Structured Approaches Flashcards
Explain the inspection, palpation and auscultation approach.
Inspection (look) - begins the moment you meet the patient, initial inspection, then look at different parts of the body in more detail
Palpation (feel) - feel for tenderness, skin, movements, swelling and mases around the body
Auscultation (listen) - listen to body sounds with a stethoscope to determine illness
What is the ABCDE(FG) assessment?
This is used for any situation and can be done in an emergency or a routine assessment.
A - airway, look for breathing, colour, sign of distress, consciousness, chest movement, ability to speak or cough, airway obstruction (wheezing, stridor)
B - breathing, look for signs of respiration, distress, cyanosis, rate, depth, use of oxygen, cough
C - circulation, look for colour, pulse, blood loss, blood pressure, capillary refill, temperature, heart sounds, blood glucose
D - disability, look for level of consciousness, tremors, ticks, facial drop, slurred speech, loss of limbs, blood glucose
E - exposure, look for wounds, bruising, trauma, rashes, skin
F - further information, patient history, drug charts, medical notes, friends and family, investigations, social assessment
G - goals, aims, short or long term, monitoring plan
What is a head to toe assessment?
Do an initial ABCDE first, then head to toe. Which provides a systemic approach and thorough assessment,
- Start with hands and arms - examine palms and back of hands to check colour, temp, nails, capillary refill, tremors, deformities, swellings rashes, joints in hands. Then examine arms to check for blood pressure and joints.
- Then head and neck - examine face for shape, expression, eye contact and anxiety. Examine eyes for conjunctiva, sclera, pupils, movement and symmetry. Examine mouth for cyanosis, hydration, dentition. Examine ears for hearing aid and discharge. Examine nose for discharge. Examine neck for carotid pulse and abnormalities in shape.
- Then back - examine for shape, scares, rashes, lumps, use of muscles, symmetry, breathing, tenderness, crepitus, symmetry of breathing, skin, listen to back.
- Then front chest - examine for shape, rashes, bruising, breathing, peristalsis, tenderness, lumps and bumps, surgical emphysema, pulses, breath sounds, bowel sounds.
- Then legs and feet - examine for colour, musculoskeletal abnormalities, skin, movement, sensation, pulse and oedema.
What is ICE?
Ideas, concerns and expectations. ICE should be used to explore the patient’s perspective at the beginning of the information gathering process. It allows you to understand what a patient is thinking and feeling about their health problem
What is SOLER?
Sit squarely, open posture, lean forward, eye contact, relax - used for effective communication skills for nurse to the patient
What is OLDCART?
OLDCHART is used for exploring a symptom or problem
O - onset
L - location
D - duration
C - characteristics (quality, severity, timing)
A - associated manifestations (if it affects other body systems)
R - relieving or aggravating factors (food, medication, activity)
T - treatments/therapies
