Rachel Cartwright-Vanzant – Practical Approach to the Physical Assessment
Description:
Documentation elements of a comprehensive review of systems
Interviewing techniques to address the most sensitive topics
Strategies to detect abnormal cardiac and pulmonary sounds
Demonstration of a complete neurological assessment in two minutes
Critical thinking techniques to move from assessment to nursing intervention
Characterization of signs and symptoms with disease states
You have been assigned your patients for the shift. One of your patients is particularly complex. You have a gut feeling about this patient, which usually means something is not quite right…. Your time is divided amongst all your assigned patients because they require you attention too. How do I perform an accurate, thorough, and timely assessment when I have such little time, and then, how do I chart all the care I performed?
Time is a commodity healthcare providers are not afforded in today’s reality. We must learn to perform our job with excellence, precision and with efficiency. It can be done but we must work at it. One way is to be certain of your assessment skills and what to look for so you can quickly establish your priorities. No Rapid Responses on my shift if I can help it!
Whether you are a novice or expert, have been in practice for a few years or decades, it is possible that you may not have heard or seen enough examples of abnormal symptom and assessment findings. Attend this information-packed seminar and learn the latest research findings, evidence-based practice guidelines and techniques, including assessment tools for evaluation and treatment that you can implement into your practice immediately. Enhance your current interviewing and examination techniques, critical thinking skills, and learn new fun mnemonics to aid in the recall of many clinical conditions. Your speaker, Rachel Cartwright-Vanzant, MS, RN, CNS, LHRM, LNCC, will present topics using a variety of methods, including sample charting, discussion of differential symptom analysis and clinical case studies.
OUTLINE
INTERVIEWING, HISTORY-TAKING AND DOCUMENTATION TECHNIQUES
Communication Skills and Interview Strategies
Communications strategies for sensitive topics
Mental health issues
Drug/alcohol issues
Sexuality issues
Other sensitive issues
General literacy & health literacy
Core Adult History and Physical Exam Skills
Accountability for obtaining baseline data
Recording the assessment
Reporting relevant data
Past medical history
Chief complaint
Analysis of a symptom
Remember “OPQRST”
Elements of a history
Problem focused
Detailed
Comprehensive
Physical Exam Techniques
Inspection
Palpation
Percussion
Auscultation
Critical Thinking Skills
Assessment
Nursing diagnosis
Planning & outcome identification
Implementation
Evaluation
Documenting the Physical Exam
Electronic medical records
Strategies to overcome the dangers of
Charting by Exception
Legal implications & nursing standards
ASSESSMENT STRATEGIES FOR CHALLENGING SYMPTOMS
Integumentary System
Legal issues surrounding the skin
Assessment and common abnormalities
Anatomy of the skin
Pressure sore staging/grading
National Pressure Ulcer Advisory Panel
Head and Neck
Assessment and common abnormalities
Abnormal facial features
Thorax and Lungs
Assessment and common abnormalities
Respiratory landmarks
Oxygen transport and delivery
Abnormal breath sounds
Acute respiratory failure
Pulmonary embolism
ABG interpretation
Cardiac and Vascular Systems
Assessment and common abnormalities
Cardiac landmarks
Basic EKG analysis
Abnormal heart sounds
Abdomen
Assessment and common abnormalities
Musculoskeletal System
Assessment and common abnormalities
Grading muscle tone and strength
Osteoarthritis vs autoimmune
Nervous System
Assessment and common abnormalities
Autonomic nervous system
Parasympathetic nervous system
Sympathetic nervous system
Interactive cranial nerves
Normal findings
Abnormal significance
Head injury
“Nature of the injury”
Concussion
Increasing intracranial pressure
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Case Studies
OBJECTIVES
List eight system elements included in a review of systems.
Identify three strategies to assess patients for low health literacy.
Revise documented entries applying the “FACT” rule.
Interpret arterial blood gases in a flash.
Name three signs and symptoms of inadequate oxygenation.
Identify the waveforms of a normal EKG pattern.
Discuss possible etiology and significance of common cardiovascular assessment abnormalities.
Identify structures in regions of the abdomen.
Discuss abdominal assessment findings that warrant emergent intervention intestinal obstructions.
Incorporate the cranial nerves assessment, Glasgow coma scale, and reflex grading scale to the neurologic exam.
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