Week 1 - Health Assessments Flashcards
Describe Person-Centred Care
- Knowing the person as an individual
- Providing care that is meaningful, coordinated and integrated
- Respecting the individual’s values, preferences and needs and putting them at the centre of care
List Person-Centred Approaches
- Discussing and unpacking the person’s goals of care
- Effective communication
- Incorporating cultural safety
- Understanding health literacy
What do you need to include when performing a health history?
- Demographic information
- Reason for seeking care
- Own perception of health
- PMHx, surgical Hx, recent hospitalisations, family Hx
- Immunisations/exposure to communicable diseases
- Medications/Allergies
What are the different assessment approaches
- Primary Assessment
- Secondary Assessment
- Tertiary
What is a Primary Assessment
- Primary phase (rapid)
- Identify and address potentially life-threatening conditions
What Acronym do we use for Primary assessments
- Airway
- Breathing
- Circulation
- Disability
- Exposure
- Fluids
- Glucose
Explain Airway for Primary Assessments
- Airway and Alertness
- Assess the level of consciousness using AVPU
- Maintain C-spine protection
- If pt not alert - open their mouth using jaw thrust or head tilt-chin lift.
- Inspect for potential obstructions (vomit/blood/tongue)
- Listen for upper airway sounds (snoring/gurgling/stridor)
- Palpate for bony deformity
Explain Breathing for Primary Assessments
- Is the patient breathing spontaneously
- What is the RR, depth, rise and fall of the chest
- Is the breathing symmetrical
- Is there any increased WOB
(recession/accessory muscles) - Are there any open wounds or signs of respiratory distress?
- Assess the colour of the skin
- Auscultate for breath sounds
- Consider repositioning or applying O2 if alert
- If the patient is not alert do you need to consider supporting respirations via a BVM?
Explain Circulation for Primary Assessments
- Check for external haemorrhage (apply pressure/tourniquet).
- Assess and compare the central and peripheral pulses
- Observe and palpate the skin for warmth, colour and moisture
- If circulation is absent (BLS algorithm/chest compressions/defib)
- Assess for capillary refill
- Connect to the monitor/12 lead ECG, BP, PIVC insertion, collect bloods, IVT consideration (fluid bolus-isotonic/bloods).
Explain Disability for Primary Assessments
- Evaluate neurological status using the GCS (best EVM breakdown)
- Check the BGL level
- Review the documentation (what interventions of medications have they received)
Explain Environmental Control for Primary Assessments
- Remove the patient’s clothing (if appropriate) to rapidly expose the body to assess for any other signs of illness or injury (rash, external bleeding)
- Keep the patient warm (apply warming methods)
- Assess their core temperature
What is the Secondary Assessment
- Complete a secondary assessment after the primary assessment process and once the life threats have been managed.
- This approach is a more comprehensive assessment. Some suggest to follow the F-J mnemonic (after A-E)
What are included in the Secondary Assessment
- Full set of vital signs and include the family
- Get monitoring devices and give comfort
- History and head-to-toe
- Inspect posterior surfaces
- Just continue to monitor and keep reevaluating
- Documentation
What monitoring devices needed for Secondary Assessment
- Review any laboratory studies (bloods)
- Attach monitoring
- Consider the need for NGT/OGT insertion
- Assess and apply oxygen and ETCO2
- Complete a pain assessment and manage accordingly
How to do a Head to Toe?
Inspect and palpate the body using a systematic approach from the head to the toes, assess the following:
- Head and face
- Neck
- Chest
- Abdomen and flanks
- Pelvis and perineum
- Extremities
What is a Focused Assessment
- Focused assessments are targeted to the specific area of the complaint/ presenting issue
- Relating to the specific presenting problem or body system (respiratory/cardiovascular)
- Relating to current patient concern
What is a Comprehensive Assessment
- Legal considerations
- Ethical considerations
- Cultural considerations
- Subjective data (what they tell you) and objective data (what you find)
- Physical assessment/ exam (primary, secondary and focused)
- Medical and Surgical health history (present and past)
- Family health history
- Social History
- Medication/allergy History
- Laboratory and diagnostic data (investigations)
- Documentation (reports, notes, correspondence)
What is Subjective Data
- Information provided verbally by the patient
- Often the patient’s perception of the problem
- Documented in quotes
- Referred to as the chief or primary complaint
What is Objective Data?
- Data considered at factual
- Things seen and/or measured
- Investigative results: Pathology, Vital signs, Ward UA/MSU, Xray etc.
- Used to validate the patient’s subjective complaint / presentation
How do you do a Physical Assessment?
General Appearance:
- Physical status
- Psychological/mental status
- Distress (Physical, emotional, psychological)
- Vital signs
- Pain assessment- OPQRST (Wong-baker/FLACC for pediatrics/
disabilities)
What is HIPPA
- History Subjective information (‘stated’)
- Inspection
- Palpation
- Percussion
- Auscultation
