Communication failures in healthcare contribute to 30% of the $1.7 billion in malpractice claims and 1700 related deaths between 2010 and 2015.1 Poor communication has been identified as both the leading cause of preventable adverse events in hospital settings and the major root cause of sentinel events.2 The Joint Commission emphasizes the importance of structured face-to-face communication, which allows for direct interaction among the sender and receiver with the opportunity for questions and clarifications to reduce the risk of “misadventures” (eg, medication complications and errors, readmissions, and loss of life).3,4
Healthcare education competencies and curricular recommendations stress communication skills with patients and between providers.5,6 All clinical nurse specialist (CNS) students are expected to communicate accurate, concise details about their patients to faculty and preceptors during clinical rotations. A student’s ability to convey the salient issues of patient problems/concerns assists in the formulation of timely, targeted interventions developed in collaboration with other healthcare professionals such that unintended patient consequences and errors can be prevented.7
Adult Gerontology Clinical Nurse Specialist (AGCNS) students’ clinical experiences are ideally suited to provide experiential learning opportunities through supervised clinical practice that develops the required skills mastery, including use of evidence-based practice guidelines, clinical reasoning, and advanced communication competencies.8 Benner et al8 recommend on-the-spot assessment of a students’ critical thinking including rationale for clinical decisions and “what-if” questioning to encourage examination of the patient needs and potential outcomes to the plan of care. Experiential learning with a clinical preceptor provides students real-time supervised practice experience with coaching opportunities that help students learn and reflect upon clinical situations and establish priorities that assist students in the development of their practice. Clinical experiences are high-stakes learning and necessary for skills acquisition, development of critical thinking, learning to identify clinical resources, and linking theory and evidence to practice.8
Complete, clear, concise, and timely verbal reports are essential, demonstrating CNS education competencies that facilitate collaboration with other healthcare professionals. Advanced communication skills in complex situations such as consultations, critical conversations, and development of shared decision making with the interprofessional team are core competencies in the CNS Statement on Clinical Nurse Specialist Practice and Education and are key to reducing medical error and improving patient, nursing, and system-level outcomes.7
Providing a concise focused verbal report that includes the key elements of the review-of-systems, physical examination findings, test results, and the differential diagnosis and plan requires an organized plan. Often, initial student verbal reports are disorganized, are lengthy, and contain extraneous details or lack key assessments.9 Faculty evaluate students with questioning and “on-the-spot assessments” to clearly understand their knowledge application and improve the students’ verbal reports and communication with other healthcare professionals. Active learning, applied contextually to the clinical experience in real-time, motivates student learners by its relevance to practice.8,10
The goal of a verbal report is to communicate essential patient information between individuals, groups, and organizations in a timely, accurate, concise and organized manner, allowing for rapid generation of an appropriate treatment plan.4 A focused verbal report using a standardized template provides the student with a structure to cluster significant positive and negative findings from the patient history, review of systems, and physical examination when communicating critical information, differential diagnosis/diagnoses, and management with other healthcare professionals.
Presentation of an organized verbal report requires practice to master. The brevity of the verbal report format can make verbal reporting a stressful event for students since faculty and preceptors use verbal report as an evaluation tool for clinical performance. To further complicate matters, the structure and presentation of a verbal report often changes depending on the medical specialty, provider preferences, and clinical setting (ie, inpatient versus outpatient setting).9 The Joint Commission and Agency for Healthcare Quality and Research recommend that a standard format be used across all members of the interprofessional team.3,11 The verbal report template (see Appendix 1) created for our students includes elements from TeamSTEPPS’s “I PASS THE BATON,”12 a well-established interprofessional healthcare communication tool.
In previous semesters, faculty and preceptors documented that AGCNS students’ initial verbal case reports were lengthy and disorganized, often lacked key assessments, and contained extraneous details as students attempted to present every detail of an assessment, whether significant or not, in an attempt to “not leave anything out.” Students inaccurately categorized data including subjective assessment data in the physical examination and objective data in the history and review of systems. Faculty noted that students did not link test results to their assessment of the patient to demonstrate critical thinking supporting the patient’s differential diagnosis and treatment plan.
Feedback from preceptors about student difficulty with accurate, succinct verbal reports were noted when faculty visited the clinical site for observation of student performance. This preceptor feedback included excessive length of verbal report, failure to link essential test results to the review-of-system/physical examination findings, and the inclusion of normal assessments or values that did not contribute to the formation of a differential diagnosis. Because of the specialty nature of AGCNS students’ clinical experiences, student placements were in multiple locations across rural and urban areas so faculty were not able to make daily student observations at every clinical site. Clinical site preceptors reported that the AGCNS students’ inability to provide a concise verbal report slowed productivity of the preceptor and increased the length of time for patient appointments.
Videoconference education has demonstrated high participant satisfaction with equivalent effectiveness compared to face-to-face instruction,13 but there is a paucity of literature supporting videoconference use for clinical performance evaluation. The use of videoconferencing for verbal reports provides an opportunity for faculty to deliver more frequent feedback and evaluation of a students’ performance and communication competencies without the travel time and expense needed for weekly student evaluations (see Appendix 2). Videoconferencing, like face-to-face interactions, adds the element of nonverbal communication (ie, body language, facial expressions, posture, etc) that can hold the attention of the interprofessional team more than a recording or written report alone.4 Based on a systematic review of qualitative studies on nurses and midwives’ experiences with videoconferencing, videoconferencing was useful, making consultations more real, facilitating collegial support, and improving decision making.14 Videoconferencing meets the Joint Commission requirements of using a standardized approach to handoff communications that includes an opportunity to ask and respond to questions with the 2-way exchange of information in an environment with limited distractions.3
With support of an Advanced Nursing Education grant from the Department of Health and Human Services, the AGCNS faculty evaluated the use of iPad minis issued to the clinical faculty and students for enhancing communication and information access. Tablets and smart phone technology, like the iPad, enables students to rapidly access information regarding medications and potential life-threatening interactions and practice guidelines and provides secure videoconferencing real-time communication between faculty and students. The purpose of this article is to present a program evaluation of the effectiveness of using video conferencing technology (iPad minis) for verbal reports as a learning strategy used to role model and to evaluate AGCNS communication competencies and advanced practice decision making in the clinical setting.
DESCRIPTION OF PROJECT
Tablets (iPad-minis) were provided to AGCNS faculty 1 year in advance of students to orient faculty to the use of the device. The faculty, with input from clinical preceptors, identified ways that the tablets could augment student clinical performance, including face-to-face case reports when the student was in a clinical site, preconference and postconference discussions, and access to practice guidelines throughout the AGCNS program. Students were provided iPad minis equipped with SIM cards providing a shared Internet access plan for use in their clinical rotations as part of a Department of Health and Human Services grant. This ensured equal access to resources, which allowed faculty to evaluate the impact on student outcomes and to also monitor the number of minutes used on each device.
Students in the final year of the AGCNS program (N = 28 over 2 cohorts) were issued iPad minis. In-class demonstration of faculty expectations regarding verbal reports were provided.
Templates for verbal and written reports were created by faculty and reviewed with the AGCNS students for use in the clinical setting (Appendix 1). These templates provided structured student experiences and differentiated the verbal report format from that required for written documentation. Verbal report elements included chief complaints, applicable history, a focused review of systems, the focused physical exam and related laboratory test results, differential diagnoses, and plan of care. Faculty demonstrated use of the verbal report template at the beginning of each semester and provided a written progress note for the same patient case to contrast the differences. All students practiced videoconferencing of verbal reports in the classroom setting before participating in videoconferencing of verbal reports in the clinical setting. One additional face-to-face training session on technology and use of Apps was required by 7 students (24%). Students were required to schedule a videoconferencing session with faculty while at their assigned clinical site.
Faculty listened to student verbal reports, made anecdotal notes, and asked open-ended questions after the students’ verbal report to evaluate use of the verbal report template and subsequent organization and presentation of the patient. Duration of verbal report time was tracked in minutes and seconds for each student contact. Faculty provided real-time feedback to students on the structure of their report along with development of differential diagnoses and plan of care based on evidence-based guidelines and in collaboration with the patient, family, and community’s context.
Students’ knowledge, application of practice guidelines, clinical reasoning, and judgment were assessed throughout the 2 semesters, including verbal report performance. Verbal reports accuracy was documented in the Clinical Evaluation Tool comment section during the videoconference (Appendix 2). If a performance issue was identified by a faculty member during a student verbal report, a different faculty would evaluate the student’s verbal report performance on the following clinical day and provided student feedback. The week after the videoconferencing verbal report, students were required to submit a written progress note of the patient presented in the verbal report for feedback and evaluation purposes.
The Clinical Evaluation Tool used to evaluate overall student performance was reviewed by faculty, and items related to verbal report performance were clearly identified for students (see Appendix 2). Anecdotal notes regarding the deficiencies in a student’s videoconferenced verbal report were documented on the clinical evaluation tool (eg, missing history, assessment and/or examination data, lack of laboratory data or inaccurate interpretation, failure to cluster findings to form differential diagnosis, failure to link practice guideline(s) to support diagnosis and interventions, as well as organization, clarity, and conciseness of report and being prepared to present the case and call faculty for verbal report at the scheduled time).
The time students spent in presenting the videoconferenced verbal report was tracked over 2 years with 2 cohorts of students using the minute log on the teleconferencing App. Descriptive statistics for the time logs of the verbal reports were analyzed using Microsoft Excel. Number of errors was determined by review of the clinical evaluation tool and supported with documented anecdotal notes.
The program evaluator/research scientist for the School of Nursing conducted several focus groups with AGCNS students. The goal of the focus groups was to determine how the student’s experiences in the AGCNS program contributed to their ability to care for patients, use evidence-based practice, communicate and collaborate with other healthcare professionals on an advanced level, and enhance their competence and confidence to work as a member of an interprofessional team. Three faculty reviewed the focus group data for trends in student feedback on their experiences using videoconferencing for verbal report of clinical cases to determine the student’s perceptions on their ability to care for patients, use of evidence-based practice, communication skills, and capability to work with an interprofessional team.
Mean time for the initial verbal report for students was greater than 20 minutes (mean [SD], 32.47 [22.86] minutes; range, 24–58 minutes). In the initial verbal reports, all students exceeded 5 errors. At the end of the program, 100% of students were able to present a videoconference verbal report in less than 5 minutes (mean [SD], 3.47 [1.25] minutes; range, 2.50–4.8 minutes). Student accuracy improved with 0 to 1 errors for 100% of the student reports.
Focus Group Results
Feedback from students in the focus group indicated they appreciated having access to faculty when off campus in clinical sites through the videoconferencing. They appreciated the immediate faculty feedback on verbal reports, which students stated had assisted them with “pattern recognition” and in formulation of differential diagnosis. However, students also indicated that some preceptors wanted a “different” verbal report format from what was required by faculty. Preceptor reports were shortened to chief complaint, history of present illness, and abnormal findings from review of systems and physical examination linked to a diagnosis and treatment plan. Different sites had individualized verbal report styles that students were required to follow. Comorbid conditions were typically not included in the verbal report to preceptors. Student impressions were that this shortened report was related to the time constraints placed on providers in the outpatient setting and was less of an issue when they were on hospital rounds.
A variety of issues need to be considered before using videoconferencing for verbal report: (1) planning for amount of time needed to schedule videoconferencing, (2) patient confidentiality and student privacy, (3) amount of time (ie, frequency over what period of time) required for students to master verbal report skills, and (4) equipment and apps used.
Time Needed for Scheduled Videoconferencing
Faculty need to consider the amount of time required in scheduling the videoconferenced verbal reports. We found that faculty needed at least 1 hour per call during the initial calls, as well as additional time to provide student feedback and document anecdotal notes on the clinical evaluation tool. The amount of time decreased for students as they integrated the feedback provided so that 15-minute appointments were adequate by the end of the second semester.
In the first year of implementation, faculty provided a daily time span for student call-ins with videoconference verbal reports without setting specific appointment times for AGCNS students. This resulted in faculty waiting for AGCNS students to contact them, with multiple calls being made at the end of the student’s clinical day. Changing to a scheduled sign-up time period allowed faculty and students to plan their clinical day around the appointment time for the videoconference. If students were unable to keep their appointment, which occurred on rare occasions, they were required to contact faculty in advance of the appointment (text or voicemail) with a plan for rescheduling.
Confidentiality and Privacy
Faculty wanted students to incorporate verbal report feedback into their patient care plan, preferably while the patient was still in the clinic setting. To accomplish this, AGCNS students were instructed to videoconference with faculty during their clinical day from a secure, private location in their clinical site. Preceptors were apprehensive of videoconferenced verbal reports and related clinic information security. Once preceptors observed videoconferencing of verbal reports, they were more confident that clinic and patient information was secure.
Two instances occurred in the first semester in which students called from a public area, creating potential privacy issues. These incidences were used as examples to coach the students and review patient Health Insurance Portability and Accountability Act privacy protection rules and regulations. On the rare occasion that a clinical site did not have a private area available to make a videoconference call, students notified faculty and made arrangements to call at a different time from a secure location.
Settings for videoconferencing must be evaluated before the start of the verbal report process. Since a private/quiet setting may not always be available at the clinical site, alternative arrangements may need to be made to protect both patient confidentiality and student privacy. For example, students may need to give their verbal report from school, home, or their car as long as the setting meets the privacy requirements.
Amount of Time Required for Mastery
Faculty questioned the number of calls that might be needed for students to demonstrate mastery of the communication skills required in the verbal report. It was initially anticipated that 1 semester would be adequate for faculty feedback on students’ verbal reports. This assumption proved to be false. When students began the second semester, many had changed clinical sites and their preceptors indicated that the students’ verbal report was not as clear, concise, and accurate as required in the practice setting. Students needed to adapt to the preferences of the new clinical site and preceptor, a finding that was also seen by others.9 In addition, students needed more practice to master the critical reasoning and decision making needed in verbal reports especially when exposed to multiple clinical sites and preceptors.
We required an every-other week videoconference call and 2 faculty site visits per clinic setting. On the weeks students were not being observed (by site visit or videoconference call), they were required to submit a written progress note documentation for the patient they had presented to faculty during their site visit or in the videoconferenced verbal report from the previous week. The written progress note provided opportunities to determine if faculty feedback was incorporated into the student’s plan of care for that patient. By the end of the AGCNS program, all students were able to meet or exceed goals related to the accuracy of verbal reports and time for verbal reports set at less than 5 minutes.
Equipment and Communication Apps
The primary advantage to using a consistent videoconferencing device with faculty and students was the ability to troubleshoot when students reported technical difficulties. Having everyone use the iPad mini with a SIM card meant that access to secure Internet communication was available regardless of the clinical site or student’s personal technology. When students in rural clinical settings experienced connection issues using 1 App (FaceTime), we found Skype or GoToMeeting would connect in their location. No communication App worked 100% of the time, but all students were able to identify an App that worked from the location on the day of the scheduled video-conference.
A concise, clinically relevant report template combined with videoconferencing technology improved AGCNS students’ communication competencies and decision making. Minimal training was required by the students to successfully use iPad minis for verbal report. The use of tablets and smart phones presents opportunities to enhance learning and communication, especially when faculty cannot be in the clinical setting for “real-time” coaching and feedback. Faculty are able to act as role models for critical thinking, advanced decision making, and professional behaviors and attitudes while simultaneously evaluating students’ progress.
In an era of limited resources and cost containment for those in academia, it may be tempting to conduct all student clinical evaluation via videoconferencing, thus eliminating costs associated with travel time and expense. However, we continue to conduct on-site visits with each preceptor throughout the semester. The advantages of continuing faculty site visits include (1) maintaining community relationships; (2) identification of student learning opportunities, potential new preceptors, and gaps in preceptor knowledge; and (3) direct observation of the student in the clinical setting with patients to evaluate communication competencies with the patient and interprofessional team and the efficiency and accuracy of patient assessment, physical examination, and plan of care.
As with any teaching strategy, there are advantages and disadvantages. With careful planning beforehand, the disadvantages of using videoconferencing for verbal reports can be minimized. A case can be made for combining periodic on-site visits with videoconferencing to improve outcomes. The additional practice and immediate feedback of verbal reports using videoconferencing enhanced student learning and improved their communication. Preceptors supported and reinforced faculty requirements of student collaboration with other healthcare professionals and insisted on clear, concise, and accurate communication of verbal reports to show student’s clinical reasoning and decision-making ability and which enhanced patient care and safety.
Heather Becker, PhD, Research Scientist, The University of Texas at Austin, School of Nursing
1. Malpractice risks in communication
failures: 2015 CRICO Strategies National CBS Report. CRICO Strategies website. https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
. Published 2018. Accessed June 19, 2018.
2. Manojlovich M, Harrod M, Holtz B, Hofer T, Kuhn L, Krein SL. The use of multiple qualitative methods to characterize communication
events between physicians and nurses. Health Commun
. 2015;30(1):61–69. doi:10.1080/10410236.2013.835894.
3. Bronk KL. The Joint Commission Issues new sentinel event alert on inadequate hand-off communication
failures a major contributor to adverse events in health care. The Joint Commission. https://www.jointcommission.org/the_joint_commission_issues_new_sentinel_event_alert_on_inadequate_hand-off_communication/
. Published September 12, 2017. Accessed June 19, 2018.
4. ACOG Committee opinion no. 517: communication
strategies for patient handoffs. Obstet Gynecol
. 2012;119(2 Pt 1):408–411.
5. Report I: learning
objectives for medical student education
: Guidelines for medical schools; Medical School Objectives Project: January 1998. Association of American Medical Colleges website. https://members.aamc.org/eweb/upload/Learning%20Objectives%20for%20Medical%20Student%20Educ%20Report%20I.pdf
. Published 1998. Accessed June 19, 2018.
6. What is a CNS? What is a clinical nurse specialist
? National Association of Clinical Nurse Specialists Web site. http://nacns.org/about-us/what-is-a-cns/
. Published 2018. Accessed June 19, 2018.
7. CNS statement. National Association of Clinical Nurse Specialists website. http://nacns.org/professional-resources/publications/cns-statement/
. Published 2018. Accessed June 19, 2018.
8. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation
. Sanford, CA: The Carnegie Foundation for the Advancement of Teaching; 2010.
9. Goldberg C. A practical guide to clinical medicine. The Regents of the University of California website. https://meded.ucsd.edu/clinicalmed/oral.htm
. Published 2015. Accessed June 19, 2018.
10. Spencer J. ABC of learning
and teaching in medicine: learning
and teaching in the clinical environment. BMJ
. 2003;326: doi:https://doi.org/10.1136/bmj.326.7389.591
11. About TeamSTEPPS®. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/teamstepps/about-teamstepps/index.html
Published April 2017. Accessed June 19, 2018.
12. TeamSTEPPS fundamentals course: module 3. Communication
. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
. Published March 2014. Accessed June 19, 2018.
13. Chipps J, Brysiewicz P, Mars M. A systematic review of the effectiveness of videoconference-based tele-education
for medical and nursing education
. Worldviews Evid Based Nurs
. 2012;9(2):78–87. doi: 10.1111/j.1741-6787.2012.00241.x.
14. Penny RA, Bradford NK, Langbecker D. Registered nurse and midwife experiences of using videoconferencing
in practice: a systematic review of qualitative studies. J Clin Nurs
. 2018;27(5–6):e739–e752. doi:10.1111/jocn.14175.
Verbal Report Versus the Written Progress Note
ADULT GERONTOLOGY CLINICAL NURSE SPECIALIST PROGRAM: ORAL PRESENTATION VERSUS THE WRITTEN PROGRESS NOTE
The best reason to develop your oral presentation skills is to facilitate communication of accurate, concise information between interprofessional team members. Discussions with colleagues and consultants about patients are often informal and subject to time limits. Lengthy oral presentations (especially if read) bore listeners, resulting in missed information. The oral presentation needs to complement the comprehensive written progress note.
- ○ A clear, concise verbal report communicates data, clinical reasoning, and critical thinking and reduces medical errors and malpractice risk.
- ○ Presentation is oral, not read. Eye contact with other healthcare providers is maintained.
- ○ Fall semester goal: less than 7 minutes. Spring semester goal: 3-5 minutes.
Key Elements of Verbal Reports
- ○ Patient: initials, age, gender, and/or race (eg, “AG is a 58 yo Hispanic male with NKDA presenting to clinic with chief complaint of….”). Do not use identifying patient information (name social security number, room number, etc).
- ○ Chief complaint (CC): clearly stated in one sentence.
- ○ History of present illness (HPI) is chronological, with appropriate focused positive and negative findings, including how the illness has impacted the patient’s life.
- ○ Patient history (Hx): organized, concise with significant data only. Present the social Hx if there is smoking, alcohol (ETOH), or illicit drugs in the past or current Hx. (eg, “Comorbidities include T2DM Rx w/ metformin, 2 mo ago HgA1c was 7.4, hyperlipidemia with LDL < 70 on simvastatin, CAD w/o reported angina on Isordil and prn NTG; OA self-treats with NSAIDs, HTN controlled on lisinopril, smoker: 55 pack-year Hx”)
- ○ Don’t read the med list—link medications to the HPI (see above).
- ○ The review of systems (RoS): Focus on significant findings. Present negative findings if they relate to the CC (eg, “CC: I am short of breath. You should mention a lack of cough, respiratory effort, etc.”). The remainder of the RoS is noncontributory. Be prepared to answer questions if you state noncontributory in your verbal report.
- ○ Physical examination (PE): Present the patient’s general appearance and vital signs (for oral presentation, you can say vital signs stable or within normal limits if not related to CC).
- ○ Should be organized and concise and describe significant findings. (If a system is noncontributory to the CC/HPI say so, do not present a list of normal findings. If an abnormality such as crackles or rhonchi are anticipated but not present, mention it).
- ○ Include significant available laboratory/radiographic data. Omit normal values if data are not directly related to active problems, but be prepared to answer questions about results, if asked.
- ○ Prioritize the problem list accurately and specifically. Present differential reasoning.
Plan of Action/Intervention
- ○ Problem based with emphasis on the CC, presenting or primary problem.
EXAMPLE: ORAL REPORT
P.L. is a 63-year-old African American (AA) man readmitted from X-hospital s/p tonic-clonic seizures (Sz) after missing dialysis treatments.
CC/HPI: “My tongue hurts.” Resident is being readmitted after discharged home 3 weeks ago with his sister as caretaker. Four days ago, he was admitted to the hospital after emergency medical services call for witnessed 3-minute tonic-clonic Sz. He reports that he stopped his medications and missed 2 dialysis appointments because of “not feeling well” the past 5 days. At the hospital, he was started on Dilantin and Keppra for his Sz and amlodipine for hypertension (HTN) (190/110). His admission potassium was 6.7. He was noted to have 1 × 0.25-in laceration on the left side of his tongue, which did not require sutures.
PMHX: End-stage renal disease (ESRD) with arteriovenous (AV) fistula on the left (L) forearm, dialysis 3× a week, and associated anemia Rx with epoetin as needed. Renal associated malignant HTN was previously managed with metoprolol and hydralazine and was changed to amlodipine at the hospital. Distant Hx of head trauma with resulting Sz, mild cognitive impairment, and debility. Long Hx of medication nonadherence.
SOC Hx: He denies illicit substance, tobacco, or ETOH use.
RoS: He denies difficulty eating, speaking, or swallowing. He has no memory of his Sz. The remaining systems are noncontributory.
PE: He appears in no acute distress with stable vital signs.
- HEENT: There is a 1-in × 0.25-in deep laceration on the left side of his tongue, well approximated without redness or bleeding.
- CV: Blood pressure (BP) is controlled at 134/78; otherwise, within normal limits.
- GU: scheduled for dialysis 3× a week. Arteriovenous fistula L forearm + bruit and thrill. Last dialysis was this AM.
- Neuro: oriented ×2 (person and time), unable to do 3-item recall after 5 minutes, clock drawing displaced to 1- to 6-o’clock positions.
- Other systems are noncontributory.
Labs are pending from today’s dialysis. Potassium was 4.6 after the first dialysis at the hospital.
EXAMPLE: WRITTEN PROGRESS NOTE
Patient Name: P.L. Room: XXX Allergies: NKDA DoB: XX/XX/XXXX
Age: 63 Gender: Male Race: Black, non-Hispanic Code Status: Full
CC: My tongue hurts, I bit it when I had the seizure I think.
HPI: Resident is being readmitted after discharged home 3 weeks ago with his sister as caretaker. Four days ago, he was admitted to the hospital after emergency medical services call for witnessed 3-minute tonic-clonic Sz. He reports that he stopped his medications and missed 2 dialysis appointments because of “not feeling well” the past 5 days. At the hospital, he was started on Dilantin and Keppra for his Sz and amlodipine for HTN (190/110). His admission potassium was 6.7. He was noted to have 1 × 0.25-in laceration on the left side of his tongue, which did not require sutures.
Current Medical Problems:
PMHx: peripheral neuropathies, chronic pain, anemia of chronic disease, debility, hyperkalemia, medication noncompliance
PSHX: AV fistula L forearm, 2012
SocHx: single, disabled plumber; denies tobacco, illicit drug, or ETOH use
Family Hx: Both parents had HTN; father died of MI at the age of 58 years, and mother died at the age of 75 years (“old age”). Four siblings alive and well. No children. Negative for DM and cancer.
Immunizations: pneumonia, flu, HPV up-to-date, last PPD 1 month ago: negative
General: denies fever or weight change or fatigue
HEENT: c/o pain on his tongue, worse when he drinks hot liquids or bites it when he eats. Denies diplopia, pain, and redness in eyes; hearing issues, earache, or ringing; nose bleeds, runny nose, or allergy symptoms; and/or hoarseness, dry mouth, or swallowing problems.
Neck: denies pain or swollen glands
CV/Pulm: denies pain, swelling in extremities, palpation, or shortness of breath. Denies cough, wheezing, or difficulty breathing.
GI: denies abdominal pain, change in bowel habits, or constipation/diarrhea/nausea/vomiting. Denies rectal bleeding.
GU: states he voids “a little bit” 3 times a week. Denies pain, blood in urine, or incontinence. States he has long-standing impotence, which does not concern him (“I am not seeing anybody.”).
Musculoskeletal: denies joint pain or problems with range of motion; states he needs a walker to “keep me from falling.”
Skin: denies issues with rash change in color, or nails
Psych/mental status: denies sadness or mood disruption; states he sleeps well and wakes rested
PE: Blood pressure, 121/82; HR, 95/min; resp, 18/min; T, 98.5°F; temporal artery; O2 sat 94% on RA; pain, 7/10 tongue
General: 63-yo AA male in bed sleeping, NAD
HEENT: normocephalic, PERRLA, EOMI, nares, and oral membranes pink, no drainage. Left side of the tongue has 1-in × 0.25-in laceration to which resident attributes oral pain, missing back molars on the right, TM clear, able to hear whisper voice
Neck: supple; no lymph node enlargement, thyroid mass, or JVD
CV: RRR NL S1 S2 w/o S3, S4, rub, or murmur apical pulse = radial. No edema. 2+ pulses throughout
Resp: decreased bases without crackles; nonlabored AP diameter normal
GI: soft round active bowel sounds throughout; nontender to palpation without mass or organomegaly noted. Last BM this AM.
GU: by Hx voids 50-100 mL 3 times a week. Arteriovenous fistula on the L forearm with palpable thrill and audible bruit. Dialysis dependent 3 times weekly.
Skin: normal color for ethnicity; warm dry with scaling lower extremities
Extremities: 4/5 strength all extremities, equal bilaterally. Able to stand using arm of chair to assist and walker to steady gait. Without tremor. Monofilament not detected on feet.
Skin: warm dry, color normal for ethnicity without breakdown
Neurological: reflexes brisk, oriented to person and time, not place. Able to do immediate 3/3 recall and 1/3 recall after 3 minutes. MMSE score of 18; clock drawing deviates to 1- to 6-o’clock position.
Psych/mental status: PHQ-9 score of 0
Functional assessment: behavior: cooperative; affect: appropriate to situation; continent of bowel and bladder; ambulation: uses walker, stable gait; ADLs: minimal assist with encouragement; cognitive: make simple decisions, reduced memory
Labs: CBC w/ diff, CMP, PHT level—pending from dialysis this AM. At the hospital, VPA level is 43.
- Tongue laceration s/p generalized Sz (diagnosis in 1999) after missing 5 days of medication and dialysis.
- Start back on Depakote ER 1000 mg po bid, and increase gabapentin to 300 mg tid
- Will taper phenytoin over the next week and discontinue Keppra in 1 week.
- VPA level in 1 month
- Xylocaine 4% solution give 5 mL Q3h prn
- ESRD dialysis dependent:
- Change PhosLo to calcium acetate 667 mg tid with meals (low cost, better tolerated)
- Obtain copy of today’s labs from dialysis
- Continue Epogen per dialysis protocols for anemia related to ESRD
- Malignant HTN related to ESRD:
- Stop amlodipine
- Restart metoprolol ER 100 mg po bid and hydralazine 100 mg po tid
- Traumatic head injury in 1998, with residual cognitive impairment: Continue Aricept
- Long Hx on medication nonadherence: Plan family meeting for long-term placement for patient safety within the week
The University of Texas at Austin School of Nursing
Adult Gerontology Clinical Nurse Specialist Clinical Evaluation Tool