear) Occipital Submental (under chin) Submandibular (jaw)  Jugulodigastric (tonsillar) Superficial cervical Deep cervical Posterior cervical Supraclavicular Located in 4 regions: Head and Neck Axilla Arm Inguinal Developmental considerations: Infants and Children: Fontanelles Head growth Lymphatic System – swollen on kid = abnormal but not worrisome Skull – head circumference, caput succedaneum (swelling after birth), cephalhematoma (goose egg) Face – symmetry, appearance, presence of swelling Neck – muscle development and head control Pregnant Women: Slight enlargement of thyroid Older Adults: Sagging facial – normal as long as its symmetrical Senile tremors Concave cervical curve Dizziness during ROM Subjective Data Collection: Headaches Head injury Dizziness Neck pain or limitation of motion Lumps or swelling History of head or neck surgery Objective Data Collection: Head – inspect and palpate Size and Shape – normocephalic = in keeping with body size (be careful with obesity) Temporal Area – temporal artery (should be even or not seen), temporomandibular joint Examine face – expression and structure Facial structures – eyes moving, eyebrows, symmetry Neck – symmetry, ROM, lymph nodes, cervical muscle testing, trachea, thyroid gland Eyes: Anatomy and Physiology of Eyes: Eyelids form Palpebral Fissure which close fully while blinking Limbus: between iris and sclera Canthus Caruncle Sclera – tough, white, smooth Cornea – sensitive to touch Conjunctiva – clear protectant Pupil – in the midle, symmetrical and equal in size Developmental Considerations: Infants and Children: Newborns are typically born farsighted which decreases after 7-8 yrs of age Should begin yearly visits at 2 yrs of age Older Adults: Presbyopia, macular degeneration, cataracts, glaucoma (loss of vision in center or sight), diabetic retinopathy Cultural and Social considerations: African Heritage have 3-6x higher rate of glaucoma Subjective Data: Vision Difficulty Pain Strabismus (crossed eyed) or diplopia (double vision) Redness, swelling Watering, discharge History of ocular problems Tested for glaucoma Wear glasses or contacts Medications like eye drops Vision loss within 3-6 months Snellen Chart: Farsightedness Coloured lines = colour blindness OD = Right Eye OS = Left Eye 20 ft away 30/20 = you can see at 30 ft what a normal person can see at 20 ft away Jaeger Chart: Nearsightedness 30 cm from face Confrontation Test: 60 cm away from patient Same eye covered as pt To test visual field Extraocular Muscle Function: Test 1 = Corneal light reflex Test 2 = Cover-uncover test Test 3 = Diagnostic positions test Objective Data: Inspect: Eyebrows Eyelids and lashes Eyeballs Conjunctiva and sclera Eversion of the upper eye lid Lacrimal apparatus Cornea and lens Iris and pupil Pupils Equal Round Reactive to Light and Accomadation Refer any abnormal findings to ophthalmologist Ears: Anatomy and Physiology: External Ear – external auditory canal and tympanic membrane Middle Ear – malleus, incus, stapes and eustachian tube (equalizes pressure, is shorter in kids which causes more ear infections) Inner Ear – vestibule and semicircular canals (used for proprioception), cochlea Hearing is most effective through air Auditory system levels: Peripheral – Amplitude and Frequency Brain Stem Cerebral Cortex Pathways of Hearing - Air conduction - Bone conduction Hearing loss: Conductive: osteosclerosis, stapes become fixed Sensorineural: pathways get tired Mixed loss: mix of both above Equilibrium: Vertigo Nystagmus Older adults are at greater risk of accumulation of cerumen, presbycusis (degenerative changes in ear) Audism: discrimination based on hearing ability Subjective Data: Earaches Infections Discharge Hearing Loss Environmental noise Tinnitus Vertigo Self-care behaviours Objective Data: External ear : size and shape, skin condition, tenderness, external auditory meatus Inspect with otoscope: pull pinna up and back, put pinky against head Look for colour and swelling, lesions/ foreign body and discharge Tympanic Membrane: colour and characteristics, position, integrity, cone of light(OD= 5 o’clock, OS = 7 o’clock) Tests: whispered voice test and Romberg test (30 seconds eyes closed checks for swaying) Developmental Considerations: Infants: pull lobe down and back, do last during exam, ask about behavioural milestones Older adult: loss of elasticity of pinna, ear drum whiter and more opaque, loss of hearing in high tone frequencies