8/17/2019 514 Study Guide 1

1/12

History & Culture – 12

Terms to know:Autonomy: the patient’s need for self-determinationBenecence: do good for the patientNonmalecence: do no harm

Utilitarianism: consider appropriate use of resourcesFairness and justice: recognize balance beteen autonomy and competinginterests!eontological imperati"es: be aare of tradition and cultural conte#ts

Efective Communication1. Courtesy

2. Comfort

3. Connection

a. Dress professionally

 b. Have clear goals for interaction

c. Have Pt provide information

d. Use open-ended questionse. Use gentle guidance

. Confirmation

Enhancing Pt Resonses

• !pen-ended questions" gives Pt discretion about t#e e$tent of t#eir ans%er 

• Direct questions" see&s specific information

• 'eading questions" may limit %#at information t#e Pt provides( avoid t#is type of question

• )acilitate" encourage t#e Pt to say more( silence is o&ay* it give Pt time to gat#er t#oug#ts

• +eflect" repeat %#at you #ave #eard to encourage more detail

•  Clarify" if unsure* as& Pt to e$plain

• ,mpat#ie" s#o% your understanding and acceptance* if acceptable•  Confront" do not #esitate to discuss difficult issues

• nterpret" repeat %#at you #ave #eard to confirm Pt/s meaning

Potential !arriers to Communication

• Curiosity

• 0n$iety

• Depression

• ilence

• Crying and compassionate moments

• P#ysical and emotional moments

• eduction

• 0nger 

• 0voiding t#e full story

• )inances

"tructure o# $nterview1.  dentifiers

a. ame* date* time* age* gender* occupation* race* referral source

8/17/2019 514 Study Guide 1

2/12

2.  C#ief Complaint CC4

a. 5rief statement of %#y t#e Pt is see&ing care

 b. Direct quote

3.  History of Present llness HP4

a. tep-by-step evaluation of circumstances surround CC b. C!'DP0 details belo%4

c. nclude Pt/s vie% of cause.  Past 6edical History P6H4

a. )ull #istory t#at e$plores Pt/s overall #ealt#

 b. Components

i. 7eneral #ealt#

ii. C#ild#ood illnesses measles* mumps* c#ic&enpo$* etc4

iii. 6a8or adult illness 95* #epatitis* D6* #ypertension* etc4

iv. mmuniation flu* HP:* #epatitis* measles* tetanus* etc4

v. 6edical and surgical #istory date* #ospital* diagnosis* complications4

vi. 0ccidents any information t#at is available4

vii. 6edications !9C* prescriptions* #erbals* vitamins* etc ta&en in t#e past

and currently( include dosage* %#at it is for* #o% often it is ta&en

viii. 0llergies food* medication* environmental( reaction it causes4i$. 9ransfusions date* reason* units transfused* any reactions4

$. creenings P0P* P0* c#olesterol* etc4

$i. ,motional tatus mood* psyc#iatric attention4

;.  )amily History )H4a. )amily/s past and current #ealt# #istory* including illnesses* deat#s* genetic*

environmental influences

 b. ote age and outcome of any illness

c. nclude blood relatives %it# similar illness or blood relatives %it# ma8or disease

d. ote age and #ealt# of spouse* if applicable

alco#ol use( smo&ing( nutrition( e$ercise( se$ual #istory( militarye$perience( religion

?.  +evie% of ystems +!4

a. Detailed revie% of possible complaints in eac# body system to loo& for additional

symptoms not presented in #istory

 b. Document as @Pt reportsA >@Pt deniesA or B>-

History o# Present $llnessC $ %haracter &'hat is it li(e)*% $ +nset &'hen did it start)* $ ,ocation &'here is it) !oes it radiate)*' $ !uration &o long does it last)*

" $ .e"erity &.cale of /-0/*P $ 1attern &'hen does it occur) o often) 'hat are you doing henit occurs)*( $ Aggra"ating and associating factors &'hat ma(es it orse)*

)eneral "ymtoms

 

)ever 

8/17/2019 514 Study Guide 1

3/12

 

C#ills

 

6alaise

 

)atigue

 

 ig#t s%eats

 

leep patterns

  =eig#t

Review o# "ystems *'etaile+,1. &in* Hair* ails

a. +as#* itc#ing* pigment or te$ture c#ange* e$cessive s%eating* abnormal nail or

#air gro%t#

2. Head and ec&" 7eneral

a. Headac#es* diiness* syncope* #ead in8uries* '!

3. Head and ec&" ,yes

a. 0cuity* blurring* diplopia* p#otop#obia* pain* vision c#ange* glaucoma* eye

medications* trauma

. Head and ec&" ,ars

a. Hearing loss* pain* disc#arge* tinnitus* vertigo;. Head and ec&" ose

a. ense of smell* colds* obstruction* epista$is* postnasal drainage* sinus pain

cold intolerance* %eig#t c#ange* diabetes* polydipsia*

 polyuria* c#anges in facial>body #air* increased glove>#at sie* s&in striae

1;. ,ndocrine

a. )emale" menses* disc#arge* itc#ing* last pap* libido* birt# control* infertility*

 pregnancy* menopause

 b. 6ale" puberty onset* erections* emissions* pain* libido* infertility

1

8/17/2019 514 Study Guide 1

4/12

a. 9s* dysuria* pain* urgency* frequency* nocturia* #ematuria* polyuria.* #esitancy*

dribbling* loss in force* stones* edema* stress incontinence* #ernias

1?. 6usculos&eletal

a. oint stiffness* pain* restriction of motion* s%elling* redness* #eat* bony deformity

1. eurologica. yncope* seiures* %ea&ness* paralysis* abnormalities in sensation or

coordination* tremors* loss of memory1E. Psyc#iatric

a. Depression* mood* concentration* nervousness* tension* suicidal

attempts>t#oug#ts* irritability* sleep disturbances

(lcoholC $ cutting don( $ annoyance by criticism) $ guiltyE $ eye-openers Also can use 2A%3 or %4AFF25

'omestic (-use

H $ hurt you physically)$ $ insult you)T $ threaten you ith physical harm)" $ scream or curse at you)

"irituality. $ faith6 belief6 meaning$ $ importance and in7uenceC $ community( $ address8action in care

(+olescents

H / ome en"ironmentE - 3ducationE - 3ating( - Acti"ities6 a9ect6 ambitions6 anger' - !rugs" - .e#uality" - .uicide8depression" $ .afety

P $ parents6 peers( $ accidents6 alcohol8drugsC - cigarettes

E $ emotional issues" $ school and se#uality

Pregnant 0omen

• Current pregnancy and obstetric #istory

• ,$posure to environmental>occupational #aards

• )amily genetic conditions>congenital abnormalities

• Personal and social issues of pregnancy and parenting

8/17/2019 514 Study Guide 1

5/12

• +eproductive* cardiovascular* endocrine* respiratory system focus

• +is& factors t#at t#reaten mot#er and fetus

%l+er (+ults

 

Polyp#armacy

 

C#ronic symptoms

 

0ssessment of functional capacity

Tyes o# histories1. Complete" most often recorded t#e first time you see a Pt

2. nventory" touc#es on ma8or points %it#out going into complete detail( does not replacecomplete #istory( entire #istory completed in multiple sessions

3. Problem or focused" ta&en %#en t#ere is an acute issue t#at needs full attention

%verview o# Physical Eam –

+rder of assessment1. Hand #ygiene

2. 7eneral survey" distress* pain* appearance* #ygiene* '!C* place and time3. ntegumentary

. H,,9 inspect and palpate4;. +espiratory inspect* palpate and auscultate4

8/17/2019 514 Study Guide 1

6/12

a. Palmer surface of fingers and finger pads for position* te$ture* sie*

consistency* fluid* mass* crepitus

b. Ulnar surface for vibration

c. Dorsal for temperature

1ercussion tone indications1. 9ympany" loudest* #ig#-pitc#ed* moderate duration* drum-li&e( gastric bubble

2. Hyper-resonance" very loud* lo%-pitc#* very long* booming( #yperinflation and airtrapping( emphysematous lungs, abnormal

3. +esonance" normal* loud* lo%-pitc#* long* #ollo%( #ealt#y lung tissue

. Dullness" soft to moderate* moderate to #ig# intensity* moderate duration* t#ud-li&e(#eard over liver 

;. )lat" soft* #ig#-pitc#ed* s#ort* very dull( #eard over muscle

;odications for disabilities,ifting

1. Pivot transfer 

a. Place patients &nees bet%een o%n* grasp around bac& and under arms* raise to

vertical position* pivot* lo%er to table

2. Cradle transfer 

a. 5end or stand be#ind pt.* put one arm under &nees and one around bac& and

under arms* stand and carry

3. 9%o-person transfer 9%o met#ods4

a. Patient crosses arms* assistant places elbo%s under patients armpits and #olds

 patients opposite %rist* second assistant lifts and supports under patients &nees

 b. Used if patient can not cross arms* t#e first assistant puts arms around t#e patient

8/17/2019 514 Study Guide 1

7/12

Pulmonary – 13=Normal> lung sounds and locations

1. 5ronc#ovesicular #eard over trac#ea* #ig#-pitc#ed and intensity

2. :esicular #eard over lung fields* lo%-pitc#ed and intensity

3. 5ronc#ial breat# sounds #eard over bronc#i* moderate in pitc# and intensity* softer 

??Both broncho"esicular and bronchial breath sounds are abnormal if they areheard o"er the peripheral lung tissue

o to di9erentiate ad"entitious breath sounds1. Crepitus" crac&ly sensation t#at is felt and #eard( indicates air in C

2. )riction rub" palpable* course* dry* rubbing* grating vibration>sound usually on

inspiration( loudest over lo%er lateral anterior surface( caused by inflammation of pleural

space

3. Crac&les" abnormal respiratory sounds #eard on inspiration

o )ine" #ig#-pitc#ed* discrete* discontinuous* #eard at end of inspiration

o 6edium" lo%er* more moist sound #eard during midstage inspiration

o Coarse" loud* bubbly noise #eard during inspirationo  ot cleared by coug#

. +#onci" deeper* more rumbling during e$piration and inspiration( caused by passage of

air obstructed by t#ic& secretions* spasm* gro%t# or e$t pressure;. =#eees" continuous* #ig#-pitc#ed* musical noise on inspiration or e$piration( usually

louder during e$piration( caused by #ig# velocity air flo% t#roug# narro% or obstructed

air%ay( may be caused by ast#ma or bronc#itis

;inor structural "ariation "s5 chronic illness structural "ariation1. 6inor  

a. Pectus carinatum e$cavatum %#en t#e sternum protrudes( usually causes no

issues

2. 6a8or  a. !lder adults

i. 5arrel c#est due to loss of muscle strengt# in t#ora$ and diap#ragm

ii. 5ony prominences mar&ed

iii. Dorsal curve of t#oracic spine

1. ncreased 0P diameter 2. Gyp#osis

3. 7ibbus e$treme &yp#osis4

o to count ribs and intercostal spaces1. 6anubriosternal 8unction

a. 0ngle of 'ouis" 2nd rib articulates %it# t#e sternum

 b. ust belo% rib is t#e 2nd intercostal space

@ndication of abnormal percussion tones1. Hyper-resonance" very loud* lo%-pitc#* very long* booming( #yperinflation and air

trapping( emphysematous lungs, abnormal

@ndication of absent breath sounds

8/17/2019 514 Study Guide 1

8/12

1. 0pnea

a. 0bsence spontaneous breat# sounds

 b. 9ypes

i. Primary" self-limited* common after #ead in8ury* immediately after birt#

ii. econdary" breat#ing stops and %ill not start unless resuscitated( due tolac& of o$ygen absorption

iii. +efle$" involuntary* temporary( due to vapors or gases t#at are in#aledand irritating

iv. leep" periods of absent breat#ing and o$ygenation during sleep(

v. 0pneustic breat#ing" inspiration prolonged and e$piration constrained(

damage to pons

vi. Periodic breat#ing of ne%born" normal condition* usually associated %it#

+,6 sleep

1A alidation .heet$nsect: .ymmetry6 signs of distress6 trachea position6 breathing pattern6A1: trans"erse diameter &0:*

Inspection" inspect c#est for s#ape and symmetry* movement* superficial venous* rib

 prominence* 0P diameter* sternal protrusion* spinal deviation( inspect respiration rate* quality*

 pattern

Palate: %hest all6 masses6 crepitus4 thoracic e#pansion6 tactile fremitusPalpate: t#oracic muscles and s&eleton for pulsations* tenderness* depressions* bulges* masses*

unusual movement or positioning* elasticity of rib cage* immovability of sternum* rigidity of

t#oracic spine* crepitus* t#oracic e$pansion* tactile fremitus* trac#eal postioning

(uscultate: seuential fashion6 &anterior6 posterior and lateral*Auscultate" using stet#oscope listen for condition of t#e lungs and pleura( intensity* pitc#*

quality* duration( breat# sounds" vesicular* bronc#ovesicular* bronc#ial* adventitious crac&les*

%#eeing* r#onci* friction rub4( vocal resonance bronc#op#ony* pectoriloquy* %#ispered

 pectoriloquy* egop#ony4

1. 5ronc#ovesicular #eard over trac#ea* #ig#-pitc#ed and intensity

2. :esicular #eard over lung fields* lo%-pitc#ed and intensity

3. 5ronc#ial breat# sounds #eard over bronc#i* moderate in pitc# and intensity* softer 

??Both broncho"esicular and bronchial breath sounds are abnormal if they areheard o"er the peripheral lung tissue

(Note location of bronchovesicular, vesicular and bronchial 

breath sounds.Note presence and location of adventitious breath sounds)

 

C5/ 131A alidation .heetCar+iovascular an+ 6eck 

$nsect: "aricosities &legs*6 s(in colorPalate: &palpate at the Cth @%.*: 1;@6 %apillary rell(uscultate: %orrect use of diaphragm and then the bell

(Listen to all landmarks, name and identiy location of each)(State where S1,S are located and heard best)

8/17/2019 514 Study Guide 1

9/12

8/17/2019 514 Study Guide 1

10/12

i5 !iaphragmii5 clic(

d5 Friction rubsi5 'idely heard6 clearest near ape#ii5 .ystole and diastole6 intense grating

e5 Assess the folloing characteristics of murmurs:

i5 1rolonged e#tra sounds during .8!ii5 2iming and durationiii5 1itchi"5 @ntensity"5 1attern

"i5 Iuality"ii5 ,ocation"iii5 4adiationi#5 ariation ith respiratory phase

D5 .ystematically auscultate in each of the "e areas hile the patient isbreathing regularly and holding breath for the folloing:

a5 4ateb5 4hythm

'hat to do if you hear a friction rub in pt5 ith pericarditis1. ,$pected in pt %it# pericarditis

2. +ule out more serious issue by assessing for :D* #ypotension* muffled #eart sounds

3. Can lead to cardiac tamponade

'hat pulse nding is associated ith "entricular brillation)1. Cardiac output is reduce* no pulse CP+ 

2. Complete loss of regular #eart r#yt#m %it# e$pected conduction pattern absent if

%ea&ened and rapid* ventricular contraction is irregular 3. 9#e ventricular #as lost t#e r#yt#m of its e$pected response* and all evidence of vigorous

contraction is gone. t calls for immediate action and may immediately precede sudden

deat#

4egurgitation

1. 0ortic regurgitation

a. Heard %it# diap#ragm and patient sitting>leaning for%ard b. 0ustin )lint murmur #eard %it# bell at ape$

c. ,8ection #eard in 2nd intercostal space

2. Pulmonic regurgitation

a. Difficult to distinguis# from 0+ on P,3. 9ricuspid regurgitation

a. Heard at left lo%er sternum and occasionally radiates a fe% cm to t#e left

. 6itral regurgitation

a. Heard best at ape$

 b. 'oudest t#ere* transmitted into left a$illa

8/17/2019 514 Study Guide 1

11/12

%arotid bruits- indication1. Heard 8ust above t#e medial end of t#e clavicle and anterior margin of C6

2. 9ransmitted murmurs

a. :alvular aortic stenosis

 b. +uptured c#ordae tendinae of mitral valve

c. evere aortic regurg

3. Can be #eard %it# vigorous left ventricular e8ection

. !ccur %it# stenosis d in cervical arteries at#erosclerosis4

;. 6ild obstruction produces s#ort* localied bruit( greater stenosis lengt#ens duration and

 pitc#( complete may eliminate bruit

ascular assessment and the indication of a pulsatile mass1. HP

2. P6H

3. )H

. H

;. 0ssessment for Perip#eral arterial disease

a. Pain b. Pallor 

c. Pulselessness

d. Parest#esias

e. Paralysis

8/17/2019 514 Study Guide 1

12/12

%ardiac structure1. 'ayers

a. Pericardium" double-%alled* fibrous sac encasing and protecting #eart

 b. Epicardium: t#in outermost layer* covers surface of #eart and e$tends onto t#e

great vessels

c. yocardium" t#ic&* muscular layer* middle layer 

d. Endocardium" innermost layer* lines c#ambers of #eart and covers #eart valves

and muscles

2. C#ambers

a. Atria" rig#t and left* upper c#ambers

 b. !entricles" rig#t and left* lo%er c#ambers

c. eptum divides into rig#t and left #eart

3. :alves

a. Permit flo% of blood in only one direction

b. Atrio"entricular

i. 9ricuspid

ii. 6itral

c. #emilunar eac# #as t#ree cusps4i. Pulmonic

ii. 0ortic