NR 509 Midterm Exam Study Guide (V2)(LATEST, 2024) : Chamberlain college of Nursing, Study Guides, Projects, Research of Nursing

Download NR 509 Midterm Exam Study Guide (V2)(LATEST, 2024) : Chamberlain college of Nursing and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NR 509 Midterm Exam Study Guide Ch. 1  Basic and Advanced Interviewing Techniques  Basic o Gather a sensitive and nuanced hx. o Perform thorough and accurate exam o Improve pt. rapport o Focus your assessment o Sent guideposts that direct clinical decision making o Avoid interpreting your findings- may be premature. o Warn pt. that your assessment may take longer but that doesn’t mean negative findings  Advanced o With time and practice- able to integrate: o Empathetic listening o Ability to interview pts of all ages, genders, races, ethnicities, etc. o Improved techniques to examine different body systems o Differentiate level of sick vs. not sick o Improved process of clinical reasoning leading to diagnosis and plan o Will grow and begin clinical reasoning from first impression of meeting pt. o ID Sx. And abnormal findings, linking underlying pa xtho o Establish and test explanatory hypotheses  Components of the Health History  Identifying data – age, gender, marital status, occupation o Source of hx. - usually pt. but could be family or friend, letter of referral or clinical record o Establish the source of referral is necessary  Reliability - pt. memory, trust, mood  Chief Complaint - one or more symptoms or concerns causing pt. to seek care o Try and keep this in patients own words “my stomach feels awful”  Present illness - amplifies CC o **Complete, clear and chronologic description of the problems prompting the pts. Visit including onset, setting it developed how it manifests and tx. To date o Includes pt. thoughts and feelings about illness o *pertinent positives and pertinent negatives* o May include meds, allergies, tobacco, ETOH… o Seven attributes of a symptom 1. Location 2. Quality 3. Quantity or severity 4. Timing (onset, duration, frequency) 5. Setting it occurs 6. Factors that aggravate or relieve 7. Associated manifestations o Consider placing PMHx in this area to support potential problem (hx. Of CAD with pt. presenting with CP) o How these sx are affecting ADLs o Medications taking to help or than may exacerbate  Past medical hx . – list illnesses (childhood and adult) with dates o Surgeries o OBGYN o Health maintenance o psych o Immunizations, screenings, lifestyle issues and home safety  Family hx. – include parents, siblings and grandparents o Outline current age or age at death, medical hx. / illnesses, reason of death  Personal and social hx . – education, family origin, current household, interests and lifestyle, relationship? Stress, job, important life experiences, financial status, religion, retirement plan, leisure activities, friends/ support  Review of symptoms o Documents presence or absence of common symptoms related to each of the major body symptoms o Start- General, skin, HEENT, neck, breasts, respiratory, cardiovasc., GI, peripheral vasc., urinary, genitals, musculoskeletal, psych, neuro, hematologic, endocrine.  All this health hx. is done with the following o Physical exam o Clinical reasoning o Assessment o Plan o The quality clinical record o Comprehensive vs. focused?  Comprehensive o New pt. o Identifies or rules out causes related to concerns o Lengthy or difficult pt. complaint o Platform for health promotion o Has potential for increased health care savings and decreased testing o Can be seen as a diagnostic test  Focused o Problem focused o Good for routine or urgent visits o Symptoms related to specific body system.  **** MAKE SURE THE DATE IS ALWAYS ON THE HEALTH HX****  Subjective Data  What the patient tells you  “the symptoms and hx. From chief complaint through review of systems  Pain, reports “headache”  Objective Data  What you observe or detect through exam, lab results and test data  Psychical exam findings or signs  If probability of diagnosis is high- move ahead with diagnostic tests and tx.  Area between low and high threshold is considered ‘clinical uncertainty’ which means more testing to revise and guide clinical decision making  The more invasive the diagnosis or treatment regimen- the higher probability of treatment threshold required (starting chemo must be sure vs. starting abx for UTI)  Pathological and Physiological Processes   Problem List  list the most active and serious problems first and record onset date.  Helps individualize and prioritize pt. care  Allows other members of care team to learn about pt. health status at a glance.  Problems can be symptoms, signs, past health events (hospital admissions or surgery), or diagnoses.  Problem Prioritization  Most urgent problem listed at top of problem list.  Include things that effect care or can change care plans o Could include severe allergies to meds, tx., etc. o Surgeries that may hinder or change care  Make sure to list any and all dx. Or thoughts that could change how you’re treating the pt., talkative pt., angry or disruptive pt., language barriers, low literacy or health literacy, hearing or vision impaired, limited intelligence, medication seeking, seeking personal advice, seductive pt. Ch. 3  Interpretation and Analysis of Data  Logical Examination Sequence-  Greet the pt. and establish rapport  Take note  Establish the agenda  Invite the pts. Story  ID and respond to emotional cues  Expanding and clarifying the pt story  Generating and testing diagnostic hypothesis  Share tx. Plan  Close the interview and visit  Take time for self-reflection  Associated Symptoms- “OLD CARTS” = onset, location, duration, characteristics, aggravating factors, relieving factors and timing  Adaptive Questioning-several ways to elicit more info without challenging the flow of the pts. Story.  guided questions show your sustained interest in the pt. feelings and disclosures  goal is to facilitate full communication in the pt. own words.  Start general & move to more specific questions as you progress  Challenging Patients- challenging pts. Are those who are nonverbal or silent, the confusing or confused pt., with impaired capacity, talkative pt., the angry or disruptive pt., language barrier, low literacy or health literacy, hearing or visually impaired, limited intelligence, pt. seeking personal advice, seductive pt. Ch. 4  General Approach to the Physical Examination  Comprehensive vs. focused approach.  Annual- comprehensive  Specific complaint- focus a thorough exam on areas of concern  Interview Facilitation  ‘motivational interviewing’ - use open ended questions to encourage pt. to describe what they experience  listen and ask common sense questions  follow a thorough and systematic sequence to hx. And physical  stay open minded toward pt. and clinical data  always include ‘worse case scenario’  analyze any mistakes in data collection or interpretation  heighten your focus on pt. mood, build, behavior  reflect on your approach- ID as a student and will take more time to focus on certain areas- this does not indicate a problem o avoid interpreting your findings as a beginner- may jump to the wrong conclusion o avoid negative reactions  adjust lighting to set the environment  check your equipment o ophthalmoscope and otoscope o flashlight and penlight o tongue depressor o tap measure o thermometer o watch with second hand o sphygmomanometer o stethoscope with thick, short tubing and with bell and diaphragm o Snellen chart o Reflex hammer o Tuning forks 128 Hz and 51 Hz o Cotton swab, pins- testing sensation o Speculum and lube for vaginal examination  Make pt. comfortable- show sensitivity and privacy for pt. modest  Standard and universal precautions  Inspect, palpate, percuss and auscultate  Vital Signs-  HR, BP, SPO2, RR, temp.  If abnormal upon arrival- NP should retake once with pt.  Review at beginning of apt. or just before if recorded by staff  BMI Interpretation- use BMI calculator, <18.5= underweight, 18.5-24.9= normal/ healthy weight, 25.0-29.9- overweight, >30= obese  Review of Systems  o  Primary and Secondary Skin Lesion Nomenclature  Primary: flat or raised o Flat: cannot palpate lesion with eyes closed  Macule: lesion flat and <1cm  Patch: lesion is flat and <1cm o Raised: you can palpate the lesion with the eyes closed  Papule: lesion raised and <1cm and not fluid filled  Plaque: lesion is raised and >1cm and not fluid filled  Vesicle: lesion is raised and <1cm and fluid filled  Bulla: lesion is raised >1cm and fluid filled  Secondary: occur from an outside source affecting the skin such as scratching  Psoriasis hollier pg. 139  Characterized by a chronic, pruritic, inflammatory skin disorder characterized by a rapid proliferation of epidermal cells  Exacerbations common  Common forms- plaque psoriasis- plaque like lesions  Unknow etiology but common with family hx. Beta hemolytic strep in kids  Strep, fam  **Risk factors o Strep, family hx, stress, diabetes, obesity, local trauma, sunburn, drugs (lithium, beta blockers, systemic steroids/ rebound effect)  Assessment findings o Silvery white scales on erythematous base, pruritis, common on elbows, knees, scalp, gluteal cleft, finger/toes, nails may be pitted in 50% of pt. o + Asupitz sign (bleeding when lesions scraped) o Intergluteal lesions are pink and smooth  ** Very negative self-image/ self-esteem found with many of these pts.  Diff. Dx.- o Scalp- seborrheic dermatitis o Trunk, pityriasis rosea, tinea corporis o Candida infections o Contact dermatitis o Eczema  Diagnostic studies- o Swab for strep, biopsy, ESR/ CRP- usually elevated  Prevention o Avoid: sun, sudden withdrawal from steroids, stimulating drugs (ACE inhib., BB, NSAIDS, PCN, Salicylates, sulfas, tetracyclines)  Non-pharm management o Warm soaks, oatmeal bath, wet dressings (burrows solution)  Pharm management Hollier pg. 140 o 80% have mild disease and need only topical agent o Steroids from low to high potency  Low- hydrocortisone 1.0 or 2.5% BID for 2 weeks- caution on face  ** Consult derm if a chronic condition  Tinea- (Hollier 157) group of fungal infections affecting various parts of body o more common/ prevalent during summer months or warm climates  hair shedding/ breakage at hair shaft caused by tinea capitis- ringworm  round, scaling patches of alopecia mainly seen in kids  may be black dots of broken hairs and corkscrew hairs on dermoscopy  usually caused by Trichophyton tonsurans from humans o less commonly microsporum canis from dogs or cats o boggy plaques are called kerions  assessment findings o tinea capitis: round patchy scales on scalp, occasionally alopecia, most common in kids  risk factors- daycare, contact with infected items (combs, hats), diabetes, poor hygiene.  Tx: good hygiene, monitor liver function if taking antifungal, wear sunscreen/. Minimize sun exposure, treat family and pets, shaving head NOT necessary  Tx- Griseofulvin- takes 4-6 weeks, take with high fat meal for better absorption, contraindicated in pt with pyphoria and hepatic dysfunction, derived from PCN.  Tx- shampoo ketoconazole 2%- usually resolves in 2 months  o Tinea Corporis : rash, pruritis, well- circumscribed, red, scaly plaque usually on trunk, may occur in groups of 3+  Risk factor- close contact with pets, warm climates, obesity, prolonged use of topical steroids, immunocompromised  Tx- good hygiene, avoid contact with lesions, econazole- use for 2+ weeks  o Tinea Cruris: pruritus, well marginated half-moon plaques in groin and thighs, may appear as vesicles, may look like eczema from scratching, doesn’t affect scrotum/ penis, rare in peds before puberty  Keep area dry, don’t scratch, Econazole- not for vaginal use. o Tinea Pedis: itching, malodorous, and burning of feet, laceration in toe webs, scaling or blistering on soles of feet, bacterial super infections possible, spreads easily to groin and hands  Dry between toes, trim dead skin, econazole- use for 2+ weeks o Tinea Versicolor: well marginated lesions of varying colors (white, red, brown) gives its name versicolor, rarely itchy, common in axillary, shoulders, chest back (sebum rich areas)  Prevention: good hygiene, remove wet clothes ASAP, dry between toes after showers, avoid contact with surfaces in public such as bathing facilities, put socks on before undergarments, avoid sharing clothes, sports equipment or towels.  Pityriasis Rosea- single, oval, flat topped superficial pink/ rose to skin colored plaque. Starts as one large patch (herald patch) and remains for the first week then several more patches start  Occur on back and abdomen. Pattern similar to Christmas tree. Usually disappear on own after 6-8 weeks. Cause unknown- may be autoimmune or HHV6 HHV7 involved.  Oatmeal bath, UVB tx 3-5 times/wk or direct sun exposure for 5 mins.  Topical antipruritic and antihistamines for itching.  Lyme Disease- (hollier 130)  Complex, multisystem disease transmitted by the ixodid tick. Symptoms range from mild- severe and include joint pain, flu like symptoms and rash.  Highest exposure in the Midwest and east US during June and July 80%, pacific NW jan-may  Hunting, hiking, camping.  Tick must be attached 36- 48 hours before lyme bacterium can be transmitted o Early stage 1: asymptomatic, erythema migrans (60-80%), bulls eye rash, HA, fever, malaise, myalgias o Early disseminated lymes stage 2: erythema migrans, aseptic meningitis, heart block, pericarditis, hepatitis, loss of muscle tone, severe head and o May be prolonged in older adults and immunocompromised pt.  Testing- none usually, consider testing for HIV or diabetes testing for younger pt.  Cultures of areas for RNA  Tx- o Domeboro soaked wet compresses several times/day to rash o Avoid contact with high risk groups o Antiretroviral meds- acyclovir, valacyclovir and famciclovir  May shorten the time and severity  Most effective if administered at onset of rash o Analgesics, antipruritic, topical lidocaine  Cellulitis (hollier 111) o Acute bacterial infection of the skin and subcutaneous tissues, most common from beta- hemolytic streptococci and S. aureus o To the arms and legs and face most common- possibly elsewhere o Acute, spreading infection o Erythema, edema, warmth and pain. o May be accompanied by lymphangitis and lymphadenitis o Approx. 21.2mill cases per year in the US o Risks  Prior trauma  Undertreated furunculosis  Burns  DM  URI in kids  Bug bite  Lacerations  Advanced age >80 o Findings:  Fissuring, scaling or maceration in toe webs may be a source of colonization- tx. With antifungal. other findings noted above o C&S of area (yield is low <45% even with good culture) o CBC- mid leukocytosis with shift to left o ESR- elevated o Imaging if osteo is suspected o Prevention- keep areas clean and dry, avoid swimming with skin abrasions, early tx. Of URI, wear compressions and elevate o Tx.  Elevation, moist warm compress for pain  Abx for specific cultures obtained: MSSA- cephalexin, MRSA- Bactrim first line unless recurrent, MRSA + beta-hemolytic strep- clinda, ammox plus Bactrim. Group A strep- PCN o  Non-melanoma Skin Cancer  Nonmelanoma skin cancer refers to all the types of cancer that occur in the skin that are not melanoma. Several types of skin cancer fall within the broader category of nonmelanoma skin cancer, with the most common types being basal cell carcinoma and squamous cell carcinoma   Basal cell carcinoma is the most common CA in the word- rarely spreads. It can invade and destroy local tissues. o Consists of immature cells similar to those in the basal layer of the epidermis and account for roughly 80% of skin Ca. should be biopsied for confirmation before tx. o