OSCE - Assessment Station

Summary

This transcript captures a detailed patient assessment process conducted by a nurse, Audrey, as she interacts with a patient, Mira, who is admitted due to abdominal pain. Audrey walks Mira through a series of health assessments, including confirming her personal details, allergies, and vital signs, while ensuring comfort and clarity. The nurse carefully explains each procedure, including airway checks, breathing and circulation assessments, and questions about pain and past medical history. The session culminates in a thorough chart review and patient education, ensuring Mira’s needs and preferences are well-documented and met, with regular monitoring and follow-ups.

Takeaways

• 😀 The nurse begins by following proper hand hygiene techniques, as recommended by the World Health Organization (WHO).
• 😀 The nurse introduces herself to the patient, Mira, and checks for basic patient details, including name, date of birth, and medical record number.
• 😀 The nurse confirms Mira’s known allergies to penicillin and roofing, ensuring safety by verifying against the patient chart.
• 😀 The nurse proceeds with a systematic A to E (Airway to Exposure) assessment of the patient, including questions about the reason for admission and medical history.
• 😀 Mira's abdominal pain is identified as the reason for her hospital admission, with pain starting approximately two days ago.
• 😀 The nurse conducts physical assessments, checking the patient's airway, breathing, circulation, and overall condition, including pulse, oxygen saturation, and blood pressure.
• 😀 The nurse observes that Mira is alert and oriented, indicating no signs of confusion or cognitive impairment.
• 😀 The nurse checks Mira's respiratory system for wheezing or distress, finding no abnormalities in breathing or air entry.
• 😀 Blood pressure, oxygen saturation, and pulse rate are monitored and recorded, with Mira’s vital signs falling within normal ranges.
• 😀 The nurse conducts a full exposure assessment, including checking for body temperature, signs of infection, and confirming no injuries or abnormalities.
• 😀 Mira's medical history includes asthma, eczema, and anemia, with the nurse confirming her use of a ferrous sulfate supplement for anemia management.
• 😀 The nurse ensures that Mira's spiritual, psychosocial, and emotional needs are also considered, confirming her social history and living arrangements.

Q & A

What steps did the nurse follow for hand hygiene before approaching the patient?

The nurse followed the seven steps outlined by the World Health Organization for hand hygiene, which included washing the back and front of the hands, interlacing the fingers, interlocking the thumb, and performing rotational motions with the wrists. Afterward, the hands were air-dried.

How did the nurse confirm the patient's identity?

The nurse confirmed the patient's identity by asking for the patient's name and date of birth, checking the patient's ID band, and verifying the Medical Record Number (MRN) in the patient's chart.

What allergies does the patient, Mira, have, and what happens when she is exposed to those allergens?

Mira has allergies to penicillin and roofing. If exposed to penicillin, she experiences anaphylaxis, and if exposed to roofing, she experiences bronchospasms.

What assessment did the nurse conduct for Mira's respiratory health?

The nurse assessed Mira's breathing by checking for any wheezing, stridor, coughing, or rattles. The nurse also looked for signs of respiratory distress, such as the use of accessory muscles, sweating, or cyanosis. After confirming the absence of these signs, the nurse assessed Mira's air entry and checked her breathing pattern by asking her to inhale deeply and exhale.

What were the findings during Mira's pulse and respiratory rate assessments?

Mira's pulse rate was 88 beats per minute, with a regular rhythm and good strength. Her respiratory rate was 18 breaths per minute, with normal depth and rhythm.

What is Mira's blood pressure, and how did the nurse assess it?

Mira's blood pressure was 119/57 mmHg. The nurse assessed this using a blood pressure cuff on Mira's right arm, ensuring no issues like bruising or infections were present.

What did the nurse find regarding Mira's capillary refill and temperature?

Mira's capillary refill time was less than 2 seconds, and her body temperature was measured at 36.3°C, which is within the normal range (36.5°C to 37.5°C).

What did the nurse ask about Mira's abdominal pain, and how did Mira rate her pain?

The nurse asked Mira if she was still experiencing abdominal pain. Mira rated her pain as 6 out of 10, indicating moderate pain.

What did the nurse do after completing the A to E assessment?

After completing the A to E assessment, the nurse documented Mira's findings, including her vital signs, and confirmed that Mira was alert and oriented. The nurse also provided Mira with a summary of the care plan, including the monitoring schedule.

What additional medical history and social details were shared about Mira?

Mira has a history of asthma, eczema, and anemia. She takes ferrous sulfate for anemia. Socially, she exercises 2-3 times a week and consumes no more than two alcoholic drinks per session. She is a non-smoker, lives in a two-story house with her daughter Sophia, and follows a vegan diet.