Final Exam Review
PCC1 - Final Review
Nicole Hall, MSN, RN
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Chapter 3 – The Interview (Jarvis)
Items to Review:
Verbal/Nonverbal Communication:
Verbal communication includes the spoken word, tone, and pacing. Paying attention to tone and inflection can reveal underlying emotions.
Nonverbal communication includes body language, facial expressions, eye contact, gestures, and touch. These often convey more meaning than verbal communication.
Negative Nonverbal Behavior that can Hinder an Interview:
Closed Body Language: Crossed arms, turning away from the patient.
Lack of Eye Contact: Can convey disinterest or dishonesty.
Distracting Gestures: Fidgeting, looking at a watch repeatedly.
Inappropriate Facial Expressions: Showing shock, disgust, or impatience.
Standing Over the Patient: Can be intimidating and create a power imbalance.
Positive Nonverbal Communication that will Strengthen an Interview:
Open Body Language: Relaxed posture, uncrossed arms.
Appropriate Eye Contact: Maintaining eye contact intermittently to show engagement and respect.
Nodding: Shows attentiveness and encourages the patient to continue.
Smiling: Conveys warmth and approachability.
Sitting at Eye Level: Promotes a sense of equality and comfort.
Therapeutic Touch: Used judiciously to convey empathy and support.
Open-Ended Questions vs. Closed or Direct Questions:
Open-Ended Questions: Encourage narrative responses, allowing patients to express their feelings and perceptions in their own words. They are used to begin the interview, introduce new topics, or prompt further discussion. Examples: "Tell me about your pain," "What brings you to the hospital today?"
Closed or Direct Questions: Elicit specific, brief answers, often yes/no or single-word responses. Used to fill in details, clarify information, or review systems. Example: "Do you have a fever?" "Where does it hurt?"
Interviewing Patients with Special Needs: Adapt communication strategies for patients with hearing impairments (speak clearly, face them), vision impairments (describe environment), acute illness (focus on immediate needs), under the influence (be direct but non-judgmental), or those who are crying (offer empathy, allow time).
Use of Interpreter Services: Use a trained medical interpreter for language barriers; avoid using family members if possible to ensure accuracy and patient privacy. Speak to the patient, not the interpreter.
Chapter 8 – Assessment Techniques and Safety (Jarvis)
Items to Review:
Order of Assessment: The sequence of assessment techniques is crucial for obtaining accurate data, especially in the abdomen.
Inspection: Careful, close observation of the individual as a whole and then of each body system. It begins the moment you first meet the patient and continues throughout the examination.
Palpation: Using touch to assess texture, temperature, moisture, organ location and size, swelling, vibration, pulsation, rigidity, crepitation, lumps, or pain.
Light Palpation: Used to detect surface characteristics.
Deep Palpation: Used for abdominal organs and masses (requires caution).
Percussion: Tapping the skin with short, sharp strokes to assess underlying structures. It yields a palpable vibration and characteristic sound that depicts the location, size, and density of the organ.
Auscultation: Listening to sounds produced by the body, such as heart and blood vessels, lungs, and abdomen, using a stethoscope.
Equipment Used for Examination:
Stethoscope: Used to auscultate body sounds.
Differences in Diaphragm/Bell:
Diaphragm: Flat edge, used for high-pitched sounds (breath, bowel, normal heart sounds). Press firmly against the skin.
Bell: Cup-shaped, used for soft, low-pitched sounds (extra heart sounds, murmurs, bruits). Apply lightly to the skin.
Otoscope: Handheld instrument used to examine patients’ ears, specifically the external ear canal and tympanic membrane (eardrum).
Ophthalmoscope: Instrument used to examine patients’ eyes, specifically the internal structures of the eye such as the retina, optic disc, and blood vessels.
Chapter 9 – General Survey (Jarvis)
Items to Review:
What is the General Survey?
General observations of a patient’s overall health state, obvious physical attributes, and presenting characteristics. It’s a rapid, systematic observation during initial contact.
When is it Performed on a Patient?
Done immediately when you first see the patient and continues throughout the entire patient encounter.
Components of a General Survey:
Physical Appearance: Overall impression including age (appearing stated age), sex, level of consciousness (alert, oriented), skin color (normal for ethnicity, no pallor/cyanosis/jaundice), facial features (symmetric), and overall appearance (no signs of acute distress).
Body Structure: Stature (height within normal range), nutrition (weight for height, even distribution of body fat), symmetry (bilateral features equal), posture (erect, plumb line alignment), position (comfortable, relaxed), body build/contour, and any obvious physical deformities.
Mobility: Gait (smooth, coordinated, balanced) and range of motion (full mobility of joints, no involuntary movements).
Behavior: Facial expression (appropriate to situation), mood and affect (cooperative, comfortable), speech (clear, articulate, appropriate pace), dress (appropriate for climate, clean), and personal hygiene (clean, groomed).
Measurements: Obtain height, weight, body mass index (BMI), and waist circumference, and calculate ideal body weight when relevant.
Chapter 10 – Vital Signs (Jarvis)
Items to Review:
Normal Vital Signs: These are general adult ranges and can vary based on age, activity, and underlying conditions.
Temperature: 98.6 (or 37C ) is the average oral temperature, normal range is96.4-99.1 . Influenced by diurnal cycle, exercise, and hormones.
Pulse: 60-100 bpm (beats per minute). A rate below 60 is Bradycardia, above 100 is Tachycardia.
Respiratory Rate: 12-20 breaths/min. Rates below 12 are Bradypnea, above 20 are Tachypnea.
Blood Pressure: 120/80 . Hypertension is >130/80 Hypotension is too low (defined by signs of inadequate perfusion rather than a specific number).
Oxygen Saturation: >95\% measured by pulse oximetry, it indicates the percentage of hemoglobin carrying oxygen.
Pain: Considered the “5th” vital sign. Any amount of pain is considered abnormal and requires assessment and intervention. It is subjective.
Temperature Measurement:
Different Routes:
Oral: Most common, convenient. Not suitable for unconscious or uncooperative patients, or those with oral trauma.
Axillary: Safe and non-invasive, but less accurate than oral or rectal. Often 1 degree lower than oral.
Tympanic (Ear): Non-invasive, quick. Affected by earwax or ear infections.
Rectal: Most accurate, but invasive and uncomfortable. Often 1 degree higher than oral. Used for infants or when other routes are impractical.
Postpone oral temperature measurement for 15 minutes after cold/hot beverages, smoking, or chewing gum.
Pulse Measurement:
Measure and Document: Rate (BPM), Rhythm (regular/irregular), Force (amplitude: 0=absent, +1=weak, +2=normal, +3=bounding).
Count for 30 seconds and multiply by 2 if regular; if abnormal (irregular or very slow/fast), count for a full 60 seconds to ensure accuracy.
Count using Radial pulse (most common) or Apical pulse (at apex of heart, using stethoscope for 60 seconds).
Respiratory Rate Measurement:
Watch for Patient Chest Rise/Fall (inspiration and expiration count as one breath). Often best done unobtrusively after taking pulse.
Count for 30 seconds and multiply by 2 if regular; if labored or irregular, count for a full 60 seconds.
Measure and Document: Rate (breaths/min), Rhythm (regular/irregular), Ease (unlabored/labored), Depth (shallow/normal/deep).
Blood Pressure Measurement: Measures the force of blood against arterial walls.
Taken on Upper Extremity, usually the brachial artery.
Correct Cuff Size: Crucial for accurate readings.
Too Small Cuff Size: Yields falsely HIGH BP because it requires more pressure to compress the artery.
Too Large Cuff Size: Yields falsely LOW BP because the pressure is distributed over a wider area.
Width of Bladder: Should cover 40% of the circumference of the patient’s arm.
Length of Bladder: Should equal 80% of this circumference.
Don’t Take BP in Extremity When Patient Has Had a Mastectomy on that side (due to lymphedema risk) or Patient Has Dialysis Fistula/Shunt in that Extremity (to avoid damaging the vascular access).
Oxygen Saturation Measurement:
Sensor is placed on patient’s finger (most common), earlobe, or toe. It measures the peripheral oxygen saturation (SpO_2).
Chapter 11 – Pain Assessment (Jarvis)
Pain Definition:
Pain is Whatever the Patient Says it is, Whenever the Patient Says it. It is a highly subjective experience and the patient's self-report is the most reliable indicator.
Subjective Report is the Most Reliable Indicator of Pain. Objective signs (grimacing, guarding) may be present but do not truly measure the patient's pain experience.
Types of Pain Scales: Tools to quantify pain intensity.
Number Scale 0-10: (Numeric Rating Scale - NRS) 0 = no pain, 10 = worst possible pain. Suitable for adults and older children who can consistently rate their pain.
Wong-Baker Faces Scale: Uses a series of faces ranging from a happy face (no pain) to a crying face (worst pain). Suitable for children (3+ years), non-English speakers, or adults with cognitive impairments.
PQRST Method to Assess/Document Pain: A comprehensive approach to gather detailed pain information.
P: Provocation/Palliative: What caused the pain? What makes it better or worse?
Q: Quality: What does the pain feel like? (e.g., sharp, dull, throbbing, burning, aching).
R: Region/Radiation: Where is the pain located? Does it spread anywhere else?
S: Severity: How severe is the pain on a scale of 0-10?
T: Timing: When did the pain start? How long does it last? Is it constant or intermittent?
Acute vs. Chronic Pain:
Acute Pain: Short-term, self-limiting, follows a predictable trajectory, and dissipates after injury heals. Often has an identifiable cause (e.g., surgery, trauma).
Chronic Pain: Persistent pain, lasting for 6 months or longer. It may or may not have an identifiable cause and can significantly impact quality of life.
Health Promotion: Educate patients on pain management options, importance of reporting pain, and non-pharmacological interventions.
Chapter 13 – Skin, Hair, Nails (Jarvis)
Assessment Techniques:
Subjective Data: Patient's Report about skin changes, history of skin disease, allergies, rashes, itching, medications, environmental hazards, and self-care behaviors.
Objective Data: What is Observed by inspection and palpation.
Inspection Techniques: Systematically observe the entire skin surface, hair, and nails.
Color: Localized or Generalized Areas of color change, such as:
Cyanosis: Bluish discoloration due to inadequate oxygenation of blood (central - lips, oral mucosa; peripheral - nail beds, extremities).
Jaundice: Yellowish discoloration of skin and sclera due to excess bilirubin (often seen in liver dysfunction).
Other color variations: Pallor (paleness), Erythema (redness).
Lesions: Note color, elevation, pattern, shape, size, location, exudate. Primary lesions develop on previously unaltered skin; secondary lesions result from changes over time.
Nails: Assess contour, consistency, and color. Clubbing (nail bed angle >160 and Its Indications: Often a sign of chronic hypoxia (e.g., congenital heart disease, pulmonary diseases like emphysema or lung cancer).
Edema: Swelling from fluid accumulation in interstitial spaces. Staging of Pitting Edema:
+1 Pitting: Mild pitting, slight indentation, no perceptible swelling of the leg2\operatorname{mm} indentation).
+2 Pitting: Moderate pitting, indentation subsides rapidly (4\operatorname{mm} indentation).
+3 Pitting: Deep pitting, indentation remains for a short time, leg looks swollen6\operatorname{mm} indentation).
+4 Pitting: Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted (8{ mm} indentation).
Palpation Techniques: Use fingertips to assess specific characteristics.
Moisture: Dry, clammy, diaphoresis (sweating).
Texture: Smooth, firm, even.
Temperature: Use the back of your hands. Warm, cool, hot (bilaterally).
Thickness: Assesses for thinning, thickening, or calluses.
Edema: Confirm presence and assess for pitting.
Vascularity: Assess for easy bruising, cherry angiomas, petechiae, purpura.
Review Normal vs. Abnormal Variations: Be familiar with benign findings (e.g., freckles, moles, cherry angiomas, skin tags) vs. suspicious lesions (e.g., ABCDE rule for melanoma: Asymmetry, Border irregularity, Color variation, Diameter >6\operatorname{mm}
Health Promotion: Teach self-skin exams, sun protection, warning signs of skin cancer, and proper hygiene.
Chapter 14 – Head, Face, Neck, and Regional Lymphatics (Jarvis)
Assessment Techniques:
Assessing Head, Face, and Neck: Inspect and palpate for size, shape, symmetry, tenderness, and range of motion.
Lymph Nodes Assessment: Systematically palpate lymph nodes of the head and neck.
Gentle Pressure with Pointer Fingers, Feeling Lymph Nodes on Either Side Symmetrically: Use a circular motion with fingertips.
What do Abnormal Lymph Nodes Indicate? Enlarged, tender, firm, or fixed nodes can indicate infection (tender, mobile), malignancy (hard, non-tender, immobile), or autoimmune disease.
Review Developmental Competencies: Changes in head circumference, fontanels in infants; thyroid changes in pregnancy; facial appearance and neck range of motion in older adults.
Subjective Data: Headaches, head injury, dizziness, neck pain, lumps or swelling, history of head/neck surgery.
Objective Data: Inspection and Palpation findings.
Inspecting Face:
Assess for Symmetry: Observe facial expressions, note any drooping, weakness, or involuntary movements.
Note Abnormal Facial Features/Movements (Tics): Uncontrolled, repetitive muscle movements. Also observe for signs of stroke (facial droop), Bell's Palsy (unilateral facial paralysis), or other neurological conditions.
Review Normal vs. Abnormal Variations: Craniosynostosis (premature fusion of skull bones), micro/macrocephaly, torticollis (wryneck), goiter.
Health Promotion: Safety measures (helmets, seatbelts), recognizing signs of stroke, self-examination for lymph node changes.
Chapter 15 – Eyes (Jarvis)
Assessment of Eyes Techniques:
How to Use Ophthalmoscope: Darken the room, turn on ophthalmoscope light, instruct patient to look straight ahead. Begin about 10-15 inches away, shining light on pupil to locate the red reflex. Steadily move closer to the eye, bringing the optic disc into focus. Use your right eye to examine the patient's right eye, and your left eye for their left eye.
Pupil Assessment: Review Normal/Abnormal: Normal pupils are 3-5{ mm}> in size, round, and react to light.
PERRLA: Pupils Equal, Round, and React to Light and Accommodation. This acronym describes normal pupillary findings.
Light Reflex: Pupils constrict directly and consensually when light is shined.
Accommodation: Pupils constrict and converge when focusing on a near object.
Abnormalities: Anisocoria (unequal pupils), fixed and dilated pupils (neurological emergency), sluggish or absent light reflex.
Review Developmental Competencies: Vision development in infants and children (strabismus, amblyopia); presbyopia (far-sightedness) in older adults; cataracts, glaucoma, macular degeneration.
Subjective Data: Vision difficulty, pain, strabismus/diplopia, redness/swelling, watering/discharge, history of eye problems, glaucoma, use of glasses/contacts, self-care behaviors, medications.
Objective Data: Inspection of external eye structures, visual acuity, visual fields, extraocular movements, and internal eye structures.
Normal Eyesight Assessment:
20/20 Eye Charts: (Snellen Chart).
Specialized Tests: Refraction assessment, color vision tests, and tonometry for intraocular pressure measurements.
Additional Considerations: Patient's age, history of systemic diseases, and environmental factors impacting vision. Factors that may influence test results include lighting conditions during assessment, previous corrective lens prescriptions, and patient's adherence to test protocols.