The initial recognition of the need for a genetics referral may arise when a nurse suspects a genetic contribution to disease because of personal or family medical history and/or findings from a physical assessment. Family history is a valuable and cost-effective tool that is often underutilized in clinical practice. Many common genetic conditions result from complex interactions between genetic and environmental factors. It is critical to collect information about potential environmental exposures to help inform a patient’s risk assessment. Health care professionals should become familiar about toxic environmental agents that are common in their specific geographic location. A growing number of Food and Drug Administration (FDA) approved drugs have labeling that includes pharmacogenomic information, which can be used to optimize drug dosage and prevent adverse and life-threatening drug reactions in a patient or family member.
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In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.
Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.
Electrodiagnostic medicine (EDX) should be considered an extension of a comprehensive patient history and physical examination. Combining data found on nerve conduction studies and needle electromyography, the pathophysiology of a peripheral nerve disease process can be further defined to illustrate location, duration, severity, and prognosis. It can function as a valuable aid in patient management, serving as an extension of the clinical exam, but not a substitute. This chapter focuses on board-related topics about EDX medicine as well as neuromuscular disorders and their associated electrophysiologic changes. It discusses basic peripheral nervous system anatomy followed by the pathophysiology, clinical instrumentation, nerve conduction studies and somatosensory evoked potentials. Then it describes basic needle EMG, radiculopathy, plexopathies, upper limb mononeuropathies, lower limb mononeuropathy, peripheral neuropathies, neuromuscular junction disorders, myopathies, motor neuron disease and differential diagnosis of weakness.
The physical assessment of the pediatric obese patient is similar, yet different, to that of an adult obese patient. It is important to include family in the interview and assessment, as the goal needs to be a collaborative effort for evaluation, assessment, and treatment. Similar to an adult assessment, key skills, including critical thinking, scientific knowledge bases, experience, clinical competencies, attitude, and standard of care, need to be utilized. The health history should be taken directly from the patient and a family member. It is important to use any previous medical records for a complete review. A physical examination should start with the head and progress downward to the toe. Variations in the obese pediatric patient’s physical examination can be seen in multiple areas. Pediatric variations also need to be considered in physical examination. Differential diagnoses should be considered with pediatric obesity. This includes hypothyroidism, Down syndrome, or Prader-Willi syndrome.
During the past several years, simulation pedagogy has taken off in leaps and bounds. The breadth of simulation design and implementation has become woven into the fabric of the majority of nursing education in the United States and beyond. As faculty members who teach in both graduate and undergraduate courses, the authors of this chapter find that simulation can be challenging to both the novice and seasoned educator. This chapter focuses on the use of simulation in the fundamental physical assessment course. The use of simulation technology is especially useful in creating the equivalent of “muscle memory” for the students because of the ability to do frequent and repetitive exercises using this technology. It is especially useful in assisting students to learn, develop, and mature their assessment skills. The chapter briefly describes specific objectives for simulation usage within a specific course and the overall program.
Critical thinking is required in performing an accurate physical assessment. Critical thinking encompasses analysis of data using the scientific knowledge base, experience, clinical competencies, attitude, and standard of care. These specific areas allow the advanced practice nurse (APN) to hone in on the health assessment and physical examination. Prior to the physical examination, a thorough health history needs to be taken. The health history or history of present illness (HPI) provides the patient’s reason for seeking out the APN and documents the chronological signs and symptoms of the problem from beginning to end. The APN should complete a head-to-toe physical assessment and review vitals and measurements. A complete physical examination for the obese patient should be similar to a normal physical examination with some slight variations. A head-to-toe physical examination includes four basic skills: inspection, palpation, percussion, and auscultation.
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Primary Care Patients With Gastrointestinal Problems: Graduate Program Advanced Physiology and Pathophysiology
This three-credit course is mandatory for all graduates of accredited master’s programs in nursing. It is commonly referred to as one of the “three Ps” (physical assessment, physiology and pathophysiology, and pharmacology). The course is a prerequisite for any of the specialty track courses for nurse practitioners (NPs), midwives, and nurse anesthetists. Analysis of physiologic responses and implications of the genome model to illness are included. Interpretation of laboratory data for patient management of acute and chronic disease is discussed. Students analyze case studies of hospitalized and primary care patient scenarios. This scenario is focused on gaining experience with analyzing patients’ differential diagnoses and explaining the etiology for each diagnosis. In identifying patient signs and symptoms to determine three differential diagnoses, the students gain much confidence in their reasoning skills. Also, the case provides some application of assessment skills for students to collect data regarding this patient’s Gastrointestinal (GI) complaints.
Simulation-based learning occurs in an innovative fashion for baccalaureate and nurse practitioner students. The objective of simulation- based pedagogy is to provide opportunities for baccalaureate and nurse practitioner students to acquire critical thinking skills before encounters in the clinical setting. In addition, the development of role acquisition in the context of interprofessional learning is a key feature unique to simulation. This chapter introduces the concepts and techniques of physical assessment in the context of the nursing process. High- fidelity simulation provides opportunity for these undergraduate nursing students to apply advanced health assessment skills and delivery of care in the context of an acute, high- risk trauma resuscitation. Simulation learning is intrinsically safe, adaptive, and fun. Student anxiety is lessened through repetitive practice of responsive actions and debriefing as a group process provides insight into the broad strokes of applied knowledge and team effort.
This chapter incorporates students’ knowledge of postsurgical patients, emphasizing operative assessment, problem recognition, interprofessional collaboration, and patient education for the prevention of postoperative complications. The authors of this chapter present a brief scenario about a patient who had an appendectomy and was in pain postoperatively. The primary objective of this scenario is to assess the prelicensure student’s ability to conduct a thorough postoperative assessment, recognize abnormal findings, and cluster cues to diagnose actual and potential problems. The authors incorporate elements of patient education, interprofessional collaboration and communication, infection control, and judgment in medication administration. To achieve the objectives of more complex scenarios, students need to have mastered the content on postoperative care, medication administration, and physical assessment, including identifying abnormal laboratory results. Use of simulation has grown as a learning tool and, in many programs, counts for a portion of clinical hours. Universities need to support this growth financially.