Health Assessments

Question 1

What is included in a Cardiovascular Assessments - focused assessment?

Answer 1

Use SOAPIE for a subjective assessment first – this is subjective, objective, assessment, plan, intervention, and evaluation.

Take a health history

Pain assessment PQRST - Provocation, Quality, Region, Severity, Timing, AND gut feeling

Inspection, Auscultation, Palpation

Always assess the ABC’s first in emergency

Question 2

What is importatnt to check for a respiratory assessment

Answer 2

A = Airway patent

B= Breathing

C = circulation – BP and pulses

What is the patient’s work of breathing WOB

Question 3

What else does a respiratory assessment include

Answer 3

Inspection – RR, depth, work of breathing

Vital signs - BP, HR, Sp02, peak flow, LOC

Auscultation - breath sounds – wheeze

Palpation – warmth / perfusion

Presence of dyspnoea, cough, sputum, hemoptysis, chest pain

Question 4

What are some common diagnostic tests for respiratory?

Answer 4

Pulse oximetry – oxygen saturation of Hb (estimate only)

Arterial blood gas (ABG) - pH, O2 and C02 in arterial blood

Lung function tests – spirometry

Culture

CT Chest/MRI -xray air show black

Biopsy

Question 5

What would a nurse do initially when meeting a patient as form of an assessment?

Answer 5

General Survey - observations

Question 6

What is the physcial assessment done?

Answer 6

Head to toe
- patient demograhics
-medical history
- te whare tapa wha
-pain, nutritional, fall assessment for risk factors
- physical assessments
-vital signs, EWS
- medication reviews

Deteriorating patient - use A-E assessment
Airway
Breathing
Circulation
Disability
Exposure

Question 7

Explain what the clinical reasoning cycle is

Answer 7

The process focuses on the patient’s needs, values, and preferences
Used to be able to form a nursing diagnosis
Uses evidence based practice

1. Consider patient
2. Collect cues/information
3. Process information
4. identify needs
5. establish goals
6. take action
7. evaluate outcomes
8. Reflect on process and new learning

NOT LINEAR - condition can change so new information can be added

Question 8

What is the IPPA approach to assessments

Answer 8

• Inspection - What can we see?
• Palpation – What can we feel?
• Percussion – What can we hear through listening and feeling (sometimes
  contraindicated!)
• Auscultation – What can we hear? (sounds – cardio/respiratory/bowel)