Patient Assessment Techniques

Assessment

• Assessment is a crucial part of a patient's care, conducted by Lynne Ordoyne MSN, RN.
• This involves a holistic approach, encompassing various aspects of the patient's well-being.

Learning Objectives

• Safe and effective care environment: Preparing the patient and environment for assessment, understanding variations in assessment techniques for different age groups, identifying factors affecting vital signs (temperature, pulse, respirations, blood pressure).
• Health promotion and maintenance: Discussing the purposes of the health assessment, describing four assessment techniques, describing methods of assessing vital signs, demonstrating knowledge of normal ranges of vital signs across the lifespan, demonstrating accurate assessment of vital signs.
• Physiologic integrity: Demonstrating steps used in selected examination procedures, discussing expected health assessment findings and variations across the lifespan, explaining the physiology of body temperature, pulse, respirations, and blood pressure.

Holistic Assessment

• Physical: Physical aspects of the patient's body.
• Psychological: Mental state of the patient.
• Social: Social interactions and support systems.
• Spiritual: Spiritual beliefs and values.

Types of Assessments

• Initial (baseline) assessment
• Ongoing reassessment
• Problem-focused assessment
• Emergency assessment

Age Considerations

• Infants
• Toddlers
• School age children
• Adolescents
• Adults
• Older adults

Cultural Considerations

• Cultural factors are important in assessment.

History

• Review of acute and chronic medical problems.
• Medications.
• Family health history.
• Disease prevention and health maintenance.
• Disease contact tracing.

Functional Assessment

• Self-care abilities
• Risk for falls
• Cognition
• Nutrition and feeding
• Continence
• Mobility
• Sleep
• Skin care

Case Study- Morse Fall Scale

• History of falling (Yes/No)
• Ambulatory aid (Furniture, Crutches, Cane, Walker, None)
• Gait/Transferring (Impaired, Weak, Normal)
• Secondary diagnosis (Yes/No)
• IV or Heparin lock (Yes/No)
• Mental Status (Ask ability to use bathroom)

Hester Fall Scale

• 9 factor scale with scores ranging from 0-77
• Age, Last known fall, Mobility, Toileting, Mental status / LOC / awareness, Communication / sensory, Behavior, Medication, Volume / electrolyte status.

Psychologic Assessment

• Open-ended or closed questions
• Suicide prevention screening

Spiritual Assessment

• Assessment of spiritual beliefs and values

Social Assessment

• Identify the patient's social support network (community member, partner, neighbor, friend, family member, co-worker).

Physical Assessment

• Inspection
• Palpation
• Percussion
• Auscultation

Start of Assessment

• Introduce yourself
• Infection control
• Explain purpose of assessment
• Ask permission
• Ensure privacy

Vital Signs

• Temperature
• Pulse
• Blood pressure
• Respirations
• Oxygen saturation
• Pain

Environmental Inspection

• Room
• Equipment
• Lines

Assess Patients General Appearance

• Observe skin color, respiratory effort, presence/absence of distress.
• Evaluate mood and affect.
• Assess posture.
• Observe hygiene, grooming, dress.
• Check for odor of breath and body.
• Measure height and weight.

Neuro Assessment

• Glasgow Coma Scale
  • Eye opening (Spontaneous, To loud voice, To pain, None)
  • Verbal response (Oriented, Confused, disoriented, Inappropriate words, Incomprehensible sounds, None)
  • Best motor response (Obeys, Localizes, Withdraws, Abnormal flexion posturing, Extension posturing, None)
  • Pupil size and reaction to light (undilated pupil, dilated pupils)

Sample Documentation: Normal Neurological Findings

• When awake, person is alert and oriented to person, place, and time, speech is clear.
• Follows commands, appropriate neurologic response to auditory, visual, and tactile stimuli.
• Pupils equal, round, react briskly to light (PERRLA).

Head Assessment

• Head
• Eyes
• Ears
• Nose & Mouth
• Face and expressions

Sample Documentation: Normal Head Assessment

• Normocephalic, Face symmetrical, No redness, swelling, or drainage from eyes, ears, or nose.
• Mucus membranes moist, all teeth present and well-cared-for.

Neck Assessment

• Trachea
• Carotid arteries
• Jugular vein distension
• Lymph nodes
• Thyroid gland

Sample Documentation: Normal Neck Assessment

• Trachea midline. Carotid pulses equal, no JVD, no swelling or painful lymph nodes.

Skin Assessment

• Color
• Temperature
• Moisture
• Turgor
• Edema
• Lesions
• Hair
• Nails

Sample Documentation: Normal Skin Assessment

• Skin warm and pink, no lesions or edema.
• Skin turgor non-tenting. Nails clean and well-pedicured.

Cardiac Assessment - Apical Pulse

• Anatomy diagram of the heart, showing relevant structures.

Cardiac Assessment

• Heart sounds (S1 and S2)
• Lub, Dub (beginning and end of systole/beginning of diastole)

Pulses

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis

Sample Documentation: Normal CV Assessment

• S1 and S2 heard, pulse rate within normal limits (WNL) and regular.
• Radial and pedal pulses 3+, absence of cyanosis, edema, capillary refill less than 2 seconds.

Respiratory Assessment

• Shape and symmetry of the chest
• Respiratory rate
• Respiratory effort
• Cough
• Breath sounds

Breath Sounds

• Wheeze: Continuous, high-pitched
• Fine Crackles: High-pitched, short duration, just before expiration
• Coarse Crackles: Low-pitched, long duration, inspiration
• Rhonchi : Continuous, rumbling, snoring
• Stridor: Continuous, musical or crowing

Sample Documentation: Normal Respiratory Assessment

• Respirations regular pattern and depth, unlabored, symmetrical chest expansion.
• Clear bilateral breath sounds heard. Pink mucous membranes, no cough, no sputum production.

Gastrointestinal (GI)/Nutrition Assessment

• Inspection
• Auscultation
• Percussion
• Palpation
• Appetite
• Diet
• Weight (Anatomy diagram shows GI structures)

Sample Documentation: Normal GI Assessment

• No difficulty swallowing or chewing.
• Soft, non-tender, non-distended abdomen. Bowel sounds present in all four quadrants.
• Absence of nausea, vomiting, or diarrhea. Last bowel movement (date).

Genitourinary (GU) Assessment

• Bladder palpation
• Fluid intake & output
• Assessment of genitalia

Sample Documentation: Normal GU Assessment

• Continent, able to empty bladder without difficulty.
• Urine clear, yellow to amber color, no odor or sediment. No complaints of frequency, dysuria, or hematuria.

Sample Documentation: Normal Genital Assessment

• Genitalia normal, without redness, swelling, or discharge.
• Breasts soft (firm) and non-tender.

Muscular Skeletal Assessment

• Posture assessment (Sway Back, Lordosis, Thoracic Kyphosis, Forward Head, Good Posture)
• General body symmetry
• Muscle strength
• Movement
• Gait

Normal Muscular Skeletal Assessment

• Full range of motion (ROM) in all extremities.
• Equal strength bilaterally. Absence of weakness.
• Steady balanced gait.

Safety Assessment

• Bed in low position
• Side rails Up
• Call light within reach
• Personal belongings within reach
• Restraints

This quiz covers various aspects of patient assessment techniques essential for providing safe and effective care. It emphasizes understanding different age group variations, health promotion, and vital signs assessment. Engage with the material to enhance your assessment skills and knowledge of physiological integrity in patient care.