NURS 6512: Advanced Health Assessment – Diversity and Health Assessment Essay
Initial Post
Diversity and Health Assessment
Cultural competence is the gradually developed capacity of nurses and healthcare providers to provide safe and quality healthcare to clients of different background (Duan-Ying, 2016). Cultural competence involves recognizing one’s own culture, values, and biases, and using effective patient-centered communication skills (Ball et al., 2015). To be culturally competent, the practitioner must be able to respond to the cultural diversity of her or his patients and adapt to the unique needs of patients from the cultural and spiritual background different from her or his own (Ball et al., 2015). For this forum, the cultural health assessment of MR, the 23-year-old Native American male will be discussed. Diversity and Health Assessment Essay.
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Case 3: Culturally Competent Health Assessment of the 23-year-old Native American Male
MR, a 23-year-old Native American presents with complain of anxiety, history of smoking “pot,” alcoholism, a family history of diabetes, hypertension, and alcoholism. He is afraid of the adverse outcomes of his lifestyle choices. He is not currently on prescription medication and denies drug use. He needs some prescriptions to help him with his anxiety.
According to Espey at al. (2013), “American Indians in the United have long endured a legacy of injustice and discrimination with multiple negative manifestations, including alarming health disparities and inadequate healthcare.” Patterns of mortality among Native Americans are strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking, and social determinants (Epsey et al., 2013). For many young Native Indian Americans like MR, the problem of poor health, smoking, and alcohol abuse can be explained by poverty, unemployment, and lack of education. Diversity and Health Assessment Essay. Sarche & Spicer (2008) state that more than one-quarter of American Indian and Alaskan Native is living in poverty, a rate that is more than double of that of the general population. The discrepancy in education and employment is also found and overall, there are fewer individuals within the American Indian and Alaska community who possess a high school diploma or GED (71% versus 80%) or a bachelor degree (11% versus 24.4%) (Sarche & Spicer, 2008). The social determinants of health including poor-socioeconomic status, poor education, low income as well as unhealthy lifestyle and poor access to healthcare services play a major role in MR’s anxiety, alcohol use, and “pot” smoking. MR health seeking behavior is related to his spiritual beliefs that he might not “get into heaven” if he continues to have an unhealthy lifestyle. This attitude is an excellent initiative towards a healthier lifestyle Diversity and Health Assessment Essay.
Addressing critical issues when interacting with the patient
According to scenario 3, MR has multiple health risks. He has a family history of hypertension, diabetes, and alcoholism. He is a current “pot” smoker, alcohol drinker, and a very anxious young man looking for prescriptions against anxiety. Anxiety is one the withdrawal symptoms and therefore, MR may have drug addiction issue. This patient may need a psychiatric consult for better assessment of his drug addiction status. He is also at risk for cardiovascular diseases and lung cancer related to “pot” smoking, hypertension and diabetes-related to family history and alcoholism. Diversity and Health Assessment Essay.
Targeted Questions
1- How are you doing today? How can I help you with your visit?
2- You stated that you have been smoking “pot.” How long have you been smoking?
3- What do you think is the cause of your anxiety?
4- You stated that drinking alcohol can help cope with your anxiety. How many drinks do you have in one day?
5- Have you ever felt you should cut down on your drinking? (CAGE questionnaire)
6- Have people annoyed you by criticizing your drinking? (CAGE questionnaire)
7- Have you felt bad or guilty about drinking? (CAGE questionnaire) (Addiction & Recovery, 2018).
8- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (CAGE questionnaire)
9- Do you have insurance coverage? Do you have concerns about how to cover your medical expenses?
10- Before coming to this health center did you seek help from a family member, spiritual leader or a friend? Did they listen to you or provide any support? Reference
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015).
Seidel’s Guide to
NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum
Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.
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GENITALIA ASSESSMENT
Subjective:
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum
Assessment:
Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:
With regard to the SOAP note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify
at least five
possible conditions that may be considered in a differential diagnosis for the patient.
NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum
To complete:
Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or Why not?
Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.
NURS 6512 Assignments – Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
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To prepare:
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies? NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions.
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Download the SOAP Template found in this week’s Learning Resources.
To complete:
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case. NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of
three to five
possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.
Submission and Grading Information
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
L =location
O= onset
C= character
A= associated signs and symptoms
T= timing
E= exacerbating/relieving factors
S= severity
SUBJECTIVE DATA:
Include what the patient tells you, but organize the information.
Chief Complaint (CC):
In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI):
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the
seven attributes of
each principal symptom in paragraph form not a list
.If the CC was “headache”, the LOCATES for the HPI might look like the following example: NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Medications:
Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies:
Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History:
Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions
Immunization History:
Includelast Tdap, Flu, pneumonia, etc.
Significant Family History:
Include history of parents, grandparents, siblings, and children.
Lifestyle:
Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems:
From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General:
Include any recent weight changes, weakness, fatigue, or fever, but
do not restate HPI data here
.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA:
From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course.
Do not use “WNL” or “normal.” You must describe what you see.
Physical Exam:
Vital signs:
Include vital signs, ht, wt, and BMI.
General:
Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things. NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions
HEENT:
Neck:
Chest
Lungs:
Heart
Peripheral Vascular: Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.
ASSESSMENT:
List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.
PLAN:
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
REFLECTION:
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
NURS 6512 Week 6 Assignment: Assessing the Abdomen
NURS 6512 Week 6 assignment Assesment 1: Assessing the Abdomen
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions.
Abdominal Assessment
SUBJECTIVE:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:
With regard to the SOAP note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
To complete:
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or Why not?
What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature. NURS 6512 Week 4 Assignment 1- Differential Diagnosis for Skin Conditions
Communication techniques used to obtain a patient’s health history (found in Seidel’s guide to physical examination, chapter 1, pages 1-7)
Ask the patient how the prefer to be addressed
b. Ask open-ended questions. Ensure to let the patient have time to discuss their concerns.
c. Be courteous- Knock before entering, ensure confidentiality, meet and acknowledge others that may be in the room and level of participation, respect modesty, allow patient to dress after examination before follow-up discussion
d. Ensure comfort- ensure physical comfort, have minimal furniture, maintain privacy, comfortable room temperature, good lighting, and do not overtire the patient NURS 6512 Midterm exam study Guide
e. Establish a connection- Maintain good eye contact (if cultural preferences allow), avoid professional jargon, actively listen, establish the patients history and conduct the physical exam before viewing previous studies and tests to avoid a predetermined path, be flexible, watch nonverbal cues, define concerns completely (where, severity, length, context, soothers/aggravators)
f. Establish confidentiality- Have patient summarize the discussion, allow more discussion if the patient has other concerns by asking “anything else you would like to bring up,” follow-up if there are questions you are unable to answer right away, if you make a mistake own up to it and make every effort to repair it
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g. Ensure appropriate dress and grooming paying attention to clean fingernails, modest clothing, and neat hair.
h. Seek certainty if patients responses to questions are unclear
i. Be direct and firm when discussing sensitive issues and document after the discussion is over
documentation
Medical record should be complete and legible
Each patient encounter should include
Reason for encounter (Chief Complaint)
Relevant history, PE findings, and test results
Assessment, clinical impressions, or diagnosis
Plan of care
Date and legible identity of the observer
Why test was ordered
Consulting physicians
Health risk
Patients progress
SOAP notes are a quick and efficient way to compile information and make decisions based on the information provided by the patient.
The information for SOAP notes can be found in the Sullivan Text
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
S-Subjective
O-Objective
A-Assessment
P-Plan
S-Chief Compliant (CC), history of present illness (HPI), Pertinent past medical history (PMH), Pertinent family history (FH), Pertinent psychosocial history (SH), any specialized history related to the chief complaint, and Pertinent review of systems (ROS) (Sullivan, pp.91-92).
O- Objective: includes the vital signs, a general assessment of the patient, physical examination findings, results from laboratory or diagnostic tests (Sullivan, p. 93)
A- Assessment: is an analysis and interpretation of the subjective and objective data to provide a diagnosis or a list of differential diagnoses (Sullivan, pp. 96-97).
P- Plan: this area includes diagnostic studies that will be obtained, referrals, therapeutic interventions, educational material, disposition of the patient, next visit (Sullivan, p. 99)
Subjective Data vs Objective Data (#4)
Information collection is a vital piece of any assessment process, regardless of whether it is for risk management, a health diagnosing, or an execution assessment. The emotional and target techniques for information accumulation are two conspicuous ones used to decide the kind of information gathered and the suspicions. While the previous is identified with verbal articulation of thought and the statements to take after, the last is identified with unquestionable and strong actuality.
Subjective Data
Subjective data or abstract information is information that is gathered or acquired through personal interactions, i.e., talking, sharing, clarifying, and so forth.
It is gathered to make an assumption about what the reality may be, what occasion may have happened, what estimations must be done, and so on.
Subjective information can likewise be gathered by methods for judgment, doubt, or rumors
This information fluctuates from one person to another, with each circumstance, consistently.
It can’t be announced as reality, as it advances from such a large number of changed sources with various information sources.
Abstract dialect as a rule starts with, ‘I think’, ‘I require’, ‘I feel’, and so on
Objective Data
By definition, objective data is information that is gathered or acquired by means of established or obvious realities and sources.
It is gathered to affirm your doubts and suppositions – or only to accumulate trustworthy data. It is something that can be felt, contacted, smelled, seen, heard, and tasted.
Objective information will be the same from numerous sources and can be checked and portrayed precisely and affirmed.
This information does not fluctuate from one person to another or with each circumstance.
It tends to be proclaimed as evident information since it stays same and reliable regardless of whether numerous sources are included.
Objective dialect more often than not starts with ‘I said’, ‘I watched’, ‘I gauged’, and so forth.
Subjective Data Vs. Objective Data
Underlying Basis
◼ Its underlying base is personal interpretation. Whatever is perceived is done so, upon communicating with the person about the same and believing what was said by the person/source.
◼ Its underlying base is observing what happened, observing the facts. The facts are straightforward or proved by means of a test/analysis/experiment, and are true and measurable.
Decision-making
◼ It cannot be completely relied on for taking decisions. After all, personal opinions and beliefs vary, and may present an entirely new perspective of the same problem. In such a scenario, a level-headed decision cannot be taken.
◼ It is based on facts; hence, it is usually reliable for decision-making. Whatever decision is taken is done so in the light of what has actually happened, that which can be trusted upon, with experiments and facts.
Common Arenas
◼ Subjective data and analysis can usually be found on personal blogs, forums, Internet chat stations, biographies, editorials, etc.
◼ Objective data is not a discussion. It is found in important scientific papers, encyclopedias, textbooks, reference books, tutorials, etc.
Reporting Information
◼ It cannot be used for reporting any news. As it is collected through discussions and interpretations, it is not totally reliable; therefore, making a definite assumption about an event or subject is incorrect.
◼ It can be used for reporting information. Data collection is done through efficient methods and reliable, set procedures. It is dependable and can be reported.
Examples
◼ When you have a cough and you go to the hospital, the doctor/nurse will ask you questions regarding your cough, like ‘When did it start?’, ‘Is it a dry cough or wet cough?’, ‘Did you eat/drink something cold?’, etc. The information obtained thus, is classified as subjective data.
◼ When you get a cough and go to the doctor, the doctor will examine you thoroughly, check your vital signs, conduct tests, and then, based on the test results, he will ascertain the problem you are suffering from (like bronchitis, pneumonia, etc.). This is objective data.
Ethical Decision Making and Beneficence
Four principles of medical ethics are autonomy, beneficence, non-maleficence, and justice. Beneficence is the principle of acting with the best interest of the other in mind, it is the basic premise that healthcare providers have a duty to be of a benefit to the patient as well as to take positive steps to prevent harm from the patient (Levitt, 2014). Ethics are moral principles that govern a person’s behavior. Ethical decision making is based on a person’s moral compass. Choosing to make the right decision is based on what a person believes is right.
Cultural Awareness (6)
*Cultural reflects the whole of human behavior including ideas and attitudes; ways of relating, speaking manners, products of physical effort, ingenuity and imagination.
*Cultural awareness- being knowledgeable of one’s thoughts, feelings, sensation and how these things affect interactions
Crossing the cultural divide helps, but skepticism is a barrier.
*Cultural humility- recognizing one’s limitation in knowledge and cultural perspective to be open to new perspectives; view each patient individually
*Seeleman et al framework- emphasizes on awareness of social context which specific ethnic groups live Social context in minority group means assessing stressors and support networks, sense of life control and literacy
*Campinha- Bacote’s process of Cultural Competence Model- includes (cultural competence dimensions): Awareness- self- examination and in -depth exploration of your biases, stereotypes, prejudices, and assumption
Knowledge- seeking and obtaining education
Skill- collecting culturally relevant data assessing in a cultural manner
Encounter- patient interactions used to validate, redefine or modify existing beliefs and practices and develop cultural desire or modify existing beliefs and practices and develop cultural desire awareness, skill, and knowledge
Desire- motivation to want engagement in being culturally competent
Socioeconomic, Spiritual and lifestyle factors affecting
diverse populations
Socioeconomic status is the social standing or class of an individual or group. It is often measured as a combination of education, income and occupation.
a. Diverse populations are often financially challenged, have educational limitations and have poor access to health care due to of lack of insurance or funding to pay for medication. The lack of health insurance reduces access to care and often results in poorer health outcomes (Bittoni et al, 2015). Healthcare providers must be sensitive to this factor and be knowledgeable about resources within the community to aid these populations to sustaining adequate healthcare (Ball et al, 2015 pg. 10).
b. Many patients want attention paid to spirituality and faith can be a key factor in the success of a management plan. When assessing spirituality continue to be sensitive and ask open ended questions such as:
i. What are your spiritual or religious beliefs?
ii. How do our religious beliefs affect your health care decisions (i.e. birth control)?
iii. Is there anyone from your faith that you would like to include in your healthcare needs (i.e. pastors, priest, or male family members)?
c. Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and well-being. Many people of diverse populations have higher rates of engagement in factors that increase health risks such as smoking, poor diet, sedentariness, and poor sexual habits.
i. Assess dietary habits and make nutritional recommendations as needed.
ii. Encourage smoking and alcohol consumption modification or cessation.
iii. Encourage active lifestyle habits (vigorous exercise at least 30 min per day for cardiovascular health, and decreasing obesity)
iv. Assess the 5 Ps of sexual history
1. Partners, practices, protection, past history, and pregnancy prevention practices (Ball et al, 2015 pg. 12).
FUNCTIONAL ASSESSMENT
• Functional assessment is an attempt to understand your patient’s ability to achieve the basic ADL’s
• Should be made for all older adults and for any person who may be limited by disease or disability, acute OR chronic.
• Well-taken history and a meticulous physical exam can bring out subtle influences, such as tobacco and alcohol use, sedentary lifestyles, poor food selection, overuse of medications, and potentially emotional distress.
• Physical limitations such as cognitive ability or of the senses may be founded
• Keep in mind patients tend to overstate their abilities and obscure reality
When performing a functional assessment, consider a variety of disabilities: physical, cognitive, psychological, social, and sexual. It is just as important to understand a patient’s social and spiritual support system as it is their physical disabilities.
Disabilities include but are not limited to
Mobility
• Difficulty walking standard distances: ½ mile, 2-3 blocks, across a room, etc.
• Difficulty with stairs- climbing or descending
• Problems with balance
Upper Extremity function
• Difficulty grasping small objects or opening jars
• Difficulty reaching out or up overhead (reaching a shelf)
Housework
• Heavy (scrubbing floors, vacuuming)
• Light (dusting)
• meal preparation
• shopping
• medication use/set up
• money management
Instrumental ADL’s
• bathing, dressing, toileting, moving from bed to chair or from sitting to standing, eating, walking inside the home, etc.
**Any limitations, even is perceived as mild, will affect the patient’s independence and autonomy. This leads to increased reliance on other people and/or assistive devices.
** These limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty
** The patient’s support system and material resources become an integral part of development of reasonable management plans
Growth and Development Ch 6 of text book
Growth Hormone-Releasing Hormone stimulates the pituitary to release the growth hormone.
70% of secretion of the growth hormone occurs during sleep
Critical brain growth between conception and 3 yrs old.
P
uberty- Dependent on the GH and androgens (Sex Steroids). They stimulate and increase in the growth Hormone.
Lymphatic tissues reach adult size by 6 yrs old and double by 10-12 yrs old.
Pregnancy Weight
Child- 6-8lbs of wt blood-3-4lbs Maternal Fat/protein 4-6lbs
Physical activity- Low? Moderate? High? How many days per week? How many minutes?
How often do you have a bowel movement? Any use of laxatives? Gas? Diarrhea? Constipation? N/V?
Fluid Intake
Women 2.7 liters or 91 ounces or 11.5 cups of total water (from food and beverage)
Men 3.7 liters of 125 ounces or 11.5 cups of fluids daily.
Energy requirements:
Calculation is BMR X Activity Factor = Total daily energy expenditure
Macronutrients vs Micronutrients – Seidel p 95 & 96
• Macronutrients are carbohydrates, protein and fat and the main sources of calories in the diet.
o Carbohydrates are mostly from plants and in milk and is the main source of energy 4 calories /gram.
o Protiens provide 4 calories /gram and is present in all animal and plant products and is a part of more than half of the organic matter in the body.
o Fat provides 9 calories/gram and present in fatty fish, animal, and some plant products particularly seeds. Main source of linoleic acid.
• Micronutrients – vitamins, minerals, and electrolytes required and stored in very small quantities by the body. Essential for growth, development, and hundreds of metabolic processes.
Food Diary (pg. 101)
• A food diary can help to determine if a patient’s diet is adequate.
• It should be recorded in real time and include at least one weekend day.
• Practitioners should use a food diary to assess the eating habits and if a nutrition consult would be effective.
• The food diary can help the patient and practitioner to see trends and make suggestions in problem areas.
• A good resource to help can be found at
ChooseMyPlate.gov
BMI measurements for normal, overweight, obesity, morbid obesity in adults and children
Tape measure
– use to examine multiple raised lesions.
Transilluminate
– An appropriate examination technique to assess vesicle in the skin. It also a source of light with a narrow beam.
Otoscope
– use to visualize the lower and middle turbines of the nose.
Inspection –
is applied throughout the entire examination and interview process.
Auscultation
– is carried out last except when examining kidney or abdomen . it is also used to listen for sounds produced by the body
Fist
– use for indirect finger percussion involves striking the middle finger of the nondominant hand
Deep abdominal palpation of the kidney
is used to assess tenderness over the kidney.
Ulnar surface of the hand
is used to palpate Mass in the skin
Diaphragm
– pressed lightly against skin to detect high frequency.
Scoliometer- measures the degree of rotation of the spine to screen for scoliosis. Pg. 49 8
th
edition.
Pneumatic attachment of an otoscope
– use to evaluate the cone of light reflex in adult and kids.
Red – free light
-seen through the ophthalmoscope to estimate the size and location of lesion.
Dorsal surface of the hand
– sensitive to vibration
Amsler grid
– use to screen patient at risk for macular degeration
Pederson speculum
– use for women with small vaginal opening
Near-vision (Rosenbaum
) or
Jaeger chart
– Use for screening near vision
Dermatoscope
– is a skin surface microscope used to inspect the surface of pigmented skin lesions
Bell of stethoscope
– detects low frequency sound.
Wood lamp-
black light used to detect fungal infection.
Pan-optic ophthalmoscope
– larger field of view in eye examination.
Palpation-
gathering information through touch.
Monofilament
– help identify a patient with decreased sensation and increased risk for injury
Percussion Tone Expected
Stomach-
Tympanic
Sternum
-flat
Liver
-Dull
Lung with patient with Pneumonia
-Dull
Abdomen with lung tumor
-Dull
Assessment Tools
• Tuning Fork (p.45-46)- creates vibrations to produce frequencies of sound waves that can be expressed as cycles per second (cps) or Hertz (Hz).
o Auditory- Frequency of 500-1000 Hz is utilized. Activated by gently squeezing, or tapping on your knuckles.
o Vibration- use lower frequency between 100-400 Hz. Activated by tapping on heel of hand, and then applying the base to a bony prominence.
• Stethoscope (p. 39-40)- 3 basic types acoustic, magnetic, electronic with acoustic being most utilized.
o Acoustic- closed cylinder, the diaphragm has a frequency of 300 Hz, and is best for high pitched sounds such as the heart. The bell can pick up low frequency with light pressure, and high frequency with heavier pressure. (Stereophonic stethoscope has a dual channel with single tube, each ear piece picks up sound from its side of the bell.
o Magnetic- contains iron disk, and magnet. Contains dial to adjust from high to low frequency.
o Electronic- turns vibrations to sound, can record and store.
o Proper use- Hold between index and middle finger with firm pressure. To avoid unwanted noise, do not touch tubing during auscultation.
• Otoscope (p.45)- used for examining external auditory canal and tympanic membrane. Utilize the largest speculum that can fit comfortably in the patients ear.
• Ophthalmoscope (p.42-43)- Used to visualize interior eye structure. Some models offer a variety of apertures.
o Large Aperture produces large round beam, and is most often used.
o Small Aperture used for small pupils
o Red-free filter- produces green beam, and is used to evaluate the optic disc for pallor and small vessel changes. Can also detect retinal hemorrhages (blood appears as black),
o Visualizing
§ Eye structure is examined by converting or diverging light through different magnification powers.
§ Magnification power is selected by moving the lens selector. Black numbers represent positive, while red represents negative.The use of different lenses can assist in compensation of the patient and examiner with hyperopia and myopia. (No compensation for astigmatism is available)
Skin lesion characteristics
Skin lesion can describe any pathologic skin changes and can be primary or secondary.
Characteristics
• Size
• Shape
• Color
• Texture
• Elevation or depression
• Attachment at base: pedunculated (having a stalk) or sessile (without a stalk)
• Exudates
• Color
• Odor
• Amount
• Consistency
• Configuration
• Annular (rings)
• Grouped
• Linear
• Arciform (bow-shaped)
• Diffuse
• Location and distribution
• Generalized or localized
• Region of the body
• Patterns
• Discrete or confluent
Documenting Skin Lesions using the ABCD Rule
Skin lesions are evaluated based on the ABCDE rule (Melanoma Research Foundation)
A=Asymmetry- i.e. irregular shape
B=Borders- not easy to define the margins of the border
C=Color- presence of multiple colors may be a sign of malignancy
D=Diameter- >6 mm can be a sign of malignancy (size of pencil eraser)
E=Evolution- changes over time
Pay attention to location of lesions- Box 8-6, (Seidel, p. 132)
Pay attention to any exudate- Box 8-5, (Seidel, p. 125)
Table 8-4 Primary Skin lesions (Seidel, p. 126-128)
Table 8-5 Secondary Skin lesions (Seidel, p. 129-131)
Anatomy and Physiology of Skin Layers
Skin functions:
Protect against microbial and foreign substance invasion and physical trauma
Restrict body fluid loss
Regulate temperature
Sensory perception via nerve endings
Produce Vitamin D from precursors in skin
Contribute to blood pressure regulation through constriction
Repair surface wounds
Excrete sweat, urea, and lactic acid
Epidermis
Outermost portion of skin
Two layers
Stratum Corneum : Protects body against harmful environmental substances and restricts water loss
Contains dead squamous cells that form a protective barrier
Cellular stratum: keratin cells are synthesized here
Contains stratum germinativum – keratinocytes matures here- then make way through stratum spinosum, stratum granulosum, into stratum corneum
Stratum germinativum contains melanocytes which synthesize melanin and give skin color
Stratum lucidum is only in thicker skin of palms and soles
Avascular- depends on dermis for nutrition
Dermis
Richly vascular connective tissue layer that supports and separates the epidermis from the cutaneous adipose tissue
Papillae from this layer penetrate the epidermis to provide nourishment
Elastin collagen and reticulum fibers are found here and provide resilience, strength, and stability
Sensory nerve fibers are located here to provide sensation of pain, touch, and temperature
Additionally, found are autonomic motor nerves that innervate blood vessels, glands, and the arrectores pullorum muscles
Hypodermis:
A subcutaneous layer that is loose connective tissue filled with fatty cells
This adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories
Appendages:
Eccrine sweat glands
Open onto the surface of the skin and regulate body temperature through water secretion
Everywhere except lip, eardrum, nail beds, inner surface of prepuce, and glans penis
Apocrine sweat glands
Only found in the axillae, nipples, areolae, anogenital areas, eyelids, and external ears
Emotional stimuli= these glands secrete a white fluid containing protein, carbs, and other substances; odorless; body odor is due to bacterial decomposition of apocrine glands
Sebaceous glands
Secrete sebum that keeps the skin and hair from drying out
Secretory activity varies according to hormonal levels throughout the life span
Hair
Consists of root, shaft, and follicle
Papilla at the base of the follicle supplies nourishment for growth
Melanocytes in shaft provide color
Vellus hair: short, fine, soft, and nonpigmented
Terminal hair: coarser, longer, thicker, and pigmented
Three stages of hair
Anagen (growth)
Catagen (atrophy)
Telogen (Rest)
Nails
Epidermal cells converted to hard plates of keratin
Vascular nail bed gives nail its pink color
Stratum corneum layer of skin covering the nail root is the cuticle or eponychium, which pushes up and over the lower part of the nail body
Paronychium : soft tissue surrounding the nail border
ALL ABOVE INFORMATION FOUND IN SEIDEL’S GUIDE TO PHYSICAL EXAMINATION: EIGTH EDITION PAGES 114-116
Abnormal nail findings in older adults
Nail changes associated with aging are common in the elderly and include characteristic modifications of color, contour, growth, surface, thickness, and histology. The calcium content of the aging nail increases and iron decreases.
keratinocytes of the nail plate are increased in size with an increased number of ‘pertinax bodies’ (remnants of keratinocyte nuclei)
• nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail.
• Nail growth decreases by approximately 0.5% per year between 20 and 100 years of age.
• Prominent longitudinal ridges were the most common change
• Brittleness of the nail is a common condition related to aging.
• Onychauxis which is an age-associated thickening of the nail plate
• changes in nail contour, increased transverse curvature
White banding (Terry Nails) is a nail disorder that is specifically linked to age – p. 158.
Pathophysiology: associated with cirrhosis, CHF, adult-onset diabetes mellitus, and age.
Appearance: transverse white bands cover the nail except for narrow zone at the distal tip
Onychomycosis is a fungal infection that causes the nail plate to crumble – p. 156.
Pathophysiology: this is not specifically related to older adults but is associated with loss of manual dexterity (interfere with exercise or walking).
Appearance: distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed
PSORIATIC SKIN LESIONS
Psoriasis is a common skin condition that speeds up the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin. The extra skin cells form scales and red patches that are itchy and sometimes painful.
Psoriasis is a chronic disease that often comes and goes. The main goal of treatment is to stop the skin cells from growing so quickly.
There is no cure for psoriasis, but you can manage symptoms. Lifestyle measures, such as moisturizing, quitting smoking and managing stress, may help
here are several types of psoriasis. These include:
• Plaque psoriasis. The most common form, plaque psoriasis causes dry, raised, red skin lesions (plaques) covered with silvery scales. The plaques might be itchy or painful and there may be few or many. They can occur anywhere on your body, including your genitals and the soft tissue inside your mouth.
• Nail psoriasis. Psoriasis can affect fingernails and toenails, causing pitting, abnormal nail growth and discoloration. Psoriatic nails might loosen and separate from the nail bed (onycholysis). Severe cases may cause the nail to crumble.
• Guttate psoriasis. This type primarily affects young adults and children. It’s usually triggered by a bacterial infection such as strep throat. It’s marked by small, water-drop-shaped, scaling lesions on your trunk, arms, legs and scalp.
The lesions are covered by a fine scale and aren’t as thick as typical plaques are. You may have a single outbreak that goes away on its own, or you may have repeated episodes.
• Inverse psoriasis. This mainly affects the skin in the armpits, in the groin, under the breasts and around the genitals. Inverse psoriasis causes smooth patches of red, inflamed skin that worsen with friction and sweating. Fungal infections may trigger this type of psoriasis.
• Pustular psoriasis. This uncommon form of psoriasis can occur in widespread patches (generalized pustular psoriasis) or in smaller areas on your hands, feet or fingertips.
It generally develops quickly, with pus-filled blisters appearing just hours after your skin becomes red and tender. The blisters may come and go frequently. Generalized pustular psoriasis can also cause fever, chills, severe itching and diarrhea.
• Erythrodermic psoriasis. The least common type of psoriasis, erythrodermic psoriasis can cover your entire body with a red, peeling rash that can itch or burn intensely.
• Psoriatic arthritis. In addition to inflamed, scaly skin, psoriatic arthritis causes swollen, painful joints that are typical of arthritis. Sometimes the joint symptoms are the first or only manifestation of psoriasis or at times only nail changes are seen. Symptoms range from mild to severe, and psoriatic arthritis can affect any joint. Although the disease usually isn’t as crippling as other forms of arthritis, it can cause stiffness and progressive joint damage that in the most serious cases may lead to permanent deformity.
Causes
The cause of psoriasis isn’t fully understood, but it’s thought to be related to an immune system problem with T cells and other white blood cells, called neutrophils, in your body.
T cells normally travel through the body to defend against foreign substances, such as viruses or bacteria.
But if you have psoriasis, the T cells attack healthy skin cells by mistake, as if to heal a wound or to fight an infection.
Overactive T cells also trigger increased production of healthy skin cells, more T cells and other white blood cells, especially neutrophils. These travel into the skin causing redness and sometimes pus in pustular lesions. Dilated blood vessels in psoriasis-affected areas create warmth and redness in the skin lesions.
The process becomes an ongoing cycle in which new skin cells move to the outermost layer of skin too quickly — in days rather than weeks. Skin cells build up in thick, scaly patches on the skin’s surface, continuing until treatment stops the cycle.
Just what causes T cells to malfunction in people with psoriasis isn’t entirely clear. Researchers believe both genetics and environmental factors play a role.
Psoriasis triggers
Psoriasis typically starts or worsens because of a trigger that you may be able to identify and avoid. Factors that may trigger psoriasis include:
• Infections, such as strep throat or skin infections
• Injury to the skin, such as a cut or scrape, a bug bite, or a severe sunburn
• Stress
• Smoking
• Heavy alcohol consumption
• Vitamin D deficiency
• Certain medications — including lithium, which is prescribed for bipolar disorder, high blood pressure medications such as beta blockers, antimalarial drugs, and iodides
Risk factors
Anyone can develop psoriasis, but these factors can increase your risk of developing the disease:
• Family history. This is one of the most significant risk factors. Having one parent with psoriasis increases your risk of getting the disease, and having two parents with psoriasis increases your risk even more.
• Viral and bacterial infections. People with HIV are more likely to develop psoriasis than people with healthy immune systems are. Children and young adults with recurring infections, particularly strep throat, also may be at increased risk.
• Stress. Because stress can impact your immune system, high stress levels may increase your risk of psoriasis.
• Obesity. Excess weight increases the risk of psoriasis. Lesions (plaques) associated with all types of psoriasis often develop in skin creases and folds.
• Smoking. Smoking tobacco not only increases your risk of psoriasis but also may increase the severity of the disease. Smoking may also play a role in the initial development of the disease.
Complications
If you have psoriasis, you’re at greater risk of developing certain diseases. These include:
• Psoriatic arthritis. This complication of psoriasis can cause joint damage and a loss of function in some joints, which can be debilitating.
• Eye conditions. Certain eye disorders — such as conjunctivitis, blepharitis and uveitis — are more common in people with psoriasis.
• Obesity. People with psoriasis, especially those with more severe disease, are more likely to be obese. It’s not clear how these diseases are linked, however. The inflammation linked to obesity may play a role in the development of psoriasis. Or it may be that people with psoriasis are more likely to gain weight, possibly because they’re less active because of their psoriasis.
• Type 2 diabetes. The risk of type 2 diabetes rises in people with psoriasis. The more severe the psoriasis, the greater the likelihood of type 2 diabetes.
• High blood pressure. The odds of having high blood pressure are higher for people with psoriasis.
• Cardiovascular disease. For people with psoriasis, the risk of cardiovascular disease is twice as high as it is for those without the disease. Psoriasis and some treatments also increase the risk of irregular heartbeat, stroke, high cholesterol and atherosclerosis.
• Metabolic syndrome. This cluster of conditions — including high blood pressure, elevated insulin levels and abnormal cholesterol levels — increases your risk of heart disease.
• Other autoimmune diseases. Celiac disease, sclerosis and the inflammatory bowel disease called Crohn’s disease are more likely to strike people with psoriasis.
• Parkinson’s disease. This chronic neurological condition is more likely to occur in people with psoriasis.
• Kidney disease. Moderate to severe psoriasis has been linked to a higher risk of kidney disease.
• Emotional problems. Psoriasis can also affect your quality of life. Psoriasis is associated with low self-esteem and depression. You may also withdraw socially.
Vesicular Skin Characteristics
o Vesicles are small, clear, fluid-filled blisters. (page 127)
o A vesicle is elevated, superficial and less than 1cm. The vesicle does not go into the dermis. (page 127)
o Examples of a vesicle are varicella (chickenpox) and herpes zoster (shingles) viruses. (page 127)
o A bulla is a vesicle (blister) that is greater than 1cm. (page 128).
Normal vs abnormal hair distribution during aging
Characteristics of Hair Distribution
Quantity and distribution of hair vary according to individual genetic makeup
Hair is commonly on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples
Hair loss is generalized or localized
Hair loss on toes may indicate poor circulation or nutritional deficit
Diffuse hair loss usually occurs without inflammation and scarring
Note if the hair shafts are broken off or completely absent
Scarring is helpful in diagnosis
During adulthood men who are genetically predisposed often display gradual symmetric hair loss on the scalp as a response to androgens
Asymmetric hair loss may indicate pathologic condition
Women in their 20s and 30s can also develop adrenal androgenic female pattern alopecia (hair loss), gradual hair loss from the central scalp
Fine vellus hair covers the body
Coarse terminal hair occurs on the scalp, pubic, axillary area, arms, legs (to some extent), and a man’s beard
Male pubic hair configuration is upright triangle with the hair extending midline to umbilicus
Female pubic hair configuration is an inverted triangle; hair may extend midline to the umbilicus
Assess for hirsutism in women- the growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, alone or with other signs of virilization, may indicate an endocrine disorder
Ball et al., 2015, p. 133-134
Hair loss on lateral eyebrows and scalp may indicate a thyroid dysfunction
Dains et al., 2016, p. 251
Evaluate hair loss that is diffuse or localized and compare areas such as temporal and crown region to the occiput
Hair pull test will reveal any increased hairs shed with a gentle pull
Dains et al., 2016, p. 335
Hair disorders
Alopecia Areata
o Sudden, rapid, patchy loss of hair, usually from face or scalp
o Unknown cause may be triggered by genetic-environmental interactions
o Any hair may be affected
o Regrowth begins in 1-3 months
o Subjective data: sudden, rapid, patchy hair loss, may report nail pitting, may have family history
o Objective data: hair loss sharply defined round areas, hair shaft is poorly formed and break off at skin surface
Ball et al., 2015, p. 154
Scarring Alopecia
o Replacement of hair follicles with scar tissue
o Skin disorders of the scalp or follicles resulting in scarring and destruction of hair follicles and permanent hair loss
o Subjective data: may have other concurrent skin or systemic disorders
o Objective data: patchy hair loss, scalp may be inflamed, hair follicles may be pustular or plugged
Ball et al., 2015, p. 155
Traction Alopecia
o Hair loss that is the result of prolonged tightly pulled hairstyles
o Prolonged tension of the hair from traction breaks the hair shaft
o Follicle is not damaged, loss is reversible
o Subjective data: history of wearing certain hairstyles: braids, hair rollers, or hot combs
o Objective data: patchy hair loss that corresponds directly to the area of stress
o Scalp may or may not be inflamed
Ball et al., 2015, p. 155
Hirsutism
o Caused by high androgen levels (from ovaries or adrenal glands) or by hair follicles that are more sensitive to normal androgen levels, free testosterone causes hair growth
o Causes: genetic, physiologic, endocrine, drug-related, and systemic disorders
o Subjective data: excessive hair growth on face or body; onset, severity, and rate depend on underlying cause
o Objective data: thick dark terminal hairs in androgen-sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea able; may or may not be accompanied by other signs of virilization
Ball et al., 2015, p.155
Hair-Pulling (Trichotillomania)
o Loss of scalp hair caused by physical manipulation
o Hair is twisted around the finger and pulled or rubbed until it breaks off; the act of manipulation is usually an unconscious habit
o Subjective data: may report tension, anxiety, emotional stressors
o Objective data: affected area has an irregular border, and hair density is greatly reduced, but the site is not bald
Ball et al., 2015, p. 163
Tinea capitits- the triad of hair loss, scaling, and lymphadenopathy in children
Crainial nerves associated with the HEENT system:
God gave you 1 nose (Olfactory) and 2 eyes (Optic). Nerves 3,4, and 6 make your eyes do tricks (3 Occularmotar, 4 Trochlear, and 6 Abducens). FIVE rhymes with TRI (5 Trigeminal). 7 is like an “F” backwards (F for Facial). 8 looks like earrings (8 Vestibulocochlear (Auditory)). “9 and10, under my chin” (IX Glossopharyngeal (Swallowing, saliva, taste), X Vagus (Control of PNS e.g. smooth muscles of GI tract) (just check gag reflex), 12 for swallowing (XII Hypoglossal (Tongue muscles – speech & swallowing)), and the number 11 looks like the neck (XI Accessory (Moving head & shoulders).
In the pic of the face attached, each part of the number 5 the crosses the face (3 lines) corresponds with the first, second, and third segments of the Trigeminal nerve (Forhead, maxila and mandible).
Here is a quick, meat and potatoes crainial nerve assessment video that is to point:
As the video suggests, the 1st crainial nerve is not tested during routine exam, but you could blindfold the patient and hold coffee, alchohol, etc under the nose and test like you would a taste for sugar and salt.
Now, to remember the order, a “clean” acronym for remembering the crainial nerve order would be,
“Oh Oh Oh To Touch And Feel Very Good Velvet, Such Heaven.” Take the first letter of this acronym for the order of the nerves.
There is another acronym that helps you determine whether the nerve is sensory, motor, or both. This acronym is, “Some Say Marry Money But My Brother Says Big Brains Matter Most.”
Normal Assessment Findings of an Adolescent’s (10-19years) Nose and Throat
*All information retrieved from Seidel’s Guide to Physical Examination 8
th
Edition-Chapter 12, pages 242-243 & 248-249*
Nose
External
Smooth skin, no swelling, & conforms to the color of the face
Columella should be midline and does not exceed diameter of a naris
Nares-oval in shape and symmetrically positioned
Nasal structures should feel firm and stable-no crepitus, tenderness or masses should be present
Nasal Cavity
Nasal mucosa-should glisten and is deep pink in color
Clear discharge is normal on the septum
Hairs may be visible on the vestibula
Turbinates should be firm and same color as surrounding area
Septum-close to midline and fairly straight
Anterior septum is thicker than posterior septum
No perforations, bleeding or crusting
Throat
Oropharynx
Tonsils-same pink color as pharynx & should fit within the tonsil pillars
Crypts may be present in tonsils-cellular debris and food collects here
Posterior wall of the pharynx should be smooth, glistening and pink
Some small irregular spots of lymphatic tissue and small blood vessels should be seen
FONTANELS Seidel’s guide (8
th
edition) says anterior fontanel closes by
12-15 months
(page 186). In infant the cranial bones are separated by
sagittal, coronal, and lambdoid
suture. Please note that, some books refer that closure of the skull fontanel should occur by 24 months for sure or anterior fontanel can remain palpable till 24 months. So, I hope we don’t get a very complicated question about it in the test. NURS 6512 Midterm exam study Guide
Ossification of skull sutures is complete about 6 years old.
Posterior fontanel closes by 2 months.
Anterior fontanel by 12-15 months.
Abnormality
Torticollis (Wry neck): shortening or excessive contraction of sternocleidomastoid muscle (p. 200 of Seidel’s). Happens due to birth trauma.
Caput Succedaneum
: (Seidel’s p. 195)
subcutaneous edema over presenting part of head at delivery.
Most common
form of
birth trauma
and usually occurs over occiput and crosses suture lines. Poorly defined margins. Edema goes away in a few days.
The most common form of birth trauma of the scalp is
A. caput succedaneum.
B. cephalhematoma.
C. cranial bossing.
D. torticollis.
E. dilated scalp veins.
Correct ans C
Cephalhematoma
: subperiosteal collection of blood and is bound by suture lines.
Most common in parietal region and may not be obvious at birth. Firm and well-defined edges. Does not cross suture lines. NURS 6512 Midterm exam study Guide.
Question: Which of the following is true regarding a cephalohematoma?
a. It is bound by suture lines.
b. The affected part feels soft.
c. It is obvious at birth.
d. The margins are poorly defined.
Correct answer: A
Bossing
: bulging of skull. Bossing is associated with prematurity, thalassemia, Paget disease, rickets.
Plagiocephaly
: flattened spot on back or one side of head. Can result from premature fusion of sutures.
Examination findings of a patient with Hypothyroid and Hyperthyroid
Hypothyroidism-
Seidel’s guide to physical Examination eighth edition p. 190, 201- Table 10-1
Overactive thyroid
Pathophysiology-
• Excess thyroid hormone causes increase in metabolic rate
• Associated with increase in total body heat production and increased heart contractility, heart rate and vasodilation
• Multinodular goiter (Plummer disease
Subjective Data
• Weight loss
• Tachycardia
• Diarrhea
• Heat Sensitivity
Objective Data
• Normal size thyroid. Goiter or nodules
• Fine hair
• Bridle nails
• Proptosis
• Tachycardia
Hypothyroidism-
Underactive Thyroid
Pathophysiology
• Primary: Thyroid gland produces insufficient amounts of thyroid hormone.
• Secondary: Insufficient thyroid hormone secretion due to inadequate secretion of either thyroid-stimulating hormone (TSH) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the hypothalamus
• More common than hyperthyroidism
Subjective Data
• Weight gain
• Constipation
• Fatigue
• Cold intolerance
Objective Data
• Normal size thyroid, goiter or nodules
NURS 6512 Midterm exam study Guide
Techniques for Examining the HEENT
Chapters 10, 11, 12 Seidel’s Guide to Physical Examination
HEAD 189:
Observe position. Should be upright and still, no tilts or tremor
Skull/Scalp 189-192
: Front to back
Symmetry by parting the hair -assess size, shape and for lesions during the above
Palpate for indents/depressions (should be smooth/fontanels undetectable p 6mo)
Palpate over sinuses (no tenderness) NURS 6512 Midterm exam study Guide
Scalp should move freely over skull
Special attention at hair line, crown and behind the ears
Palpate hair, noting texture, color, distribution (smooth, even, no split ends)
IF
appropriate- auscultate & palpate temp arteries for thickness/hardness/tenderness
Facial Features 189:
Includes eyelids/brows, palpebral fissures (under eye) nasolabial folds, mouth
Check Symmetry at rest (slight difference common w movement/expression)
Note unusual features (edema, bruising, bulging eyes, abn hair growth)
Tics (spasmodic movement)
Do features appear syndrome like? (characteristic facies)
Variation in skin color
Salivary Glands 192:
inspect/palpate for asymmetry, size, flexibility, firmness
Transillumination of Infant skull 196
: to check for fluid/decreased brain tissue
Palpate lower trachea w thumbs at each side to eval space between trachea and sternocleidomastoid muscles on each side (uneven indicates displacement)
Palpate movement with swallowing (smooth and nontender) movement of cartilages should be felt under finger
ROM 193/516/578: Flex, extend, rotation without pain, resistance or dizziness
Palpation for tenderness in the paravertebral musculature and spinous processes (upper/lower back) coupled with ROM of neck for eval of stiff neck
Take note of any mass, webbing, skin folds (excessive posterior cervical skin) NURS 6512 Midterm exam study Guide
Thyroid 194:
inspection, palpation, and auscultation for bruit if enlarged
Gently extend neck, use water for swallowing, gentle touch
Can be done from front or behind (learn and be consistent with your method)
Palpation for size, shape, configuration, pain, nodules
Lymph nodes 174-175:
Palpation (so much info pictures, I wasn’t sure how to break it down)
Eyes 208-209:
Near vision- Rosenbaum pocket vision screen (14 inch from face)
Distant Vision- Snellen eye chart/Pin hole (no glasses first)
Peripheral Vision- Confrontation test (bringing fingers in from the side)
Eyebrows 210:
Inspect texture, size, extension to temporal canthus
Eyelids 210-211:
Open and closes completely?
Eyelash position (should curve away)
Ptosis (drooping eyelid)
Fasciculation (twitching/tremor)
Flakey, redness, swelling?
Palpate for nodules -closed lids w gentle push into orbit (should be no discomfort)
Pull lower lid down to assess for color, discharge, lacrimal gland punctum, pterygium
Orbits 210:
Inspect for edema, puffiness, excess tissue
External Eye 212-214:
Corneal clarity using a pen light
Corneal sensitivity using a cotton wisp (slight touch across the cornea)
Corneal arcus: circle around the cornea
Color of irises should be the same
Pupils should be round, regular, equal size, and reactive to light
Pupillary defect with swing flashlight test (checks optic nerve)
Nystagmus- have patient follow your finger to check for involuntary movement
Muscle balance & movement 214-216:
Corneal light reflex 215: light source (used to check strabismus)
Cover-uncover test 215
Six cardinal fields of gaze: assess extraocular muscles and cranial nerves
Nasal- straight, up, and down
Temporal- straight, up, and down
Opthalmic examination 216-218:
Give rest periods between tests using bright light
Dim the lights
Ophthalmoscope in the hand with corresponding eye (right hand-right eye)
Instill dilating medications as necessary
Ears 239:
Inspect for size, shape, symmetry, landmarks, color, abnormalities.
Position- pull ear up and back
Palpate auricles and mastoid area for pain, swelling or nodules
Auditory canal 240: otoscope 1-1.5 cm depth- color, cerumen, abnormalities
Tympanic membrane 240-241: otoscope- movement (w positive pressure), color, landmarks, abnormalities
Hearing 240-242:
Response to questions during history, whispered voice, and tuning forks (top of head and mastoid area)
Nose and Sinuses 242-244:
Inspect external nose NURS 6512 Midterm exam study Guide
Palpate bridge and soft tissues of nose
Nares -nasal speculum and light source
Palpate maxillary and frontal sinuses for swelling or pain
Transillumination 244: of sinuses if tender or infection is present
Mouth 245-249:
Inspect lips, teeth, and oral cavity for abnormalities
Palpate and inspect gingivae and buccal mucosa for color, lesions, and pain
Inspect and palpate the tongue
Elicit a gag reflex
Inspect tonsils and pharynx
#30 Examination findings for a patient with sinus symptoms
Seidel page 231, 243-244
Inspect the external nose, noting the shape, size, color, and nares.
Palpate the bridge and soft tissues of the nose, noting tenderness, displacement, and masses.
Evaluate the patency of the nares
Inspect the nasal mucosa and nasal septum for the following: color, alignment, discharge, selling of turbinates, or perforation.
Inspect the frontal and maxillary sinus area for swelling
Palpate the frontal and maxillary sinuses for any tenderness, pain, or swelling
NURS 6512 Midterm exam study Guide
Signs and Symptoms
Sinus infections often follow a cold and cause pain and pressure in your head and face. Palpating over the infected sinus will cause tenderness.
Sinusitis can be either acute or chronic. With chronic sinusitis, the infection or inflammation does not completely go away for 12 weeks or more.
Sinusitis can be caused by three things: viruses, bacteria, fungi. The same viruses that cause the common cold cause most cases of sinusitis.
-Viral Sinusitis: When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat.
-If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain.
-Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.
Other common symptoms of sinusitis may include: headache, bad breath, cough that produces mucus, fever, pain in your teeth and a reduced sense of taste or smell.
Viral infections normally resolve without antibiotics within 14 days. Bacterial infections may require antibiotics. OTC medications can be obtained to relieve discomforts and sinus symptoms. Fungal infections (less common) require anti-fungals, these infections can require additional interventions (surigal).
Transillumination of the sinuses:
A transilluminator or small, bright light can be used.
Darken the room.
Maxillary sinuses: place the light source lateral to the nose, just beneath the medial aspect of the eye. Look through the patients open mouth for immunination of the hard palate.
Frontal sinuses: place the light source against the medial aspect of each supraorbital rim. Look for a dim red glow just above the eyebrow.
The sinuses may differ in degree of illumination
-Opaque: no transillumination
-Dull: reduced transillumination
-Glow (expected): transillumination.
-An opaque response may indicate the sinus is filled with secretions or never developed.
-Asymmetry of transillumination is a significant finding NURS 6512 Midterm exam study Guide.
#31 appropriate tuning fork frequencies to approximate vocal frequencies
Seidel page 241-242
Weber test: helps assess unilateral hearing loss. Place the base of the vibrating tuning fork on the midline of the patients head. Ask the patient if the sound is heard equally in both ears or is better in one ear. If the sounds is heard better in one ear, have the patient identify which ear.
-To test reliability have the patient occlude one ear. Repeat the test, the sound should be heard better in the occluded ear.
Rinne test: helps to distinguish if the patient hears better by air or bone conduction. Place the base of the vibrating tuning fork against the patients mastoid bone and ask the patient to tell you when the sound is no longer heard. Time this interval of bone conduction, noting the number of seconds. Quickly position the still vibrating tines 1-2 cm from the ear, and again ask the patient to tell you when the sound in no longer heard. Time the interval of sound conduction as well. Compare the seconds recorded for both bone and air conduction.
-Air conduction should be heard twice as long as bone conduction. (see figure 12-16 on page 242 in Seidel)
*Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for? Lateralization of sound
*To approximate vocal frequencies, which tuning fork should be used to assess hearing?
Ans. 500 to 1000 Hz
Examining the oral mucosa-
*Careful examination of the oral cavity may reveal findings indicative of an underlying systemic condition, and allow for early diagnosis and treatment.
**A good light source is fundamental for a good intraoral examination. Any intraoral lesion should be described with respect to size, extent, thickness, color, texture, consistency, and tenderness. Major salivary gland should be palpated and milked to assess salivary gland duct orifices patency and salivary flow and to evaluate the quality of saliva (e.g., frothy versus serous). In a healthy individual unstimulated whole salivary flow rate ranges 0.3–0.4 mL/min, while chewing-stimulated whole salivary flow is 1.5–2.0 mL/min.
*Teeth should be examined to evaluate possible dental decays, fractures, mobility, defects in restorations, gingival recession and bone loss with inspection, palpation and percussion NURS 6512 Midterm exam study Guide.
**Examination should include evaluation for mucosal changes, periodontal inflammation and bleeding, and general condition of the teeth. Oral findings of anemia may include mucosal pallor, atrophic glossitis, and candidiasis. Oral ulceration may be found in patients with lupus erythematosus, pemphigus vulgaris, or Crohn disease. Additional oral manifestations of lupus erythematosus may include honeycomb plaques (silvery white, scarred plaques); raised keratotic plaques (verrucous lupus erythematosus); and nonspecific erythema, purpura, petechiae, and cheilitis. Additional oral findings in patients with Crohn disease may include diffuse mucosal swelling, cobblestone mucosa, and localized mucogingivitis. Diffuse melanin pigmentation may be an early manifestation of Addison disease. Severe periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus infection, thrombocytopenia, and leukemia. In patients with gastroesophageal reflux disease, bulimia, or anorexia, exposure of tooth enamel to acidic gastric contents may cause irreversible dental erosion. Severe erosion may require dental restorative treatment. In patients with pemphigus vulgaris, thrombocytopenia, or Crohn disease, oral changes may be the first sign of disease. NURS 6512 Midterm exam study Guide.
*****************
Ask patient to open mouth wide (use a pen light or otoscope if needed)
Inspect the surface of the tongue and the hard palate
Use a tongue depressor to allow movement of the oral cavity contents
Inspect the uvula and soft palate
Examine the buccal area and the gingivolabial (gingivobuccal) sulcus
Inspect lateral, superior, and inferior walls
Ask the patient to lift their tongue in the air
Inspect the floor of the mouth (use the tongue depressor if needed)
Use a tongue depressor to move the tongue down
Inspect the uvula, tonsillar tissue, palatal folds, and posterior pharyngeal wall NURS 6512 Midterm exam study Guide
Hearing loss findings when examining the elder patient
• Nearly 1/3 of adults over the age of 65 have hearing loss.
• Age-related hearing loss is associated with degerneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degerneration of the cochlear conductive membrane, and decreased vascularity in the cochlea.
• Sensorineural hearing loss-first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of high frequency sounds usually interferes with the understanding of speech and localization of sound.
• Conductive hearing loss- may result from an excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a sclerotic tympanic membrane.
Risk Factors of hearing loss in adults (obtained in history portion of assessment)
• Exposure to industrial or recreational noise
• Genetic disease: Meniere disease
• Neurogenerative and autoimmune disorders
• Syphilis
• Ototoxic medication use (Ex: aminoglycosides, gentamicin, streptomycin, quinine, salicylates, and furosemide.
Hearing loss findings
• Cranial nerve VIII is tested by evaluation of hearing
• Hearing screening begins when the patient responds to your questions and directions
• Asking patients if they have a hearing problem is associated with detecting a mild to moderate hearing impairment with audiometric assessment.
• Behaviors such as cupping hand behind ear or tilting an ear toward you when listening
• Excessive requests for repetition may indicate hearing loss
• Speech with a monotonous tone and erratic volume may indicate hearing loss
NURS 6512 Midterm exam study Guide
Whisper Test
Check the patients response to your whispered voice, one ear at a time, while having the patient insert finger into opposite ear canal. Stand 1-2 d=feet away from the ear being tested and out of the patients line of vision. Whisper a random combination of three to six letters and numbers. EX. 3, T,8 and ask the patient to repeat what was heard. The patient should correctly repeat 50% of the sounds. Repeat process with other ear.
Examination techniques used to examine the trachea and thyroid
Please refer to pages in Siedel pp. 185-188, pp. 194-195, Hyper and Hypothyroidism (pp 200-201) and pg. 273
View video on YouTube demo:
The Thyroid Exam
(Stanford Medicine 25) on YouTube:
View Video:
Thyroid Status Examination
– OSCE Guide:
View Video:
Examination of the Trachea
Thyroid Anatomy:
One gland two lobes, butterfly-shaped and joined by an isthmus at their lowest aspect (Seidel, p.185).
Thyroid Gland that straddles the trachea in the middle of the neck
. Secretes T4 and T3. Has two lobes.
Thyroid is the largest endocrine gland
in the body producing two hormones Thyroxine (T4) and Triiodothyronine (T3).
Thyroid feels
: Rubbery and easier to feel on a long slender neck
What do you do if the thyroid is enlarged?:
Listen over lateral lobes w/ bell and listen for thyroid bruit
Inspect Neck
for range of motion, strength, trachea, thyroid, and lymph nodes.
Trachea
: The trachea, colloquially called the windpipe, is a cartilaginous tube that connects the pharynx and larynx to the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs NURS 6512 Midterm exam study Guide
What techniques do you use to examine the neck?
inspection
: inspect the neck in the usual anatomic position, in slight hyperextension as the patient swallows ( Seidel p. 193 see pictures).
palpation
: palpate the trachea for midline position (Seidel p.192, see picture)
auscultation
: when checking for bruits often noted in children and uncommon in neonates (Seidel p. 192).
Refer to Website: https://depts.washington.edu/physdx/thyroid/tech.html
Techniques: Thyroid Exam
There are several physical examination maneuvers described for examination of the thyroid described below that are at least moderately sensitive and specific. Much of the exam is based on physiological reasoning and tradition rather than on studies of reliability or precision. Combining the examination and association signs and symptoms increases the
accuracy of the physical examination of the thyroid
.
Goiter: Examination of the thyroid for size
Note: An enlarged thyroid is referred to as a goiter. There is no direct correlation between size and function- a person with a goiter can be euthyroid, hypo- or hyperthyroid.
A normal thyroid is estimated to be 10 grams with an upper limit of 20 grams or 2 to 4 teaspoons.
Examination for goiter can increase the possibility of thyroid disease in patients with symptoms of hypo- or hyperthyroidism, in determining the choice of treatment in hyperthyroidism and monitoring the response to therapy directed at decreasing the size of the thyroid in cases of symptomatic goiter. NURS 6512 Midterm exam study Guide.
The examination consists of three portions:
Inspection,
Palpation, and
Synthesis of data from these techniques
In addition to palpating for size, also note the gland texture, mobility, tenderness and the presence of nodules.
Inspection
Inspection: Anterior Approach
The patient should be seated or standing in a comfortable position with the neck in a neutral or slightly extended position.
Cross-lighting increases shadows, improving the detection of masses.
To enhance visualization of the thyroid, you can:
Extending the neck, which stretches overlying tissues
Have the patient swallow a sip of water, watching for the upward movement of the thyroid gland.
251KB video demo
from
Return to the Bedside
Inspection: Lateral Approach
After completing anterior inspection of the thyroid, observe the neck from the side.
Estimate the smooth, straight contour from the cricoid cartilage to the suprasternal notch.
Measure any prominence beyond this imagined contour, using a ruler placed in the area of prominence.
Palpation
Note: There is no data comparing palpation using the anterior approach to the posterior approach so examiners should use the approach that they find most comfortable.
Palpation: Anterior Approach
The patient is examined in the seated or standing position.
Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch.
Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid.
Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.
454KB video demo
from
Return to the Bedside
.
Palpation: Posterior Approach
The patient is examined in the seated or standing position.
Standing behind the patient, attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and the suprasternal notch.
Move your hands laterally to try to feel under the sternocleidomstoids for the fullness of the thyroid.
Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland.
Note: This traditional technique is based on physiological reasoning; data of effectiveness is lacking.
Synthesis of data from these techniques
Using the data from anterior and lateral inspection and from palpation, categorize the gland as:
goiter ruled out [normal or small (1 to 2 times normal) with lateral prominence <2 mm ],
goiter ruled in [large (& 2 times normal) or lateral prominence >2 mm] or
See
Evidence Base
and
Differential Diagnosi
s.
back to top
Nodules: Examination of the thyroid for nodularity
Thyroid nodules are common (prevalence 4%). Half of the thyroids glands examined by ultrasound or direct visualization (surgery or autopsy) have nodules. Physical examination detects approximately 10% of the nodules found by these methods. Nodules increase in frequency with age and are four times more likely in women than men. Less than 5% of all nodules are cancerous.
Technique
The
location
of the thyroid is identified by inspection.
Using the anterior or posterior approach
, palpate the thyroid to identify nodules
Note the
size and number
of nodules. NURS 6512 Midterm exam study Guide
Note the
consistency
of the nodule.
Palpate
regional lymph nodes for consistency and mobility
.
Take a look at a teaching demo video.
Also called the digestive tract, the alimentary tract is composed of the following hollow organs: the mouth, the esophagus, stomach, small intestines, large intestines, and the anus. The solid organs of the tract include the liver, pancreas, and gallbladder.
#36- The correct assessment order for examining the abdomen is: 1) Inspect 2) Auscultate 3) Percuss 4) Palpate
Inspect the skin characteristics, contour, pulsations, and movement
Auscultate all 4 quadrants for bowel sounds. Auscultate the aorta and renal, iliac, and femoral arteries for bruits or venous hums.
Percuss all quadrants for tone. Percuss liver borders and estimate spans. Percuss left midaxillary line for splenic dullness.
Lightly palpate quadrants x4. Deeply palpate quadrants x4. Palpate right costal margin for liver border. palpate left costal margin for spleen. Palpate laterally at the flanks for left and right kidneys. Palpate midline for aortic pulsation. Test abdominal reflexes.
Finally, have the patient raise the head as you inspect the abdominal muscles. NURS 6512 Midterm exam study Guide.
ABDOMINAL EXAMINATION CORRECT SEQUENCE
WHEN YOU PERFORM a physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you’re performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you’d inspect, auscultate, percuss, then palpate an abdomen.
Seidel’s Guide to Physical Examination—Examination of the Liver pg. 385-386
Assessment YouTube Video:
Liver palpation
The lower edge of the liver can be palpable on inspiration about 3 cm below the right rib cage. The liver palpation can be performed with one hand or bimanually, and in the case of obese patients, the so-called “hooking” technique might be helpful as well.
One-hand liver palpation
Place your right hand on patient’s abdomen, lateral to the rectus muscle, well below the level of percussed border of liver dullness.
Orient your fingers towards the patient’s head or slightly diagonally towards the midline. Press your fingers firmly in and up (towards the patient’s head).
Ask the patient to take a deep breath. On inspiration, the liver descends, and its edge meets the fingertips of the palpating hand.
Continue palpating, moving your hand toward the coastal margin until you feel the liver edge (usually a few cm below right costal margin). Note liver edge texture and regularity. Slight tenderness on palpation is normal.
When your fingers meet the liver edge, slightly reduce the pressure on the abdominal wall while the patient is still taking a deep breath in. This maneuver allows the examiner to feel the anterior liver surface as it slips under the finger pads. Make a note of the consistency of the liver surface-nodes, granularity, etc. (Figure 2) NURS 6512 Midterm exam study Guide
Bimanual liver palpation
Place your left hand posteriorly at the level of the patient’s two lower ribs, and gently press upward to elevate the liver into a more accessible position.
Ask the patient to take a deep breath and perform palpation with your right hand as described above.
The “hooking” technique
This can be helpful when the liver is not palpable by the standard techniques.
Stand on the right of the patient, facing the patient’s feet.
Place your flexed fingers over the edge of costal margin.
Ask the patient to take a deep breath and try to feel the liver edge as you press downward and upward (towards the patient’s head). NURS 6512 Midterm exam study Guide
Signs and symptoms of liver disease include:
Skin and eyes that appear yellowish (jaundice)
Abdominal pain and swelling
Swelling in the legs and ankles
Itchy skin
Dark urine color
Pale stool color, or bloody or tar-colored stool
Chronic fatigue
Nausea or vomiting
Loss of appetite
Tendency to bruise easily
Examination findings associated with appendicitis
Appendicitis
The incidence of appendicitis peaks at age 10 to 20 years, although it can occur at any age.
The patient reports sudden onset of colicky pain that progresses to a constant pain.
The pain can begin in the epigastrium or periumbilicus and later localize to the RLQ.
The pain worsens with movement or coughing. NURS 6512 Midterm exam study Guide
Vomiting after the onset of pain sometimes occurs.
On physical examination, the patient will be lying still and demonstrate involuntary guarding.
Classically, tenderness occurs in the RLQ.
The other tests for peritoneal irritation will be positive.
Rebound tenderness may be present.
Variation in presentation is common, particularly with infants, children, and the elderly.
Diagnostic testing includes complete blood count (CBC) with differential to confirm or rule out infection and the use of either ultrasonography, CT scan, or laparoscopy. NURS 6512 Midterm exam study Guide.
Psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the right lower quadrant are signs of appendicitis.
Conditions that cause irritation of the obturator muscle are late findings usually associated with a ruptured appendix or pelvic abscess.
An accurate diagnosis based on history and physical examination can facilitate immediate surgical evaluation and definitive treatment and prevent unnecessary use of radiologic imaging.
In adults, historical symptoms that increase the likelihood of appendicitis are right lower quadrant (RLQ) pain, initial periumbilical pain with migration to the RLQ, and the presence of pain before vomiting.
The presence of rigidity, a positive psoas sign, fever, and/or rebound tenderness are physical examination findings that increase the likelihood of appendicitis.
EVIDENCE-BASED PRACTICE
Clinical Diagnosis of Appendicitis
In a review of clinical decision rules to assist in diagnosing appendicitis, the authors concluded that decision models that score combinations of findings from the history and clinical examination are more powerful than any single finding.
They point to the Alvarado model as one that balances accuracy with ease of use and familiarity to clinicians.
It combines the results for eight findings; a score of 7 or more out of a potential 10 indicates the need for surgical intervention.
The Alvarado model has a sensitivity of 81% and a specificity of 74%. NURS 6512 Midterm exam study Guide.
ALVARADO SCORE FOR EARLY DIAGNOSIS OF ACUTE APPENDICITIS
VARIABLE
SCORE
Migration of pain
1
Anorexia-acetone
1
Nausea/vomiting
1
Tenderness in RLQ
2
Rebound pain
1
Elevation of temperature
1
Leukocytosis
2
Shift to the left on differential (neutrophils >75%)
1
Maximum total score
10
Positive score
≥7*
*A score of 7 or more indicates the need for surgical intervention.
Examining Mc Burney’s Sign
Positive sign associated with appendicitis
+ tenderness at the RLQ (Mc Burney’s Point) Measure 1/3 between ASIS and umbilicus (Ball, Dains, Flynn, Solomon, & Stewart, 2015) pgs. 390-391
Video to assess for a positive Mc Burney’s sign –
(YouTube, 2016)
Assessment of abdominal pain in women
*Key Points
Auscultation should be done last when examining the abdomen
Example question found through Elsevier online: Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to: inspect for ecchymosis of the flank.
When assessing abdominal pain in college-aged women always ask when the first day of their last menstrual period was!!!
Before performing an abdominal exam have the patient empty their bladder!
After abdominal inspection then AUSCULTATE
Inspection of the abdomen should begin with the patient SUPINE
Advanced Health Assessment and Clinical Diagnosis in Primary Care (Dains, Baumann, & Scheibel: Chapter 3 pg. 11
Pg. 20: Perform a pelvic exam in women to rule out STI, PID, ovarian pain, ectopic pregnancy, and uterine fibroids. Cervical motion tenderness (CMT) is the hallmark of PID.
Pg. 28-32 table with common causes of acute abdominal pain
Examples for women:
Ectopic Pregnancy:
women of childbearing age, sudden onset of spotting and persistent cramping in lower quadrant that begins shortly after missed period.
Dysmenorrhea:
typical premenstrual pain onset soon after menarche, gradually diminishes with age. Gynecology consult is needed with pelvic ultrasound. (pg. 30)
Uterine Fibroids:
pain related to menses or intercourse. (
Physical Findings:
Palpable myomas. Pelvic ultrasound is needed with gynecology consult (pg. 27, 31)
Ovarian Cyst:
common with younger women. (pg. 27, 31)
Physical Findings:
adnexal pain and palpable ovarian cysts especially later in cycle
Cholecystitis:
more common in women. Pain located in RUQ and radiates to right scapular area, dark urine, N/V, light stools, and may be aggravated by certain foods. (pg. 29)NURS 6512 Midterm exam study Guide
Pelvic Inflammatory Disease (PID):
common in women younger than 35 who are sexually active usually with more than one partner. Often caused by chlamydia trachomatis and Neisseria gonorrhoeae with onset occurring after menses. Patients present with lower abdominal pain that progressively becomes severe. Upon examination: tender abdomen, CMT, and adnexal tenderness. Patients may guard and have rebound tenderness, fever, irregular bleeding, vaginal discharge, and vomiting, WBC and ESR are usually elevated. (pg. 25)
Causes of lower abdominal or pelvic pain
Lower abdominal or pelvic pain, refers to discomfort that occurs at or below your belly button. Most women will experience pain in the
lower abdomen
from time to time. More often than not this is due to menstruation.
The bladder and reproductive organs are often where pelvic pain occurs. In many cases it is difficult to diagnose the exact cause of the pain, but noting certain symptoms will help come to a diagnosis.
The most common lower abdominal pain causes are:
A urinary disorder, such as bladder or kidney problems.
A bowel problem.
A problem with the reproductive system – the uterus, fallopian tubes and ovaries.
Abdominal pain arising from the urinary system
Urine infections
are common and present symptoms, such as burning when you pass urine and going to the toilet more often.
Infection can spread to the kidneys (pyelonephritis) and can make you feel unwell with a high temperature and back pain.
If you have pain that spreads from your back down to your groin and is severe – your doctor may be more concerned that you have
kidney stones
. The doctor will test your urine if you have any of the above symptoms. NURS 6512 Midterm exam study Guide.
Abdominal pain arising from the digestive system
Pain arising from the large intestine is a particularly common cause of lower abdominal pain in both men and women. Features suggesting your pain may be to do with the bowel are:
Pain associated with bowel movement
A change in bowel habit
Blood with bowel movement
Bloating
Both
constipation
and
diarrhea
can give you pain. The pain they are often associated with is described as crampy or ‘colicky.’ This means that it comes and goes in waves. Large bowel pain is characteristically relieved on opening the bowels.
Potential causes of pain arising from the bowel include
irritable bowel syndrome
(IBS), which can give you alternating diarrhea, constipation and bloating.
Other conditions include diverticular disease and its complications which are more frequent in older patients. Inflammatory bowel disease (ulcerative colitis or Crohn’s). A rare but important diagnosis is colorectal cancer.
Bloating and swelling is also a common symptom that people report and can be due to a problem affecting the bowels NURS 6512 Midterm exam study Guide.
Abdominal pain arising from the reproductive organs
Pain can originate from your uterus (womb), fallopian tubes or ovaries. It’s usually felt in the middle of the lower abdomen.
Pain that is felt more to the side can be more typical of a pain coming from the ovary.
Pain coming from the uterus is often worse during your period and is called dysmenorrhea.
Some conditions affecting the reproductive system can also cause pain during intercourse. This is called
dyspareunia
and it is important to let your doctor know if you are concerned.
Examples of conditions of the reproductive organs include:
Endometriosis
Fibroids
Pelvic inflammatory disease
Ovarian cysts
Problems related to the early stage of pregnancy, such as a miscarriage or ectopic pregnancy.
*Seek immediate medical assistance if your symptoms include a fever, vomiting blood, passing dark or bloody stools or acute and worsening pain.
Questions about a person’s emotional life-family, home, work and sex life are appropriate.
Further abdominal pain investigations
Depending on the exact symptoms and duration, referral to the appropriate specialist is often required. These may include:
Gynecological causes may require vaginal swabs, cervical smears or pelvic ultrasound examination. Ultrasound may also be performed from within the vagina. Specialized blood test for ovarian cancer, CA-125, are usually performed. More invasive tests will depend upon the doctor’s suspicion of the cause of the pain.
Urinary causes can be investigated by urine culture, ultrasound or CT scan.
Colonic causes may require internal endoscopic examination of the bowel by Flexible Sigmoidoscopy or Colonoscopy.
A CT (Computerized Tomography Scan) may be appropriate for all three major sites of pain. NURS 6512 Midterm exam study Guide
QUESTION #41 &42
Anatomic correlates of Nine regions of abdomen. Seidel p. 378-379
Right Hypochondriac
Right lobe of liver
Gallbladder
Portion of duodenum
Hepatic flexure of colon
Portion of right kidney
Right adrenal gland
Epigastric
Pylorus
Duodenum
Pancreas
Portion of the liver
Left hypochondriac
Stomach
Spleen
Tail of pancreas
Splenic flexure of colon
Upper pole of left kidney
Left adrenal gland
Right Lumbar
Ascending colon
Lower half of right kidney
Portion of duodenum and jejunum
UMBILICAL
Omentum
Mesentery
Lower part of duodenum
Jejunum and ileum
Left lumbar
Descending colon
Lower half of left kidney
Portions of jejunum and ileum
Right Inguinal
Cecum
Appendix
Lower end of ileum
Right ureter
Right spermatic cord
Right ovary
Hypogastric (pubic)
Ileum
Bladder
Uterus (if enlarged)
NURS 6512 Midterm exam study Guide
Left inguinal
Sigmoid colon
Left ureter
Left spermatic cord
Left ovary
Characteristics of Bowel sounds heard during auscultation: (Seidel p. 381)
Range from 5 to 35 per minute
Borborygmi: loud prolonged gurgles
Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger.
High-pitched tinkling suggest intestinal fluid or air under pressure (in early obstruction)
Decreased bowel sounds occur with peritonitis and paralytic ileus.
*MUST auscultate in all four quadrants if there are any major concern and the absence of bowel sounds is the inability to hear ANY bowel sounds after 5 minutes of continuous listening; typically associated with abdominal pain and rigidity and is considered an EMERGENCY. NURS 6512 Midterm exam study Guide
Building a Health History Essay – NURS 6512 Week 1 Discussion
Post a description of the interview and communication techniques you would use with your selected patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Building a Health History
Building an accurate health history is more than just asking patients questions during their appointment. It is the entryway to building a compelling clinician–patient relationship that will empower patients to feel calm, supported, and engaged. It involves many different steps and techniques to collect patient health information, so patients can receive the accurate care that they need. Building a Health History Essay – NURS 6512 Week 1 Discussion.
BUY A PLAGIARISM-FREE PAPER HERE
The Patient
The patient I chose to interview is the 76-year-old Black/African-American male with disabilities living in an urban setting. According to Elsawy & Higgins (2011), the geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. Geriatric patients regularly present with complex medical issues that have been recently overseen by various health care practitioners, a considerable list of medications, and physical constraints. Building a Health History Essay – NURS 6512 Week 1 Discussion. Additionally, numerous patients go to their appointments joined by others, including relatives and home chaperons. Bearing this in mind, to increase productivity at the patient’s first encounter, I would ask the patient and/or their families to complete a pre-visit questionnaire. The answers provided can facilitate the initial visit by concentrating the dialog on the patient’s concerns, while enabling me to obtain an intensive history including medications and review of systems.
Although the patient most likely will have someone present with them, making him the focus of my attention during the appointment will enable a healthy patient-practitioner relationship. Active listening, empathy, validation, reassurance, adaptive questioning, and partnering and summarization all build for effective health assessment interview techniques. Using the pre-visit questionnaire will enable me to implement any environmental adjustments for the patient since I do not know what disabilities the patient has. According to Helzner (2005), presbycusis affects more than half of adults by age 75 years so I will make a conscious effort to make accommodations such as using my stethoscope as an amplifier by placing the earpieces into the patient’s ears and speaking through the diaphragm if needed. Also, using slow, clear speech and low-pitched voice allows for hearing impaired patients to lip read if needed. Other accommodations include proper lighting in the examination room and sitting closed enough to the patient to help the him see my facial expressions and gestures, which is imperative to making the patient feel comfortable. If this patient is aphasic, having a pen and paper available will assist with effective communication. Building a Health History Essay – NURS 6512 Week 1 Discussion.
Unless told to do otherwise, I will address my patient by his title and last name to show respect. All questions will be directed to the patient and I will make sure everyone present understands the patient should answer all the questions unless he is unable or gives them permission. This will empower the patient and validate that his voice matters. Listening attentively and allowing for the patient to finish rather than correcting or speaking for him and using open ended questions will allow for more information such as feelings and understanding of the subject to emerge. If the patient comes alone, eliciting formal and informal social support information is important to forming practical treatment plans. Gathering educational background, literacy, and cultural preferences also offers a bridge to understanding the goals of the patients and his significant other’s.
In a descriptive‐correlational study, the purpose was to analyze relationships between cultural mistrust, medical mistrust, and racial identity and to predict patient satisfaction among African American adults who are cared for by primary‐care nurse practitioners using Cox’s Interaction Model of Client Health Behaviors. The conclusion was, “participants simultaneously held moderate cultural mistrust of European American providers and mistrust of the health care system, and high levels of trust and satisfaction with their nurse practitioners. One racial identity schema (conformity) and trust of nurse‐practitioner (NP) providers explained 41% of variance in satisfaction” (Benkert, Hollie, Nordstrom, Wickson, & Bins-Emerick 2009). Building a Health History Essay – NURS 6512 Week 1 Discussion. There is also a link between the Tuskegee Syphilis Study and its effect on the trust of many African Americans of the health system especially those living in urban areas. With this in mind, I will do my best to gain his trust, be aware of any nonverbal communication, and address all of his questions and apprehensions.
Because elderly patients usually have several concerns, the initial visit will focus on the one or two most active issues that affect his activities of daily living (ADL) and instrumental activities of daily living (IADL). ADLs include eating, dressing, and bathing while IADLs include doing housework, managing finances, and preparing meals. I would utilize the Katz ADL Scale and the Lawton IADL scale. Deficits can indication the patient’s necessity for a more thorough evaluation and the need for further assistance.
Questions
Can you go shopping for groceries without help, with some help, or completely unable to do any shopping?
In the past 12 months, have you fallen or been afraid you would fall because of a walking problem?
Over the past 2 weeks, have you been bothered by little interest or pleasure in doing things?
Do you have problems with your memory?
Have you unintentionally lost any weight within the past 6 months?
Building a Health History Essay – NURS 6512 Week 1 Discussion
Who do you live with?
References
Benkert, R., Hollie, B., Nordstrom, C. K., Wickson, B., & Bins-Emerick, L. (2009). Trust, mistrust, racial identity and patient satisfaction in urban African American primary care patients of Nurse Practitioners.
Journal of Nursing Scholarship,41
(2), 211-219. doi:10.1111/j.1547-5069.2009.01273.x
Elsawy, B., & Higgins, K. (2011). The geriatric assessment.
American Family Physician
, 83(1), 48-56. Retrieved from
https://www.aafp.org/afp/2011/0101/p48.html
.
Helzner, E. P., Cauley, J. A., Wisniewski, S. R., Zmunda, J. M., Talbott, E. O., Harris, T. B., . . . Newman, A. B. (2005). Race and sex differences in age-related hearing loss: The health, aging and body composition study.
Journal of the American Geriatrics Society,
53
(12), 2119-2127. doi:10.1111/j.1532-5415.2005.00525.x Building a Health History Essay – NURS 6512 Week 1 Discussion
Personal reflection and discussion with colleagues is essential to your development as a psychiatric mental health nurse practitioner. In Week 8, you collaborated with colleagues as you participated in your first Clinical Supervision. This week, you have the opportunity to continue your collaboration as you reflect on and discuss your experiences with counseling older adults. Keep in mind that although there may be challenges to counseling this population, these clients offer unique learning opportunities. For this Clinical Supervision, consider an older client you are counseling whom you do not think is adequately progressing according to expected clinical outcomes.Students will:
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Assess clients presenting for psychotherapy
Evaluate effectiveness of therapeutic approaches for clients
receiving psychotherapy
Review this week’s media and consider the insights provided.
Reflect on the clients you are currently counseling at your practicum site.
Describe an older client you are counseling whom you do not think is adequately progressing according to expected clinical outcomes.
Explain your therapeutic approach with the client, including the perceived effectiveness of your approach.
Identify any additional information about this client that may potentially impact expected outcomes Discussion: Clinical Supervision Essay.
NUR 699 EBP Section C: Literature Support Example Essay
NUR 699 GC Week 3 Section C Literature Support
Evidence-Based Practice Proposal – Section C: Literature Support
Details:
To begin, work through the reference list that was created in the “Section B: Problem Description” assignment in Topic 2. Appraise each resource using the “Rapid Critical Appraisal Checklists,” available in the textbook appendix. The specific checklist you use will be determined by the type of evidence within the resource.
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Develop a research table to organize and summarize the research studies. Using a summary table allows you to be more concise in your narrative description. Only research studies used to support your intervention are summarized in this table. Refer to the “Evaluation Table Template,” available in the textbook appendix. Use the “Evaluation Table Template” as an adaptable template. NUR 699 EBP Section C: Literature Support Example Essay.
Write a narrative of 750-1,000 words (not including the title page and references) that presents the research support for the projects problem and proposed solution. Make sure to do the following:
Include a description of the search method (e.g., databases, keywords, criteria for inclusion and exclusion, and number of studies that fit your criteria).
Summarize all of the research studies used as evidence. The essential components of each study need to be described so that readers can evaluate its scientific merit, including study strengths and limitations.
Incorporate a description of the validity of the internal and external research.
It is essential to make sure that the research support for the proposed solution is sufficient, compelling, relevant, and from peer-reviewed professional journal articles.
Although you will not be submitting the checklist information or the evaluation table you design in Topic 3 with the narrative, the checklist information and evaluation table should be placed in the appendices for the final paper. NUR 699 EBP Section C: Literature Support Example Essay.
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
Upon receiving feedback from the instructor, refine “Section C: Literature Support” for your final submission. This will be a continuous process throughout the course for each section. NUR 699 EBP Section C: Literature Support Example Essay.
Evidence-Based Practice Proposal, Section C: Literature Support
Literature Support – Narrative
Prevention of inpatient falls remains a priority for medical centers across the country. While one should want to have zero falls, it is not a reality. The most commonly reported adverse event in hospitals are patient falls. In the United States, there are hundreds of thousands of patient falls in the hospitals. Of those falls, approximately 30-50% of these events result in injuries (Mitchell, 2015). Eliminating falls is ideal but even with all of the tools and equipment provided, it seems like the work of preventing falls is in vain. Rather than focusing on patients that are at risk of falling, nurses and healthcare workers need to focus on patients that are at risk of injury if they fall. This distinction protects the patients from injury, which is, after all, what every healthcare worker would like to avoid. One tool that has helped in identifying the at risk patients is the Hester-Davis Fall Risk Assessment Scale.
University of Arkansas for Medical Sciences Journal
In the article, ‘Falls and Frailty: Finding Who’s at Risk and Keeping Them Safe (2014),’ Katrina Dupins speaks with Amy Hester, R.N., clinical services manager and Dee Davis, R.N., advanced practice partner about their risk assessment tool, the Hester-Davis Scale. Hester and Davis, who work at UAMS, began looking into falls and falls with injuries in 2010. Together, they developed a tool to assess falls and the risk of falls for patients. The tool that they came up with, not only addresses the patient’s risk of falling, but also includes interventions and care plans as a comprehensive way to prevent falls. NUR 699 EBP Section C: Literature Support Example Essay. The Hester-Davis Scale decreased the falls rates at UAMS by 11 percent, decreased falls with injuries by 60 percent and continue to have decreases in both areas (Dupins, 2014). Not only were they able to save the hospital $1.27 million in costs related to falls, they were also able to save them $330,000 in sitter costs (Dupins, 2014) NUR 699 EBP Section C: Literature Support Example Essay. Through their collaboration, they have created HD Nursing, a business that Amy Hester and Dee Davis began through UAMS BioVentures.
University of Mississippi Medical Center
Cummins wrote, ‘Patient Falls: First Predict, Then Prevent,’ in 2015, which supports use of the Hester-Davis Scale in University of Mississippi Medical Center (UMMC). There are over 900 nurses at UMMC that are dedicated to preventing falls. In March, 2015, they began using the Hester-Davis Falls Risk Assessment Scale (HDS). Based on the nurses’ documentation, the HDS creates an individualized care plan for each patient. This care plan predicts the patient’s risk of falling. Furthermore, the plan includes interventions, like signage, bed or chair alarms, falls mats, etc., that are meant to be tailored to the patient’s needs based on their risk level. After the Centers for Medicare and Medicaid Services rated UMCC a 10 (the worst score) on serious patient complications (based on data that was two years old), UMMC decided to aggressively and proactively work at lowering the falls incidence using the HDS. Prior to implementing the HDS, UMMC was averaging 30 to 40 falls a month (Cummins, 2015), but since use of the HDS, they have had zero falls with injury in four months. UMMC chose the HD Scale because it is proven by research and evidence-based.
Amy Hester and Dee Davis
Amy Hester and Dee Davis wrote about their Hester-Davis Falls Risk Scale in, ‘Validation of the Hester Davis Scale (HDS) for Falls Risk Assessment in a Neurosciences Population (2013).’ Being that the fall risk assessment is an essential component in any falls prevention program, Hester and Davis decided to trial their HDS in a neurosciences population. The goal was to validate the HDS in an acute care setting for falls risk assessment. Using 1,904 patients on a neurosciences unit, the HDS was prospectively validated. The results reflected that, “Using an initial cute score of seven produced a sensitivity of 100% and specificity of 24.9%. Receiver Operating Characteristics Analysis evidenced a cut score of ten that would produce a more desirable sensitivity and specificity of 90.9% and 47.1%, respectively,” (Hester & Davis, 2013). The evaluation and validation of the HDS supported use in clinical practice.
Inpatient Falls Prevention Programs as a Patient Safety Strategy: A Systematic review
Miake-Lye, Hempel, Ganz, and Shekelle, (2013) wrote the article, ‘Inpatient fall prevention programs as a patient safety strategy: A systematic review,’ for Annals of Internal Medicine. This article was written to address the problem of falls in acute care hospitals, which reported a rate of 1.3 to 8.9 per 1000 bed days (Miake-Lye, et al., 2013). Based on their research, they found that using multicomponent interventions can reduce the risk of falls by approximately 30 percent (Miake-Lye, et al., 2013). While this study did not establish a falls bundle, it recommended risk assessments for the patients, staff and patient education, signage and wristband alerts, non-skid footwear, etc. They also found that there are other important factors that affect the success with implementation. These factors include, “leadership support, engagement of the front-line clinical staff in the design of the intervention, guidance by a multidisciplinary committee, pilot-testing the intervention, and changing nihilistic attitudes about falls,” (Miake-Lye, et al., 2013) NUR 699 EBP Section C: Literature Support Example Essay.
Searching is time consuming but it is the only way to complete the project. Terms used during the search process were Hester Davis, Falls Risk Scale, Falls Prevention, and fall interventions. Databases searched were CINAHL and GCU’s library.
In conclusion, there are several reasons that one would want to use another risk assessment tool to identify patients at risk for injury/fall. Nurses and other healthcare providers are tasked with patient safety while patients are hospitalized. However there are other factors that can affect the patient’s risk for falls and injury (i.e., medication, immobility, etc.). Through the implementation of a new falls risk assessment scale and following the care plans, nurses are able to protect their patients from falls and injuries from falls. Safety of the patients is priority. NUR 699 EBP Section C: Literature Support Example Essay.
References
Agency for Healthcare Research and Quality (AHRQ). (2015). New tools help health providers reduce patients’ risk of falls. Retrieved from http://www.ahrq.gov/patients-consumers/patient-involvement/patients-risk-of-falls.html
Agency for Healthcare Research and Quality (AHRQ). (2014). Never events.
Patient Safety Network.
Retrieved from https://psnet.ahrq.gov/primers/primer/3/never-events
Centers for Disease Control (CDC). (2016). Important facts about falls. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html NUR 699 EBP Section C: Literature Support Example Essay
Cummins, R. (2015). Patient falls: First predict, then prevent.
University of Mississippi Medical Center
. Retrieved from https://www.umc.edu/News_and_Publications/Press_Release/2015-02-23-00_Patient_falls__First_predict,_then_prevent.aspx
Dupins, K. (2014). Falls and frailty: Finding who is at risk and keeping them safe.
UAMS Journal
. Retrieved from http://journal.uams.edu/article/falls-and-frailty-finding-whos-at-risk-and-keeping-them-safe/
Hester, A.L. & Davis, D.M. (2013). Validation of the Hester Davis Scale for fall risk assessment in a neurosciences population.
Journal of Neuroscience Nursing. 45
(5), pp. 298-305. doi: 10.1097/JNN.0b013e31829d8b44. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24025469
jointcommission.org. (2015). Sentinel event: Preventing falls and fall-related injuries in health care facilities. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_55.pdf
Miake-Lye, I.M., Hempel, S., Ganz, D.A., Shekelle, P.G. (2013). Inpatient fall prevention programs as a patient safety strategy: A systematic review.
Annals Intern Medicine,
158(5), pp. 390-396. doi:10.7326/0003-4819-158-5-201303051-00005. Retrieved from http://annals.org/article.aspx?articleID=1656443&utm_medium=referral&utm_source=pulsenews#Discussion
Mitchell, K. (2015). Is zero falls the right target? Retrieved from http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=177 NUR 699 EBP Section C: Literature Support Example Essay
Evidence-Based Practice Proposal—Section B Problem Description
A nurse on a medical-surgical floor in a northeast hospital examined a study regarding the reason for falls within the hospital environment. Reviewing a computerized data retrieval system that recorded falls relating to call light usage in a 15-month study, she found a fall rate of approximately as high as 3.37 patients per every 1000 patients per day (Olrich, Kalman, & Nigolian, 2012). The main reasons given for using the call light were for patient care needs, such as, toileting, the need for pain control, and repositioning (Olrich, Kalman, & Nigolian, 2012). When call lights go off and they are not answered in a timely manner, the patient will often become inpatient and instead of waiting for help, they will get up on their own, which puts them at a high risk for injury or a fall (Mitchell, M. D., Lavenberg, J. G., Trotta, R., & Umscheid, C. A. 2014). NUR 699 EBP Section B: Problem Description.
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Fall prevention intervention, include an act of everyone getting involved, from the patient, family, nurses, other staff members and leadership that practice a safe fall prevention plan, which includes education and changes in attitudes that understand the importance to follow a fall prevention program that has been put in place (Goldsack, Bergey, Mascioli, & Cunningham, 2015). After incorporating hourly rounding into a fall prevention plan, it was determined that hourly rounding on patients did reduced falls significantly in the hospital setting (Goldsack et al., 2015) NUR 699 EBP Section B: Problem Description.
Along with the general public, a variety of stakeholders that include administrators, physicians, nurses, accrediting agencies, professional associations, student nurses, and legislative groups are concerned about patient safety and are responsible to make sure that care is delivered safely to the patient. These stakeholders are responsible for taking certain actions and making specific decisions that encourages safe care (ECRI Institute, 2014). A qualitative study was conducted that focused on the patient experiences during hospitalization, AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you), and hourly rounding. After the data was collected, transcribed and coded; the outcome findings presented a common theme that all residents who participated in this study felt that their emotional needs were met NUR 699 EBP Section B: Problem Description
PICO Question
On a medical-surgical hospital unit, how does implementing hourly nursing rounding, compared to no scheduled rounding, affect patient safety, within 6 months of implementing?
The Purpose and Objective of the Project
To educate nurses and other staff members that participating in a hourly rounding routine will decrease hospital falls in the hospital setting and will create a safer environment for the patient. This EBP has been proven to improve a safer outcome for patients and it also has increased patient satisfaction by decreasing anxiety from not having to have to use the call light as frequent and knowing that there would be someone there to check on them frequently during their stay in the hospital NUR 699 EBP Section B: Problem Description.
The project literature research will be measured through using the interactive online DISCERN, which allows the researcher to follow a brief questionnaire for assessing the quality of literature and other published articles online regarding EBP research. This online tool consists of 15 questions that includes a rating system for quality information on literature research (The DISCERN Instrument, 1997).
Reference
Allen, T., Rieck, T., & Salsbury, S., (2016). Patient Perceptions of an AIDET and Hourly Rounding Program in a Community Hospital: Results of a qualitative study.
Patient Experience Journal
. (3)1. Retrieved from http://pxjournal.org/cgi/viewcontent.cgi?article=1115&context=journal
ECRI Institute (2014). Patient safety, risk, and quality.
Healthcare Risk Control
. Retrieved from
https://www.ecri.org/components/HRC/Pages/RiskQual4.aspx
Goldsack,J., Bergey, M., Mascioli, S., & Cunningham,J., (2015). Hourly rounding and patient falls: What factors boost success
? Nursing Journal
2017
, 45(2), 25-30. Retrieved from NUR 699 EBP Section B: Problem Description
http://journals.lww.com/nursing/Fulltext/2015/02000/Hourly_rounding_and_patient_falls__What_factors.10.aspx
Mitchell, M. D., Lavenberg, J. G., Trotta, R., & Umscheid, C. A. (2014). Hourly Rounding to Improve Nursing Responsiveness: A systematic review.
The Journal of Nursing Administration
,
44
(9), 462–472.
http://doi.org/10.1097/NNA.0000000000000101
Olrich,T., Kalman, M., & Nigolian, C. (2012). Hourly Rounding: A replication study. MedSurg Nursing, 21(1), 23. Retrieved from
http://search.proquest.com/openview/78664e73c9de01b6ca2b1580c98ca4b6/1?pq-origsite=gscholar&cbl=30764
The DISCERN Instrument (1997). DISCERN Online: quality criteria for consumer health information. British Library and the University of Oxford. Retrieved from
http://www.discern.org.uk/discern_instrument.php#feedback
NUR 699 EBP Section B: Problem Description
Evidence-Based Practice Proposal—Section B Problem Description
Today, maternal depression can be as common as one in every seven women during their third or fourth trimester’s. Postpartum depression (PPD) is a mental health condition that can start before delivery or right afterwards. If postpartum symptoms are not recognized, it can become very serious if it goes undiagnosed. It is important to educate the mother, significant other, and family members to recognized the symptoms of PPD so that symptoms may be detected early and seek help right away because PPD can have a very negative impact on mother, family and the baby. . (Fitelson, Baker, & Leight,, 2011).
It is important to help the mother differentiate the different types of postpartum depression through proper education. Many mothers may experience the baby blues, which is very common amongst most women and have been known to affect up to 75% of new mothers. The baby blues usually will have an onset within ten days following the delivery of their baby and will only last for approximately two weeks. Symptoms are mild and will consist of mild emotional disturbance such as feeling fatigue, anxiety and tearfulness. Next is postpartum depression, which is often, inaccurately diagnosed for the baby blues at first because the symptoms are very similar to the baby blues but with more intensity and the symptoms can last up to six months and may interfere with mother’s ability to care for herself, her baby and many other task throughout the day. Next we have postpartum psychosis which is a extreme mental health condition that needs intervention immediately. Symptoms found with postpartum psychosis are severe mood swings, mothers can experience delusions and hallucinations, anxiety, mood changes and suicidal ideation to hurt themselves or homicidal ideation towards their baby and other children. (Fitelson, Baker, & Leight, 2011).
According to Zauderer, there has been several studies showing that bringing awareness about postpartum depression through education and parenting classes has helped unprepared expecting moms and new mothers learn about unusual emotions that they may feel, what to watch for regarding postpartum depression and resources that they can seek if needed. By educating new moms and family, the hope is to give them the knowledge they need to empower them to speak up for help when they recognize possible symptoms of postpartum depression to seek the help that is needed (2009). NUR 699 EBP Section B: Problem Description
Along with the general public, a variety of stakeholders that include administrators, physicians, nurses, accrediting agencies, professional associations, student nurses, specialized Obstetricians, Pediatricians, APNs, Mental Health and Social Service. Legislative groups are concerned about patient safety and are responsible to make sure that care is delivered safely to the patient. These stakeholders are responsible for taking certain actions and making specific decisions that encourages safe care (ECRI Institute, 2014). Much of the research and studies presented in the articles were empirical studies, systematic reviews and meta-analyses that were published between the years of 2009-2016.
PICO Question
Does postpartum education (I) during the third and fourth trimester (T) reduce the risk of postpartum depression (O) in mothers (P) compared to those who receive no form of education on postpartum depression (C). NUR 699 EBP Section B: Problem Description
The Purpose and Objective of the Project
To research data and provide data that there is evidence-base practice showing that there is a benefit to providing new moms and families education on postpartum depression compared to new mothers who do not receive any form of education on postpartum depression. Will education help decrease the risk of postpartum depression because the mother and family have been taught to recognize the symptoms in advance so that they may seek help as needed.
The project literature research will be measured through using the interactive online DISCERN, which allows the researcher to follow a brief questionnaire for assessing the quality of literature and other published articles online regarding EBP research. This online tool consists of 15 questions that includes a rating system for quality information on literature research (The DISCERN Instrument, 1997). NUR 699 EBP Section B: Problem Description
Reference
Ertel, K. A., Rich-Edwards, J. W., & Koenen, K. C. (2011). Maternal Depression in the United States: Nationally Representative Rates and Risks.
Journal of Women’s Health
,
20
(11), 1609–1617.
http://doi.org/10.1089/jwh.2010.2657
Field T (2017) Postpartum Depression Effects, Risk Factors and Interventions: A Review
3: 122. doi:10.4172/2572-0791.1000122
Fitelson, E., Kim, S., Baker, A. S., & Leight, K. (2011). Treatment of postpartum depression: clinical, psychological and pharmacological options.
International Journal of Women’s Health
,
3
, 1–14.
http://doi.org/10.2147/IJWH.S6938
Kettunen P, Koistinen E, Hintikka J (2014). Is postpartum depression a homogenous disorder: time of onset, severity, symptoms and hopelessness in relation to the course of depression
Is postpartum depression a homogenous disorder: Time of onset, severity, symptoms and hopelessness in relation to the course of depression. BMC Pregnancy Childbirth 14:1-18.
Warfa N, Harper M, Nicolais G, Bhui, K (2014). Adult attachment style as a risk factor for maternal postnatal depression: a systematic review. Retrieved from
Adult attachment style as a risk factor for maternal postnatal depression: A systematic review. BMC Psychol 2: 56.
Zauderer, C. (2009). Postpartum Depression: How Childbirth Educators Can Help Break the Silence.
The Journal of Perinatal Education
,
18
(2), 23–31. http://doi.org/10.1624/105812409X426305 NUR 699 EBP Section B: Problem Description
Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
Safety issues
Clinical emergencies/actions taken
Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
Treatment compliance/lack of compliance
Clinical consultations
Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
Therapist’s recommendations, including whether the client agreed to the recommendations
Referrals made/reasons for making referrals
Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
Issues related to consent and/or informed consent for treatment
Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
Information reflecting the therapist’s exercise of clinical judgment
Note: Be sure to exclude any information that should not be found in a discoverable progress note.
Part 2: Privileged Note
Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment. Assignment 2: Practicum – Assessing Client Progress
The privileged note should include items that you would not typically include in a note as part of the clinical record.
Explain why the items you included in the privileged note would not be included in the client’s progress note.
Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.
Question
Differentiate progress notes from privileged notes
Privileged records is a set of information which involves only two parties, the client and the therapist and this information remains confidential, and even the law does not permit forceful disclosure of the content. On the other hand, a progress note is a medical record where a medical practitioner or psychiatrist records details of a patient, the clinical status and the progress they have made during Assignment 2: Practicum – Assessing Client Progress therapy.
Question
Reflect on the client you selected for the Practicum Assignment.
Review the Cameron and Turtle-Song (2002) article on this week’s Learning Resources for guidance on writing case notes using the SOAP format.
Progress Note
Name of Patient:
Date:
Subjective
Amabella suffers from mental distress as a result of being in an abusive marriage for almost fifteen years. Due to the constant abuse, she has developed mild depression as well as anger issues. Her health has deteriorated which has led to weight loss caused by malnutrition.
I have gone through her past medical history in an attempt to investigate any medications she has been under in the past. I have also enquired about any family or social history that would have led to her condition. (Dick, S, 1999, 41) Assignment 2: Practicum – Assessing Client Progress
Objective
Her physical exam findings show that her body is bruised and full of stubborn scars which are a result of being forcefully grabbed or hit with blunt objects. Her neck also reveals that she has been chocked severally. Also, there is a fresh wound cut on her face.
Assessment
The therapeutic sessions have been productive. Amabella is collaborative and is improving. She is open when talking about why she thinks her husband is an animal and whether he can change or not. She does not get as angry and aggressive as she used to when our treatment sessions began. She is now calm, lively and happier. Her health is also improving.
Plan
I have found it very useful to involve a marriage counselor during the therapy to assist because marital issues are beyond my level. I recommended it to her, and she agreed. Afterwards, I have helped Amabella get a competent divorce lawyer who has legally advised her about the whole divorce process as well as her rights upon leaving the toxic marriage. She agrees to this for it is good for the safety of the children and her too. The divorce papers will be ready soon, and she will be moving to her new apartment in a few days. Assignment 2: Practicum – Assessing Client Progress
Privileged Note
Question
Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your
Answer
My client was troubled at the beginning of our sessions. She disclosed that apart from physical torture from the husband, she was also sexually abused. In fact, the children know what their dad was doing to their mother. She was almost reaching her breaking point, but after completing her therapy, her attitude has changed. Her being able to open up helped a lot. Assignment 2: Practicum – Assessing Client Progress
The above-privileged note includes vital information about abuse in Amabella’s marriage. Sensitive issues like rape are covered, which should be regarded as highly confidential information which should not be disclosed to any other party. (Steen, B, 1999,37)
My preceptor uses privileged notes because I prefer to discuss my issues with him alone because I like my right to privacy to be respected. If other people know my problems, it would increase my mental illness.
Reference
Dick, R, Steen, E (Editors): 1991. The Computer Based Patient Record; Washington DC, National Academy Press.
Practicum – Assessing Client Family Progress
Part 1: Progress Note
Subjective
The client admits that both psycho-educational and interpersonal therapies have been efficient considering his ability to manage his anger and depressive episodes. He reports that the family therapy has enabled him to change the perception of his diagnosis and drug regimen despite his inability to resume work. Assignment 2: Practicum – Assessing Client Progress. However, the client is concerned about the performance of his son who he thinks has been affected by his reckless behavior in the past. At 14 years and attending school, he believes that the boy may not benefit from the therapy. He also feels the same for his wife who is always busy at school or performing house chores in the evening. All members of his family are supposed to attend all therapy sessions for optimal outcomes. Consequently, he feels that he is presently not benefiting from the family therapy sessions since he can only benefit from supportive therapy considering the extent of his illness.
Objective
Mr. J.K maintained calmness throughout the sessions. He made sound remarks to approve the strategies aimed at improving his condition. Despite the few challenges during the meeting, the client demonstrated satisfaction and a willingness to continue with the therapy at the end. He claimed that he was prepared enough to overcome attempts to withdraw from the interventions. Of the three members of the family, he was the only one that attended all the sessions. His wife missed three, while the son missed five. Assignment 2: Practicum – Assessing Client Progress.
Assessment
In as much as the client presented a few episodes of weariness and sadness during the family therapy, the review of the system, physical evaluation, and the mental status exam did not reveal any abnormalities. The same can be said of the other members of his family who had been dressed appropriately for the day and session. They were all oriented to time, place and person. The patient presents to the session with alcohol use disorder and admits he uses tobacco and marijuana. He resorted to abusing alcohol after being diagnosed with stage two lung cancer. At the time the diagnosis was made, Mr. J.K felt that only alcohol consumption would enable him to overcome the grief and anxiety of having to live with the deadly disease. The support from his family has been insignificant, primarily due to the busy schedule of his wife as well as by the fact that she has suffered depression in recent months. She attributes the depression to her husband’s illness, alcohol consumption the burden of having to support the family single-handedly.
Plan
There is a need for the therapist to consider making changes to his schedule to ensure that all members of this family benefit from the sessions. Becvar & Becvar, (2017), share the same assertions in their article. The client’s wife who has reportedly suffered from depression will require to attend all the family therapy sessions so that she may find better ways of supporting her son and husband who has been reduced to supportive and palliative care by his illness. Assignment 2: Practicum – Assessing Client Progress. The therapy sessions also need to take into consideration the school timetable to enable the 14-year old boy to attend them. He has been affected adversely by the current illnesses that both his parents are suffering from in the last few years. The therapist should prescribe antipsychotics for the client’s wife to make sure that she can put her moods under control. However, there is a need for the family to make sure that they progress with the interpersonal and psychoeducation therapy for at least three weeks for better outcomes (Weitz et al., 2015). There is an immense need for each one of them to change their thoughts and general perception about life and resume the activities of daily living.
Part 2: Privileged Note
Mr. J.K provides a perfect example of a person that is frustrated in life due to his reckless behavior. His excessive intake of alcohol has not only resulted in being sacked by four different employers but has also been arraigned in court for dangerous driving. Besides diagnosis of stage 3 lung cancer and spouse depression episodes complicates the family. The mental status examination does not reveal any incidences of him being suicidal or homicidal, but the actions make a justification. The failure to put in place therapeutic interventions for this patient may result in the loss of his life through reckless actions. Had the therapist visited the family a bit earlier, the family would not be experiencing the challenges they are in at present. The client would not have resorted to consuming alcohol in excess amounts as a strategy to overcome the grief and sorrow that comes with a lung cancer diagnosis. Assignment 2: Practicum – Assessing Client Progress.
The information presented in the privilege note could not be displayed in the progress note because of the HIPAA regulations concerning privacy and confidentiality Weitz et al., 2015). This information is intended for use by a therapist alone and no other party. It is not uncommon for my preceptor to use the privilege notes to preserve the information on the experiences of those with psychiatric conditions. This information guides the development of strategies that guide the treatment of these disorders (American Psychiatric Association, 2013).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing.
Becvar, R. J., & Becvar, D. S. (2017). Systems theory and family therapy: A primer. Rowman & Littlefield.
Weitz, E. S., Hollon, S. D., Twisk, J., Van Straten, A., Huibers, M. J., David, D., … & Faramarzi, M. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs. pharmacotherapy: an individual patient data meta-analysis. JAMA Psychiatry, 72(11), 1102-1109. Assignment 2: Practicum – Assessing Client Progress
NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples
Organizational Culture and Readiness Assessment-Section A
Organizational Culture Survey Tool
The selected organization culture survey tool for the assessment is “Organization Culture and Readiness for System-Wide Integration of Evidence-Based Practice” (Brown, 2014). The survey tools will help in the investigation, evaluation and identification of the organization’s readiness to involve itself in the EPB. NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples
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Organization’s Readiness Level
Basing o the findings of the Organizational Culture and Readiness evaluation, the organization has the readiness to participate in evidence-based practice. The nurses have the commitment to drive the evidence-based practice. Additionally, the physicians also have the passion for supporting the nursing staff in the evidence-based practice. The organization also has a research department linked with the regional and national research centers with nurses who are dedicated having several published journals about the research topic (Brown, 2014). Furthermore, the organization has libraries with the dedication on evidence-based practices and research with a well-established mentoring program. NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples.
The Barriers
The barrier to the evidence-based practice includes both the organizational and human factors. The first barrier is less time in reading the literature because of heavy workload. The second barrier of the practice is little staff experience as most of the staff had less experience to participate in the evidence-based practice (Brown, 2014). There is also lack of resources to facilitate the procedure of the evidence-based practice.
The Facilitators
The facilitators of the evidence-based practice as identified will help in the adoption of new cultures that improve the treatment of stress urinary incontinence in women (Jankowski et al., 2014). Facilitators include increased information access as well as the application of role modeling. NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples.
Conclusion
Conclusively, for the achievement of better treatment of the treatment of stress urinary incontinence, the adoption of an EBP culture is significant; the organization has the readiness for EBP.
References
Brown, C.G. (2014). The Iowa model of evidence-based practice to promote quality care: An illustrated example in oncology nursing.
Clinical Journal of Oncology Nursing, 18
(2): 157-9.
Jankowski, R., Werner, S., Snyder, S., Chancellor, M., Kultgen, P., & Pruchnic, R. (2014). Cell therapy for treatment of stress urinary incontinence in women: potential dose effect of autologous muscle-derived cells for urinary sphincter repair (AMDC- USR).
Cytotherapy
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When evaluating the culture of an organization, it is important to conduct a thorough evaluation and appraisal of the willingness for implementation by considering the evidence executed for that of evidence based practice (EBP). To successfully implement EBP and prevent failure there need to be essential fundamentals in place that will include a required set of time, having the necessary supplies and resources needed. When EBP is implemented the organizations’ culture needs to be identified and the motivation behind the implementation or change all while considering possible obstacles not matter when they might arise during any stage of the implementation process for an EBP (Houser, J., & Oman, K.S., 2011)
For Midland Memorial Hospital the result from the survey shows that they are ready for the change to the nurse intern program. The organization is ready for a change to help keep new nurse retention up. Most of the new nurses stay for the time needed to get experience then move on to other jobs in a more urban area. One barrier seen from this plan is, the increase of disgruntled experienced nurses who no longer due to the high turn around rate. Another barrier is having new trainers in place because they need to learn the new system themselves. However, they can also facilitate because they don’t know the old ways and are not stuck in how things were done. In the organization the culture is right for implementing a new nurse intern program. When implementing a new system staff and managers will be constantly engaged with the process. NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples.
References
Houser, J., & Oman, K.S., (2011). Evidence-Base Practice: An Implementation guide for Healthcare Organization. Retrieved from http://sgh.org.sa/Portals/0/Articles/Evidence-based%20Practice%20-%20An%20Implementation%20Guide%20for%20healthcare%20Organizations.pdf NUR 699 EBP Section A: Organizational Culture and Readiness Assessment Essay Examples.