Clinical education: methods and practice

center23002311409410012100center818008227695Name Class 941009200 Name Class center700007040880 Abstract Physical Examinations are an integral part of preventative care, learning how to perform and evaluate during a physical examination is key to learning about the patient's current status and their overall health. 9410010000 Abstract Physical Examinations are an integral part of preventative care, learning how to perform and evaluate during a physical examination is key to learning about the patient's current status and their overall health. center300003017520 LESSON PLAN FOR PHYSICAL EXAMINATION With Literature Review 9410036300 LESSON PLAN FOR PHYSICAL EXAMINATION With Literature Review

Intended Audience This classroom lesson plan is intended for nursing students. It is meant to teach them how to properly conduct physical examinations. More often than not, nursing students have questions related to proper handling of patients. A lot of times nursing students forget the basics such as confirming a patient's identity by asking them for their full name and birthday, checking the patient's weight, blood pressure, height, body temperature, and asking for personal medical history. It takes patience and practice in order to develop a good rapport with patients while also making the physical examination quick and efficient. There are many steps involved in performing a standard physical examination with patients needing to learn everything from checking for abnormalities to assessing patient movement, vision, and so forth. Proposed Goals * The purpose of performing periodic physical/health examinations is to assess the health status of a patient, along with proper screening of possible risk factors and disease by providing preventive counseling intervention in age-appropriate method (McGonigle & Mastrian, 2012, p. 112). * The goal of evaluating and screening the patient is to prevent onset of illness or worsening of any existing illness. A good example is measuring patient's blood pressure in order to detect possible hypertension to begin treatment and prevent subsequent death through renal failure or stroke. * A further goal of physical examination is to enable patient education about unhealthy environmental exposures or behavioral patterns that can often pose risks for future illness. Examples include counseling on keeping a healthy BMI to offset any obesity related diseases such as type 2 diabetes, and counseling on preventing smoking habits to keep risk of developing lung cancer low and practicing safe sex through the use of condoms to keep patient from getting any sexually transmitted disease. Literature Review Patient history is often a hurried and overlooked aspect of physical examination, this literature review will look at generated and modified questionnaires as a means for gather succinct and detailed patient history, a vital part of a preventative strategy in physical examination. It will also look at the recent changes in medical practice and the use of technology to aid in providing simulated instruction ad practice to aid in fulfilling learning objectives. It is always important to keep up to date with the latest medical innovation and methods. Viewing how others alter their approaches to physical examination is a great way to learn and grow. In a study by Wendel-Vos, Schuit, Saris, & Kromhout (2003), they set out to determine reproducibility and relative validity of the Short Questionnaire to Assess Health-enhancing physical activity (SQUASH). A questionnaire such as SQUASH is an important an innovative way to approach patient medical history. It not only offers a new way to gather patient information, but it also uses current technologies, such as an activity monitor to view patient's behavior after the initial questionnaire. "Participants (36 men and 14 women, aged 27 - 58) were asked to complete the SQUASH twice with an inbetween period of approximately 5 weeks. In addition, participants wore the Computer Science and Applications (CSA) Activity Monitor for a 2-week period following the first questionnaire" (Wendel-Vos, Schuit, Saris, & Kromhout, 2003, p. 1163). Results proved the questionnaire to be useful and quick, especially for possible use in physical examinations. "Because the SQUASH is a short and simple questionnaire, it may proof to be a very useful tool for the evaluation of health enhancing physical activity in large populations" (Wendel-Vos, Schuit, Saris, & Kromhout, 2003, p. 1163). It is a reliable approach to patient history and a good addition to any lesson plan involving physical examinations. In another study by Idler & Benyamini (1997) they examine the ever-expanding "number of studies of survey respondents' global self-ratings of health as predictors of mortality in longitudinal studies of representative community samples" (Idler & Benyamini, 1997, p. 21). The results of their findings were consistent with their hypothesis that "Global self-rated health is an independent predictor of mortality in nearly all of the studies, despite the inclusion of numerous specific health status indicators and other relevant covariates known to predict mortality" (Idler & Benyamini, 1997, p. 21). Their analysis of the studies helps to find better methods of research for students to learn more from a desired topic. This study also highlighted need for improvement in research methodology to continue improved performance and health standard. Another questionnaire, assessing patient satisfaction in performance of daily activities through a modified Stanford Health Assessment Questionnaire (HAQ) demonstrated successful implementation of modifications to an existing standard questionnaire in order to get more accurate and detailed information from respondents. As Pincus, Summey, Soraci, Wallston, & Hummon (1983), "The HAQ includes questions to determine a patient's degree of difficulty and need for help and assistive devices in ADL. A modification of the HAQ (MHAQ) was developed to include questions concerning perceived patient satisfaction regarding the same ADL, along with perceived change in degree of difficulty" (Pincus, Summey, Soraci, Wallston, & Hummon, 1983, p. 1346). Their findings revealed: "A major determinant of expression of patient satisfaction was perceived change in difficulty: 81.4% of patients noting that their function was "less difficult now," in contrast to 16.9% of patients responding "more difficult now," expressed satisfaction" (Pincus, Summey, Soraci, Wallston, & Hummon, 1983, p. 1346). This study suggests that information in regards to perceived change in difficultly and patient satisfaction can be assessed to more completely characterize patients' functional health status. An article by Issenbeg (1999) discusses medical practice change and the need for continual adaptation. Issenberg states: "Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education" (Issenberg, 1999, p. 861). Many times classrooms are overcrowded or lacking the funds necessary to apply a hands on approach to medical practice, especially in a classroom setting. Utilizing simulated approaches, such watching videos on YouTube of medical procedures, helps students learn how to perform necessary tasks without having to buy the equipment. Furthermore, it can be done conveniently in their own homes in their own time. Issenberg states some benefits of using simulation technology: "Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures" (Issenberg, 1999, p. 861). Simulation technology may assist in addressing the dilemma of poor skills training and proficiency while also providing an approach for medical students to become self-directed lifelong learners.

Outline for Physical Examination (Face to Face Lesson) * Technology/instruments used: Stethoscope, flashlight, blood pressure cuff, thermometer, and Capnograph/Oximeter First steps of Physical Examination * Wash hands * Take vitals which includes monitoring blood pressure, heart rate, and respiration, * Assessment of BMI through height and weight, assessing emotional, behavioral, and cognitive wellbeing. Hands on Aspect of Physical Examination * When performing the hands on aspect of the physical examination, it is best to start from the head. Looking for any bumps, lesions, or abnormalities on the scalp and also check for any hair loss. * Then from there checking the posterior cervical, then mandibular mastoid area to see and check for muscle tone, rigidity. Checking the face for asymmetry and any other abnormal signs such as lesions, sore, or muscle weakness. Having the patient open the mouth, with one hand one side of the cheek, while the other at the bottom of the jaw, allows for assessment of jaw weakness. Then proceeding to ask the patient to puff out cheeks, smile, frown, having him/her push their tongue against their cheek while putting hand on the side of cheek will all help determine if there is any facial muscle weakness (cranial nerves # 5 & 7). * A sensory test afterwards is a great way to assess nerve function. To start with, touch the forehead, sides of face, bottom of face, and then ask when the patient feels the presence of the finger on the forehead. Be sure to observe the eyebrows, lashes, and eyes for additional lesions or abnormalities. * To check pupils, ask patient to look straight ahead. If the person has dark or light irises, use a flash light. Check for reactions to light from the pupils not just from the front view, but also from the side. Checking for sight may also include having patient hold one piece of paper of his/her eye and then reading a piece of paper with the other eye. He/she can read it normal the first time, switch sides, then read it backwards. * Assessing eye movement is also important, so with one finger move the finger from side to side while having the patient track it with their eyes. * To check cranial nerves # 3, 4, & 6, check the ears beginning with the lateral canvas of patient's eyelid to his/her ear. Then pull on the tip of the ear and ask if patient is feeling any pain or discomfort. Feel for any lumps, bruising, and lesions around the ear. * Then whisper into the patient's ear while the patient has one hand covering one ear. Have the patient relay back any words he/she hears from the whispering. Usually a nurse can whisper 3-4 words, and if the patient hears and relayed the 3-4 words it provides enough confirmation of the patient's hearing ability. When whispering the words, the nurse should be arm's length from patient. * Then proceed to begin palpating patient's nose to feel for any abnormalities. Placing pressure on one nostril with a finger, and asking the patient to blow from his/her nose helps in assessing any possible obstructions in the nose. * Moving from the nose to the mouth, assess the patient's lips and oral cavity. Detect for any possible sores, lesions, etc. Ask the patient to open his/her mouth and look at patient's dentation, check for any cavities and dental work. Check for redness, lesions, especially on the tongue. Ask the patient to stick out his/her tongue. * In checking cranial nerve #10 check the neck for any abnormal lymph nodes, starting with the sternal. Check trachea for intactness. Also check scapular area for any abnormalities. * Assess patient's thorax, view anterior posterior and the shoulders. * Assess lung sounds through asking patient to take a deep breath and exhale out of the mouth with a stethoscope on patient's back to hear breathing. Ask patient to take multiple breaths. Then feel the back after deep inhales and exhales to detect normal chest compression. Do the same but on the front of the chest for clear osculation. * Ask the patient to lie down to check alveolar shunting. Press the sides beneath the clavicle and, pulmonic, tricuspid, and mitral region, also check for PMI by asking patient while lying down to take a deep breath. * Hear diaphragm for any high pitched sounds when using stethoscope for assessment of shunting. Begin with the aortic region is near the right sternal base. Then move to pulmonic, left sternal base, tricuspid, then mitral. Be sure to listen for deeper tones and reverse the order after listening from mitral. Check for corroded, aorta, renal. * Afterwards, continue physical assessment by checking patient's abdomen for any abnormalities. * Listen to bowel sounds and start with lower quadrant, then up to right upper quadrant, left upper quadrant, left lower quadrant. * Perform palpation by pressing gently on patient's belly and ask patient to take deep breath in, press when patient exhales. * Start with right lower quadrant, checking each quadrant, this helps check pancreas, spleen, and so forth. * Also ask patient if it is okay to check femoral artery to assess for pulses. Proceed with muscular-skeletal examination * Start with lifting patient's leg up and asking patient to flex his/her foot. Bend patient's knee and ask him/her to push against the force of bringing the knee to his/her chest. Then ask patient to push knee towards him/her with nurse behind the knee. Check external hip rotation with knee still bent and moving knee to the side, followed by assessment of internal hip rotation with knee moved inward. Ask patient if he/she feels uncomfortable at any time during examination as this might present pain or discomfort in the patient. * Lengthen leg and abduct to the side, then go across the midline. Lift patient's leg up, straight leg, and then ask patient to push down. Do the opposite side, same thing. Check sensory by touching sides of the legs and ask patient if they feel each touch. * Check pedal pulses, check for any swelling, edema, and skin changes around the legs. Ask patient to slide down to check for reflexes. Start with tapping the back of the Achilles on each side. Check the patellar reflex by tapping the front of the knee. Check arch of foot as well. * Ask patient to stand, bend over, and check patient's spine for any deformities and abnormalities. Ask patient to move neck back and forth, side to side. * Check upper body thorax by asking patient to lean to the left, right and center, then behind forward and lean back, also rotate upper body clockwise and counter clockwise. * Ask patient to place arms to the side and front and then push against the nurse's applied force, do the same with wrists, and fingers. Also assess patient's nail beds and touch the arms asking if patient feels each touch. * Analyze gait by asking patient to walk back and forth. Then perform a heel, ball balance test by having patient walk in a close line with arms to the side, turning and putting arms by side and closing eyes. Ask patient to bring left thumb to the nose, then right index finger to the nose. This helps check for balance and coordination. Have patient lift one leg and hold the position, repeating on other side. * Lastly in a squatted position, ask patient to take a couple of steps, ending physical assessment. Summary A physical examination is a necessary process to learn for any nursing student. The best experience can often be learned from a hands on, face to face method, where the nursing student can see and practice what to say and do when performing the actions of a standard physical examination. It is important to not only assess a patient's health, but also educate patient when performing a physical examination. The main purpose of a physical examination is to prevent disease, or worsening of any present disease(s) through monitoring and correcting unhealthy behaviors. References Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: a review of twenty-seven community studies. Journal of Health and Social Behavior , 38(1), 21-37. Issenberg, S. B. (1999). Simulation Technology for Health Care Professional Skills Training and Assessment. Jama-journal of The American Medical Association, 282(9), 861-866. doi:10.1001/jama.282.9.861 Jarvis, C. (2008). PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE. Retrieved from e Kentucky Public Health Practice Reference website: http://nursing.wright.edu/sites/default/files/page/attachements/Physical%20Assessment%20Exam%20Study%20Guide.pdf McGonigle, D., & Mastrian, K. (2012). Nursing Informatics and the Foundation of Knowledge. Burlington, MA: Jones & Bartlett Learning. Pincus, T., Summey, J. A., Soraci, S. A., Wallston, K. A., & Hummon, N. P. (1983). Assessment of patient satisfaction in activities of daily living using a modified stanford health assessment questionnaire. Arthritis and Rheumatism, 26(11), 1346 - 1353. Wendel-Vos, G. C., Schuit, A. J., Saris, W. H., & Kromhout, D. (2003). Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity.Journal of Clinical Epidemiology, 56(12), 1163 - 1169. doi:10.1016/S0895-4356(03)00220-8