PATIENT ASSESSMENT

1. PATIENT ASSESSMENT Michele Archdale Revised 2012

2. WHAT IS GOOD HEALTH? Optimum health ill health Independence Dependence Adaptation Maladaption Self care Reliance on others

3. When good health turns to bad health • Physical health vs mental health separate but interdependent • Strictly mental health patient? • Patient with physical health issues & mental health problems • Strictly physical health patient? – is there such a thing? • Admission to health care facility • Full nursing and medical assessment required

4. Admission – initial responsibilities • Room preparation • Orientate patient to room / ward / clinical area. • Inform pt re smoking / health facility policies and procedures. • Pt rights • Valuables • Obtain pt records • ID band • Check identification to notes / labels • Check next of kin / DOB.

5. ADMISSION CRITERIA • All patients should have a complete “head to toe” assessment within 24 hour of an admission to a health care facility. • In specialised areas – e.g. Emergency dept an initial assessment is made at Triage and a full assessment is done immediately on admission. • The patients’ health history shall be reviewed and documented in the patients’ record Admission Summary and Care Plan.

6. Assessment should be carried out: • By or under supervision of allocated nurse. • With the agreement and cooperation of the patient. • Be evidence based • Must be in accordance with best practice standards, code of professional conduct and Legislative guidelines.

7. Nursing Assessment • Reason for Admission • Past medical history • Signs and symptoms • Contributing Factors • Social and environmental • Holistic approach • Individualised assessments

8. Guidelines for patient assessment • Environment – provide privacy, make sure patient is comfortable, respect patient’s personal space, keep noises to a minimum & ask visitors to step out of the room • Communication – introduce yourself, maintain eye contact, explain the process of patient assessment, establish a rapport with the patient. • Interview – ask open questions, involve the patient to contribute to their physical assessment, avoid pre-empting, keep questions short, use language that the patient understands, listen, give them time to answer and keep the interview focused.

9. Patient Assessment • Collecting data • Validating data • Organising data • Identifying patterns • Reporting and Recording data

10. Where do you find the answers? • Patient • Family and Friends • Case Notes • Past Admissions • Test Results • Nursing Text Books & literature

11. Sources of Data Written records • GP Referral letter • Nursing Home transfer letter • Previous admissions • Test results Verbal • Patient interview • Family and friends

12. Guide to successful assessment • Prepare adequately – be organised • Introduce yourself • Listen and do not rush the interview • Clarify and show understanding • Formulate your questions clearly, using accurate nursing terminology. • Make notes • Take the time to analyze the data • Extract the relevant and important points

13. Communication aids Non Verbal - body language • Posture • Gestures • Facial expressions • Eye contact • Touch • Cultural considerations? Verbal • Tone • Volume • Speed of talking • Language difficulties

14. What do you need to know as the nurse? • How is this person feeling? • How does this patient make me feel? • How has this event affected their usual life-patterns and roles? • How can I help this person? • What is important for this person to make their stay in hospital comfortable? • What support does this person have in life? • How does this patient view the future and themselves? • How can we get this person back to optimal well being again? Discharge Planning • Critical thinking

15. Why is communication important? • To establish and maintain a relationship with patients and their families. • To encourage patients to describe all relevant aspects of their problems. • To get and give accurate information • To use time and opportunity effectively • To improve patient satisfaction with the care given • To improve trust and cooperation with the care • To reduce negative emotions and fears

16. What are we assessing? - The Person Physical / Biological • Activities of daily living • Mobility • General health • Habits – alcohol, smoking, drugs • Height, weight, vital signs • Skin assessment – existing scars/ injuries / Braden scale on admission Psychological • Healthy mind / intellect • Awareness / Alertness • Mental stress – fears, memories • Emotional support • Family and significant others • Work – interests - hobbies • Religion / Culture • Spirituality – meaning of life, fear of death

17. What are we assessing? -Environmental factors • Home, neighbours, town / country • Pets • Financial status • Level of health cover WHAT WOULD YOU MISS IF YOU WERE IN HOSPITAL? What would need to be managed?

18. What are we assessing? - Activities of Daily Living what can the patient do for themselves? Eating Vision, hearing Cognition – mental Dressing Washing Personal Hygiene –brushing your teeth Toileting Walking Housekeeping – cooking, laundry, cleaning Talking Shopping All the things we take for granted and do every day.

19. What are we assessing? - Patient Observations (obs) Vital Signs • Blood pressure – BP • Temperature • Pulse • Respirations • SPO2 • Urinalysis • A set of patient observations must be done on admission to establish a baseline, then regularly as ordered or indicated by patients’ clinical condition, procedures or medical orders.

20. Head to Toe Approach • CNS: COGNITION & MOBILITY • CARDIOVASCULAR • RESPIRATORY • GIT / RENAL • REPRODUCTION • INTEGUMENTARY • METABOLIC

21. Initial Assessment – Primary survey • General impression • Responsiveness • Alertness • Orientation • Airway • Breathing • Circulation • Disability • Prioritise care

22. Primary Assessment Inspect • Head and neck • Face • Shoulders • Back • Arms, wrists and hands • Chest • Abdomen • Pelvis and lower back • Lower limbs and Feet

23. Secondary Assessment – focused history and physical exam Vital Signs – A SET OF OBSERVATIONS • Temperature • Pulse • Respiration • Blood Pressure Check for medical information • diagnostic imaging • Test results

24. The Physical Examination Look for; DEFORMITY OPEN WOUNDS TENDERNESS SWELLING JOIN THE DOTS

25. Gather Patient History “S.A.M.P.L.E” Signs and Symptoms Allergies Medications Past Medical History Last oral intake Events leading to illness

26. Maintain a systematic approach to data collection – Head to Toe, evidence based, do not assume. • Thank the patient for their time and cooperation. • Inform them when you will be coming back to see the patient. • Discuss what will happen next – answer any questions. • Objective – What is observed • Subjective – What is stated

27. Assessment and Planning Effective planning depends on the quality and comprehensiveness of the assessment. • Determine the problems • Establish the risks and priorities • Assess potential for emergencies or injury • Presence of pain? – pain management • Can they maintain a safe environment? • drugs, alcohol, mental or psychological problems? • Are they compliant with nursing directions?

28. Risk Assessment Indentify; • Actual risk • Potential risk Compile and develop an • individualised, • holistic • CARE PLAN

29. Ongoing Assessment • Make note of variances

30. Progress Notes • On admission • Daily, each shift, or per hospital policy • Each time patient care changes • Variances – changes / deterioration • Facts and nursing actions • Allied health interventions