Fundamental Tools and Assessments

ADPIE

Assessment

Diagnosis

Planning

Intervention

Evaluation

ISBAR

Identity

Situation

Background

Assessment

Recommendation

SOAPIE

Subjective

Objective

Assessment

Plan

Intervention

Evaluation

PQRST pain assessment

P - provocations (what brings pain on),

Q - quality or quantity of pain (how long it lasts),

R - region, radiation,

S - severity,

T - timing (when it started, how long it lasts, does anything cause it)

COLDSPA pain assessment

C - character,

O - onset (when did it begin?),

L - location (where is it?),

D - duration (how long does it last?),

S - severity (how bad is it?),

P - pattern (what makes it better or worse?),

A - associated factors (what makes symptoms occur)

FLACC

Face, Legs, Activity, Cry, Consolability

FLACC score of 1-3

Indicates mild discomfort

FLACC score of 4-6

Indicates moderate pain

FLACC score of 7-10

Indicates severe discomfort/pain

Te Whare Tapa Wha

Holistic Maori model of health that encompasses spiritual, mental/emotional, family/social and physical health

Ottawa Charter

Developed by WHO to address the determinants of health

Ottawa charter action areas

• Building healthy public policy

• Creating supportive environments

• Strengthening community action

• Developing personal skills

• Reorientating health services

Integumentary assessment

Assesses:

• Rashes

• Skin turgor

• Warmth

• Dryness

• Colour

Neurological assessment

Assesses:

• AVPU

• GCS - Verbal reponse, Eye opening, Motor response

• Behaviour changes

• Slurred speech

• Facial drooping

• Hemiplegia

Cardiovascular assessment

Assesses:

• Heart rate and rhythm

• Blood pressure

• Oedema,

• Skin signs of CVS concern (i.e. cyanosis)

• Peripheral pulses

• Heart sounds

• Capillary refill (peripheral and central)

Respiratory assessment

Assesses:

• Work of breathing

• Accessory muscle use

• Respiratory rate

• Bilaterally equal chest rise and fall

• Lung sounds

• SpO2

• Cyanosis

Gastrointestinal assessment

Assesses

• Bowel sounds

• Bowel movements e.g. types, frequency

• Abdomen distended

• Painful/tender abdomen

Genitourinary assessment

Assesses

• Urinary concerns

• Hydration

• Urination frequency and urgency

• Pain

• Oliguria

• Hematuria

Musculoskeletal assessment

Assesses

• Muscle wastage

• Weakness

• Mobility issues

• Pain

• Falls risk

A-E assessment

A - airway,

B - breathing,

C - circulation,

D - disability,

E - exposure

IPPA approach

I - inspection (what can we see?),

P - palpitation (what can we feel?),

P - percussion (what can we hear through listening and feeling?),

A - auscultation (what can we hear?)

Child Health Assessment - ABCDEENTTTUDEFG

• Airway

• Breathing

• Circulation

• Disability (neurological state)

• Exposure (examine top to toe, infections)

• ENT (ear nose throat)

• Temperature

• Tummy (soft, distended, tender)

• Urinalysis/urine output (intake vs. output)

• DEFG (don't ever forget glucose).

Adolescent Health Assessment - HEEADSSS

• Home (home situation, family life, relationships, stability)

• Education/employment (sense of belonging, relationships, performance, bullying)

• Eating/exercise (how they look after themselves, eating and sleeping patterns)

• Activities and peer relationships (relationships, risk-taking behavior, attitudes about themselves)

• Drug use/cigarettes

• Sexuality (knowledge, understanding, experiencing, gender identity, sexual orientation and practices)

• Suicide/self-harm (depression, risk of mental health problems, strategies for coping, support)

• Safety (risk-taking behavior, environment).

Wound Assessment

• Contributing factors that may impair healing e.g. diabetes

• Pain

• Tissue type (Necrotic, Granulation tissue, Yellow slough, Epithelizing)

• Exudate type/amount (Serous, Purulent, Haemopurulent)

• Malodour

• Wound size

• Surrounding skin (Macerated, intact)