1 reflection4reflection (thorax and l

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REFLECTION 4
Reflection (Thorax and Lungs and Cardiovascular and
Peripheral Vascular Systems)
Week # 8 Discussion 2: Reflection
One of the key challenges in completing this assignment is the
need to recognize many systems and organs at the same time.
The thorax, lungs, cardiovascular, and peripheral vascular
systems are closely related both in structure and functionality.
The comprehensive understanding of these systems and organs
without dissociating them from each other is significantly
complex especially for less experienced nurses like me. Thus, in
responding to the assignments as well as posts by classmates, I
may offer inaccurate information occasioned by my relative

inexperience in the assessment of the structures of one of the
most complex systems and regions of the human body.
Age differences tend to have a significant impact on the
interpretation of findings from the assessment of these organs
and systems. For instance, the normal respiratory rate (RR) and
pulse rate will differ across the lifespan (Jarvis, 2019). For the
less experienced nurses, there is the likelihood to use the
normal findings of a healthy adult to interpret the findings on
the pediatric case. Another challenge in pediatric populations is
that they may not offer supplemental information during the
inspection, palpation, percussion, and auscultation processes.
Communication with the patient can provide the nurse with
valuable hints. For instance, an adult will most likely report that
the chest pains elevate with a certain sitting position. In
pediatrics, the nurse will have to observe the facial expressions
with every change of posture or sitting position to identify
abnormalities (Lewis et al., 2016). The interpretation of sounds
is usually a subjective task for the nurse. The best strategy to
ensure accurate interpretation of sounds is via collaboration
with experienced nurses. However, aspects such as the capillary
refill patterns may not have significant variations in
interpretation because of standard values. However, patient-
specific factors such as skin texture may affect these findings.
Factors such as the patient’s occupation may come in handy in
the interpretation and description of variations (Ball et al.,
2015).

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015). Seidel's Guide to Physical Examination
(8th ed.). St. Louis, MO: Elsevier Mosby.
Jarvis, C. (2019). Physical Examination and Health Assessment
E-Book. Elsevier Health Sciences.
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M.,
Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-
Book: Assessment and Management of Clinical Problems,
Single Volume. Elsevier Health Sciences.
Simulation Design Template
(revised May 2019)
(name of patient) Simulation

Date:
Discipline: Nursing
Expected Simulation Run Time:
Location:
Today’s Date::
File Name:Student Level:
Guided Reflection Time: Twice the amount of time that the
simulation runs.
Location for Reflection:
Brief Description of Client
Name:
Date of Birth:
Gender: Age: Weight: Height:
Race: Religion:
Major Support:Support Phone:
Allergies: Immunizations:
Attending Provider/Team:
Past Medical History:
History of Present Illness:
Social History:
Primary Medical Diagnosis:

Surgeries/Procedures & Dates:
Psychomotor Skills Required of Participants Prior to Simulation
(list skills)
Cognitive Activities Required of Participants Prior to
Simulation
(textbooks, lecture notes, articles, websites, etc.)
Simulation Learning Objectives
General Objectives (Note: The objectives listed below are
general in nature and once learners have been exposed to the
content, they are expected to maintain competency in these
areas. Not every simulation will include all of the objectives
listed.)
1. Practice standard precautions.
1. Employ strategies to reduce risk of harm to the patient.
1. Conduct assessments appropriate for care of patient in an
organized and systematic manner.
1. Perform priority nursing actions based on assessment and
clinical data.
1. Reassess/monitor patient status following nursing
interventions.
1. Communicate with patient and family in a manner that
illustrates caring, reflects cultural awareness, and addresses
psychosocial needs.

1. Communicate appropriately with other health care team
members in a timely, organized, patient-specific manner.
1. Make clinical judgments and decisions that are evidence-
based.
1. Practice within nursing scope of practice.
1. Demonstrate knowledge of legal and ethical obligations.
Simulation Scenario Objectives (limit to 3 or 4)
For Faculty: References, Evidence-Based Practice Guidelines,
Protocols, or Algorithms Used for This Scenario:
Setting/Environment
|_| Emergency Room
|_| Medical-Surgical Unit
|_| Pediatric Unit
|_| Maternity Unit

|_| Behavioral Health Unit
|_| ICU
|_| OR / PACU
|_| Rehabilitation Unit
|_| Home
|_| Outpatient Clinic
|_| Other:
Equipment/Supplies (choose all that apply to this simulation)
Simulated Patient/Manikin/s Needed:
Recommended Mode for Simulator:
(i.e. manual, programmed, etc.)
Other Props & Moulage:
Equipment Attached to Manikin/Simulated Patient:
|_| ID band
|_| IV tubing with primary line fluids running at __mL/hr
|_| Secondary IV line running at ___mL/hr
|_| IVPB with _______ running at mL/hr
|_| IV pump
|_| PCA pump
|_| Foley catheter with ___mL output
|_| 02
|_| Monitor attached
|_| Other:
Other Essential Equipment:
Medications and Fluids:
|_| Oral Meds:
|_| IV Fluids:

|_| IVPB:
|_| IV Push:
|_| IM or SC:
Equipment Available in Room:
|_| Bedpan/urinal
|_| 02 delivery device (type)
|_| Foley kit
|_| Straight catheter kit
|_| Incentive spirometer
|_| Fluids
|_| IV start kit
|_| IV tubing
|_| IVPB tubing
|_| IV pump
|_| Feeding pump
|_| Crash cart with airway devices and
emergency medications
|_| Defibrillator/pacer
|_| Suction
|_| Other:
Roles
|_| Nurse 1
|_| Nurse 2
|_| Nurse 3
|_| Provider (physician/advanced practice nurse)
|_| Other healthcare professionals:
(pharmacist, respiratory therapist, etc,)
|_| Observer(s)
|_| Recorder(s)

|_| Family member #1
|_| Family member #2
|_| Clergy
|_| Unlicensed assistive personnel
|_| Other:
Guidelines/Information Related to Roles
Learners in role of nurse should determine which assessments
and interventions each will be responsible for, or facilitator can
assign nurse 1 and nurse 2 roles with related responsibilities.
Information on behaviors, emotional tone, and what cues are
permitted should be clearly communicated for each role. A
script may be created from Scenario Progression Outline.
Pre-briefing/Briefing
Prior to report, participants will need pre-briefing/briefing.
During this time, faculty/facilitators should establish a safe
container for learning, discuss the fiction contract and
confidentiality, and orient participants to the environment,
roles, time allotment, and objectives.
For a comprehensive checklist and information on its
development, go to http://www.nln.org/sirc/sirc-resources/sirc-
tools-and-tips#simtemplate.

Report Students Will Receive Before Simulation
(Use SBAR format.)
Time:
Person providing report:
Situation:
Background:
Assessment:
Recommendation:
Scenario Progression Outline
Patient Name:Date of Birth:
Timing (approx.)
Manikin/SP Actions
Expected Interventions
May Use the Following Cues
0-5 min
(Verbal information provided by manikin or SP should be in
quotes so a script can be created for individuals in those roles.)
Learners should begin by:

· Performing hand hygiene
· Introducing selves
· Confirming patient ID
Role member providing cue:
Cue:
5-10 min
Learners are expected to:
Cue:
10-15 min
Cue:
15-20 min
Cue:
Debriefing/Guided Reflection
Note to Faculty

We recognize that faculty will implement the materials we have
provided in many different ways and venues. Some may use
them exactly as written and others will adapt and modify
extensively. Some may choose to implement materials and
initiate relevant discussions around this content in the
classroom or clinical setting in addition to providing a
simulation experience. We have designed this scenario to
provide an enriching experiential learning encounter that will
allow learners to accomplish the listed objectives and spark rich
discussion during debriefing. There are a few main themes that
we hope learners will bring up during debriefing, but if they do
not, we encourage you to introduce them.
Themes for this scenario:
·
·
·
We do not expect you to introduce all of the questions listed
below. The questions are presented only to suggest topics that
may inspire the learning conversation. Learner actions and
responses observed by the debriefer should be specifically
addressed using a theory-based debriefing methodology (e.g.,
Debriefing with Good Judgment, Debriefing for Meaningful
Learning, PEARLS). Remember to also identify important
concepts or curricular threads that are specific to your program.
1. How did you feel throughout the simulation experience?
2. Give a brief summary of this patient and what happened in
the simulation.
3. What were the main problems that you identified?
4. Discuss the knowledge guiding your thinking surrounding
these main problems.
5. What were the key assessment and interventions for this
patient?
6. Discuss how you identified these key assessments and

interventions.
7. Discuss the information resources you used to assess this
patient. How did this guide your care planning?
8. Discuss the clinical manifestations evidenced during your
assessment. How would you explain these manifestations?
9. Explain the nursing management considerations for this
patient. Discuss the knowledge guiding your thinking.
10. What information and information management tools did
you use to monitor this patient’s outcomes? Explain your
thinking.
11. How did you communicate with the patient?
12. What specific issues would you want to take into
consideration to provide for this patient’s unique care needs?
13. Discuss the safety issues you considered when implementing
care for this patient.
14. What measures did you implement to ensure safe patient
care?
15. What other members of the care team should you consider
important to achieving good care outcomes?
16. How would you assess the quality of care provided?
17. What could you do improve the quality of care for this
patient?
18. If you were able to do this again, how would you handle the
situation differently?
19. What did you learn from this experience?
20. How will you apply what you learned today to your clinical
practice?
21. Is there anything else you would like to discuss?
Simulation Design Template (revised May 2019)
© 2019, National League for Nursing Originally adapted from
Childs, Sepples, Chambers (2007). Designing simulations for
nursing education. In P.R. Jeffries (Ed.) Simulation in nursing
education: From conceptualization to evaluation (p 42-
58).Washington, DC: National League for Nursing.

This Simulation Design Template may be reproduced and used
as a template for the purpose of adding content for specific
simulations for non-commercial use as long as the NLN
copyright statement is retained on the Template. When used for
this purpose, no specific permission is required from the NLN.
Simulation Design Template (revised May 2019)
© 2019, National League for Nursing
8
Date:
Discipline:
Expected Simulation Run Time:
Location:
Sim Name:
Your Name:Target Learning Group:
Estimated Debriefing Time:
Guided Reflection Time:
Brief Description of Patient
Admission Date: Today’s Date:
Name:
Gender: Age: Race: Weight:

Height:
Religion:
Major Support: Support
Phone:
Allergies:
Immunizations:
Primary Care Provider/Team:
Past Medical History:
Social History:
Surgeries/Procedures & Dates:
Nursing Diagnoses:
Simulation Summary
Educational Rationale

Learning Objectives
· General Objectives:
· Simulation Scenario Objectives:
Standards aligned
Supplies and Equipment Needed
2
© 2015, National League for Nursing. Adapted from Child,
Sepples, Chambers (2007). Designing simulations for nursing
education. In P.R. Jeffries (Ed.) Simulation in nursing
education: From conceptualization to evaluation (p 42-
this purpose, no specific permission is required from the NLN.
Adapted from : © 2015, National League for Nursing. Adapted
from Child, Sepples, Chambers (2007). Designing simulations
for nursing education. In P.R. Jeffries (Ed.) Simulation in
nursing education: From conceptualiza tion to evaluation (p 42-

Psychomotor Skills Required Prior to Simulation:
Cognitive Activities Required Prior to Simulation:
[i.e. independent reading (R), video review (V), computer
simulations (CS), lecture (L)]
References, Evidence-Based Practice Guidelines, Protocols, or
Algorithms Used for This Scenario:

Fidelity (choose all that apply to this simulation)
Setting/Environment:
|_| ER
|_| Med-Surg
|_| Peds
|_| ICU
|_| OR / PACU
|_| Women’s Center
|_| Behavioral Health
|_| Home Health
|_| Pre-Hospital
|_| Other:
Simulator Manikin/s Needed:
Props:
Equipment Attached to Manikin:
|_| IV tubing with primary line
fluids running at |_| mL/hr
|_| Secondary IV line running at mL/hr
|_| IV pump
|_| Foley catheter |_|mL output
|_| PCA pump running
|_| IVPB with running at |_| mL/hr
|_| 02 |_|

|_| ID band
|_| Other:
|_| Bedpan/Urinal
|_| Foley kit
|_| Straight Catheter Kit
|_| Incentive Spirometer
|_| Fluids
|_| IV start kit
|_| IV tubing
|_| IVPB Tubing
|_| IV Pump
|_| Feeding Pump
|_| Pressure Bag
|_| Defibrillator/Pacer
|_| Suction
|_| Other:
Medications and Fluids: (see chart)
|_| IV Fluids
|_| Oral Meds
|_| IVPB
|_| IV Push
|_| IM or SC
Diagnostics Available: (see chart)
|_| Labs
|_| X-rays (Images)
|_| 12-Lead EKG
|_| Other:

Documentation Forms:
|_| Provider Orders
|_| Admit Orders
|_| Flow sheet
|_| Medication Administration Record
|_| Graphic Record
|_| Shift Assessment
|_| Triage Forms
|_| Code Record
|_| Anesthesia / PACU Record
|_| Standing (Protocol) Orders
|_| Transfer Orders
|_| Other:
Recommended Mode for Simulation:
Student Information Needed Prior to Scenario:
|_| Has been oriented to simulator
|_| Understands guidelines /expectations for
scenario
|_| Has accomplished all pre-simulation
requirements
|_| All participants understand their assigned
roles
|_| Has been given time frame expectations
|_| Other:
Roles/Guidelines for Roles:
|_| Primary Nurse
|_| Secondary Nurse
|_| Clinical Instructor
|_| Family Member #1
|_| Observer/s
|_| Recorder

|_| Physician/Advanced Practice Nurse
|_| Respiratory Therapy
|_| Anesthesia
|_| Pharmacy
|_| Lab
|_| Imaging
|_| Social Services
|_| Clergy
|_| Unlicensed Assistive Personnel
|_| Code Team
|_| Other:
Important Information Related to Roles:
Student Roles
Instructor Role
Environment

Overview of Expected Student Interventions
Correct Treatment
Timing (approx.)
Manikin/SP Actions
0-5 min
Cue:
5-10 min
Cue:
10-15 min
Cue:

15-20 min
Cue:
Debriefing/Guided Reflection Questions for This Simulation
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to
Adapt to Different Levels of Learners
9
1
© 2015, National League for Nursing. Adapted from Child,
Sepples, Chambers (2007). Designing simulations for nursing
education.
In P.R. Jeffries (Ed.) Simulation in nursing education: From
conceptualization to evaluation (p 42-58). Washington, DC:
National

League for Nursing.
this
purpose, no specific permission is required from the NLN.
Date:
Discipline: Nursing
Expected Simulation Run Time: Approx. 15
mins.
Location: Community Clinic or
Primary Healthcare Provider Office
File Name: Care to the Trans* and Gender Non-
Conforming Identified Patient
Student Level: Adapted to Cover All Levels
Guided Reflection Time: Approx. 45 mins.

Location for Reflection:
Admission Date: | Today’s Date: XX/XX/XX
Name: Joe Ramirez
Gender: MtFTG Age: 25 Race: n/a Weight: n/a
Height: n/a
Religion: n/a
Major Support: Parents & Girlfriend Support Phone: 301-XXX-
XXXX
Allergies: NKDA Immunizations:
Primary Care Provider/Team: No current primary provider. Has
been under the care of an endocrinologist, Samuel
Gordon, MD, for masculinizing hormone therapy treatments.
Past Medical History: Relatively healthy. Taking testosterone
therapy for over 1-year.

History of Present Illness: Presents today to obtain a flu-shot
and annual physical
Social History: In a committed heterosexual relationship for
approximately two years. Feels supported in relationship
with his girlfriend. Otherwise history unremarkable.
Surgeries/Procedures & Dates: Mastectomy and Chest
Reconstruction
Nursing Diagnoses: discuss with participants in debriefing
2
© 2015, National League for Nursing.

Psychomotor Skills Required Prior to Simulation:
Review and practice effective inter-professional communication
tools and strategies; namely, ISBARR
Review strategies for therapeutic communication in the patient
care setting, and practice those strategies;
Review and practice patient assessment skills.
Cognitive Activities Required Prior to Simulation:
I. Pick at least one (1) of the following nursing articles to read
prior to the simulation.
Caring for....Transgender Patients:
http://www.nursingcenter.com/cearticle?an=00152258-
201411000-00006
Addressing Health Care Disparities in the Lesbian, Gay,
Bisexual, and Transgender Populations: A Review of

Best Practices
http://journals.lww.com/ajnonline/Fulltext/2014/06000/CE___A
ddressing_Health_Care_Disparities_in_the.21.a
spx
Culturally Sensitive Care for the Transgender Patient:
201505000-
00005&Journal_ID=682710&Issue_ID=3106455
Open the Doors for LGBTQ Patients:
201308000-
Providing Care to GLBTQ Patients:
201212000-
Treating Transgender Patients With Respect:
http://www.americannursetoday.com/viewpoint-treating-
transgender-patients-respect/

Nursing Care of Transgender Patients:
http://nursing.advanceweb.com/Features/Articles/Nursing-Care-
of-the-Transgender-Patient.aspx
201411000-00006
ddressing_Health_Care_Disparities_in_the.21.aspx
ddressing_Health_Care_Disparities_in_the.21.aspx
201505000-00005&Journal_ID=682710&Issue_ID=3106455

3
II. Review the information contained in Injustice at Every Tur n:
A Report
of the National Transgender Discrimination Survey (2011).
This is a most comprehensive
investigation and published report on transgender and gender
non-conforming matters related to
health and the social determinants of health; namely, education,
employment, family life, housing,
public accommodation, identification and documentation,
policing and incarceration. Please pay
particular attention to the identified health section, although all
factors addressed in this report have
health implications:
Injustice at Every Turn: A Report of the national Transgender
Discrimination Survey:
http://www.thetaskforce.org/static_html/downloads/reports/repo
rts/ntds_full.pdf

General Objectives:
1. Describe barriers faced by transgender and gender non-
conforming patients in the context of receiving
care in a community health clinic;
2. Identify the various roles of a nurse in the context of
providing care to a transgender patient in the
context of a community health clinic;
3. Evaluate the effectiveness of the nurse in carrying out those
roles in the context of patient care in this
interaction;
4. Identify tools to incorporate into nursing care to develop a
practice that is sensitive, informed, affirming
and empowering to the transgender and gender non-conforming
patient.
Simulation Scenario Objectives:
1. Demonstrate therapeutic communication skills with the
patient;
2. Recognize and demonstrate behaviors that create a safe,

welcoming and professional working
environment;
3. Demonstrate effective communication within the context of
interprofessional collaboration (Identify,
Situation, Background, Assessment, Recommendation, Read
back);
4. Demonstrate proper assessment techniques in carrying out the
tasks of providing care to the trans*
identified and gender nonconforming patient;
5. Identify primary nursing diagnoses and/or collaborative
issues in the context of the scenario.
http://www.thetaskforce.org/static_html/downloads/reports/repo
rts/ntds_full.pdf
4

Coleman, E., Botking, W., Botzer, M., Cohen-Ketteris, P.,
DeGuypere, G., & Feldman..., J. (2012).
Standards of Care for the Health of Transsexual. Transgender
and Gender Non- Conforming People,
7th version. Retrieved 2015, from
http://www.wpath.org/site_page.cfm?pk_association_webpage_
menu=1351&pk_association_webpag
e=3926
Hein, L., & Levitt, N. (2014). Caring for... Transgender
patients. Nursing Made Incredibly Easy!,
(12)6, 29-36. doi:10.1097/01.NME.0000454745.49841.76
Hill, M., & Mays, J. (2013). The gender book (1st ed.).
Houston, Texas: Marshall House Press.
Makadon, H., Mayer, K., Potter, J., & Goldhammer, H. (2015).
The Fenway guide to lesbian, gay,
bisexual, and transgender health (2nd ed.). Philadelphia,
Pennsylvania: American College of
Physicians.
Teich, N. (2012). Transgender 101: A Simple Guide To A
Complex Issue. New York: Columbia
University Press.
Resiner, S., Bradford, J., Hopwood, R., Gonzalez, T., Makadon,
H., Todisco, D., Cavanaugh, T.,
VanDerwarker, R., Grasso, C., Zaslow, S., Boswell, S., and K.
Mayer (2015). Comprehensive
Transgender Healthcare: The Gender Affirming Clinical and
Public Health Model of Fenway Health,
Journal of Urban Health (92) 3. doi:10.1007/s11524-015-9947-2
Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource
for the transgender community (1st

ed.). New York, New York: Oxford University Press.
The Agency for Healthcare Research and Quality: Improving
Cultural Competence to Reduce Health
Disparities for Target Populations (2016) Retrieved 2016
http://www.ncbi.nlm.nih.gov/books/NBK361126/
The health of lesbian, gay, bisexual, and transgender people
building a foundation for better
understanding. (2011). Washington, DC: National Academies
Press. Retrieved 2015, from
http://www.nationalacademies.org/hmd/Reports/2011/The-
Health-of-Lesbian-Gay-Bisexual-and-
Transgender-People.aspx
The Joint Commission: Advancing Effective Communication,
Cultural Competence, Patient- and
Family- Centered Care: A Field Guide. (2014). Oak Brook, IL:
The Joint Commission. Retrieved 2016
from https://www.jointcommission.org/lgbt/
menu=1351&pk_association_webpage=3926
menu=1351&pk_association_webpage=3926
http://www.ncbi.nlm.nih.gov/books/NBK361126/
Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx
Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx
https://www.jointcommission.org/lgbt/
5

6
ER
Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Behavioral Health
Home Health

Pre-Hospital
Other: Primary Care Setting—Health Clinic or
Physician’s Office
Props:
Signage to create an environment that looks like a
clinic setting;
Legal Identification Cards: Driver’s License for a
gender other than the person playing the role of the
patient.
IV tubing with primary line
fluids running at mL/hr
Secondary IV line running at mL/hr
IV pump
Foley catheter mL output

PCA pump running
IVPB with running at mL/hr
02
Monitor attached
ID band
Other:
Bedpan/Urinal
Foley kit
Straight Catheter Kit
Incentive Spirometer
Medications and Fluids: (see chart)
IV Fluids
Oral Meds
IVPB
IV Push
IM or SC

Diagnostics Available: (see chart)
Labs
X-rays (Images)
12-Lead EKG
Other:
Provider Orders
Admit Orders
Flow sheet
Medication Administration Record
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other: New Patient Intake Forms

Has been oriented to simulator
Understands guidelines /expectations for
scenario
Has accomplished all pre-simulation
requirements
All participants understand their assigned
roles
Has been given time frame expectations
Other:
7

Fluids
IV start kit
IV tubing
IVPB Tubing
IV Pump
Feeding Pump
Pressure Bag
02 delivery device (type)
Crash cart with airway devices and
Defibrillator/Pacer
Suction
Other:
Primary Nurse
Secondary Nurse
Clinical Instructor
Family Member #1

Administrative Clerk/Secretary- this role is
played by a standardized patient
Observer/s: Patient’s in the waiting room
(Student roles)
Recorder
Physician/Advanced Practice Nurse – played by
faculty running sim
Respiratory Therapy
Anesthesia
Pharmacy
Lab
Imaging
Social Services
Clergy
Nursing student assistant
Code Team

8
Time:
Joe Ramirez is a 25 year old Latino who identifies as a
transgender female to male person (TGFtM). His name
and gender at birth, and as identified on legal documents , is
Josephine Ramirez and female. Joe presents at the
clinic for a flu shot and a physical. His last visit with a primary
care physician had been several years ago, and
the only other healthcare professional he has seen lately and

regularly is his endocrinologist.
Joe has been taking testosterone prescribed by the
endocrinologist for well over a year now. Except for a
surgical procedure at 22 (a mastectomy and chest
reconstruction), he has avoided most doctors. No other
masculinizing interventions have taken place or are planned at
this time. Joe is in a committed relationship with
his cisgender female partner.
The community clinic practice is relatively new--full of young,
hardworking nurses and doctors, and unlicensed
assistive personnel. The practice prides itself on a team-based
approach to healthcare and is committed to
addressing the needs of ALL patients in the community.
Significant Lab Values: none
Provider Orders: refer to chart
Home Medications: refer to chart

9
Timing
(approx.)
Manikin/SP Actions
Expected
Interventions
May Use the
Following Cues

0-5 min
Waiting for name to be called for
basic check-in at front desk.
Responds to call.
Waiting for name to be called by
tech for set up for vital signs.
Responds to the call.
Primary RN is
observing the
interaction
between the patient
and staff while
completing other
assignments.
Role member
providing cue:
From clerk: Josephine

Ramirez. Repeat the
calling of the name
until there is a
response by the
patient. *
From nursing student
assistant: Josephine
Ramirez. Repeat the
calling of the name
until there is a
response by the
patient. *

5-10 min Patient is appropriate but initially
reluctant to participate in care with
nurse.
Primary RN
introductions; hand
hygiene, therapeutic
communication, as
appropriate for
observable actions of
colleagues, and
proceeds in
ascertaining the
patient’s purpose for
visit, and with
assessment, as
10

appropriate.
10-15 min
Primary RN addresses
concerns in ISBARR
format with Doctor/NP
.
Role member
providing cue:
Cue: If RN omits

sections of the
ISBARR, then the
Doctor/NP will ask:
What is the situation?
What is the
background?
What is your
assessment?
What do you
recommend, etc., as
appropriate.
.
11

Debriefing/Guided Reflection Questions for This Simulation
(Remember to identify important concepts or curricular threads
that are specific to your program)
2. Describe the objectives you were able to achieve.
3. Which ones were you unable to achieve (if any)?
4. Did you have the knowledge and skills to meet objectives?
5. Were you satisfied with your ability to work through the
simulation?
6. To Observer: Could the nurse have handled any aspects of the
simulation differently?
7. If you were able to do this again, how could you have
handled the situation differently?
8. What did the group do well?

9. What did the team feel was the primary nursing diagnosis?
10. How were physical and mental health aspects interrelated in
this case?
11. What were the key assessments and interventions?
12. What knowledge have you gained as a result of preparing
for and engaging in this simulation that has helped you
to understand the trans* and gender nonconforming community?
13. What are the skills, strategies, or interventions a nurse
could use to address the barriers and inequities that affect
trans* identified and gender non-conforming patients? In what
ways did you see those skills utilized in this
simulation?
14. What professional nursing values would apply to the
situation identified in this scenario (altruism, autonomy,
human dignity, integrity, honesty, social justice)? How were
those values displayed in the context of this simulation?
15. How has this simulation helped to further develop your
understanding of the meaning of nursing and the
therapeutic use of self in assisting others—most particularly,
the transgender and gender non-conforming population?

16. Is there anything else you would like to discuss?
12
Complexity – Simple to Complex
Adapt to Different
Levels of Learners
With application of the NCLEX test plan to this simulation,
student discussions can be further exploited as a
way of expanding on the complexity of the current simulation as
designed:

Safe and Effective Care and Environment: advocacy, case
management, client rights, collaboration with
interdisciplinary team members, confidentiality, ethical
practice, performance improvement, to name a few.
Health Promotion and Maintenance: developmental stages and
transitions, health promotion and screening,
lifestyle choices, self-care, techniques of physical assessment,
to name a few
Psychosocial Integrity: coping mechanisms, cultural awareness
and influences on health, family dynamics,
support systems, therapeutic communication and therapeutic
environment, to name a few
Physiologic Integrity: non-pharmacologic comfort interventions,
therapeutic procedures, to name a few.
The administration of an IM injection is one of the skills
addressed in this simulation. This could be modified
to address the IM injection of testosterone to this patient.
Discussion of the intersectionality issues that present in this
simulation (Latino, African-American, Catholicism,

Living with disabilities). For example, while there are
particular health implications and social determinants
that impact health affecting the transgender and gender
nonconforming population, the goal of achieving
optimal health may be further affected by ethnicities, faith,
disabilities, etc. Thus, the fact that the patient
identifies as transgender is simply one way to describe him/her.
Engaging in a discussion about other factors
impacting health outcomes can enhance the complexity of the
simulation.
This simulation, while taking place in the community setting, is
adaptable to the inpatient setting with some
modifications.
Supplementing the discussion with additional required resources
either before or after the simulation may also
impact its complexity. Some of those resources are noted below:

13
Online video Resources to Access:
Re-Teaching About Gender & Sexuality from the Youth
Perspective:
https://youtu.be/51kQQuVpKxQ
Buck Angel's PSA for Cervical Exams:
https://youtu.be/X_uNFmZHvO0
Buck Angel's PSA for Prostate Exam:
https://youtu.be/YK2fFjDlDE4
Southern Comfort Movie Trailer:
https://youtu.be/R6JIWD2DNyY

Southern Comfort: The Documentary:
https://youtu.be/IH0L3wlV0hg
Australian Rugby Team demonstrating testicular exams:
https://vimeo.com/74742259
The Trans* experiment at Montgomery College:
https://www.youtube.com/watch?v=JO3cIuBHf-U
Online nursing articles to access:
Caring for....Transgender Patients:
201411000-00006
Culturally Sensitive Care for the Transgender Patient:
https://www.nursingcenter.com/CEArticle?an=01271211-
201505000-
Treating Transgender Patients With Respect:

Nursing Care of Transgender Patients:
https://youtu.be/51kQQuVpKxQ
https://youtu.be/X_uNFmZHvO0
https://youtu.be/YK2fFjDlDE4
https://youtu.be/R6JIWD2DNyY
https://youtu.be/IH0L3wlV0hg
https://vimeo.com/74742259
https://www.youtube.com/watch?v=JO3cIuBHf-U
201411000-00006
14

12 Tips for Nurses and Doctors in Treating Transgender
Patients:
http://commonhealth.wbur.org/2014/11/treating-transgender-
patients-tips
Caring for Transgender Patients at the Johns Hopkins ED:
http://www.hopkinsmedicine.org/news/articles/caring-for-
transgender-patients
Movies in Popular Culture that Address the Topic of
Transgender Issues:
The Danish Girl
The Dallas Buyers Club
Transamerica
Boys Don't Cry
Paris Is Burning

The Crying Game
The Adventures of Priscilla Queen of the Desert
All About My Mother
Television Programs in Popular Culture that Address
Transgender Issues:
Orange Is the New Black
Transparent
Trade Books on the Topic of Being Trans* or Transgender
Health:
Mock, J. (2014). Redefining realness: My path to womanhood,
identity, love & so much more. New York, New
York: Atria Paperback.
McKenzie, M. (2014). Black Girl Dangerous: On Race,
Queerness, Class and Gender. Oakland, CA: BGD
Press, Inc.
Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource
for the transgender community (1st ed.). New
York, New York: Oxford University Press.

Teich, N. (2012). Transgender 101: A Simple Guide To A
Complex Issue. New York: Columbia University
Press.
http://commonhealth.wbur.org/2014/11/treating-transgender-
patients-tips
http://www.hopkinsmedicine.org/news/articles/caring-for-
transgender-patients
15
Selected Resources on Transgender Health:
National LGBT Health Education Center:
www.lgbthealtheducation.org
The Fenway Institute: www.thefenwayinstitute.org

GLMA: Health Professionals Advancing LGBT Equality:
www.glma.org
CDC: Lesbian, Gay, Bisexual, and Transgender Health:
www.cdc.gov/lgbthealth
Center of Excellence for Transgender Health:
www.transhealth.ucsf.edu
National Center for Transgender Equality:
www.transequality.org
World Professional Association for Transgender Health:
www.wpath.org
DC Trans Coalition:
https://dctranscoalition.wordpress.com/about-dctc/
I AM Transpeople Speak: http://www.transpeoplespeak.org
Healthy People 2020:
http://www.healthypeople.gov/2020/topics-
objectives/topic/lesbian-gay-bisexual-and-
transgender-health
http://www.lgbthealtheducation.org/
http://www.thefenwayinstitute.org/
http://www.glma.org/

http://www.cdc.gov/lgbthealth
http://www.transhealth.ucsf.edu/
http://www.transequality.org/
http://www.wpath.org/
https://dctranscoalition.wordpress.com/about-dctc/
http://www.transpeoplespeak.org/
objectives/topic/lesbian-gay-bisexual-and-transgender-health
objectives/topic/lesbian-gay-bisexual-and-transgender-health
16
17
Simulation Design Template:
Millie Larsen-Simulation #1
Date: 07/01/2013
Discipline: Nursing
Expected Simulation Run Time: 20 minutes
Location: Simulation lab

File Name: Millie Larsen
Student Level: Varied
Guided Reflection Time: 20 minutes
Location for Reflection: Classroom/debriefing area
Admission Date: 07/01/2013 | Today’s Date: 07/01/2013
Name: Millie Larsen
Gender: F Age: 84 Race: Caucasian Weight: 48 kg
Height: 61 in
Religion: Lutheran
Major Support: Dina (daughter) Support Phone: 555-1210
Allergies: no known allergies Immunizations: Influenza &
pneumonia (2 years ago)
Attending Physician/Team: Dr. Eric Lund
Past Medical History: Glaucoma, hypertension, osteoarthritis,
stress incontinence, hypercholesterolemia
Millie’s daughter became concerned yesterday when she stopped
over to check on her and found her still in her bathrobe at 5:00
PM. The house was very unkempt, and Millie couldn’t
remember her daughter’s name. Millie was brought to the
emergency department by her daughter and she was finally
admitted to the general medical-surgical unit around 9:30 AM.
U/A, CBC, and basic metabolic panel labs have been completed
and sent to the lab. Results are available.
Social History: Widow for one year; involved in church

activities and gardening. Daughter and grandchildren live
nearby.
Primary Medical Diagnosis: Dehydration; UTI
Surgeries/Procedures & Dates: Cholecystectomy at age 30
Nursing Diagnoses: Urinary incontinence; acute confusion; fluid
volume deficitPsychomotor Skills Required Prior to Simulation
· General head-to-toe assessment
· SPICES and Confusion Assessment Method (CAM) assessment
tools
Cognitive Activities Required Prior to Simulation
· Basic knowledge of geriatric syndromes and the atypical
presentation of older adults. (L, R)
· Tools in the Try This: ® and How to Try This Series,
available at http://consultgerirn.org/resources. Specific tools
recommended for this scenario are the SPICES and CAM
assessment tools, (R)
· Read chapter in fundamentals text related to care of the older
adult; stress incontinence and confusion.(R)
General Objectives
1. Practice standard precautions throughout the exam.
1. Employ effective strategies to reduce risk of harm to the
client.
1. Assume the role of team leader or member.

1. Perform a focused physical assessment noting abnormal
findings.
1. Recognize changes in patient symptoms and/or signs of
patient compromise.
1. Perform priority nursing actions based on clinical data.
1. Reassess/monitor patient status following nursing
interventions.
1. Perform within scope of practice.
1. Demonstrate knowledge of legal and ethical obligations.
1. Communicate with client in a manner that illustrates caring
for his/her overall well-being.
1. Communicate appropriately with physician and/or other
healthcare team members in a timely, organized, patient-
specific manner.
Simulation Scenario Objectives
1. Conduct a head-to-toe physical assessment.
2. Assess the patient’s individual aging pattern and cognitive
status using the Confusion Assessment Method (CAM) and
Brief Evaluation of Executive Dysfunction tools.
3. Interpret findings from assessments and recommend a plan of
care.
4. Use therapeutic communication techniques to respond to
patient and family.
5. Discuss appropriate resources to support maintaining patient
independence.
These and other tools in the Try This: ® and How toTry This
Series are available on the ConsultGeriRN.org
(http://consultgerirn.org/resources), the website of the Hartford
Institute for Geriatric Nursing, at New York University’s
College of Nursing. The tool, an article about using the tool,

and a video illustrating the use of the tool are all available for
your use.
SPICES- An Overall Assessment Tool
Tool:
http://consultgerirn.org/uploads/File/ trythis/try_this_1.pdf
Video:
http://consultgerirn.org/resources/media/?vid_id=4200873#play
er_container
Confusion Assessment Method: CAM
Tool:
http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Video:
http://consultgerirn.org/resources/media/?vid_id=4361983#play
er_container
Article:http://journals.lww.com/ajnonline/Fulltext/2007/12
000/How_to_Try_This__Detecting_Delirium.27.aspx
Read about geriatric syndromes on the following websites:
National Institutes on Aging. HealthinAging.org, created by the
American Geriatrics Society's Health in Aging Foundation, to
provide consumers and caregivers with up-to-date information
on health and aging. http://www.healthinaging.org
Read chapter in fundamentals textbook related to health
promotion in the elderly population.
Read and review information regarding SBAR communication:
Institute for Health Improvement includes several tools and
references.http://www.ihi.org/resources/pages/tools/sbartoolkit.
aspx
Look up the following medications in pharmacology text or
nurse’s drug guide: Ciprofloxacin, pilocarpine, Lipitor,
metoprolol, furosemide, Fosamax, Celebrex, tramadol,

acetaminophen
Review the Essential Nursing Actions in the ACES Framework
at: http://www.nln.org/professional-development-
programs/teaching-resources/aging/ace-s/nln-aces-framework
|_| ER
|X| Med-Surg
|_| Peds
|_| ICU
|_| OR / PACU
|_| Women’s Center
|_| Behavioral Health
|_| Home Health
|_| Pre-Hospital
|_| Other:
Human patient simulator (example: SimMan, VitalSim);
standardized patient
Props: IV bag
|X| IV tubing with primary line D 5. 45 w/
20 mEq KCL fluids running at 60
mL/hr
|_| Secondary IV line running at mL/hr
|X| IV pump
|_| Foley catheter mL output

|_| PCA pump running
|_| IVPB with running at mL/hr
|_| 02
|X| ID band
|_| Other:
|_| Bedpan/Urinal
|_| Foley kit
|_| Straight Catheter Kit
|_| Incentive Spirometer
|_| Fluids
|_| IV start kit
|_| IV tubing
|_| IVPB Tubing
|_| IV Pump
|_| Feeding Pump
|_| Pressure Bag
|_| Defibrillator/Pacer
|_| Suction
|_| Other:
Medications and Fluids:
|X| IV Fluids: see chart
|X| Oral Meds: see chart
|X| IVPB: see chart
|_| IV Push:
|_| IM or SC:

Diagnostics Available:
|X| Labs
|_| X-rays (Images)
|_| 12-Lead EKG
|_| Other:
|X| Physician Orders
|X| Admit Orders
|X| Flow sheet
|X| Medication Administration Record
|X| Kardex
|X| Graphic Record
|X| Shift Assessment
|_| Triage Forms
|_| Code Record
|_| Anesthesia / PACU Record
|_| Standing (Protocol) Orders
|_| Transfer Orders
|_| Other:
(i.e. manual, programmed, etc.) either
|X| Has been oriented to simulator
|X| Understands guidelines /expectations for
scenario
|X| Has accomplished all pre-simulation
requirements
|X| All participants understand their assigned
roles
|X| Has been given time frame expectations

|_| Other:
|X| Primary Nurse
|X| Secondary Nurse
|_| Clinical Instructor
|X| Family Member #1
|X| Observer/s
|X| Recorder
|_| Physician/Advanced Practice Nurse
|_| Respiratory Therapy
|_| Anesthesia
|_| Pharmacy
|_| Lab
|_| Imaging
|_| Social Services
|_| Clergy
|_| Unlicensed Assistive Personnel
|_| Code Team
|_| Other:
Secondary nurse is in orientation. Family member is a 50-year-
old daughter.
Student for family member role (Dina). Prepare student actors
by supplying script and objectives. Explain the roles and
emphasize that the student should represent the family member's
perspective.Report Students Will Receive Before Simulation
Time: 2:45 PM Shift report
ML is an 84-year-old female admitted from home with
confusion. Her daughter noticed she wasn’t making sense or
acting right when she stopped in to visit her yesterday evening.
Her daughter brought her in to the ED last night; she sat in the

ED all night until a bed came available a couple of hours ago.
ML has a history of hypertension, glaucoma, osteoporosis,
arthritis, elevated cholesterol, and stress incontinence. It is
unclear whether she has taken her medications properly the past
few days, her daughter couldn't tell from looking at her
medication box. Labs just came back, I haven’t had a chance to
look at them. She has medications ordered, but they just came
up from pharmacy and they all need to be given. She has not
had any pain.
Significant Lab Values:refer to chart
Physician Orders:refer to chart
Home Medications:refer to chart
Timing (approx.)
Manikin Actions
0-5 min
Disoriented and confused, can't answer questions appropriately.
VS - BP 180/110, P - 80
R - 16; T - 98.4
“My daughter dropped me off and left me here. I’m not quite
sure where I am or why I’m here. I feel ok. I can’t believe how
my life has changed in the past couple of weeks now. Harold
died a couple of weeks, no months ago. I can’t remember. Why
can’t I remember? Things have changed. I don’t like that; I’ve

always been a strong woman. I feel ok and I take a lot of pills –
not sure what they all are you can look on the kitchen counter or
ask my daughter what they are. Where is Dina? I haven’t seen
her in 6 years; no one ever comes to see me.”
· Wash hands
· Introduce self
· Identify patient
· Takes vital signs (or have assistant take vital signs)
· Begins head-to-toe, SPICES and CAM assessment
Role member providing cue: Daughter
Cue:“I don't think she's been taking her medicine.”
5-10 min
Complains of headache
“Has anyone checked on Snuggles lately?"
“My daughter dropped me off and left me here. I’m not quite
sure where I am or why I’m here. I feel ok. I can’t believe how
my life has changed in the past couple of weeks now. Harold
died a couple of weeks, no months ago. I can’t remember. Why
can’t I remember? Things have changed. I don’t like that; I’ve
always been a strong woman. I feel ok and I take a lot of pills –
not sure what they all are you can look on the kitchen counter or
ask my daughter what they are. Where is Dina? I haven’t seen
her in 6 years; no one ever comes to see me.”
· Continues assessment
· Notice elevated BP
Role member providing cue: Daughter - 7-8 minutes into
scenario
Cue: “Isn't her blood pressure too high?”

10-20 min
(If student asks about medications)
“I don't remember when I took my Lopressor last.”Continues to
complains of headache
· Calls primary care provider (PCP) to notify of BP using SBAR
communication tool.
PCP:
Cue: “Has she taken her antihypertensives? I'll be down right
away.Debriefing/Guided Reflection Questions for This
Simulation
(Remember to identify important concepts or curricular threads
that are specific to your program)
2. Describe the objectives you were able to achieve.
3. Which ones were you unable to achieve (if any)?
4. Did you have the knowledge and skills to meet objectives?
5. Were you satisfied with your ability to work through the
simulation?
6. To Observer: Could the nurses have handled any aspects of
the simulation differently?
7. If you were able to do this again, how could you have
handled the situation differently?
8. What did the group do well?
9. What did the team feel was the primary nursing diagnosis?

10. Were Millie Larsen’s presenting symptoms what you
expected? How were her symptoms different?
11. What were the key assessments and interventions?
12. How were you able to use the ACES Framework with
Millie’s situation? (Assess Function and Expectations,
Coordinate and Manage Care, Use Evolving Knowledge, Make
Situational Decisions)
13. Is there anything else you would like to discuss?Complexity
– Simple to Complex
Adapt to Different Levels of Learners
1. Have student start IV, perform venipuncture to draw labs,
administer medication – oral or parenteral.
2. Include additional findings/information that will require more
assessment, such as pressure ulcer, potential elder neglect, and
financial concerns.
3. Review of the changes in Millie’s functional status from the
beginning of the scenario to the end, and engage daughter in a
discussion of the risks/benefits of her staying at home.
Millie Larsen Simulation 1
© National League for Nursing, 2015
1
Reply Posts
Respond to your peers’ post and include the following:
· Insight on a solution to an identified peer challenge.

· Resources that may be helpful related to your peers’ post.
POST # 2 WANDA
(Wanda’s initial Post)
Reflect on the focus area or system(s) for the week.
· What challenges might you anticipate in completing this
assessment?
· What differences might you anticipate when assessing patients
across the lifespan?
· Share findings from scholarly resources that help in the
performance of this assessment.
What challenges might you anticipate in completing this
assessment?
I do not expect any significant challenges in achieving this
week's assessment because I exam patients daily with
respiratory issues such as SOB, asthma, CHF, COPD, etc.
However, one of my challenges would be accurately assessing
patients with cardiac problems. I do not have much experience
in the cardiac field of studies. I have worked with telemetry
patients. Therefore, I know what the different heart rhythms are.
However, I have no other experience working with such
patients.
What differences might you anticipate when assessing patients
Differences that I may foresee this week when assessing
patients across the life span are infants and children. Infants
and children have more significant health care needs. Their care
and outcomes depend upon the family that takes care of them.
Therefore, as an NP, you must use developmentally suitable
approaches to examine infants and children (Bickley et al.,
2017). One must also develop a great rapport with the family.
There are also social, cultural, political, and economic factors
that impact the assessment of infants and children. Young adults
typically have good health. However, social behaviors pose a
problem with their health care because they tend to have a lot of

peer pressure and try to fit in. The elderly patient has several
healthcare needs and comorbidities. Much attention must be
paid to help the elderly patient retain physical, mental abilities,
and independence. An issue that young adults and the elderly
may face are non-compliance. Therefore, this could cause a
problem with compliance, follow-up appointments, and plan of
care.
Share findings from scholarly resources that help in the
An academic resource that will help with assessments this week
is auscultation of the respiratory system.According to Sarkar et
al. (2015), the respiratory system's auscultation is a cheap, non-
invasive, safe, easy-to-perform, and one of the physicians'
oldest diagnostic techniques to identify a variety of pulmonary
diseases. However, thorough historical background and a
comprehensive physical examination, comprising inspection,
palpation, percussion, and auscultation, should be considered an
essential part of clinical examination (Sarkar et al., 2015).
References
Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2017). Bates
guide to physical examination and history taking (12th ed.).
Philadelphia: Wolters Kluwer.
Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015).
Auscultation of the respiratory system. Annals of thoracic
medicine, 10(3), 158–168. https://doi.org/10.4103/1817-
1737.160831
Reply Posts
Respond to your peers’ post and include the following:
· Insight on a solution to an identified peer challenge.
· Resources that may be helpful related to your peers’ post.

POST # 1 Jean
(Jean’s initial Post)
Reflect on the focus area or system(s) for the week.
· What challenges might you anticipate in completing this
assessment?
· What differences might you anticipate when assessing patients
· Share findings from scholarly resources that help in the
Heart disease remains the number one cause of mortality in both
men and women in the United States (Fritz, 2015), so we can
safely say that this is one of the most important system to know
and be confident in assessing. The cardiac and lung exam can be
very challenging; practitioners can detect critical information
that means life or death, that can be missed if they are not well
equipped. Cardiac is not my strong suit and I find it very
challenging to recognize the murmurs and grading them, the
clicks, the gallops and all the extra sounds that may come;
because of that I take every opportunity I get to jump in and
listen to my patient’s heart and lungs to familiarize myself with
the sounds in order to quickly determine any irregularities.
Even something that one may think is minor like knowing when
to use the bell or the diaphragm of the stethoscope can be of a
challenge. The chest should be auscultated with the diaphragm
of the stethoscope throughout the precordium to detect the high-
pitched sounds of S1, S2, pericardial friction rubs and murmurs
from aortic and mitral regurgitation and the bell is used to
detect low pitched sounds of a mitral stenosis murmur and
further heart sounds termed S3 and S4 (Scott & MacInnes,
2006). When it comes to the respiratory assessment, reading a
chest x-ray as an advance practice nurse and know how to
interpret it comes as my greatest challenge, which I plan to
overcome by taking an x-ray class in the summer.
When assessing patients across lifespan, it is important to
recognize the age-related differences that happens. Age-related
cardiac changes include reduced arterial compliance and left

ventricular diastolic dysfunction, so symptoms can present
differently in the older adult than in the younger population.
Obtaining a set of vital signs play a major role in the cardiac
and lungs assessment. The pulse and the blood pressure directly
relate to the cardiovascular system and can tell you if there’s
any blockage or if there’s any circulation issues (Scott &
MacInnes, 2006). The Cardiac and lung exam can be
intermingled with all the other systems, as if there’s an issue
with one, it will reflect on all the others. For example, if there’s
circulation issues, there might be some difficulties walking due
to shortness of breath and that will reflect on the
musculoskeletal system. Patient may be cyanotic if there are
some lung issues which will be seen in evaluating the skin and
the nails, and there is much more. So, as we can see the heart
and the lungs can bring all the other systems together.
In order to make correct diagnoses, you must inspect, palpate,
percuss and auscultate the chest, and also remember to examine
the patient’s extremities to assess arterial or venous disorders
and symmetry. While palpation of the chest is often overlooked
as a source of information regarding the cardiovascular system,
the findings can be helpful in making an accurate assessment,
palpate over the precordium to find the apical impulse and also
to note any thrills, heaves, or fine vibrations (Fitz, 2015). For
the respiratory exam, it is important to auscultate for abnormal
breath sounds, including reduced intensity, asymmetry,
wheezing, stridor, or crackles, even in the absence of a history
of wheeze, clinicians should pay close attention to any evidence
of this finding on physical examination, and note that wheezing
is always abnormal and may represent an inhaled foreign body
or other causes of airway obstruction-could be life threatening
(Chang & Marchant, 2020).
References
Chang, A. B. & Marchant, J.M. (2020). Approach to chronic
cough in children. UpToDate. Retrieved from Approach to
chronic cough in children - UpToDate (oclc.org)

Fritz, D. (2015). Cardiac Assessment. Home Healthcare Now,
33(9), 466–472.
Scott C., & MacInnes J.D. (2006). Cardiac assessment. Cardiac
patient assessment: putting the patient first. British Journal of
Nursing, 15(9), 502–508.
https://doi.org/10.12968/bjon.2006.15.9.21091

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