Assessment OSCE GUIDE (OLD)
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This document provides a script for safely assessing a patient in the hospital or community setting. It includes introducing oneself, checking the patient's identification band, asking about allergies and pain levels, explaining the assessment process, taking vital signs including blood pressure, pulse oximetry, pulse, respiration, and temperature, assessing alertness using the Glasgow Coma Scale, documenting findings, communicating the patient's condition and NEWS score, addressing any concerns, and ensuring safety before leaving. The script emphasizes infection control through hand hygiene and maintaining patient privacy and comfort.
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Assessment OSCE GUIDE (NEW)
The document provides guidance for conducting a patient assessment. It outlines the steps to check safety, introduce oneself, verify patient identification, check for allergies and pain levels, explain the observations to be taken, and conduct checks of airway, breathing, circulation, disability, exposure, and skin. It describes communicating the patient's NEWS score and escalating care if needed. The assessment is to be conducted with hand hygiene and ensuring privacy, dignity, and patient understanding throughout.
Contoh laporan pendahuluan
The nurse measured the vital signs of Mrs. Fitri in ward 3 bed 1. [The nurse] took Mrs. Fitri's temperature, blood pressure, pulse, and respiratory rate. Mrs. Fitri's temperature was 39°C, blood pressure was 150/100 mmHg, pulse was 88 beats per minute, and respiratory rate was 23 breaths per minute. The nurse documented the vital sign measurements.
Diagnostic Testing
This document provides guidelines for performing various diagnostic techniques consistently at CareNET clinics. Certain tests like blood pressure readings require a provider to be present, while others like x-rays do not. A general survey of a patient can provide early indications before diagnostic exams. Detailed instructions are given on how to properly measure blood pressure, pulse, respiratory rate, and temperature as part of a diagnostic evaluation. Normal ranges for each vital sign are provided, as well as potential causes of abnormal readings. Consistency is important for quality assurance.
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Upper Endoscopy
An upper endoscopy is an outpatient procedure that uses a thin scope with a light and camera to examine the esophagus, stomach, and first part of the small intestine. The patient is given sedation during the procedure, which takes 15-30 minutes. Afterward, the patient must have someone drive them home and should not drive or operate machinery for at least 8 hours. The doctor will discuss the results with the patient after the procedure to determine if any medical issues were found.
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Vital signs include measurements of respiration, pulse, blood pressure, temperature, and pain level. They provide important information about a patient's health status and should be assessed regularly, including upon admission, before/after procedures, and with any changes in condition. The five vital signs are used to monitor patients and detect issues that may require medical intervention.
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Assessment OSCE GUIDE (NEW)
The document provides guidance for conducting a patient assessment. It outlines the steps to check safety, introduce oneself, verify patient identification, check for allergies and pain levels, explain the observations to be taken, and conduct checks of airway, breathing, circulation, disability, exposure, and skin. It describes communicating the patient's NEWS score and escalating care if needed. The assessment is to be conducted with hand hygiene and ensuring privacy, dignity, and patient understanding throughout.
Contoh laporan pendahuluan
The nurse measured the vital signs of Mrs. Fitri in ward 3 bed 1. [The nurse] took Mrs. Fitri's temperature, blood pressure, pulse, and respiratory rate. Mrs. Fitri's temperature was 39°C, blood pressure was 150/100 mmHg, pulse was 88 beats per minute, and respiratory rate was 23 breaths per minute. The nurse documented the vital sign measurements.
Diagnostic Testing
This document provides guidelines for performing various diagnostic techniques consistently at CareNET clinics. Certain tests like blood pressure readings require a provider to be present, while others like x-rays do not. A general survey of a patient can provide early indications before diagnostic exams. Detailed instructions are given on how to properly measure blood pressure, pulse, respiratory rate, and temperature as part of a diagnostic evaluation. Normal ranges for each vital sign are provided, as well as potential causes of abnormal readings. Consistency is important for quality assurance.
_FBSFBG & RBS .pdf
A test to determine how much glucose (sugar) is in a blood sample after an overnight fast.
The fasting blood glucose test is commonly used to detect diabetes mellitus.
A blood sample taken in a lab, physician's office or hospital.
The test is done in the morning, before the person has eaten.
Upper Endoscopy
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2) Key steps to take a measurement involve placing the cuff on the upper arm and stethoscope over the brachial artery, inflating the cuff until 30 mmHg above normal blood pressure, and listening through the stethoscope as the cuff deflates to determine systolic and diastolic pressures.
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1. Adult and paediatric basic life support (CPR)
2. Male catheterization
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Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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Assessment OSCE GUIDE (OLD)
- 1. ASSESSMENT CheckSAFETY Close door,curtainor windowforprivacy Hand Hygiene Ensure hand washing 7 stepsasper whoguideline for 30 sec Introduce selfand role PreferredName (pt.name) Wristband check Pt say theirname and DOB, hospital numberor addressif communitybased Look at wristbandandcheckagainstthe admissionpaperwork Allergyandreaction Latex allergy Checkspainand comfort Score pain 0-10 if withpain Checkif theyknowwhythey’re admitted Offerrepositioningof comfortability State you are doingobservations(BP,PR,RR,Temp,O2) Checksequipmentif cleanedandcalibrated BP – anyfistula?Surgery?wound?preferredarm? Pulse oximeter–capillaryrefill<2sec,nonail polish Pulse – countfor 1 full minute Respiration- countfor1 full minute afterpulserate Temperature –check forhearingaid(tempshouldbe checkedafter30minof hearingaidremoval), no woundnordischarges CORRECT NEWSSCORE/GCS/PHQ9 SCORE State NEWS score to patientandstate whenare yougoing to redoit. Escalatingto doctoror nurse incharge as perNEWS SCORE Checkingunderstanding Buzzerand bedon the lowestpart Verbal Documentation Hand Hygiene
- 2. SCRIPT FOR ASSESSMENT: Scene issafe for me to approach Close curtainsor doorsfor privacy anddignity Hand washingUSING7 STEPS ASPER WHO GUIDELINES for 30 sec (dryhandsbefore approachingpt) Hi My name is _______, I am your nurse fortoday May I knowyourname please? Is italrightif check yourwristband? Couldyouplease confirmyourfull name anddate of birthplease?(checkitagainstthe admission paper) Do youhave any allergies? YES – What are youallergicwithandwhatis the reaction? Thank youfor givingme thatinformation,Iwill make sure youwillnotgetanymedicationcontaining Penicillin. Do youhave any pain?Can youscore itfrom 0-10 0 as no pain10 as verypainful. Do youknowwhy youare here (ptname).(If ptisunable to answer,orienthimtotime andplace) I am here todayto do yourobservationsandthiswill consistof respirations,oxygenlevel,pulserate, bloodpressure andtemperature,willthatbe alright? I will justgrabthe OBS machine andwill come backto you. Here isthe call bell if youneedanything else. The OBS machine hasbeencleanedandcalibratedinthe last24 hoursand I am happyto use it. (Handgel before goingbackto patient) Hi (ptname),I’ll be gettingyourOBSnow. I’ll be takingyourblood pressure,whicharmdo youprefer? No surgeries?Nofistula? NextI’ll pop/putthisprobe on youropposite finger. Thisistocheckyou oxygen saturations. No nail polishandcapillaryrefillis<2sec I’ll be checkingyourpulse for2 minutes ExaminerIwill nottell the patientthatIwill be countingthe respirationsaswell sothatIcan get the accurate result. Lastly,I’ll checkyourtemperature,doyouhave anyhearingaids?(YES – ill use a differentearorif bothears have hearingaid,remove the aidandwaitfor 30minutes – justverbalize this),I can see no woundsnordischarge hasbeennoted. *FOR GCS* Can youplease raise bothof your arms andresistitwhenI’mpushingitdownward(NORMAL POWER) Can youplease liftyourRightlegandresistwhenI’mpushingitdownward(NORMALPOWER) Can youplease liftyourleftlegandresist whenI’mpushingitdownward(NORMALPOWER)
- 3. (Pt.name) I am done takingthe observationsandI’ll be documentingitnow.Here isthe call bell if youneedme.(COMPUTE NEWS SCORE) Ms. Examiner,the NEWSSCORE is _____, I will /will notescalate itand I will retake itafter (asper NEWS POLICY). HANDHYGIENE whengoingbackto patient. Hi,Pt name,I am nowdone documenting,everythingisalright(state if anyobsare elevated)andI will redoyourOBSafter 12/4/6 hours/30min. Before Ileave doyouhave any concerns? (IFYES – addressit) (IFNO – reassure) Here is the call bell if youneedanything. I’ll putthe bedrailsup for safetyandbedat itslowestposition. FINALHANDHYGIENE