NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

WEEK 1 Discussion : Building a Healthy 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.  NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

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.  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.

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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. 

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.  NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

In a descriptivecorrelational 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 primarycare 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 nursepractitioner (NP) providers explained 41% of variance in satisfaction” (Benkert, Hollie, Nordstrom, Wickson, & Bins-Emerick 2009).  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?

·         Who do you live with?

WEEK 2 :Functional Assessments ,Cultural and Diversity Awareness in Health Assessment

MR, a 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle. He is not taking any prescriptions medications and denies drug use. He has a positive family history of diabetes, hypertension, and alcoholism.

Functional Assessments and Cultural and Diversity Awareness in Health Assessment

Cultural competence and patient contentedness have been one of the main approaches to improving healthcare quality.Cultural competence is the ability of healthcare providers and organizations to meet the cultural, social, and linguistic needs of their patients. The primary aim of the cultural competence movement has been to balance quality, to improve equity and reduce disparities by specifically improving care for people of color and other disadvantaged populations (Saha, Beach, & Cooper, 2008). When patients feel heard and understood by their healthcare providers, they are more likely to keep health appointments and adhere to treatment plans.

MR, a 23-year-old Native American male

Native Americans have the highest rates of alcohol use in comparison to other ethnic groups, placing them at risk for experiencing alcohol-related problems (Fish, Osberg, & Syed, 2017).Mail (1995) reports, nearly one third of Native Americans have tried alcohol by age 11 and half report use of illicit drugs by age 17.Alcohol was largely introduced to Native Americans during colonization, and it has been theorized that its intolerance is a result of changes in cultural beliefs from contact with European settlers (Abott, 1996).Abott (1996) also proposed continuous contact with White settlers transported vast sociocultural deviations in attitudes concerning drinking.According to Beauvais (1998), European colonists produced large amounts of alcohol readily accessible to Native Americans, who in turn had a small amount of time to “develop social, legal, or moral guidelines to regulate alcohol use” (p. 253).Their inexperience and lack of regulation could have converged to inspire a tradition of substantial drinking passed down from generation to generation.

Ethnographic research also supports the belief that alcohol usage is related to Native American history and that it is associated with trauma and suffering that has been passed on over generations (Myhra, 2011; Szlemko, Wood, & Thurman, 2006). Many participants in the study performed by Myhra (2011) reported what their life and their relationship with drugs and alcohol would be like.One participant stated, “it runs in our family” and “I always knew that I was going to be drunk” (Myhra, 2011, p. 26).It is as if consuming alcohol is a part of being Native American.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Current health disparities mirror a communication of socioeconomic conditions, physical and cultural community environments, individual management of health practices and medical concerns, and health care financing and delivery.Substance abuse may cause, impact, and/or exacerbate trans-generational trauma, post traumatic stress disorder, depression and anxiety among Native Americans.Other contributing behavioral risk factors that may be contributing to his anxiety include poor diet and physical inactivity related to health disparities in the Native American population.This could explain his family history of diabetes and hypertension.Ethnic minority populations in the United States often experience disparities in health outcomes, access to health care, and quality of health-care services received.

What this young patient is experiencing is not uncommon in the Native American community.Many studies have shown substance abuse and spirituality among urban American Indian youth are intertwined.The constant battle between the generational use of alcohol and spirituality/religion have proven to be cumbersome.While spirituality is practiced by many Indigenous peoples, each native group has their own ceremonies and practices. For many Native Americans, the spiritual cannot be separated from the mental and physical dimensions. All aspects of creation—including healing—have a spiritual dimension (Hodge et al., 2009).More specifically, spirituality tends to play a critical role in fostering health and wellness among American Indians (Kulis, Hodge, Ayers, Brown, & Marsiglia, 2012).In a study by Kulis (2012), it was concluded that following Native American traditional spiritual beliefs was associated with antidrug attitudes, norms, and expectancies.To be effective and culturally relevant, as this patient’s provider, I must address and incorporate his spiritual needs in his treatment plan.

Questions

1.I will provide the GAD-7 questionnaire to for him to complete to evaluate his level of anxiety.

Over the last two weeks, how often have you been bothered by the following problems?

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (4)

·Feeling nervous, anxious, or on edge

·Not being able to stop or control worrying

·Worrying too much about different things

·Trouble relaxing

·Being so restless that it is hard to sit still

·         Becoming easily annoyed or irritable

WEEK 3 :Breast Cancer Screening

A mammogram is the best breast cancer screening tests we have at this time (American Cancer Society, 2017). Even though a mammogram is the best screening test for detecting breast cancer, it has limitations as well. A mammogram can give results that are false-negative or false-positive (American Cancer Society, 2017). A false-negative mammogram looks normal even though breast cancer is present (American Cancer Society, 2017). A false-positive mammogram looks abnormal even though there’s no cancer in the breast (American Cancer Society, 2017).

There are also individual factors that can affect the results of a mammogram.Inaccurate mammogram results can occur due to improper positioning during the testing (Popli, Teotia, Narang, & Krishna, 2014). Proper positioning to produce high-quality breast images is the single most crucial factor when performing this test (Landsveld-Verhoeven et al., 2015). The second factor is and the technician’s skill. It has been studied that a technician that performs mammogram test all day without other job duties produce better images than one who has multiple job duties (Rauscher, Conant, Khan, & Berbaum, 2013).

Advanced practice nurses need to ensure that women undergoing mammogram testing are educated on the importance of the testing, as well as its limitations. Practitioners must ensure that their patients understand the value of a screening mammogram but a woman’s overall health factors in as well.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

References

American Cancer Society. (2017). Limitations of mammograms. Retrieved September 15, 2018,

from https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/mammograms/limitations-of-mammograms.html

Landsveld-Verhoeven, C., Heeten, G., Timmers, J., Broeders, M., van Landsveld-Verhoeven, C., den Heeten, G. J., & Broeders, M. M. (2015). Mammographic positioning quality of newly trained versus experienced radiographers in the Dutch breast cancer screening programme. European Radiology25(11), 3322-3327. doi:10.1007/s00330-015-3738-8

Popli, M. B., Teotia, R., Narang, M., & Krishna, H. (2014). Breast positioning during mammography: Mistakes to be avoided. Breast Cancer: Basic and Clinical Research8, 119–124. http://doi.org/10.4137/BCBCR.S17617

WEEK 5 : Allergic Rhinitis Medication

Yes, I also agree that the combination of antihistamines, nasal decongestants, and intranasal corticosteroids would have been a good course of treatment, which is exactly why I mentioned it in my initial post. Actually, the plan wasn’t a requirement for this assignment, but I mentioned it anyway. Allergic rhinitis can be treated in several ways, with many options being over the counter medicines (Marcin, 2017). Some over the counter options were actually prescription at some point, but are now available OTC.

Antihistamines include loratadine, cetirizine, and diphenhydramine, which are helpful in relieving the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion (D’deShazo & Kemp, 2017). Nasal decongestants include oxymetazoline and phenylephrine, which help to relieve runny and stuffy noses, but they are not as effective as nasal glucocorticoids. Nasal glucocorticoids include fluticasone, triamcinolone, and mometasone, which help to reduce nasal inflammation, sneezing, itching, rhinorrhea, and congestion, but should not be used more than two to three days (Sheikh, 2018). Other treatments for allergic rhinitis include oral decongestants pseudo ephedrine, which helps to relieve a stuffy nose and sinus pressure but should not be used longer than three days (D’deShazo & Kemp, 2017).  Immunotherapy, or allergy shots, is also recommended if you have severe allergies (D’deShazo & Kemp, 2017). 

As an allergy sufferer myself, I am very familiar with allergic rhinitis and the various treatment options, as I have tried them all including allergy shots and I take allergy medicine daily.

WEEK 6 : Assessing the Heart,Lungs and Peripheral Vascular System

Assessment of patients with chest tubes and/or underwater drainage systems is extremely important.  The principle of this type of drainage is simple.  The end of the tube from the thoracic cavity is placed below the level of the water in the closed bottle. The water prevents air from entering the thorax, yet allows for drainage of the pleural space.  Remember the dynamics of breathing; pressure is increased during expiration and pressure is reduced during inspiration.  See the following illustrations if you still have questions regarding the principles of a closed drainage system.

Assessment of the Patient

A patient will usually need chest tubes after any type of surgery that enters the thorax, or for treatment of atelectasis, etc.  We will try to confine our discussion to the cardiovascular system, but the lungs must also be assessed carefully.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Assess for:

  1. Subjective symptoms
    1. Breathing, any dyspnea or pain
    2. Anxiety does patient feel uncomfortable
    3. Neuro-level of consciousness, level of understanding
  2. Objective symptoms
    1. Breathing rate, rhythm, depth, breath sounds.
    2. Site dressing intact, drainage, subcutaneous emphysema (crepitus)
    3. Tubing taped properly, kinks, no dependent loops, check suction
    4. Heart sounds regular, rate easily heard
    5. Drainage measure volume, type, color, note any solid drainage (clots)
    6. Suction set a proper level, bubbling gently and continuously.
    7. Other assess entire cardiovascular system, skin color, pulses.

Study the example of bottle drainage and the Pleurevac system.  There are also other companies that manufacture a similar product.  Newer models of drainage systems are made highly portable and with fewer ways of disconnecting.  These enclosed systems give good control over the amount of suction applied to patient, and allows for large amounts of drainage.  It can be disconnected from the suction with no adverse effects.

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Imagine opening the chest cavity of an animal such as a mouse and – without any prior knowledge of the circulation – trying to make sense of the movement of the heart and blood. For those readers who have had occasion to observe the beating heart during open‐heart surgery, or the rapid motion of the heart in the living animal, they will appreciate it rises and falls in the chest as it beats. How does this alternating motion correlate with contraction (systole) and dilatation (diastole) of the heart? Is diastole a passive state or an active dilatation? It will also be noted that the arteries pulsate. How does the pulsation relate to the cardiac cycle? Knowing that the arteries contain blood, in what direction is the blood flowing? Cutting open the artery gives little clue about directional flow. Is the system open‐ended or closed? This is a difficult question to answer given that the connections between the arteries and veins cannot be seen with the naked eye. The Ancient Greeks had no prior knowledge about the structure and function of the cardiovascular system. Even worse, by the 1600s investigators were working with incorrect prior information. One cannot see the circulation of blood. Thus, its discovery – a turning point in the annals of biomedical history – depended on inference through clever experimental approaches, as pioneered by William Harvey.

Why is the discovery of the circulation considered to be so important? Prior to Harvey, the physiology of the body was essentially a question of the refinement of ingested food. Food was transformed in the liver into blood and distributed in veins throughout the body where it was assimilated to restore the tissues gradually lost. In addition to blood, veins also contained other humors, including yellow and black bile. Part of the venous blood was diverted to the heart where it was mixed with air in the left ventricle to form arterial blood imbued with vital spirits. The latter was distributed to tissues of the body through the arteries, providing heat, life and motion. (Some of the arterial blood was sent to the brain for further refinement into psychic spirits). The humors, spirits and heat ebbed and flowed around the body, according to the needs of the tissues. Disease was attributed to an imbalance of humors or a shift in the patterns of flow within the body. Treatment was directed at restoring the balance or controlling the movement of fluids. Bloodletting (venesection) was a common remedy, as was the use of ligatures (tourniquets) to redirect or divert the flow of blood from one part of the body to another. The system made sense. It was internally cohesive. However, fifteen centuries later, Harvey’s finding that blood circulates implied that blood was not constantly being consumed in the periphery and replenished by ingested nutrients, but rather that blood was conserved. From a therapeutic standpoint, the rationale for bloodletting – a mainstay of treatment for virtually every disease –was cast into doubt. In short, the new theory of blood circulation changed the intellectual system and worldview of physiology, disease and therapy.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

As modern‐day clinician‐scientists, why should we care about the history of the circulation? For one, the historical account reminds us that investigators from different eras should be judged in the context of their own times. It is difficult to put ourselves into the position of those who did not have our answers. However, Galen was a brilliant researcher and thinker, no less driven by a search for the truth than was William Harvey. The Ancient Greeks did their best to generate sound conceptual systems based on data available to them. They did not know that their system was flawed. We can only hope that our current models of the vascular system will be judged fairly and sympathetically by future generations who look back at the errors of our ways. Second, progress in science does not occur in a vacuum, but rather builds on a foundation of scholarship. As Harvey pointed out: ‘there is no science which does not spring from pre‐existing knowledge’. Science did not begin with the molecular revolution, the germ theory or the cell theory. Rather, science began when the Ancient Greeks began searching for non‐divine natural causes. Galen inherited and built on the work of the Ancients, Harvey overhauled Galenic doctrine, and we continue to build incrementally on Harvey’s model. Third, the fact that science fell dead for centuries after Galen’s death teaches us that scientific reasoning is fragile and can be suppressed under certain political, theological and cultural conditions. Progress in science continues to be hampered by such barriers, as evidenced by the recent debate over human stem cell research. Fourth, the narrative provides insights into the evolution of epistemological thinking, or ways we go about acquiring knowledge and truth about the natural world. One reason to study history is to understand why people thought the way they did, what assumptions did they make and why did they make them? This should remind us to do the same about ourselves. Finally, the story teaches us the importance of questioning existing dogmas when the evidence calls for it. Harvey, while respectful of and deferential to his predecessors, was not afraid to carve his own path. Harvey’s warnings about the power of authority and dogma are equally pertinent today as they were in his time.

WEEK 7 : Congestive Heart Failure

I also agree that congestive heart failure (CHF) is the likely diagnosis in this patient. The patient has several risk factors that are associated with CHF including being a male, smoker, and over 60 years of age. Heart failure is more prone in men with systolic dysfunction (Cleveland Clinic, 2016). Patient’s experiencing an exacerbation of CHF will typically present with fatigue, dyspnea, orthopnea, and loss of appetite (Azad & Lemay, 2014).

Upon auscultation of the lungs at the bases the detect crackles are typically present (Ball, Dains, Flynn, Solomon, & Stewart, 2015). I would suggest that in addition to the diagnostic testing that you recommended, to also include an echocardiogram (ECHO) of the heart.

An ECHO of the heart will help determine left ventricular systolic and diastolic pressure, ejection fraction, and pulmonary artery and ventricular filing pressures (Singh et al., 2017). Conducting an ECHO exam will help the provider determine the best course of treatment and will also check how well the treatment is working dysfunction (Cleveland Clinic, 2016)

The heart is one of the body’s most vital organ. The heart pumps blood throughout the body which carries nutrients other organs need. It also carries oxygenated blood to the lungs which allows us to breathe. Since the heart is so important, relying on it that it will do its job is necessary so we can live, but sometimes the heart can fail. Heart failure is a syndrome that occurs when the heart can not pump enough blood to meet the body’s metabolic needs.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

This paper will discuss what heart failure is, the signs and symptoms, and lastly the treatment and prevention of heart failure.

Heart failure is usually classified according to the side of the heart that is affected. Either “ left or right side, or by the cardiac cycle involved” (Lippincott Wilkins & Williams, 2011). Left sided heart failure occurs when there is ineffective function of the left ventricular contractile. As the pumping of the left ventricle fails, cardiac output also fails.

The blood that is suppose to go to the body is no longer being pumped out, thus backing up into the left atrium and the the lungs, causing “pulmonary congestion, dyspnea, and activity intolerance” ( Lippincott Wilkins & Williams, 2011). Right sided heart failure results from ineffective right ventricular contractile function. Blood is not being pumped effectively through the right ventricle to the lungs, causing blood to back up into the right atrium and the peripheral circulation.

When this happens, the patient gains weight and develops peripheral edema and engorgement of the kidney and other organs. Heart failure not only effects the heart but also other systems in the body. The cardiovascular system is affected by the heart not being able to pump blood throughout the body. Also, as the blood backs up into the left atrium, blood backs up into the lungs causing pulmonary congestion which affects the respiratory system. When blood backs up into the right atrium, the kidneys become engorged which cause problems with the renal system.

There are different signs and symptoms for heart failure. People with heart failure can develop shortness of breath, also called dyspnea, caused when the blood is backed up in the pulmonary veins. The patient will feel breathlessness during activity or while sleeping. Another sign and symptom is persistent coughing or wheezing, caused when fluid is being backed up in the lungs. The patient will cough up pink or blood stained mucus. Another sign and symptom is build up of excess fluid in body tissues, also called edema, and is caused when blood flow out of the heart slows down, the blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. Patient can also develop swelling in the feet, ankles, legs or abdomen, or weight gain. A patient with heart failure may also feel tired and develop fatigue caused by the heart not pumping enough to meet the body’s needs. They also might develop digestive problems causing loss of appetite and nausea. This is a result of the digestive system not receiving enough blood causing digestive problems. ( Chen, 2013)

If a patient has been diagnosed with heart failure there are some treatments that are involved to keep the syndrome under control. The patient will have medical therapy that involves medications such as an angiotensin- covering enzyme, diuretics to reduce fluid volume overload and venous return, beta- adrenergic blockers to prevent remodeling, any many others. A patient may also have to undergo surgery such as cardiac bypass. There are many life style changes that the patient also has to comply with. Some include weight loss, limited alcohol intake, smoking cessation, stress reduction, and development of an exercise program. If the case is severe, the patient might have to have a heart transplant, but even so, many complications and a hospitalizations are experienced. In order to porevent heart failure there are two ways to approach it. First is to stop or slow heart failure, and second is to avoid a repeat of any event detrimental to the patient’s life. (Shaddinger, 2014)

Heart failure is a very serious disease. It should never be be taken lightly and although the most common cause of heart failure is coronary artery disease. It can also occur in infants and children with heart defects.

WEEK 8 : Assessing Musculoskeletal Pain

History of Present Illness (HPI): MJ is a 42-year-old Caucasian male that presents to the office today experiencing lower back pain. He was in his usual state of health up until a month ago, when he began experiencing pain in his left lower back. The pain started at night and was not associated with any inciting activity, so he assumed it was his arthritis acting up. The pain was initially mild and crampy, but got progressively worse until this morning, when he experienced a sudden pain shooting down his left leg while getting out of bed. He denies any injuries or loss of consciousness. He describes the pain as a 4/10 at rest, and a 10/10 when he stands. It radiates down his left leg and has done this occasionally but not as bad as this am. He claims that Percocet and lying down helps relieve the pain, and that sitting, standing or acutely coughing worsens the pain. He denies a history of unsteady gait. He denies experiencing any falls. He does experience a burning sensation to his left buttock and down left leg with numbness and tingling in left foot since this am. He denies any fever, nausea or vomiting, or decreased appetite. Denies headaches, weakness, or paralysis in legs. Denies having urinary or bowel incontinence or pain and difficulty urinating. He denies experiencing any trauma acutely before the initial onset. He denies history of any health problems except arthritis. Denies family history of scoliosis.
NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Medications:

Percocet 5/325 mg one by mouth four times daily as needed for arthritic pain

Men’s One a Day vitamin one by mouth daily

Allergies: Amoxicillin- causes hives

Past Medical History (PMH):

Arthritis -diagnosed in 2014

Chicken pox as a child

Past Surgical History (PSH): None

Sexual/Reproductive History: Recently divorced one month ago and currently not sexually active. Denies history of STDs/STIs. States he did not use condoms when married, but will when he becomes sexually active again.

Personal/Social History: Denies using tobacco products, alcohol or illicit drugs. Walks two miles every day and lifts weights regularly at the gym up until one month ago when back pain began. States that he is a loan officer at a local bank. He lives alone with his pet dog. States he can perform his ADLs. In his spare time, he likes to travel on his motorcycle. He states that he has no children.

Immunization History: Denies having a flu and pneumonia vaccine. Tdap 2015.

Significant Family History:

The patient’s parents are alive and well. His father is 62 with no known conditions. His mother is 65 and has hypothyroidism. He has one brother who is 40 and has hypertension, and one sister who is 38 with no known conditions. He is unable to recall grandparents’ history but all are deceased.

Lifestyle: Heterosexual male, recently divorced, lives alone with pet dog. Lives in a rural gated subdivision with a low crime rate. Works as a loan officer for past 20 years with good benefits and retirement plan. States his parents and siblings are very supportive.

Review of Systems:

General: Denies recent fever, chills, or night sweats. Denies weight loss/gain

Head: Denies headaches, head injuries, syncope, dizziness or loss of consciousness

Eyes: Denies wearing glasses or contacts. Last eye exam 2015. No history of glaucoma or excessive tearing. Denies eye pain or diplopia. Denies light sensitivity, eye trauma or familial eye disease.

Ears: Denies ear pain, tinnitus, or hearing loss. Denies recent ear infections. Denies vertigo.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Nose: Denies epistaxis or smelling difficulties. Denies rhinorrhea. Denies frequent colds, obstruction, post-nasal drip or sinus pain/pressure.

Throat/Mouth: Denies hoarseness or change in voice. Denies frequent sore throats. Denies history of tonsillitis, no trouble swallowing. Last dental exam 2016. Has own teeth without dental caries or appliances. Denies bleeding gums, ulcerations, lesion or gingivitis. Denies taste change.

Neck: Denies neck pain or tenderness. Denies neck injuries. States he has full ROM of neck. Denies any neck surgeries or history of disc disease. Denies swollen glands or lymph nodes.

Breasts: Denies lumps, masses or nodules. Denies nipple discharge. Denies family history of breast cancer

Respiratory: Denies cough or hemoptysis. Denies pain with breathing. Denies dyspnea, cyanosis, wheezing or sputum production. Denies exposure to TB, unable to recall last CXR

Cardiovascular/Peripheral Vascular: denies chest discomfort or pain. Denies palpitations or chest tightness. Denies history of abnormal heart rhythms or murmur. Denies history of EKG or heart studies. Denies previous MI, edema, or hypertension. Denies orthopnea. Exercises daily for 30 minutes. Walks two miles every day. Denies bruising easy, blood clots, or inflammation of veins.

Gastrointestinal: Denies appetite gain/loss. Denies intolerance to foods. Denies dysphagia, heartburn, nausea, vomiting or hematemesis. States bowels move regularly every day. Denies constipation or diarrhea. Denies change in stool color or contents. Denies flatulence, hemorrhoids, hepatitis or jaundice. Denies dark urine. Denies history of gastric ulcers, gallstones, polyps or tumors. Denies sigmoidoscopy or colonoscopy

Genitourinary: denies dysuria, flank or suprapubic pain. Denies urgency, frequency, nocturia, hematuria, polyuria or hesitancy. Denies decreased urinary output. Denies edema to face. Denies stress incontinence or history of hernias. Denies discharge from penis.

Musculoskeletal: States history of arthritis since 2014. Denies history of gout, trauma or fractures. Denies joint swelling or redness. States limited ROM for past month in back. Reports back pain with radiation down left leg. Reports not being able to exercise or walk his daily two miles due to pain.

Psychiatric: denies history of depression, suicidal or homicidal ideations. States that he has occasionally felt “a little blue” since his divorce. Denies mood changes or difficulty concentrating. Denies nervousness or tension. Denies irritability or sleep difficulties

Neurological: denies syncope, seizures, or tremors. States he has numbness and tingling in left foot since this am. Denies weakness or paralysis. Denies recent falls or abnormal movements. States burning sensation in left buttock down left leg past knee

Skin:denies rashes, itching or bruising. Denies history of skin cancer or lesions. Denies use of tanning bed. Denies clubbing or cyanosis of nails.

Hematologic: Denies history of blood transfusions, clotting disorders or easing bruising. Denies anemia history.

Endocrine: Denies thyroid enlargement or tenderness. Denies heat or cold intolerance. Denies unexplained weight gain/loss, denies polydipsia, polyuria. Denies change in facial or body hair. Denies increased hat or glove size. Denies skin dryness or cracking.

Allergic/Immunologic: Denies frequent infections or recent infections. Denies HIV/AIDs or any STDs. He is allergic to amoxicillin which causes hives.

OBJECTIVE DATA:

Physical Exam:

Vital signs: T 98.4 oral, HR 75 and regular, R 19 and unlabored, BP 170/88 manual, sitting, left arm. Right arm, manual, sitting 168/86. 02 sat 96% RA. Height 6’0, Weight 180. BMI: 24.4

General: MJ is a well-developed white male appearing his stated age, in no respiratory distress, sitting in chair. He is alert and cooperative with the exam.

Head: Normocephalic, atraumatic. Midline of shoulders, facial features symmetrical. Scalp moves freely with no depressions, nodules or masses. No nits, parasites, or scales. No facial edema or puffiness noted. Bilateral temporal arteries 2+ without bruits or tenderness. NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Eyes: Visual acuity 20/20 Snellen chart. Peripheral vision intact. EOMI. No orbital edema, sagging or puffiness. Conjunctivae clear, no exudate or hemorrhages noted. Eyelids symmetrical without redness or flakiness, fasciculation’s or ptosis. Eyebrows symmetrical and extend past eyes bilaterally. Corneal light reflex intact. No nystagmus noted. Red reflex present. Optic disc creamy pink with sharp, well defined margins. Retina reddish-pink without vascularization’s. No neovascularization’s hemorrhages or microaneurysms noted. No AV nicking.

Ears: Auricles symmetrical bilaterally without pain or tenderness. Otoscope exam reveals minimal cerumen, no lesions, discharge or foreign bodies. Tympanic membranes are pearly grey with bony landmarks and light reflex visualized bilaterally. No bulging or retractions noted. No fluid or air bubbles visualized. Whisper, Rinne and Weber intact.

Nose: Symmetrical, nares patent bilaterally. No discharge, crusting, flaring or polyps noted. Turbinate’s pink, septum midline without perforation. No sinus tenderness or swelling noted. CN I intact.

Throat/Mouth: All teeth present and intact. No missing or chipped teeth. No dental appliances. Lips are pink and symmetrical, smooth without lesions or nodules. Tongue beefy red and symmetrical without crusting. Oral mucosa pink and moist. No nodules or lesions noted in buccal pouch. Oropharynx has no lesions or exudate. Tonsils grade II without redness, edema, or exudate.

Neck: Supple, full ROM. Thyroid moves freely with swallow test. No nodules or masses palpated. No lymphadenopathy. Trachea midline. No carotid bruits noted. No JVD. JVP 6 cm at 45-degree elevation. No webbing or skinfolds noted.

Chest: Breathing appears non-labored and symmetrical. No accessory muscles, cyanosis or nostril flaring noted. Thumbs diverge symmetrically with thoracic expansion. Respiratory excursion 4 cm bilaterally. No pain or tenderness noted over ribs or bony prominences. No pain or tenderness noted when palpating breasts. No swollen axillary lymph nodes.

Lungs: Respiration 19 and unlabored. Appears quiet and at ease. Vesicular breath sounds noted all lung fields. No adventitious sounds. Resonance heard over all lung fields with percussion. Tactile fremitus symmetrical. No cough or stridor noted. No friction rubs. No egophony, bronchophony.

Heart: Point of maximal impulse is noted in the fifth intercostal space midclavicular line. Regular rate and rhythm. S1 and S2 normal. No S3 or S4. No murmurs noted. No heaves or lifts. Capillary refill <2 seconds all extremities. Nails without clubbing or cyanosis.

Peripheral Vascular: Carotid pulses, radial pulses, tibial pulses and pedal pulses all palpable and rated a 2+. No bilateral peripheral edema noted. No lesions, sores or open wounds noted to bilateral feet.

Abdomen: Nondistended, no tenderness to palpation. Bowel sounds present all four quadrants. No masses were palpable. The liver span percussed to 9cm. No hepatomegaly or splenomegaly noted. No renal artery bruits auscultated. No hernias palpated. Negative McBurney’s point.

Genital/Rectal: Penis and testicles without lesions. No inguinal hernias are present. Rectal exam had intact tone. Firm, symmetric, nontender prostate without nodules.

Musculoskeletal: Spine vertically aligned. Normal S-curvature. No nodules, masses, or tenderness with palpation. Full ROM in all joints. BUE and BLE symmetrical. No pain or tenderness with palpation of joints. Extremities symmetrical in length, circumference, alignment, and position. Muscle size symmetrical without atrophy or hypertrophy. No pain or tenderness with passive ROM. Active and passive ROM equal between contralateral joints. No crepitation’s or tenderness with movement noted. Thoracic spine convex. Lumbar spine convex. Knees and feet in proper alignment. Cervical spine concave with head erect in appropriate position. Skin folds symmetrical.

WEEK 9 : Assessing Neurological Symptoms

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Case 1: Headaches

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

Case 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Case 3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

A focused neurological assessment of your patient can make a difference between life and death, permanent disability or complete recovery. It is a key standard of care for all patients. Yet many nurses fear the neuro exam unnecessarily. RN.com offers you an easy and manageable guide to performing a neurological exam with ease!

The purpose of a neurological assessment is to detect neurological disease or injury in your patient, monitor its progression to determine the type of care you’ll provide, and gauge the patient’s response to your interventions (Noah, 2004). Performing a neurological assessment early is important in establishing a baseline for later comparison (Anness & Tirone, 2009).

The initial evaluation is usually a comprehensive examination covering several critical areas of assessment, including level of consciousness (LOC), orientation, speech, facial symmetry, motor and sensory function and reflex activity. Assessment of cranial nerve function, cerebellar function and reflex activity are covered in a comprehensive neurological assessment.

Before beginning a focused neurological assessment, evaluation of the patient’s vital signs should be conducted, as current or progressive injury to the brain and brain stem may make vital signs unstable, which could reduce neurologic responses. It is best to conduct the neuro assessment at a time when vital signs are relatively stable (Anness & Tirone, 2009).NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

Evaluation of LOC is the most important part of the neuro exam, as a change is usually the first indication of a declining status (Noah, 2004). The Glasgow Coma Scale (GCS) is a valuable tool for recording the conscious state of a person, and is based on three patient responses: Eye opening, motor and verbal response. The total score will range from 3 (coma) to 15 (fully conscious, alert and oriented). A score of 8 or lower usually indicates coma (CDC, 2013). Although the GCS was initially used to assess LOC after head injury, it was not designed to be used for patients who are intubated, as the verbal component of the score cannot be accurately assessed. In documenting the GCS score for intubated patients, a notation of the patient’s intubation can be included as a narrative note to facilitate accurate interpretation of the GCS scores (Matis & Birbilis, 2008).

In addition to performing the GCS, assessment of your patient’s pupil size, shape and equality before and after exposure to light is an integral part of a neurological exam. The PERRLA (Pupils Equal, Round, React to Light and Accommodation) acronym is a useful tool to use. A change in pupillary response, such as unequal or dilated pupils can provide a warning sign of increasing intracranial pressure (ICP) (Anness & Tirone, 2009).

A bedside neuro assessment almost always includes an evaluation of motor and sensory function, but requires the patient to be cooperative and oriented. To assess motor response in a comatose patient, apply a painful or other noxious stimulus to a central part of the body, such as trapezius muscle squeezing, or application of supraorbital pressure. Then observe for specific motor responses, as specified in the GCS, such as flexion (decorticate posturing) or extension motor responses (decerebrate posturing) (Anness & Tirone, 2009).

The Focused Neurological Assessment course is a part of the Assessment Series on RN.com. The course provides a comprehensive review of additional motor and sensory function tests, as well as cranial nerve testing.

Once an initial, thorough assessment is conducted (on admission or at the beginning of each shift), subsequent assessments should be problem-focused, zeroing-in on the parts of the nervous system affected by the patient’s condition (Noah, 2004).

Although the comprehensive neurological exam can be complex, it is essential to the diagnosis and treatment of a wide variety of neurological conditions. With practice and repetition you will hone this essential, life-saving skill (Anness & Tirone, 2009).

Diagnostic tests and procedures are vital tools that help physicians confirm or rule out a neurological disorder or other medical condition. A century ago, the only way to make a definite diagnosis for many neurological disorders was to perform an autopsy after someone had died. Today, new instruments and techniques allow scientists to assess the living brain and monitor nervous system activity as it occurs. Doctors now have powerful and accurate tools to better diagnose disease and to test how well a particular therapy may be working.

Perhaps the most significant changes during the past 10 years have occurred in genetic testing and diagnostic imaging. Much has been learned from sequencing the human genome (the complete set of a person’s genes) and developing new technologies that detect genetic mutations. Improved imaging techniques provide high-resolution images that allow physicians to view the structure of the brain. Specialized imaging methods can visualize changes in brain activity or the amounts of particular brain chemicals. Scientists continue to improve these methods to provide more detailed diagnostic information.

Researchers and physicians use a variety of diagnostic imaging techniques and chemical and metabolic tests to detect, manage, and treat neurological disease. Many tests can be performed in a physician’s office or at an outpatient testing facility, with little if any risk to the person. Some procedures are performed in specialized settings to determine particular disorders or abnormalities. Depending on the type of test, results may be immediate or may take time to process.

WEEK 10 :Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with health care professionals 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 Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

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Case 3: Genitalia

A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient 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 had one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

To prepare:

With regard to the case study you were assigned:

·        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 you were assigned.

·        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.

Post a Soap note

1.      a description of the health history you would need to collect from the patient in the case study to which you were assigned.

2.      Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3.      List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Please read below regarding discussion case study posts 

Your response should be in soap note format

But you don’t have to make up any information.  If information is not provided in the case study do not add it.  State:  None or information not provided.

For the additional history questions you need to come up with appropriate questions that applies to case study scenarios and write them down.

For physical exam section  –  you are expected to explain the appropriate physical exam components that needs to be done with reference to the case study.  You should mention the systems and include information on what you will be looking for in each system based on the information given in the case study  .

For the diagnostic tests  –  You are expected to come up with appropriate diagnostic tests that pertains to the case study scenario and the differential diagnosis that you are required to come up with. NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

If you have five differential diagnosis include information from most likely diagnosis to lease likely diagnosis and explain why you chose those differential diagnosis and the diagnostic tests  .  Again all pertaining to the information given in the case study.  It is like proving your case  .  Why and why not  .

WEEK 11 :  Advanced Stage Cancer

A 49-year-old woman with advanced stage cancer has been admitted to the emergency room with cardiac arrest. Her husband and one of her children accompanied the ambulance.

For all patient’s it is important to have respect for them and to protect them from any harm while taking care of them.For this patient as she has advanced stage cancer and is in cardiac arrest is to find out what her wishes are.It is important to talk with the husband and child to see if an advanced directive is in place.Advance directives are used when the patient is not able to voice their wants in emergent situations.Advance directives come into effect when the patient is unable to speak for themselves (American Cancer Society, 2016).The health care provider should discuss the patient’s current medical condition with the family.The health care provider may also bring up hospice care to the family to see if they would be interested.

Scenario #3

A 27-year-old man with Crohn’s disease has been admitted to the emergency room with an extreme flare-up of his condition. He explains that he has not been able to afford his medications for the last few months and is concerned about the costs he may incur for treatment. 

According to Lee (2016), stress can cause flare-ups of Crohn’s disease.This patient is worried about the costs of treatment and he is not able to pay for his medications.First of all, I would tell the patient that I will be contacting the care coordinator in our department to discuss different resources to help him.By doing this it may help decrease some of the stress that he is having.Next it is important to discuss his current medical problem and see if it is actually a flare-up of Crohn’s or if it may be a different gastrointestinal issue.I would ask the following questions:NURS 6512 Advanced Health Assessment and Diagnostic Reasoning

What are his symptoms, when did they start, and if anything, makes it better or worse?We already know that he has not been taking his medication for Crohn’s disease because he can’t afford them, but are there any medications that he is taking?What other medical problems does he have, and what is family history is are also important questions to ask.Diet and smoking are also triggers so it is important to obtain information on the types of food he eats and if he is a smoker.

The following tests would be ordered: CBC with differential, stool culture, hemoccult of stool, and if necessary referring patient to a GI doctor for further tests such as; colonoscopy.

Scenario #6

A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is very religious and believes that the vaccine would encourage premarital sexual activity.

            According to Shelton, Snavely, Jesus, Othus, & Allen (2013), religion has a big influence on whether to vaccinate or not to vaccinate children.  It is important as health care providers to listen to our patients and family’s concerns.  Health care providers much determine how much the parents know about the vaccination and discuss their values and beliefs that have influenced their decision on vaccinating their daughter.  The benefits and risks of receiving or not receiving the HPV vaccination should be explained to the parents (Gilmour, Harrison, Asadi, Cohen, & Vohra, 2011).  It is ultimately the parents decision, but making sure they have all of the information is very important.NURS 6512 Advanced Health Assessment and Diagnostic Reasoning