NR509 Midterm Exam 2025

ocused assessment - --addresses focused concerns or symptoms -used for established clients during routine or urgent care visits -health history and physical exams are focused on the problem -includes: • brief history of the present illness • only the system related to the problem in the review of systems Comprehensive assessment - --used for new clients -provides personalized information about the client -strengthens the clinician-client relationship -provides a baseline for future assessments -provides an opportunity for health promotion education and counseling -includes: • extended history of the present illness • at least two areas of past medical history, family history, and social history • at least 10 systems in the review of systems Subjective data - -includes symptoms that the client describes such as a sore throat, headache, or pain. It also includes the client's feelings, perceptions, and concerns Information obtained from the client during any part of the health history Examples of subjective data: -lower back pain -fatigue -stomach cramps -immunization history Objective data - -includes the physical examination findings or signs observed All physical examinations, laboratory information, and test data Examples of objective data: -heart rate -blood pressure -lung sounds -wound appearance -ambulation description -weight Clinical encounter sequence (detailed) - -initiate encounter -review the clinical record -ensure the client is comfortable -clarify the goals/agenda for the encounter; balance provider and client goals -establish rapport NR 509 NR 509 -identify the client's preferred title, name, and gender pronouns -use "people first" language (i.e., a person with hearing loss, a person who uses a wheelchair) Gather information -id the client's chief complaint or reason for seeking care -invite the client's story using an open-ended approach -gather information about the client's perspective of the illness using the mnemonic fife -conduct the health history interview -gather information about past medical history, medications and allergies, family history, personal and social history, and ros Perform the physical exam -conduct the exam based on the information obtained from the health history -maintain client's comfort and privacy throughout the exam Explain and plan -assess and respond to the client's needs for information -negotiate and make decisions together -utilize teach-back to ensure the client understands the plan Close the encounter -leave time for the client to ask questions -summarize the plans for future evaluation, treatments, and follow up The general sequence of a clinical encounter is to: - --initiate the encounter -gather information -perform a physical exam -develop a shared plan -close the encounter Fife mnemonic - -feelings Ideas Function Expectations -a mnemonic for the patient's perspective on the illness • the patient's feelings, including fears or concerns, about the problem • the patient's ideas about the nature and the cause of the problem • the effect of the problem on the patient's life and function • the patient's expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences Basic interviewing techniques - --active listening -empathy -guided questioning NR 509 NR 509 -validating -empowerment -partnering -transitioning -reassuring -summarizing -nonverbal communication Active listening - -closely attending to what the client is communicating, connecting to the client's emotional state, and using verbal and nonverbal skills to encourage the client to expand on their feelings and concerns. Empathy - -identifying with the client and feeling their pain as one's own, then responding to them in a supportive manner. Guided questioning - --guided questions help to elicit more information, while still showing a continued interest in the client's feelings and story. -some techniques of guided questioning include moving from open-ended to more focused questions; clarifying what the client means; encouraging with continuers such as "go on"; using a series of questions one at a time; and using questions that require a graded response (i.e., how many stairs can you climb before feeling short of breath?). Validating - -affirming the legitimacy of the client's emotional experience. -examples: "that must have been a difficult experience. It's very common to feel the way you are feeling." Empowerment - -empowering clients to ask questions and express their concerns increases the chances that they will adopt your advice, make lifestyle changes, or take medications as prescribed. Partnering - -involves expressing commitment to an ongoing relationship with the clients to build rapport Transitioning - -transitions can be used to inform the client that the direction of the interview is changing. Reassuring - -reassurance is an appropriate way to help the client feel that problems have been fully understood and are being addressed. Summarizing - -giving a summary of the client's story during the interview helps to communicate that they have been carefully listening. Nonverbal communication - -includes eye contact, facial expression, posture, head position, and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs (i.e., crossed, neutral, or open). NR 509 NR 509 Managing challenging situations: silent clients - --clients may be quiet to collect thoughts, remember details, or decide if they trust the provider -become comfortable with periods of silence -acknowledge that the client is quiet and ask what they are thinking about or if something has upset them Managing challenging situations: talkative clients - --talkative clients should be allowed to talk for several minutes at the beginning of the interview -focus on what seems to be most important to the client -offer a summary of the main concerns and suggest a focus on one problem or ask the client to identify their priority concern for the day Managing challenging situations: clients with altered cognition - --clients with conditions such as dementia or mental health illness may not be able to provide their history -obtain information from family members or caregivers -some clients may be able to provide a history, but cannot make their own health decisions Managing challenging situations: angry clients - --clients may direct anger toward the provider even if their anger is related to being ill, suffering a loss, or feeling overwhelmed and not in control -acknowledge clients' anger and frustration, but avoid reinforcing criticism of other providers or the clinical setting -alert security staff for clients who are overly disruptive or out of control -remain calm and avoid being confrontational Comprehensive health history - -chief complaint History of present illness Past medical history Medications and allergies Family history Personal and social history Review of systems History of present illness - -use oldcarts Past medical history - --childhood illnesses: inquire about childhood illnesses such as measles, chickenpox, or scarlet fever and chronic childhood illnesses such as diabetes or asthma. -adult illnesses: inquire about illnesses such as diabetes, hypertension, or asthma and hospitalizations. -surgical: document dates, indications, and types of surgical procedures. -obstetric/gynecologic: document number of pregnancies (gravida), number of deliveries (para-term, preterm, abortions, and living children), menstrual history, methods of contraception, and sexual function. -psychiatric: document diagnoses, hospitalizations, treatments, and the time frame. NR 509 NR 509 -health maintenance: document immunizations and screening tests such as pap smears, mammograms, or colonoscopies. Include the results and dates of screening tests. Personal and social history five ps+ - - 1. Partners: inquire about gender and number of sexual partners 2. Practices: inquire about the client's types of sex (i.e., oral, vaginal, anal) 3. Protection from stis: assess about use of sti protection and for concerns about hiv infection 4. Past history of stis: assess about incidence, treatment, and testing for stis 5. Pregnancy plans: discuss plans for getting pregnant and pregnancy prevention +plus: assess for trauma, violence, sexual health concerns and provide support for sexual orientation and gender identity Review of systems - -used to obtain additional information about the client's chief complaint and history of present illness and to uncover any additional symptoms related to potential problems in systems unrelated to the chief complaint -follow a head-to-toe approach with yes or no questions and then follow up when there is a response that indicates an abnormality with open-ended questions -subjective -includes, but is not limited to: • constitutional • skin • head • eyes • ears • nose/sinuses • allergies • mouth/throat • neck • breast • respiratory/cardiac • gastrointestinal • urinary • peripheral vascular • musculoskeletal • neurological • hematologic • endocrine • psychiatric Types of review of systems - --problem pertinent -extended • reviews between 2-9 systems -complete • minimum of 10 systems NR 509 NR 509 Social determinants of health - -conditions in the environments where people are born, live, and work that affects health, well-being, and quality of life. -healthy physical, social, and economic environments strengthen the potential to achieve health and well-being -achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy -sdoh: • economic stability • education access and quality • health care access and quality • neighborhood and built environment • social and community context Sdoh: economic stability - -as a social determinant of health is the relationship between a person's financial resources and their health and wellbeing. -financial resources not only include income, but also the cost of living and socioeconomic status. -key issues related to economic stability: poverty, employment, food security, and stable housing Sdoh: education access and quality - -as a social determinant of health is the relationship between a person's education and their health and wellbeing. -key issues related to education access and quality: graduating from high school, enrollment in higher education, educational attainment, language and literacy, and early childhood education and development Sdoh: health care access and quality - -as a social determinant of health is the relationship between a person's access to and understanding of health services and their health and wellbeing. -key issues related to health care access and quality: access to health care, access to primary care, health insurance coverage, and health literacy Sdoh: neighborhood and built environment - -as a social determinant of health is the relationship between a person's housing, neighborhood, and environment, and their health and wellbeing. -key issues related to neighborhood and built environment: quality of housing, access to transportation, availability of healthy foods, air and water quality, and crime and violence rates Sdoh: social and community context - -as a social determinant of health is the relationship between the characteristics of where a person lives and their health and wellbeing. -key issues related to social and community context: cohesion within a community, civic participation, discrimination, conditions in the workplace, and incarceration NR 509 NR 509 Sdoh: two categories of determinants - -upstream factors -occur at systemic level • institutional discrimination • accessibility of resources Downstream factors -specific to individuals • employment status • education level • aspects of identity Factors that impact client health outcomes - -social determinants of health Racism and bias Spirituality Culture Physical and sensory disabilities Sexual orientation Gender identity Oldcarts - -onset Location Duration Character Aggravating factors Relieving factors Timing & treatments Severity Hx taking: 2 main questions to start - --how can i help you? -do you have any other symptoms or concerns we should discuss? Ask all patients their preferred name and gender pronouns, this includes: - --formal titles such as mr., mrs., ms. Or honorifics such as professor or doctor -preferred name may be a nickname, use of a middle name, or some other name altogether -except with children or adolescents, avoid first names until you have specific permission -gender pronouns: him/she and hers/they and theirs. Some of your patients may use nontraditional pronouns. Implicit bias - -a set of unconscious beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity. Cultural humility - --process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners -in an effort to address power imbalances and to advocate for others NR 509 NR 509 -the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients' health outcomes Three dimensions of cultural humility - -self-awareness Respectful communication Collaborative partnerships The 5rs of cultural humility - -reflection Respect Regard Relevance Resiliency Core values of medical ethics - --nonmaleficence -beneficence -respect for autonomy -decisional capacity -confidentiality -informed consent -truth telling -justice Nonmaleficence - -("first, do no harm") directive that health care professionals should avoid causing harm to patients and minimize the negative effects of treatments. Beneficence - -dictum that clinicians are to act for the patients' good by preventing or treating disease. -intent to do good Respect for autonomy - -commitment to accept the choices patients with decisional capacity make about which treatments to undergo, including to reject treatment. The addition of this value to medical ethics changed the clinician-patient relationship from a paternalistic one to a more collaborative one. "ask me three" approach - -intended to help patients become more active members of their healthcare team 1. What is my main problem? 2. What do i need to do? 3. Why is it important for me to do this? *modifying this approach to "tell them three" can also help clinicians keep their message focused and simple. Informed consent - -the following are the required elements for documentation of the informed consent discussion: NR 509 NR 509 -nature of the procedure or treatment -risks and benefits of the procedure or treatment -reasonable alternatives -risks and benefits of alternatives -assessment of the patient's understanding of the first four elements *clinicians have a legal and ethical duty to follow the process of obtaining consent without leaving out any of the core elements. Spikes - -the six-step protocol for delivering bad news: S - setting up the interview P - assessing the patient's perception I - obtaining the patient's invitation K - giving knowledge and information to the patient E - addressing the patient's emotions with empathic responses S - strategy and summary Skin tissue - -body's largest organ, acts as a protective barrier between internal structures and the outside world -three layers: • epidermis is the outermost layer of skin and is primarily comprised of keratinocytes— cells that produce the protein keratin. Keratinocytes form the skin's protective barrier and are constantly reproducing to replace old or damaged cells • dermis is the skin's thickest layer. It is filled with a matrix of collagen and elastin proteins that provide support, flexibility, and resilience, as well as several functional structures, such as mechanoreceptors, that enable interaction with the outside world. The dermis contains nerve endings, sudoriferous (sweat) glands, sebaceous (oil) glands, hair follicles, blood vessels, and lymphatics • hypodermis (subcutaneous layer) is a layer of fat and connective tissue below the dermis. This layer helps insulate and protect the internal organs, and also stores fat for future use. The hypodermis can vary in thickness throughout the body, and between individuals -skin regulates our internal temperature, repels water, synthesizes vitamin d, and registers tactile sensations such as heat, pain, pressure, and vibrations from the environment, keeps the body in homeostasis -immune organ that physically blocks and biochemically detects invading bacteria and toxins. Appendages of the skin - -hair, nails, and sebaceous and sweat glands Questions to gather subjective information about the skin, hair, and nails. - --do you have any current problems or history of diseases or issues with your skin, hair, or nails?