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1. List eight system elements included in a review of systems.
2. Identify three strategies to assess patients for low health literacy.
3. Revise documented entries applying the “FACT” rule.
4. Interpret arterial blood gases in a flash.
5. Name three signs and symptoms of inadequate oxygenation.
6. Identify the waveforms of a normal EKG pattern.
7. Discuss possible etiology and significance of common cardiovascular assessment abnormalities.
8. Identify structures in regions of the abdomen.
9. Discuss abdominal assessment findings that warrant emergent intervention intestinal obstructions.
10. Incorporate the cranial nerves assessment, Glasgow coma scale, and reflex grading scale to the neurologic exam.

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
  • Abdominal landmarks

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

Case Studies

Rachel Henderson, PhD, MS, RN, HCRM, is an expert speaker on topics focused on legal aspects of healthcare, nursing documentation, and regulatory compliance. Her 22 years as a legal nurse consultant, inpatient clinical nurse specialist and healthcare risk manager (HCRM) bring life to her presentations by sharing real case scenarios. She is a member of the National Speakers Association (NSA) and past president of the Florida Speakers Association (FSA). She is a published author in peer-reviewed journals and textbooks. In addition to owning a medical and legal consulting business, she has her PhD in Public Policy and Administration: Law and Policy. Rachel works with law firms and healthcare organizations, evaluating medical records for compliance with standards of care and applicable regulations. She has been an expert witness for medical negligence cases for both the plaintiff and the defense.
Speaker Disclosures:
Financial: Dr. Rachel Henderson has employment relationships with Medical Legal Concepts, Florida SouthWestern State College, and Palm Beach State College. She receives royalties as a published author. Dr. Henderson receives a speaking honorarium and recording royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Dr. Rachel Henderson is a member of the American Association of Critical Care Nurses, the American Society of Healthcare Risk Managers, and the American Society of Professionals in Patient Safety.

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CE Information Coming Soon
Continuing education credit information is coming soon for this non-interactive self-study package.

CEs may be available for select professions, as listed in the target audience. Hours will be dependent on the actual recording time. Please check with your state licensing board or organization for specific requirements.

There may be an additional fee for CE certificates. Please contact our Customer Service at 1-800-844-8260 for more details.

**Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards.

All members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners. For speaker disclosures, please see the faculty biography.

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Nurses/Nurse Practitioners/Clinical Nurse Specialists - Credit Expired: 2/13/2018
No CE available for this board.

California Nurses: PESI, Inc. is a provider approved by the California Board of Registered Nursing, Provider #:17118 for 6.0 self-study contact hours.

You will need to provide your license number to PESI. PESI must have this number on file in order for your hours to be valid.

Florida Nurses: PESI, Inc. is an approved provider by the Florida Board of Nursing. Provider #: FBN2858. These materials qualify for 6.0 self-study contact hours.

Iowa Nurses: PESI, Inc. is an approved provider by the Iowa Board of Nursing. Provider #: 346. Nurses successfully completing these self-study materials will earn 6.3 self-study contact hours.

Copies of the evaluation may be sent to the IBON. You will need to provide your license number to PESI. PESI must have this number on file in order for your hours to be valid.

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Other Professions
This self-study activity qualifies for 6.25 clock hours of instructional content as required by many national, state and local licensing boards and professional organizations. Retain your certificate of completion and contact your board or organization for specific filing requirements.

Disclaimer: **Information obtained in this course should be used within your scope of practice.
**It is your ethical responsibility to report accurate hours to your licensing board.
**All self-study participants must complete and pass (80% or better) a post-test and evaluation prior to receiving a certificate of completion. If you require a copy of the test/evaluation for CE purposes, please print at the time you take the test. Or you may call our customer service department and a copy of your test/evaluation will be emailed to you. Please allow 30-45 days.

Nurses, Physician Assistants, Respiratory Care Practitioners, and other Healthcare Professionals