Health assessment framework - guide PDF

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Health Assessment Framework Name: Non identifiable Day post op: Number of days post op/post procedure/post admission Medical Diagnosis:

Date of assessment/consent: Date health assessment was completed and consent was gained DOB: Age:

Date of admission: Date admitted to facility or practice visit date Day post op: Number of days post op/post procedure/post admission

Gender: Ethnicity: Male, female, prefer not to answer Chief Complaint: Describe in the patient’s/client’s own words the reason for their visit or calling for attention.

Past Health History History of Presenting illness/Concern: (using a framework to gather information COLDSPA, PQRSTU, OLDCARTS etc). A comprehensive description of the characteristics and progression of the symptoms for which the patient/client seeks care. Medication: Name, dose, frequency, date of commencement of medications Any recently discontinued medications Immunisations: Name and date of immunisations Over the counter (OTC): Consider – vitamins, laxatives, dietary supplements, herbal products, paracetamol, NSAIDS, antihistamines, antacids Allergies: Full description of any allergies. Allergies to food and/or environmental Record the rapidity of symptoms, does the patient carry a medical alert data, anaphylaxis kit. What is the reaction, what was the treatment and when was the last time the reaction happened. Past Medical History Full description of past medical health history. Consider: Major adult illnesses/conditions Childhood illnesses (if relevant). Hospitalisations Transfusions Screening exams Past Surgical History Nature of surgery: Name, date and outcome Nature of injuries: Name, cause, date and outcome

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Mental Health History Conditions that require psychological or psychiatric intervention Treatment interventions – did they complete their treatment, if not, why not. Any hospitalisations for mental health care Family Health History Major illness and health status of relatives Genetic conditions Deaths Ethnicity Social History: consider where relevant  Personal data: place of birth, birth order,  Family status: Separated/divorced/married/children living at home/single/parent/at risk environment. Level of education.  Occupation  Housing  Safety  Socioeconomic status  Diet  Exercise  Sleep  Recreation/travel  Stress management  Drug and Alcohol history  Social support Cultural: Beliefs, routines or practice that influence the patient/client health outcomes. Feelings around death and dying. Religion spirituality Cultural practices Sexuality How they what to make health care decisions. Alcohol/Drug/Smoking/Vaping: Smoking/vaping: past and present, how much, how long, when stopping, offer NRT Alcohol: Does the patient/client consume alcohol, type, amount, frequency, pattern of use. Past and current use of recreational/illicit drugs: quantity, duration, substance consumed. Drugs: type, amount, frequency, pattern of use.

Review of Systems (subjective assessment) General Ask the patient to describe their general health status. General wellbeing, strength, energy level, ability to complete ADLs. Mental health Review Mental state exam Ask about predominant mood, emotional problems, anxiety, depression, suicidal ideations; include risk assessment, unusual perceptions, and hallucinations. Integumentary Ask history question around changes in skin, rashes, itching, pigmentation, moisture, changes in colour, size, shape of moles, changes in hair growth, changes in nails

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HEENT Ask history question around: Head: changes to scalp, hair, facial structures. Eyes: Vision questions, include acuity, tearing blind spots, dryness, night vision, discharge Ears: Hearing changes, pain, discharge, tinnitus, vertigo, balance, cerumen Nose: nosebleeds, colds, obstructions, discharge, changes to smell, polyps, sneezing, postnasal drip. Mouth/Throat: dental issues, lesions issues with gums, salvia flow, hoarseness, difficulty articulating words (dysarthria), sore throats, changes to tongue, sense of taste. Neck stiffness, pain, tenderness, thyroid masses, have they notice any lymphadenopathy. Neurological Ask history question around: headaches, light-headedness, convulsions, paralyses, incoordination, sensory changes (paraesthesia, anaesthesia, hyperesthesia), changes in mentation, fainting, syncopal episodes, LOS, difficult memory, speech, sensory or motor disturbances, changes in muscle coordination (ataxia, tremor) Respiratory Ask history question around: SOB, SOBOE, dyspnoea, wheezing, stridor, cough, sputum production, respiratory infections. Note last CXR. Cardiovascular/PV Ask history question around chest pain, dyspnoea, orthopnoea, cough, fatigue, cyanosis/pallor, oedema, arrhythmias, hypertension, hyperlipidaemia, syncope, claudication, haemoptysis and cold of the extremities. Gastrointestinal/Endocrine Ask history question around appetite, dysphagia, indigestion, food intolerances, abdominal pain, heartburn, nausea, vomiting, hematemesis, jaundice, polyps, constipation, diarrhoea, stools, haemorrhoids, changes in bowel habits. Genitourinary Renal: Ask history question around: urgency, frequency, dysuria, flank pain, suprapubic pain, nocturia, polyuria, oliguria, colour of urine, stones, infections, nephritis, hernias, maintenance of stream, incontinence. Reproductive: ask if clinically appropriate. Changes in libido, genital lesions, discharge, STI, onset of secondary sexual characteristics, achieving/maintaining an erection, testicular pain or masses TSE, onset of menses, menstrual cycles, date of LMS, PAP smear, dysmenorrhea, menorrhagia, vaginal discharge, post-menopausal bleeding, HRT contraceptive therapy, sexual activity, pregnancy, complications of pregnancy, types of delivery. Breast Ask history question around: breast masses, lumps, lesions, tenderness, swelling, nipple discharge, dimpling, retraction, BSE. Musculoskeletal Ask history question around: pain, swelling, redness, or heat of muscles or joints, bone deformity, limitation of movement, muscular weakness, atrophy and cramps.

Physical (objective) Assessment S:\EAR\Dept of Nursing Midwifery & Allied Health\NursingProgrammes\BN\Health Assessment Framework working group

Weight

Temp

BP

Height

Pulse

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NZEWS:

General Assess general appearance, physical structure, mobility, speech pattern, communication difficulties. Mental health This should be driven by the mental state exam from mental health Appropriate dress, eye contact. How is the patient presenting at the given time. Are they orientated to time, person, and place? Have they got judgement – what would you do if you saw a fire etc? Do they have insight into their mental health status? Integumentary Inspect Colour, Integrity, lesions – location, shape, colour, size Palpate Texture, moisture, temperature, turgor, sensation (two types – at 6 sites, both limbs) CRT HEENT Inspect Head - Note general size and shape, assess shape Neck – Symmetry, General size and contour, Note any deformities Observe facial expression Mouth – lips, teeth and gums, tongue, palate, tonsils Palpate Head and neck, cranial bones, ears, nose, sinus area, ROM, Lymph nodes, trachea, thyroid gland, carotid artery Auscultate Carotid artery Eyes Inspect General eyebrows, eyelids, and lashes, eyeballs, conjunctiva, sclera, palpebral fissures, cornea, lens, PERRLA, cornea light reflect, cardinal points (EOM), Visual fields Confrontation test, Visual acuity, distance and near vision. Palpation of the Lacrimal apparatus Ear Inspection Size and shape of auricle, position and alignment on head, note skin condition, Palpation Check auricle and tragus for tenderness Evaluate external auditory meatus Otoscope examination Neurological: Inspection Alertness, posture, dysmorphic features, hygiene and grooming, affect, attitude, mood, supports/aids, movement, muscles, signs of illness/medical conditions, level of consciousness AVPU/GCS On-going Screening if clinically required CN Assessment: II-XII Motor System: Inspection (size, strength, tone, involuntary movement), Balance test, Gait, Tandem walking, Romberg test, Shallow knee bend.

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Coordination and movement: Rapid alternating movements, finger-to-thumb test, finger-to-nose test, heel-toshin test.

Sensory System: Spinothalamic tract - pain, temperature and light touch Posterior column tract - Turning fork vibrations, position (kinaesthesia) perception of passive movement Tactile discrimination - Stereognosis recognise objects, Graphaesthesia “read” a number, two-point discrimination using a applicators, extinction simultaneously touch both sides of body at same point , point location - touch skin and withdraw stimulus promptly; ask person to put finger where you touched

Reflexes: biceps reflex, triceps reflex, patellar reflex, achilles reflex (‘ankle jerk’) Respiratory Inspection Anterior Chest: Shape and configuration of chest wall, facial expression, level of consciousness, skin colour and condition, quality of breaths, intercostal spaces, accessory muscles. Posterior: Thoracic cage, shape and configuration of chest wall, anteroposterior/transverse diameter, position of person, skin colour and condition. Palpation Anterior Chest: Symmetrical chest expansion. Palpate the anterior chest wall. Posterior Chest: Symmetrical expansion, palpate the entire chest wall, tactile Fremitus Percussion: Posterior chest, diaphragmatic excursion. Auscultation: Anterior, Posterior and lateral chest. Cardiovascular/PV Inspect CV and PV assessments Praecorduim – general Skin, central and peripheral cyanosis, clubbing, diaphoresis, CRT, skin turgor also palpation assessment, arms and legs PV assessment: colour/movement, leg veins, oedema, JVP. Palpate Warmth, radial pulse, ulnar pulse, brachial pulse, femoral pulse*, apical impulse, popliteal pulse, posterior tibial pulse, dorsalis pedis pulse, pretibial oedema Auscultate Carotid artery, auscultate apical area, auscultate the heart sounds. Gastrointestinal Inspect Contour, symmetry, umbilicus, skin, striae, pulsation or movement. Auscultate Bowel Sounds all four quadrants Percussion Over all four quadrants, general tympany, percussion of the liver. Palpate Surface palpation, voluntary guarding, light palpation, deep palpation. Genitourinary – only if clinical appropriate Inspect – external genitalia Skin colour, scars and pubic hair. Anatomy for size, symmetry, developmental milestones. Noting lesion, rashes, skin breaks etc. Inspect urethral opening, vaginal opening, penis, scrotum, perineum and anus. Breast Inspection of breast and axillary area. Palpation of breast and noting for breast masses, lumps, lesions, tenderness, swelling, nipple discharge, dimpling or retraction. S:\EAR\Dept of Nursing Midwifery & Allied Health\NursingProgrammes\BN\Health Assessment Framework working group

Musculoskeletal Inspect GALS (Gait, arms. legs, spine) Insect joints for pain, colour, swelling, masses, warm, crepitus and ROM Palpate all sites for: movement against resistance, Tenderness, swelling, bony prominence, nodules and crepitus Labs/Blood results: U&E, CBC, Coagulation, LFTs, Cardiac Markers, Group and hold, ABGs, MSU, sputum specimen, swaps, blood cultures others Special test: ECG, Xrays, Ultrasound scans, CT Scans, others Urine analysis Patient Education and understanding: Does the patient understand their diagnosis/diagnoses? Does the patient require education around medications, pathology of disease, lifestyle changes and disease/health management post discharge? Discharge Planning: Referral to multidisciplinary teams (MDT). Does the patient require Pharmacology card and medications? Discuss accessibility to follow-up.

Final Assessment Findings (written up using SOAPIE Framework)

Subjective summary: Summary of key subjective findings

Objective summary: Summary of key objective findings

Assessment (Diagnoses) What are the KEY problems/risks for this patient? Actual or potential (see patient example document)

Plan: What are your nursing plans for your shift? These should reflect each of your diagnoses (see patient example document).

Intervention: What are your nursing interventions for your shift? Should relate to your identified nursing diagnoses and your plan (see patient example document).

Evaluation: How will you evaluate the effectiveness of care? Should relate to your identified nursing diagnoses, plan and each intervention (see patient example document).

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