Applying Health Assessment Techniques

Why is it important to develop a morning routine as a nurse?

So you are efficient and do your morning stuff the same every day so you never miss anything

What does a good hospital morning routine look like?

• Receive report at the bedside and be aware of your surroundings

• Collect data and review the information in the chart. Think about how to focus your assessment

• Prioritize who to see first

• Perform individualized shift assessments

• Document everything

What things should you always so at bedside report?

• Have your own personal report sheet ready

• Make eye contact with your patient

• When easy to do so, verify information is correct

• Assess what you can while standing in the room

What are the steps to a general head to toe shift assessment?

• General survey

• Gain room situational awareness

• Ask how they are doing

• Ask orientation questions

• Ask pain 0-10 scale

• Ask what their comfort goal is and what the goal for the day is

• Ask about numbness or tingling

• Assess PERRLA (if they are tracking you around the room you can skip this)

• Ask last BM, last void, and if they have nausea or vomiting

• Inspect skin of chest and abdomen

• Lung auscultation

• Heart auscultation

• Inspect, auscultate, and palpate abdomen

• Inspect skin of back

• Lung auscultation on back

• Inspect skin of extremities

• Palpate tenderness, edema, and temperature of skin

• Inspect nails and capillary refill

• Check radial and pedal pulses

• Check grip strength and plantar/dorsiflexion

• Close with safety check and eduction (make sure bed alarm is on if appropriate, bed in lowest position, patient has call light, no tangles of IVs or wires/lines, tell the patient the game plan and when you will be back, ask if they need anything else)

What is rounding?

Quick checks done on every patient typically every hour if possible and in a normal case

What are the 5 Ps that should be assessed every hourly rounding?

• Pain

• Personal needs

• Position (do they need to turn?)

• Placement (Of lines and tubes)

• Prevent falls

What is a comprehensive assessment?

A full blown assessment with lots of questions about past medical history, family history, problems, symptoms, etc typically done once on admission, but can be done if a new problem arises when they are at the hospital

What is the first things you do for a comprehensive patient assessment when they first arrive on your unit?

• Obtain patients weight with a standing scale if possible

• Place on monitor if applicable

• Help into gown and treaded socks

• Set up IV fluids if applicable

• Take initial set of vital signs

• Ask questions from admit profile

• Do review of systems and perform a head to toe assessment as previously discussed

What are the components and questions in an admit profile?

• Have you traveled outside the country int he last 6 months?

• Do you have any allergies?

• What are you home medications? (verify correct in system)

• ADL screening (do they need walker, hearing aid, glasses, wheelchair, etc(

• Legal caregiver designation

• 6 clicks mobility assessment (Figure out baseline movement)

• CAGE screening (alcohol use)

• Smoking and illicit drug use history

• Suicide screening/Columbia Scale

• Medical/surgical history (go through review of systems here)

• $ex history

• Preferred name/pronouns

• Privacy passwords

• Dysphagia screening (swallow eval)

• Victim of abuse of violence

• Belonging

• Spiritual Screening

• Blood transfusion consent (not everyone accepts blood)

• 4 eyes - 2 RN skin assessment

What questions are required in Nevada to be asked on addition about gender?

• $ex assigned at birth

• Gender identity (how a person sees themselves. Own internal sense and personal experience)

• Gender expression (How a person outwardly shows their gender identity. Such a s masculine, feminine, androgynous, etc

• Pronouns

• Preferred name

What are family of choice?

People who are really close friends that serve the function of family but are not blood related

Are families of choice recognized regarding visitation or decisions for the patient?

They must be recognized for visitation per Medicare/medicaid and the joint commission, however they do not have say over next of kin for medical care decisions unless an power of attorney has been signed to them

What are the assessment types?

• Comprehensive

• Emergency

• Follow up

• Screening

What do you need to do before calling the provider?

• Look over all orders in the EHR (could have orders for potential problems already)

• Perform a focused assessment

• Take a recent set of vitals

• Gather what information the provider might need

• Assess for potential complications

• Have access to the electronic chart during the call in order to answer providers questions

What is telehealth?

The use of technology in order to provide health care when the provider and patient are not in the same place at the same time

What are the 3 types of telehealth?

• Asynchronous (communication between health care team and patient is stored for future reference)

• Synchronous care (Real time interaction via text messaging, phone call, or video call)

• Remote patient monitoring (the use of technology to transmit data from patient device to provide such as blood pressure monitoring, pacemakers, glucose metes, and oximetes)

What is a nurses role with telehealth?

• Tele intake

• Tele triage

• Involve family in rounds in acute care settings

• Post discharge follow ups (monitor adherence to provider orders and teachings)