NSB103 exam

5 areas of breathing assessment

resp rate
depth of resps
patterns of resps
lung sounds
O2 sat

Disability

pupil response
LOC
muscle strength

Exposure

Body temp
general survey - head to toe assessment
treatments in progress

Secondary survey

head to toe assessment
taking focused medical history
full set of vitals
assess and compare bilaterally

General survey

Physical presence
- general appearance
- body fat
- stated age vs apparent age
- motor activity
- breath and body odours

Psychological presence
- dress, grooming, personal hygiene
- mood and manner
- speech
- facial expressions
- pain, distress

3 stages of health assessment interviewing

Stage 1 - joining stage
Introduction to the interview, nurse and person establish trust and get to know each other.
Introduce yourself and state the role and the purpose of the interview

Stage 2 - working stage
Is the time when the bulk of the patient data is collected.
Ensure the person knows why you are collecting data

Stage 3 - termination stage
Information is summarised and validated.
Look at options or next things to be done

General approach to health assessment interview

gather patient information
present professional appearance
ensure appropriate setting
SOLER
ensure patient is comfortable
build rapport before intimate questions
remind of confidentiality

Social history

Understand patient supports to see what support to give
Explain reason - sensitive topics
Alcohol/drug use, sexual activity, domestic/partner violence

Holistic health assessment

social, spiritual, cultural, psychological implications

AIDET framework

Acknowledge
Introduce
Duration
Explanation
Thank you

Facilitative communication

patient in control

clarifying, paraphrasing, using silence, sharing observations, active listening

SOLER

Sit squarely
Open posture
Leaning forwards
Eye contact
Relaxed posture

Aged care quality standards

1. Consumer dignity and choice
2. Ongoing assessment and planning with consumers
3. Personal care and clinical care
4. Services and supports for daily living
5. Organisation's service environment
6. Feedback and complaints
7. Human resources
8. Organisational governance

health issues experienced by older adults

falls
impaired cognition
urinary incontinence
constipation
pain
skin compromise

Paediatric triangle

rapid assessment of children

appearance
work of breathing
circulation

Children assessment considerations

- resp rate varies with age
- poorly developed intercostals, flat diaphragm
- rapid HR to maintain cardiac output
- use parent/carer impression (e.g. with pain)

ISBAR

Identify
Situation
Background
Assessment
Recomendation

BD

twice daily

QID

four times a day

NRS

Numerical Rating Scale (0-10)

2/24

over 2 hours

4/24

over 4 hours

semi fowler's

patient in supine position, 30-45 degrees

CVA

cerebrovascular accident (stroke)

GCS

Glasgow Coma Scale

Cephalocaudal

head to toe

FBC

full blood count

PUIT

passed urine in toilet

Void

to urinate

BO

Bowels open

Flatus

Gas in the intestinal tract or gas passed through the anus

LLQ

left lower quadrant

PRN

taken as needed

Primary survey

Airway
Breathing
Circulation
Disability
Exposure

Airway

patient - chest rise and fall, feel breath, talking

Partial obstructions - struggled resps, snoring, gurging

Complete obstructions - respiratory arrest

Breathing

reliant on airway
requires effective ventilation

Circulation

rate, rhythm, strength, equality
blood pressure
capillary refill
skin colour
heart sounds

AVPU

Assess LOC

Awake
Verbal
Pain
Unresponsive

PEARL

Assess pupil response

Pupils equal and reactive to light

Clinical reasoning cycle (CRC)

Evaluate and manage a patients medical problem
8 phases

1. Consider patient situation
2. collect cues and information
3. Process information
4. identify problems/issues
5. establish goals
6. take action
7. evaluate outcomes
8. reflect on process and new learning

CRC phase 1

Consider the patient situation

Describe or list facts, context, objects, etc.

CRC phase 2

Collect cues ( piece of information/data) and information

Review, gather, recall
Subjective (patients point of view) and objective (observable and measurable) data
After review (e.g. patient documentation, clinical documentation), gather new info - subjective or objective

CRC phase 3

Process information

Interpret - analyse/compare (normal or abnormal)
Discriminate - between relevant and irrelevant info, recognise gaps in data
Relate - look for patterns
Infer - make deductions/ form logical opinions

Therapeutic communication

Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship.

- goal directed
- listen to understand
- fully present with patient

Authoritative communication

you are in control

providing information, focusing, confronting, suggestive, advising

mechanisms of disability

physiological
- trauma
- chronic disease
- aging

Psychological
- mental illness
- brain injury

Social
- spoken language
- social interaction

Biopsychological
- combination of all 3

Assessment of children

engage parents
relax child
look before touching
appropriate concepts and language for age
least invasive first

TDS

three times a day

Mane

morning

Nocte

night

high fowler's

patient seated upright, spine straight

PI

Perfusion index
(ratio of pulsatile blood flow to non-pulsatile blood flow in peripheral tissues)

PU

passed urine

MSU

midstream specimen of urine (tested for infection)

BNO

Bowels not open

BWO

Bowels well open

RUQ

right upper quadrant

PR

per rectum

PO

by mouth

sublingual

under the tongue

Febrile

fever

4 physical assessment techniques

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

order of physical assessment for abdominal assessment

1. inspection
2. Auscultation
3. Percussion
4. Palpation

- touching abdomen can change bowel sounds

Inspection

General observation of the whole body, then specific body systems
Assess symmetry
Use senses (visual, smell, hearing)

Palpation

Use different parts of hand to feel body
Light palpation (1cm) followed by deeper palpation
Bimanual (both hands to capture organ)

Percussion

Yielding a palpable vibration
Tapping on part body for sound or pain
Elites pain if inflammation present

Auscultation

Listening with stethascope

Diaphragm - high pitched sounds (breath, bowel, normal heart sounds)
Bell - low pitched/soft sounds (extra heart sounds, murmurs)

5 moments of hand hygiene

1. Before touching a patient
2. Before a procedure
3. After a procedure or body fluid exposure risk
4. After touching a patient
5. After touching a patient's surroundings

Preparing for physical assessment

- communication
- review baseline data + medical history
- perform hand hygiene
- maintain privacy
- prepare environment
- ensure access to patient, patient in appropriate position
- warm all equipment
- if fatigued, continue later

After physical assessment

- thank patient and thoroughly document findings
- determine frequency of assessment based on findings

Assessment of urination

- frequency
- volume
- concentration
- odour
- consistency
- pain
- continence
- specific gravity

Problems with urinary system

mechanical injury (kidney)
infection and inflammation
blockage (tumours, renal calculi)

Fluid balance chart

Includes all intake and output over a 24-hour period, and the 24-hour fluid balance (fluid excess or fluid deficit)

looking for positive balance (more in than out)

Cardiovascular assessment

General survey
Primary survey (circulation)
Vital signs (manual BP, radial pulse)
Inspection
Palpation
Auscultation
ECG
Observe and record urine output and other fluid losses

CV assessment - inspection

skin colour, pallor
peripheral vessels
oedema
work of breathing
lethargic, alert, disorientated

CV assessment - palpation

light palaption

- capillary refill
- texture, moisture, warmth, tenderness, fluid
- neurovascular observation (changes in sensation, circulation, presence of pain)

CV assessment - Auscultation

Listening for heart sounds and murmurs

S1 - closure, mitral and tricuspid valve, loudest at apex
S2 - closure, aortic and pulmonary valve, loudest at base

ECG

electrocardiogram

- rhythm should be regular
- PQRST complex

P wave

atrial depolarization (atria contract)

QRS complex

ventricular depolarization (ventricles contract) and atrial repolarization (atria relax)

T wave

ventricular repolarization (ventricles relax)

Systolic blood pressure

highest pressure measured in arteries during peak ventricular contraction

Diastolic blood pressure

lowest pressure measured in arteries during ventricular relaxation

Neurological assessment

Subjective data
- health history
- altered sensation/function
- pain
- dizziness, seizures
- head injury/surgery
- medication/drug use

Objective data
- inspection
- CNS
- PNS

Objective data

Data directly observed/gathered by the health professional

Subjective data

Information or perspectives from the patient based on opinions, perceptions and experiences

Neurological assessment - inspection

alertness
symmetry
trauma
colour/texture
lesions/scars

CNS assessment

Mental status
- LOC (GCS)

Cranial nerves
- symmetry of face
- smile
- poke out tongue
- puff cheeks

PNS assessment

motor system (strength, equal movement of peripheries)
sensory systems (sensation)
reflexes

Neurological assessment tools

GCS
motor response (strength left vs right)
PEARL
Vital signs

Cognition

the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.

neuroplasticity

the ability of the nervous system to change in response to experience or the environment

Memory

Short term - access quickly, prefrontal cortex

Long term - moved from short term memmory

MMSE

mini-mental state examination

3 parts to GCS

eyes opening, best verbal response, best motor response

Delirium

Disorientation to time, person and place

sudden onset

treatable

Dementia

Disorientation to time, person and place

progresses over time

Incurable

CNS and PNS communication assessment

Motor response
- strength in peripheries
- symmetry
- squeeze hands, push hands away with feet

olfactory nerve

smell

optic nerve

vision