Rachel Cartwright-Vanzant – Practical Approach to the Physical Assessment

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Rachel Cartwright-Vanzant – Practical Approach to the Physical Assessment

Description:

• A comprehensive system review should include documentation.
• Interviewing techniques to Address the Most sensitive topics
• Strategies to Assess for abnormal cardiac and/or pulmonary sounds
• Demonstration of a complete neurologic assessment in just two minutes
• Techniques for critical thinking to Transfer from assessment to nursing intervention
• Characterization and correlation of signs and symptoms in relation to disease states

You have been assigned patients the shift. One of your patients is extremely complex. You have a gut feeling about this patient, which usually means something is not quite right…. Because they are also your patients, you must divide your time among them. How do you perform a quick, accurate, thorough and timely assessment in such a limited time? the care I performed?

Time is a commodity healthcare providers are not afforded in today’s reality. We have to learn. to Our job requires us to be efficient, precise and professional. You can do it. But we must keep at it. One way is to Be confident in your assessment skills. to look for so you can quickly establish your priorities. If I can, no rapid responses on my shift!

You may not have seen enough examples of abnormal symptom or assessment findings, no matter how experienced you are, whether you’re a beginner or an expert. This information is for you.-Learn from a packed seminar the Latest research findings and evidence-These guidelines include assessment tools and techniques for treatment and evaluation that you can immediately implement in your practice. Learn new fun mnemonics to improve your interviewing and examination skills. to Aid in the Many clinical conditions are easily remembered. Your speaker Rachel Cartwright-VanzantMS, RN CNS LHRM, LNCC. Topics will be presented using a variety o of methods such as sample charting, differential symptom analysis and clinical cases.

OUTLINE

INTERVIEWING, HISTORY-TAKING AND DOCUMENTATION TECHNIQUES

Communication skills and interview strategies

• Communications strategies for sensitive subjects
  • Mental health issues
  • Problems with drugs/alcohol
  • Sexuality issues
  • Other sensitive issues
• General literacy & health literacy

A Core Adult History Physical Exam Skills

• Accountability in obtaining baseline data
  • Recording the Evaluation
  • Reporting relevant data
• Medical history from the past
• Chief complaint
  • Analyse of a symptom
  • Keep this in mind “OPQRST”
• History’s Elements
  • Problem focused
  • Detail
  • Comprehensive

Physical Exam Techniques

• Inspection
• Palpation
• Percussion
• Auscultation

Critical Thinking Skills

• Assessment
• Nursing diagnosis
• Planning & outcome identification
• Implementation
• Evaluation

Documentation the Physical Exam

• Electronic medical records
• Strategies to Survive the Dangers of
• Charting by Exception
• Legal implications & nursing standards

ASSESSMENT STRATEGIES TO CHALLENGE SYMPTOMS

Integumentary Systems

• Legal questions the skin
• Assessment Common abnormalities
  • Anatomy of the skin
  • Grading under pressure
  • National Pressure Ulcer Advisory Panel

Head and neck

• Assessment Common abnormalities
• Facial abnormalities

Thorax & Lungs

• Assessment Common abnormalities
  • Respiration landmarks
  • Transport and delivery of oxygen
  • Abnormal breath sounds
• Acute respiratory failure
• Pulmonary embolism
• ABG interpretation

Cardiac and Vascular Systems

• Assessment Common abnormalities
  • Here are some landmarks of the Cardiac
  • Basic EKG analysis
• Abnormal heart sounds

Abdomen

• Assessment Common abnormalities
  • Abdominal landmarks

Musculoskeletal System

• Assessment Common abnormalities
  • Grading muscle strength and tone
• Osteoarthritis and Autoimmune

Nervous System

• Assessment Common abnormalities
• Autonomic nervous systems
  • Parasympathetic nervous System
  • Sympathetic nervous systems
• Interactive cranial nerves
  • Normal findings
  • Abnormal significance
• Head injury
  • “Nature of the injury”
  • Concussion
  • Increased intracranial pressure

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Case Studies

OBJECTIVES

• In a system review, list eight elements.
• Identify three strategies to Low health literacy is a sign that a patient has not been assessed.
• Revise documentation the “FACT” rule.
• It’s easy to interpret arterial blood gasses in a flash.
• Name three symptoms and signs of low oxygenation.
• Identify the Waveforms of an EKG normal pattern.
• Discuss the possible causes and significance of common abnormalities in cardiovascular assessment.
• Identify structures within regions the abdomen.
• Discuss abdominal findings that indicate an urgent intervention for intestinal obstructions.
• Incorporate the Assessment of cranial nerves, Glasgow coma scale and reflex grading system to the neurologic exam.