S O A P note
a method of documentation employed by health care providers to write out notes in a patient's chart
Subjective, Objective, Assessment and Plan
A B C D skin lesion assessment
Asymmetry
Border irregularity
Color isn't uniform
Diameter >6cm (pencil eraser)
Evolving size, shape and color
Preferred qualities of a first impression
honesty, candor, openness, flexibility, eager, explanatory, open to questions
patient centered care
providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
4 C's of effective communication
courtesy
comfort
connection
confirmation
Open ended questions goal
patient's description of answer
direct question goal
seeking specific information
Leading question goal
Limiting information to one focus / subject
Reasons patients avoid the full story of the illness
dementia, alcoholism, illness, sexual uncertainties, domestic violence, child abuse
Potential Barriers to Communication
- Curiosity about you
- Anxiety
- Silence
- Depression
- Crying and Compassionate Moments
- Seduction
- Anger
- Financial Considerations
2 goals of a patient history
1. identify what the patient's problem is
2. establish reliability of the patient
Why is it important to complete a review of systems after a history?
to identify complementary or symptoms that may seem unrelated
Tips when discussing a sensitive topic
provide privacy, direct & firm, no apologies, no judgement, avoid confrontation, no jargon, document carefully
4 steps in approaching the examination of sensitive areas
1. introduction & why
2. open ended questions to explore pt's feelings
3. repeat what's been said & give feedback
4. take questions from pt
TACE questions
Does it
T
ake more than two drinks to get you drunk?
Have people
A
nnoyed you by criticizing your drinking?
Have you ever felt you ought to
C
ut down on your drinking?
Have you ever had a drink first thing in the morning to steady your nerves (
E
ye opene
Partner Violence Screen
Have you been hit, kicked, punched or otherwise hurt by someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?
HITS tool
Hurt
Insult
Threaten
Scream
*for intimate partner violence
FICA tool for spiritual assessment
Faith, belief, meaning
Importance & influence
Community
Action in care
Sexuality History Goal
identify risk factors for unintentional pregnancy or STIs
5 P's of sexual history
Partners
Prevention of pregnancy
Protection from STIs
Practices
Past history of STIs
Functional Assessment
screens the safety of independent living and ability to perform ADLs, the need for home health services, and quality of life
Functional assessment questions
mobility, upper extremity function, housework, instrumental ADLs
pediatric triad
practitioner, parent & child
Consent by proxy
process by which people with legal right to consent to a medical treatment for themselves or for a minor/ward delegates that right to another person
developmental milestone examples
holds head erect, stands alone, rolls over, walks alone, sits alone, uses words, talks in sentences, dresses self, age of potty training, dentition, pubertal development
HEEADSSS TOOL
Home
Education and employment
Eating
Activities
Drugs
Sexuality
Suicide and depression
Safety
**adolescent screening tool
PACES TOOL
parents / peers
accidents
cigarettes
emotional issues
school / sexuality
**adolescent screening tool
fraility
>80 y/o;; ^ loss of physical function & independence, decreased physical reserve
diagnostics
tests that need performed or ordered to develop a plan of care
PAMI list
Patient's medical problems
Allergies with reaction
Medications with doses
Instructions of how administered / immunizations
OLD CARTS
Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Related Symptoms
Temporal factors -- frequency & occurance
Severity
Sensitive Patient health information
HIV status
substance abuse
mental health conditions
Terms to describe current condition status
stable
uncontrolled
resovled
cranial nerves
12 pairs of nerves that carry messages to and from the brain
Cranial Nerve 1
Olfactory (smell)
Cranial Nerve 2
Optic nerve (visual acuity)
Cranial Nerve 3, 4, 6
oculomotor, trochlear, abducens - pupillary response and eye movement
Cranial Nerve 5
Trigeminal - corneal reflex, biting
Cranial Nerve 7
facial nerve -- raise eye brows, close eyes, smile, shows teeth
Cranial Nerve 8
Acoustic/ Vestibulocochlear- Hearing and Balance
Cranial Nerve 9, 10
glossopharyngeal and vagus -- swallowing, gag reflex, speech
Cranial nerve 11
Spinal accessory--
shrug shoulders and turn head
Cranial nerve 12
Hypoglossal- stick tongue out
Grading Muscle Strength
0: None; 1: Slight contractility; 2: Full without gravity; 3: Full with gravity; 4: Full with small resisitance; 5: Full with full resistance
Grading reflexes
0: None; 1: Diminished, 2: Normal, 3: Hyperactive, 4: Hyperactive + Clonus
Clonus
rapidly alternating involuntary contraction and relaxation of a muscle in response to sudden stretch
How to write a problem list
severe problems first
date of onset
active or inactive
brief eval of problem
differential diagnosis
How to write a plan of care
additional studies
referrals / consultations
pharm management
nonpharm management
pt education
IPPA
Inspection
Palpation
Percussion
Auscultation
how to approach a visually impaired patient
identify yourself
inform pt if leaving room
environmental orientation
how to approach a hearing impaired patient
pt's choice of communication method
face the patient not the interpreter
Autonomic hyperreflexia (dysreflexia)
Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
Snellen chart
chart containing symbols that is used in the testing of visual acuity
HOTV test
the child is given a board containing a large H, O, V, T. the examiner points to a letter on the wall chart, and the child matches the correct letter on the board held in his or her hand
Tumbling E chart
should be used with those children who cannot identify alphabet letters 100% of the time, but who can correctly indicate the direction of the "E" 100% of the time after training. They must know the concepts of matching and direction to play the "E" game
transillunination
strong light focused through a body cavity to identify abnormalities
Goniometer
instrument used to measure joint angles
Wood's lamp
Filtered black light that is used to illuminate skin disorders, fungi, bacterial disorders, and pigmentation.
dermascope
An elaborate magnifying mirror/light that incorporates a black light; also called a skin scope
Monofilament
single strand of material; used to test for loss of protective sensation especially on plantar surface of the foot
Where do you perform the monofilament test?
great toe, heel, ball of foot
BMI formula
Weight (in Pounds) / Height (in inches) Squared x 703
BMI in adults
<15 severe level, indicative of anorexia
<19 underweight
19-24.9 Optimal weight
25-29.9 Overweight
30-34.9 Class I obesity; slow weight loss advised to promote permanent weight loss
35-39.9 Class II obesity, slow weight loss advised (may be candidate for
Infants double their weight in the first ____ months and triple their weight by the ____ year.
4-5; 12
Full term gestational age
37-42 weeks
stature
standing height
sexual maturity rating
measure of puberty based on stage of development of secondary sex characteristics
Acromegaly/Gigantism
-Hypersecretion of the pituitary GH over a long period of time
Etiology
: secondary to a benign tumor of the pituitary gland.
Patho
: pituitary tumor secrete GH & prolactin; stim growth of bones
Clinical Manifestations
: vision changes, oily skin, hirsuti
Cushing syndrome definition
-chronic exposure to corticosteroids, especially glucocorticoids (Cortisol)
Turner Syndrome
A chromosomal disorder in females in which either an X chromosome is missing, making the person XO instead of XX, or part of one X chromosome is deleted.
hydrocephalus
abnormal accumulation of fluid (CSF) in the brain
Failure to Thrive (FTT)
physical and developmental retardation of infants or children resulting from physical or emotional neglect, below 3-5 percentile
growth hormone deficiency
absence or deficiency of growth hormone produced by the pituitary gland to stimulate the body to grow
percocious puberty
Early Puberty
� For Girls age 8 (normal- age 10)
� For Boys age 9 (normal - age 12)
We can slow but not reverse !!!
Treatment:
� Luteinizing hormone given
� Dress childlike their age (Psychosocial)
Macronutrients
carbohydrates, proteins, and fats
Micronutrients
vitamins, minerals, water
Carbohydrates
4 calories per gram
Protein
4 calories per gram
Fat
9 calories per gram
Resting energy expenditure (REE)
the amount of energy required to maintain basic body functions
basal metabolic rate (BMR)
the rate at which the body burns energy when the organism is resting
Anthropometrics
The measurement of the size, proportions, and range of motion of the human body.
Fat soluble vitamins
Vitamins A, D, E, K
water soluble vitamins
B vitamins and vitamin C
Vitamin A function
integrity of the skin, vision in dim light, wound healing
Vitamin D function
-promotes bone mineralization (makes calcium and phosphorus available to blood that bathes bones)
-assists in immune function
Vitamin E function
antioxidant that protects erythrocytes and membranes from damage (E for Erythrocytes)
Vitamin K function
blood clotting and bone formation
Vitamin C function
-production and maintenance of collagen
-enhances immune response
-does not prevent colds
-assists in iron absorption
-antioxidant
Vitamin B1 function
vital part of energy metabolism, plays a role as a co-enzyme, synthesis of DNA and RNA
Vitamin B2 (riboflavin) function
promotes normal growth
Niacin function
used in energy metabolism along with thiamin and riboflavin
Vitamin B6 function
-amino acid synthesis
-hemoglobin synthesis
-regulation of blood glucose (assists in releasing stored glucose from glycogen)
Vitamin B-12 Functions
Maintenance for myelin sheaths, folate metabolism, DNA synthesis
folate/ folic acid function
DNA synthesis, maturation of RBCs
Biotin function
use of fats and amino acids
Calcium function
builds / maintains bones & teeth, nerve transmission, muscle contraction, blood clotting
Calcium sources
dairy products, leafy vegetables, legumes, clams, oysters
Phosphorus functions
Bone structure, component of ATP, DNA, RNA and phospholipids
Phosphorus sources
All animal tissues (meat, fish, poultry, eggs, milk)
Magnesium functions
Nerve & heart function, assists enzymatic reactions and provides rigidity to bones
Sodium functions
-Regulating fluid balance
-Regulating blood pressure
-Transmitting nerve impulses
-Contracting muscles
-Helping nutrient transport
Potassium functions
fluid balance, transmission of nerve impulses, muscle contraction
Iron function
Helps carry oxygen to the blood and helps cells use oxygen.
Iodine function
thyroid hormone synthesis
Fluoride function
part of bones and teeth formation and resistance to decay
Copper functions
Helps with the use of iron.
Helps with respiration.
Selenium function
cell growth & development, fat metabolism
Zinc function
-used with proteins for enzymes
-vision
-immune function
-wound healing
-taste perception
-normal growth
normal hemoglobin levels
12-18 g/dL
normal hematocrit levels
40-50%
normal protein level
3.4-5.4
normal serum cholesterol
<200 mg/dL
Normal triglyceride level
<150 mg/dL
Normal HDL levels
>40 mg/dL
Normal LDL levels
<130mg/dL
normal serum glucose level
75-110
Normal HgbA1c
4-6%
risk factors for skin cancer
H - history of previous melanoma
A - age over 50
R - regular dermatologist absent
M - mole changing
M - male gender
Skin types
Classification that describes a person's genetic skin type.
1-3 more likely to get skin cancer
ABCD rule
asymmetry, border irregularity, color, diameter >6mm (pencil eraser), evolving size shape or color
Sunscreen Rules
SPF 30 or higher
apply 15-20 mins before exposure
reapply after swimming
reapply every 2-3 hours
Cultural Assessment Guide Highlights
health beliefs & practices
faith-based influences & special rituals
language & communication
parenting styles & role of family
sources of support outside family
dietary practices
How does time orientation vary across cultures?
present oriented - day to day, unpredictable future
past oriented - maintains traditions, worships ancestors
future oriented - anticipates future, values change
How does activity orientation vary across cultures?
Doing - emphasizes accomplishments that are externally measured
Being - spontaneous expression of self
Being-in-becoming - emphasizes self development
How does human nature orientation vary across cultures?
Human as neutral, not evil or good.
Human as imperfect with perfectible nature. Self control & discipline necessary.
How does people to nature orientation vary across cultures?
Humans subject to environment with little control over destiny.
Humans in harmony with nature.
Humans being master over nature.
How does relational orientation vary across cultures?
Individualistic - individualism, more friends than family
Lineal - group goals more important than individual goals, positional succession (father to son)
Collateral - group goals more important than individual goals, relationships with peers emphasized
Beneficence (Definition)
do good" ; Duty to promote the patients welfare. Serve the patient and public-at-large. Competent and timely delivery of care within the bound of clinical circumstances presented by the patient.
Ethical Decision Making Process
1. Identify the ethical dilemma
2. Discover alternative actions
3. Decide who might be affected
4. List the probable effects of the alternatives
5. Select the best alternative
pernicious anemia
Vitamin B12 deficiency
Skin Exam
� Examine for...Lesions, Scars, Bruises (ecchymosis),Rashes, Abnormal appearing moles, Skin turgor and elasticity
Hair examination
Inspect
-color
-distribution
-quantity
Palpate
-texture
-infestations
Nail Examination
Inspection
- fingers and toes
-color
-shape and contour
-configuration
Palpation
-capillary refill
-texture
-firmness
-adherence to nailbed
Thyroid exam
locate/inspect trachea
feel for deviation
locate thyroid just below cricoid cartilage
observe patient swallow
displace trachea to rt/left and ask to swallow
note shape, size, consistency
abnormal nails
white spots - zinc deficiency
spoon shaped nails - iron deficiency
splinter hemorrhage - injury to brittle nail
Psoriasis characteristics
1. Thickened patches of inflamed, red skin, frequently covered by silvery scales
2. Genetic predisposition
3. Environmental changes precipitate attacks (weather change, vaccinations, trauma, season, (most psoriasis is worst in winter), hormonal changes, s
normal hair distribution
male developmental pattern (diamond), coarse, curly, penis hairless, few hairs to scrotum
Infant fontanel assessment
-gently palpate
-feel firm
-slightly concave
-well defined against edges of cranial bones
-might see arterial pulsations in anterior fontanel
hypothyroidism symptoms (MOM'S SO TIRED)
Memory loss
Obesity
Malar flush/ Menorrhagia
Slowness (mentally and physically)
Skin and hair dryness
Onset gradual
Tiredness
Intolerance to cold
Raised BP
Energy levels fall
Depression/ Delayed relaxation of reflexes
Symptoms of hyperthyroidism (SWEATING)
Sweating
Weight loss
Emotional lability
Appetite increased
Tremor/ tachycardia
Intolerance of heat/ Irregular menstruation/ Irritability
Nervousness
Goitre and GI problems (diarrhoea)
oral exam
Swellings, vesicles, fractures, foreign bodies, etc.
Hearing loss in the elderly
High frequency sounds than low frequency sounds as hearing loss progresses
Sinus exam
percuss sinuses (frontal, maxillary)
tuning fork test
evaluation of sound conduction using a vibrating tuning fork
Cranial Nerve Mnemonic
Oh Once One Takes The Anatomy Final Very Good Vacations Are Heavenly
Cranial Nerve Exam
major section of the neurological exam that assesses sensory and motor functions of the cranial nerves and their associated central and peripheral structures
eye exam
-Test central visual acuity
� Snellen eye chart
-Test visual fields
� Confrontation test
-Inspect extraocular muscle function
� Corneal light reflex (Hirschberg test)
� Cover test
� Diagnostic positions of gaze test
ear exam
- Position
- Size
- Appearance
- Canals
- Temporal Membrane
Nose exam
1. Check for tenderness of frontal and maxillary sinuses. Ask about any tenderness
2. Inspect nasal vaults using the otoscope
Throat Exam
Inspect palate and uvula: "yawn" or "say ah"
Note if uvula is midline and check gag reflex if needed (neuro exam)
Use tongue blade to assist in viewing
Tonsil enlargement is rated 1-4+, erythema, exudates
GI organs
1. mouth (oral cavity)
2. pharynx
3. esophagus
4. stomach
5. small intestine
6. large intestine
Appendicitis S/S
RLQ pain, low grade fever, nausea, rebound tenderness at McBurney's point.
McBurney's sign
appendicitis (McBurney's Point is 2/3 of the way from the umbilicus to anterior superior iliac spine)
ABDOMINAL LANDMARKS
Designated using the UMBILICUS. Imaginary vertical and horizontal lines pass through the umbilicus that divide the abdomen into 4 quadrants:
XIPHOID PROCESS - upper boundary
SYMPHYSIS PUBIS - lower boundary
1. Right Upper Quadrant - RUQ
2. Left Upper Quad
bowel sounds
Intestinal sounds heard from auscultating over the abdomen; hyperactive, hypoactive, diminished, absent, tympanitic
Recommended water intake
2.5 litres a day (more when exercising)
food diary
a detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a specified period, usually 3 to 7 days
Recommended Daily Allowance
The daily amount of vitamins or minerals needed to prevent a deficiency condition in a person's diet.
Auscultation of lungs
auscultate the posterior thorax for sounds side to side. listen over bare skin to entire respiratory cycle of inspiration and expiration.
Auscultation of the heart
1. Aortic Area 2nd right interspace close to the sternum.
2. Pulmonic Area 2nd left interspace.
3. ERB's Point 3rd left interspace.
4. Tricuspid Area 5th left interspace close to the sternum.
5. Mitral Area (Apical) 5th left interspace medial to the MCL
Auscultation of bowel sounds
Listen in all 4 Quadrants � Use diaphragm of stethoscope with light pressure � Listen in each quadrant for up to one full minute � Begin in the RLQ