CPO34 Health Assessment Handbook 2020 PDF

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SCHOOL OF NURSING, AND MIDWIFERY

Health Assessment Form Handbook C33 Bachelor of Science (Nursing) NPU1202 Nursing Practice 2 NPU2303 Nursing Practice 3 NPP2201 Professional Nursing Practice 2 NPU3505 Nursing Practice 5 NPU3606 Nursing Practice 6

J46 Master of Nursing (Graduate Entry) NPP6101 Adult Health Practice 1 NPP6102 Adult Health Practice 2 NPP6103 Mental Health Practice NPP6104 Child Adolescent and Family Nursing Practice NPP6105 Nursing Practice Capstone

Guideline Code: Owner: Date Reviewed: Revision Date:

CPO34 Health Assessment Form Handbook Document Director, Clinical January 2020 July 2020

Contact Information Email:

Clinical Skills and Simulation Facilitators [email protected]

CPO34 Health Assessment Handbook

Table of Contents

Introduction ................................................................................................................

1

Documentation ...........................................................................................................

1

Section A – Client Information / Activities of daily living.............................................

2

Section B – Client Health History ...............................................................................

3

Section C – Client Physical Assessment...................................................................

3

References .................................................................................................................

7

CPO34 Health Assessment Handbook

Introduction The purpose of this handbook is to provide students with a quick reference guide when completing a client assessment (including documentation) during any clinical placement across all semesters. The information provided informs and guides the student regarding objective and subjective data and physical assessment findings that need to be collected, collated and assessed. The health assessment form can be used across all semesters and general guidelines have been provided to advise the student how to complete the document. Table 1 below provides a description of each section within the health assessment and specialty forms. HIPPA format (history, inspection, palpation, percussion, auscultation) is be used when carrying out a physical assessment, where applicable. Table1: Summary of health assessment form Section

Description

A

Client Information/ Activities of Daily Living

B

Client’s health history (eg. reason for admission, allergies, previous medical history etc)

C

Client’s physical assessment (eg. respiratory, cardiovascular, neurological etc)

Documentation Documentation, by all healthcare professionals, is of vital importance in maintaining correct and concise evidence regarding the client’s progress. Two methods on how to correctly document in the integrated / progress notes will be introduced and reinforced throughout all clinical practice units. Table 2 below provides an outline of two principle methods; however, it is important to ensure that facility / organisational policies / procedures are also followed. Table 2: Summary of documentation methods Acronym

Description

S

Subjective data – brief statement / description of how the client feels regarding issue / problem (eg. client complains of a headache)

O

Objective data – brief statement / description of nurse’s observations of the client (eg. nurse observes client grimacing

A P I E

Assessment regarding the issue / problem (eg.vital signs, head to toe assessment) Plan determine appropriate plan of care (eg. pain medication is provided to alleviate symptoms of headache) Intervention – what you did, regarding the issue / problem Evaluate further nursing action if issue / problem has not been resolved (eg. nurse evaluates effect of pain medication provided / alternative required if headache still persisting) Focus charting - description

D

A R

Data – both subjective and objective regarding issue / problem. Can include data from nursing history, physical examination, laboratory data & diagnostic tests and information from family members or other health team members Action – After analysis of the data, what actions were taken or planned to address the problem(s). Response – Evaluate if action worked or not, the effectiveness of the intervention(s). Can include subjective and objective data here, and if further a assessment is required

1

Section A – Client Information / Demographic Data Criteria

Requirements

Client Name

• Must be fictitious / pseudo name at all times to protect client confidentiality

DOB

• Day/month/year

Age

• Age in years

Gender

• Write male, female or other

Marital Status

• Tick box to select relevant status

Client Contact Details

• Must be fictitious / pseudo name at all times to protect client confidentiality

Reason for Admission

• As per information provided Provoking/palliative • What makes it better and what makes it worse?

Symptom Assessment

Quality/quantity

• What does it feel like? Can you describe it?

Region/radiation:

• Where is it? Does it spread anywhere?

Severity

Timing: Social situation

Next of Kin (NOK) Preferred Contact Details

• When did/ does it start? How long does it last? How often does it happen?

• Tick box to select relevant situation and provide information if support services are in place NOK

Tick box if aware

Name

State name – must be fictitious to protect client confidentiality Write how NOK is related to client - must be fictitious to protect client confidentiality

Relationship Contact number

Language/speech:

• What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right now? on movement? at rest? How bothered are you by this symptom? Are there any other symptom(s) that accompany this symptom? Does it affect your ADLs?

Mobile/home number - must be fictitious to protect client confidentiality

• Tick box if relevant and add details where necessary • State type of speech impairment

Religion & Culture

• Tick box and state religion, regular practices and restrictions (eg food,) • Tick box and specify cultural needs and restrictions (eg food, male/ female nurse)

Mental status

• Tick box to select relevant status and add details where necessary

Alcohol and Drug use

• Tick box if relevant and specify amount and frequency

Hearing and vision

• Tick box to select relevant status and add details where necessary

Activity & Mobility

• Tick box if relevant and add details where necessary

Nutrition

• Tick box if relevant and add details where necessary • Weigh client on admission

Hygiene

• Tick box and state routine and requirements related to personal hygiene

Pain

• Tick box if relevant and specify location, type, intensity, pattern, triggers, pain scale

2

Section B – Client Health History Criteria

Requirements

Allergies/ adverse drug reactions

• Tick box if no known drug allergies or Circle drug or other (allergen trigger) and state type of allergen (medication, sticky plaster, pollen, seafood, etc) • Reaction - Describe reaction when exposed to the allergen (signs / symptoms / severity) • List age when client experienced first reaction

Other

• Tick box if relevant and list type of implant (eg. cosmetic, dental, orthopaedic) • Tick Micro alert box if client has a multi resistant organism (eg. methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant enterococci (VRE); carbapenem-resistant Enterobacteriaceae (CRE); multi-resistant Gram-negative bacteria (MRGNB). C33 Stage 2-6: Need to complete as per information provided J46 All stages need to complete

Medications

Previous hospitalisation for major illnesses / Surgical History

Drug Name

• State generic / trade name (preferably generic)

Dose

• State dose (including measure: g / mg / microg / units, etc) • Frequency (daily, BD, TDS, nocte etc) • Route of administration (oral, IMI, subcut, IV etc)

• If ticked Yes complete, • Year – refers to date of admission • Reason – why they were admitted into hospital (eg. childbirth, fractured arm appendectomy etc) • Length of stay – how long they were in hospital (eg. overnight, 3 days etc)

Previous Medical History

• To be completed by all stages • Tick / or state appropriate response as provided by the client • Areas for further comments / details have been provided and should be used, as required

Family medical history not covered above

• Add extra information not listed in HAF

Section C – Physical Assessment Assessment

Requirements

Integument Skin Hair & Nails History

• Any additional history not provided in Section B Skin

Inspection

Palpation

• Integrity, colour (including variations), odour, pigmentation, scars, lesions, wounds, striae, vascularity. Pressure areas - Skin intact, no reddened areas. • Moles – Asymmetry; Border; Colour; Diameter; Evolution

Scalp / Hair

• Lesions, colour of hair, quantity, condition, distribution, infestations • Scull shape, symmetry, contour (rounded over frontal bone & occiput)

Nails Skin

• Colour, cleanliness, shape, configuration • Temperature, turgor, oedema, moisture, texture

Scalp / Hair Nails

•

Temperature, turgor, oedema, moisture, texture

• Oedema, tenderness, clubbing

3

HEENT & Lymphatic History

• Any additional history not provided in Section B Head

Eyes

Inspection Ears

Nose/ sinus Throat/Neck

• Facial symmetry - ask the patient to frown, smile, clench teeth, puff cheeks. • Are there any involuntary facial movements / muscle weakness, lesions, oedema, acne. • Symmetry, alignment, position, movement, • Do you see any orbital oedema, inflammation, dryness, colour of sclera and conjunctiva, lacrimal apparatus (dry or teary eyes) discharge. • Use your Penlight to assess PERRLA - Pupils equal, round, reactive to light and accommodating • Symmetry, position, deformities, discharge • Internal signs of inflammation, oedema, • Gross hearing tests - hair rub and whisper test. • Symmetry, position, deformities, discharge • Internal signs of inflammation, oedema. • Is the trachea midline, can you see any lesions, venous distension, or an enlarged thyroid gland. • What is the range of motion (ROM) Ask the patient to move their neck from side to side and up and down.

Lymph nodes • Note any lumps - size, shape and location

Palpation

Tests

Head

• Any lesions, lumps, oedema or tenderness. • TMJ movement - ask the patient to open and close their mout,h move their chin from side to side and up and down (protract and retract)

Eyes

• Carefully palpate tear ducts for tenderness

Ears

• Carefully palpate tragus, pinna and mastoid areas for tenderness and lumps

Nose/ sinus Throat/Neck

• • • •

Lymph nodes

• Feel pre & post auricular, occipital, tonsillar, submandibular, superficial anterior & posterior cervical, supraclavicular for - size, shape delimination (discrete or matted together), mobility, consistency, tenderness N = no enlargement or inflammation; lymph nodes non palpable and non-tender

Palpate gently for any signs of tenderness or lumps Is the Trachea midline (use two fingers on either side of the trachea) ROM of neck TMJ movement (open, close, side to side)

Eyes

• PERRLA – pupils equal, round, reactive to light and accommodation • Consensual reflex, convergence, accommodation, extra ocular muscle function (cardinal fields of gaze) • Snellen Test – Visual Acuity test • Colour blindness chart if available

Ears

• Whisper Test

4

Respiratory History

• Any additional history not provided in Section B Nose / Sinus

Mouth/Throat Inspection

Thorax (anterior / posterior)

Nose / Sinus Palpation

Thorax (anterior / posterior)

Percussion

Thorax

Auscultation

Thorax

(anterior / posterior)

(anterior / posterior)

• Colour, patency, shape, inflammation, oedema, discharge, symmetrical septum • Lips, mucous membrane (pink, moist, lesions) • Teeth, gums, halitosis, orthodontic appliances, dentures, crowns, caps, cough, sputum • Tongue (midline, strength, lesions), uvula midline, gag reflex (if appropriate) • Tonsils (present, removed, inflammation, oedema) • Skin characteristics (scars / lesions) • Chest contour, shape and expansion, use of accessory muscles, presence of superficial veins, position of sternum, angle of ribs, intercostal spaces (ICS), position of scapulae • Right and left scapula lines, vertebral line, mid-axillary line, anterior & posterior axillary line • Respiration (rate, rhythm, depth, symmetry, ease, audibility) • ( Breasts not assessed) • Frontal and maxillary sinuses for tenderness • Tenderness, sensation, surface characteristics, masses • anterior / posterior (AP) transverse ratio, chest contour, expansion, crepitus • Tactile fremitus • Tone – resonance to dullness (commencing above the clavicles laterally) • Ask the patient to take slow deep breaths. • Compare bilateral sounds to determine patients normal Bronchial, bronchovesicular, vesicular and adventitious breathe sounds (location and quality – contra laterally)

Cardiovascular History Inspection

Palpation

Auscultation

Neurovascular Assessment

• Any additional history not provided in Section B • • • • • • • •

Skin characteristics (as per Integumentary System) Precordium for contours, pulsations Jugular vein distension (client at 45o angle, head slightly left) Examine circulatory status and hydration status of upper and lower extremities Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed, clubbing Capillary Refill Time: brisk (< 2 sec) or sluggish Presence of oedema (central and/or peripheral) Hydration status: Skin turgor, oral mucosa.

• Identify only precordial landmarks (Aortic, Pulmonic, Erb, Tricuspid, Mitral – APETM) • Identify only sternal line (SL) and R & L midclavicular line (MCL) • Peripheral pulses (temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibialis (rate, rhythm, amplitude, symmetry – bilateral palpation, except for carotid) • Heart sounds at APETM • Identify differences in location of S1 Lub - and S2 Dub with bell and diaphragm • Compare S1 (Loudest at Apex - represents closure of the tricuspid and mitral (bicuspid) valves) and S2 (loudest at Base represents closure of the aortic and pulmonic valves) • Any audible heart murmurs • Pulse Deficit: Apical and palpate radial • Blood pressure • Extremities (colour, warmth, movement, sensation), oedema, lesions, hair, capillary refill, varicosities – bilateral comparison

5

Gastrointestinal History

• Any additional history not provided in Section B

Inspection

• Skin characteristics (as per Integumentary System) • Contour, symmetry, movement, umbilicus (position, contour), pulsations, visible peristalsis

Auscultation

• Bowel sounds all four quadrants, vascular sounds, friction rubs, venous hum

Percussion

• Tone – tympany to dullness (four quadrants) • Liver margins, bladder

Palpation

• Light – note guarding, inguinal lymph nodes, femoral pulses, masses

Neurological History

• Any additional history not provided in Section B

Cerebral

Cerebellar Inspection

(eyes closed)

Sensory (eyes closed – bilateral comparison)

Motor Reflexes

Reflex Grading Scale

• Level of consciousness (LOC) – orientation to person, time, place, Glasgow Coma Scale (GCS) • Appearance & behaviour (dress, grooming, hygiene, facial expression, affect) • Communication (thought processes / perceptions, speech) • Cognitive ability (memory – recent / remote) • Balance (gait – heel to toe, stand, hop on one foot and tandem, Romberg’s test) • Coordination & balance (finger to thumb / nose, supination / pronation of hands, heel down shin) • Exteroceptive: light touch, superficial pain (dull / sharp), temperature (hot / cold) • Proprioceptive: vibration sense • Cortical: stereognosis (object in hand) • Muscles (coordination, movement, tone, strength, mass) • Involuntary movements (tics, tremors, fasciculations) • Superficial: abdominal, plantar (Babinski) • Deep: brachioradialis, biceps, triceps, patella, achilles 0 Absent + Present but diminished ++ Normal +++ Increased U Unobtainable

Musculoskeletal History

• Any additional history not provided in Section B

Inspection

• Overall appearance, posture, spine (‘S’ shape), gait, mobility, cervical (concave), thoracic (convex), lumbar (concave), spinal deviations • Muscle size and shape, joint contour and periarticular tissue • Limitations, pain

Palpation

Range of Motion (ROM)

• Neurovascular observations (colour, warmth, movement, sensation – CWMS – compare bilaterally) • Spine (two fingers down either side whilst standing & bending with arms / head falling free) • Limbs - for muscle mass, tone and strength, pain or tenderness • Joints - for ease of movement, swelling, pain, tenderness • Neurovascular observations – compare bilaterally Spine

• Flex, extend, lateral, bend, twist

TMJ Neck Shoulder Elbow Wrist

• • • • • • • • • •

Hand/Fingers

Hip Knee Ankle Foot / Toes

Open, close, side-to-side Flex, extend, lateral bend, lateral rotate Shrug, flex, extend, abduct, adduct, internal / external rotation Flex, extend, pronate, supinate Flex, extend, radial deviation, ulna deviation Flex, extend, abduct Flex, extend, abduct, adduct, heel to knee, internal / external rotation Flex, extend Plantar / dorsiflex, inversion, eversion Flex, extend, abduct

6

References Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning, and clinical judgment: A practical approach th

(6 ed.). Philadelphia: Elsevier.

Berman, A., Burke, K., Kozier, B., & Erb, G., (2014). Kozier and Erb’s fundamentals of nursing: Concepts process and practice (3rd ed.). Frenchs Forest, N.S.W: Pearson Australia. Carpenito-Moyet, L.J., Carpenito L.J. (2012). Nursing care plans and documentation: Nursing diagnosis and collaborative problems (5th ed.). Philadelphia: Wolters Kluwer.

Douglas, C., Rebeiro, G., Crisp, J., & Taylor, C. (Eds.). (2017). Potter & Perry’s fundamentals of nursing (5th ed.). Chatswood, NSW: Elsevier Australia. Fa...