person centred care all info

Safety in Healthcare

  • Two main aspects:
    • Patient safety
    • Healthcare worker safety (Occupational Health and Safety, OH&S)

Patient Safety

  • Defined as avoiding or reducing actual or potential harm from healthcare organizations or environments to acceptable limits.
  • Healthcare organizations should:
    • Create and maintain a safe environment.
    • Deliver professional, quality care.
    • Assess factors affecting safety.
    • Minimize risks to the patient.
  • Influenced by:
    • Age
    • Lifestyle
    • Sensory and perceptual alterations
    • Mobility
    • Emotional state
    • Culture
    • Staffing

Person-Centred Care

  • Considers preferences, needs, and values of patients.
  • Care should be respectful and responsive.
  • Foundation for safe, high-quality care.
  • Australian Commission on Safety and Quality in Health Care (2021a) states:
    • Focus on patient-centered care leads to better outcomes, experiences, and value.

National Safety and Quality Healthcare Service (NSQHS) Standards

  • Developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) in collaboration with government, providers, experts, clients, and carers.
  • Provide a nationally consistent statement on expected care levels to protect the public and improve quality.
  • There are eight (8) standards:
    1. Clinical Governance
    2. Partnering with Consumers
    3. Preventing and Controlling Infections
    4. Medication Safety
    5. Comprehensive Care
    6. Communicating for Safety
    7. Blood Management
    8. Recognizing and Responding to Acute Deterioration
  • Healthcare organizations are regularly assessed against these national standards.

NSQHS Standard Three (3) and Occupational Health and Safety

  • Strongly intertwined as nurses face workplace hazards:
    • Contact dermatitis
    • Latex allergies
    • Blood-borne pathogens
    • Work-related back pain (Musculoskeletal disorders)
    • Environmental, chemical, and/or medication exposures
    • Violence, bullying, and harassment
  • Awareness of hazards is important for consistent assessment and contribution to workplace safety.
  • Student nurses should:
    • Report exposures to immediate supervisor.
    • Document what occurred.
    • Follow organizational policies and procedures.
    • Fill in a RiskMan or similar risk assessment for incident reporting.

Chain of Infection

  • Infection control involves more than just hand washing.
  • Nurses protect individuals by using infection control practices.
  • Understanding required:
    • Types of infections
    • Modes of transmission
    • Risks for susceptibility
    • Interactions between hosts and environments
    • Infection control practices and how they control or eliminate sources of infection.

Chain of Infection Explained

  • Transmission of infectious agents requires a series of interlinked events.
  • 6 elements of the chain of infection:
    1. Infectious agent (pathogen):
      • Microorganisms, viruses, bacteria, fungi, protozoa, germs or bugs.
      • Transmitted during health care.
    2. Reservoir:
      • Where microorganisms live or survive.
      • Includes individuals, contaminated food or water, or a fomite.
      • Fomites: Inanimate objects carrying microorganisms, e.g., medical equipment, clothing, soiled linen, wound dressings, keys, pens.
    3. Portal of exit:
      • Path by which infectious agent leaves the host.
      • Usually the site where the infectious agent is localized.
      • Examples: mouth/nose (droplets), anus (diarrhea), wound site (blood or pus).
    4. Means of transmission:
      • How the infectious agent is transmitted from reservoir to a susceptible host.
      • Can be via contact, droplet, and airborne transmission.
    5. Portal of entry:
      • Way an infectious agent enters a susceptible host.
      • Often the same way it left the source host.
      • Examples: nose (inhalation), mouth (ingestion), breaks in skin (exposure to fluids).
    6. Susceptible host:
      • Individual who may become infected after exposure.
      • Factors influencing susceptibility:
        • Age
        • Comorbidities (two or more diseases)
        • Previous and recent care in a health facility
        • Invasive medical devices (IVC, breathing tube)
        • Immune status (immunosuppression, disease, exposure, pregnancy, age, vaccination status)

Healthcare Associated Infections (HAIs)

  • New infection acquired in the hospital.
  • Can lead to:
    • Longer hospital stays
    • Increased sickness
    • Need for higher level care
    • In worst cases, death
  • Healthcare staff can reduce HAIs by breaking the chain of infection:
    • Hand hygiene
    • PPE
    • Cleaning and sanitizing surfaces

Preventing and Controlling Infections - National Standard

  • Standard 3 focuses on:
    • Reducing the risk of preventable infections.
    • Effectively managing infections.
    • Preventing and containing antimicrobial resistance.
    • Promoting appropriate use of infection control resources.
  • Highlights the use of evidence-based systems to mitigate risk.
  • Strategies relevant to nursing:
    • Prompt identification of suspected infection
    • Standard and transmission-based precautions
    • Hand hygiene
    • Aseptic technique
    • Workforce immunization policies
    • Clean, hygienic and safe environment

Infection Control Precautions

  • Work practices to reduce transmission risk.
  • Different precautions used in healthcare.
    • It is important that you are familiar with these precautions when working across different health care organisations.

Standard Precautions

  • First line approach, used for all patients.
  • Practices:
    • Hand hygiene
    • PPE
    • Safe sharps disposal
    • Routine cleaning
    • Reprocessing equipment
    • Respiratory hygiene/cough etiquette
    • Aseptic technique (ANTT)
    • Appropriate waste and linen management
  • Handle contaminated items to prevent transmission.

Transmission-Based Precautions

  • Additional practices when standard precautions are insufficient.
  • Implemented during outbreaks (gastroenteritis, pandemics like COVID-19).
  • Tailored to infectious agent and transmission mode, using a combination of practices.
  • May be referred to as isolation precautions.
  • Three categories:
    • Contact Precautions
    • Droplet Precautions
    • Airborne Precautions
  • Signage should be visible to indicate which transmission-based precautions are in place.

Contact Precautions

  • Implemented when there is a known or suspected risk of direct or indirect transmission of infectious agents.
  • May be implemented for infections such as:
    • Gastroenteritis,
    • Contagious skin infections; or
    • Other infectious agents that are transmitted via contact.
  • Practices, in addition to standard precautions, include:
    • The requirement of all staff and visitors to perform hand hygiene and use PPE on entering the patient's room
    • Group people with the same infectious agent if possible (cohort)
    • Preferably allocation of a single room if possible
    • Immediate and appropriate waste disposal on leaving room
    • Appropriate environmental cleaning (disinfectants)
    • Patient dedicated equipment where possible
    • Restriction of visitors (though not strict)
    • Closed door
    • Signage on door to indicate transmission based precautions in place.

Droplet Precautions

  • Implemented when there is a known or suspected risk of transmission of infectious agents over short distances by large respiratory droplets
  • These large respiratory droplets are expelled from the reservoir (infected patient) by sneezing, coughing or talking, and come into contact with the susceptible host's eyes, nose or mouth (mucosa) either directly or via contaminated hands.
  • Droplet precautions may be implemented for respiratory tract infections such as:
    • Influenza (the flu)
    • Pertussis (whooping cough)
    • Meningococcus; or
    • Other infectious agents that are transmitted via coughing or sneezing.
  • Practices, in addition to standard precautions, include:
    • The requirement of all staff and visitors to perform hand hygiene and use PPE on entering the patient's room
    • Use of a surgical mask and protective eyewear
    • Group people with the same infectious agent (cohort) or maintain one meter distance
    • Preferably allocation of a single room if possible
    • Immediate and appropriate waste disposal on leaving room
    • Appropriate environmental cleaning (disinfectants)
    • Patient dedicated equipment where possible
    • Restriction of visitors
    • Closed door
    • Signage on door to indicate transmission based precautions in place.

Airborne Precautions

  • Implemented when there is a known or suspected risk of transmission of infectious agents from person to person by the airborne route
  • This means that the infectious agent can be inhaled by susceptible hosts (health care workers, other patients or visitors).
  • Airborne precautions may be implemented for infections such as:
    • Tuberculous
    • Varicella
    • Measles
    • Severe acute respiratory syndrome (SARS)
    • COVID-19; or
    • Other infectious agents that are transmitted via the airborne route.
  • Practices, in addition to standard precautions, include:
    • The requirement of all staff and visitors to perform hand hygiene and use PPE on entering the patient's room
    • Use of N95 mask
    • Allocation of a single room
    • Negative air pressure room
    • Immediate and appropriate waste disposal on leaving room
    • Appropriate environmental cleaning (disinfectants)
    • Patient dedicated equipment where possible
    • Restriction of visitors
    • Closed door

Hand Hygiene

  • Single most important strategy for preventing infection transmission.
  • Refers to:
    • Hand washing with soap and water, or
    • Using alcohol-based hand rubs (ABHR)
  • Use soap and water if hands are visibly soiled.
  • 5 Moments of Hand Hygiene:
    • Before touching a patient
    • Before a procedure
    • After a procedure or body substance exposure risk
    • After touching a patient
    • After touching a patient's surroundings
  • Also includes performing hand hygiene before putting on gloves, and after removing gloves.
  • Lead by example, remind colleagues, patients, and visitors about hand hygiene.
  • Clinical areas: 'bare below the elbows', limited jewelry, short/clean nails.

Hand Washing Techniques

  • Routine/Social:
    • Minimum 15 seconds with non-antimicrobial soap and water
  • Aseptic/Clinical:
    • Minimum 15 seconds with soap containing an antiseptic agent
  • Surgical:
    • Antiseptic handwash preoperatively, longer with attention to specific areas, may use a scrubbing brush

Personal Protective Equipment (PPE)

  • Worn to prevent microorganism transmission.
  • Integral component of both standard and transmission based precautions.
  • Also protects against contact, spray or splash injuries from hazardous medications and chemicals.
  • Includes:
    • Aprons
    • Gowns
    • Shoe/leg coverings
    • Hair caps
    • Gloves
    • Surgical or P2/N95 masks
    • Protective eyewear
    • Face shields
  • Selection based on patient interaction, infectious agent, and transmission mode.
  • Sequence for donning and doffing PPE is strict.
  • Donning: hand hygiene, gown, mask, eye/face protection, gloves
  • Doffing: hand hygiene after each item; gloves, eye/face protection, gown, mask.

Reflection: A Tool For Professional Learning

  • Reflection and reflective practice are essential for maintaining knowledge, skills, and competence as a registered nurse.
  • Reflection helps nurses to make informed decisions and consider alternative actions.
  • Using reflection as a student nurse is important to help you learn, acknowledge your feelings and process emotions following new, difficult or distressing events.
  • Reflective practice and professional reflection takes time to develop and may not come easily or naturally at first.
  • Various tools and models to structure the reflective process, the reflective cycle by Gibbs (1988) will be used and referred too.

Gibbs Reflective Cycle

  • Gibbs (1988) proposed a reflective cycle with six (6) components
  • This reflective cycle can be used during clinical placement, during planning and writing assignments, with group work and once you are a registered nurse and working independently.
Description
  • The description is limited to the most important points in relation to what happened.
  • Focus on the most important issues.
  • Helpful Questions to Consider:
    • What happened?
    • When and where did it happen?
    • Who was present?
    • What did you and the other people do?
    • What was the outcome of the situation?
    • Why were you there?
    • What did you want to happen?
  • Example:
    • On my first day at work as a graduate nurse, my buddy nurse and I were asked to help care for a patient in isolation with a suspected contagious respiratory illness. As I was passing the patient room, through the closed glass doors I saw the patient fall as they got out of bed. I rushed into the room to help the patient, and I forgot to undertake hand hygiene or don the correct personal protective equipment (PPE) before entering the room.
Feelings
  • What feelings did you experience during or after this experience or event, what thoughts do you have in relation to the experience?
  • Reflect on how these feelings may have impacted the experience.
  • Do not be ashamed of these feelings or emotions, as student nurses and throughout your nursing career, you will experience a range of emotions in relation to patient events and experiences.
  • Helpful Questions to Consider:
    • What were you feeling during the situation?
    • What were you feeling before and after the situation?
    • What do you think other people feel about the situation now?
    • What were you thinking during the situation?
    • What do you think about the situation now?
  • Example:
    • I was extremely shocked to see the patient fall and scared that they had injured themselves, so I ran into the room to help them without thinking about my own personal safety. When I realised I did not have the correct PPE on, or that I hadn’t used the hand rub, I was worried that I would get into trouble for doing the wrong thing. I was also scared that I might get sick as the patient was coughing towards me without covering their mouth.
Evaluation
  • Consider what the main issues were during the experience or situation, or what worked, and what did not work.
  • Be as honest and objective as possible, and consider the negative and positive aspects of the situation.
  • Helpful Questions to Consider:
    • What was good and bad?
    • What went well?
    • What did not go so well?
    • How or what did you and other people contribute to the experience? This can be a negative or a positive contribution.
  • Example:
    • The incident was extremely challenging for me. It was my first day, I was nervous about giving a good impression and I acted quickly without thinking about my own safety. I was concerned for the patient’s safety and that they may have hurt themselves, and did not consider my own safety and the possibility of droplet or airborne disease transmission. I knew you needed PPE to enter the room, but in my haste, I forgot to don the correct PPE.
Analysis
  • Make sense of what happened but analysing the aspects in greater detail.
  • Extract meaning from the experience by considering the different aspects that went well or did not go so well, and ask yourself why.
  • Helpful Questions to Consider:
    • Why did things go well?
    • Why did it not go well?
    • What sense can I make of the situation/experience?
    • What knowledge, either your own or others, can help me to understand the experience. refer to academic literature to support your understanding
  • In this section you would research the importance of PPE, patient isolation and transmission-based precautions, and use the information from your research to discuss what you have found about the topics relevant to this event.
Conclusion
  • Summarise what you have learnt about the experience. Consider what else you could have done, including alternative actions, that may improve outcomes with similar experiences in the future.
  • Helpful Questions to Consider:
    • What did I learn from this experience?
    • How could this have been a more positive experience for everyone involved?
    • What skills do I need to develop to allow me to handle a similar experience in a more positive way?
    • What else could I have done during this experience?
  • Example:
    • Looking back on this incident, I realise that I would have had time to undertake hand hygiene and don PPE before entering the room. I previously worked as a personal care attendant and registered undergraduate student of nursing (RUSON) and know how to correctly don and doff PPE. I debriefed with my buddy nurse, and they assured me that it can be difficult to take the time to don PPE when you can see, and know, a patient may be unsafe or have injured themselves. However, they assured me that it is important that I consider my own safety first, before providing aid to others.
Action Plan
  • Develop a plan to use in a similar experience in the future, based on your reflection and positive improvements.
  • Consider how you will help yourself to act differently.
  • Helpful Questions to Consider:
    • If I had to do the same thing again, what would I do differently?
    • How will I develop the required skills I need?
    • How can I make sure that I can act differently next time?
  • Example:
    • In future, I will be more careful to undertake hand hygiene and put on the correct PPE (if required) before entering a patient’s room. I have learnt that even senior nurses find it difficult to not rush directly to help patients before undertaking hand hygiene, and before putting on PPE if the patient is in isolation. I will review the hospital’s isolation guidelines and policies and undertake the hand hygiene learning module within the next 2 months to refresh my knowledge and understanding.

Clinical Reasoning and Critical Thinking

  • Consider the patient situation
  • Collect cues/information
  • Process information
  • Identify problems/issues
  • Establish goals
  • Take action
  • Evaluate outcomes
  • Reflect on process and new learning

Critical Thinking

  • A complex process which underpins clinical reasoning; clinical reasoning is dependent on critical thinking.
  • The process of analysing and assessing with a view to improving knowledge and skills, and is used to make decisions.
  • Purposeful, careful and deliberate, and should be undertaken with a fair and open mind.
  • Lies on clinical reasoning.
  • Is also the foundation for providing individualised person-centred care.

Person-Centred Practice

  • Care provided according to the patient's individual needs, and not based on a task-orientated approach, or treating the patient as a 'condition' or 'illness' that needs to be fixed.
  • Care is focused on the individual according to their health needs and priorities, but also takes into account their age, gender, culture, religion and family and/or significant others.
  • Using person-centred care provides individuality and autonomy for the patient, and helps to develop trust and respect between the patient and clinicians.
  • Includes:
    • Providing health information in easy to understand and engaging formats such as print, apps and online,
    • Asking patients about their individual needs, preferences and goals, and documenting these,
    • Encouraging patient questions, and prompting patients for questions,
    • Providing education that is specific to each patient to allow them to support self- management, and
    • Providing consumers (patients/clients/individuals) with open access to their healthcare record.
  • Evidence to show that person-centred care can improve safety, quality and cost-effectiveness of health care.

Communication

  • Effective communication is essential for the delivery of safe patient care.
  • The Australian Commission on Safety and Quality in Health Care has developed Standard 6 Communicating for Safety.

Communicating for Safety Standard

  • Recognizes the importance of effective communication.
  • Supports continuous and safe patient care.
  • Addressed:
    • Correct Identification and procedure matching
    • Clinical Handover
    • Communication of Critical Information
    • Documentation of Information

Importance of Communication

  • Nursing communication is a dynamic, continuous and multidimensional process for sharing information as determined by standards and policies.
  • An expectation that nurses are effective communicators is embedded into standards of practice for nurses.
  • Effective communication is essential in providing person-centred care and maintaining therapeutic relationships.
  • Elements of professional communication:
    • Privacy
    • Confidentiality
    • Trustworthiness
    • Respect, and
    • Courtesy.

Correct Identification and Procedure Matching

  • Communication is required to correctly identify patients and match patients to their intended care or treatment.
  • All patients admitted to hospital must have an identification band, normally placed on a wrist.
  • Information needed:
    • Full name
    • Date of birth
    • Address
    • Unique Registration Number, also known as URN or UR number.
  • At least three (3) approved patient identifiers are required each time identification occurs.
  • The wrist band is white for patients without any alerts or allergies, while a red wrist band is used for patients with allergies or alerts.
  • Checking a patient's identification can often be seen as routine, or unimportant, it is a powerful defence against making simple mistakes.

Clinical Handover

  • Occurs when you transfer the care of a patient to another person, and generally occurs at the start and end of your shift.
  • Should include review of the medication chart, a visual inspection of the patient and any invasive medical devices, wounds, wound dressings and/or skin assessment.
  • Clinical handover is the transfer of professional responsibility and accountability for a patient, or a group of patients, to another person.
  • Must be clear, organised, involve all relevant clinicians and should be standardised.
  • Handover is important for continuity of care and patient safety.
  • Using a structured or standardised approach to handover reduces communication errors and improves patient safety.

ISBAR

  • A standardised format to ensure all relevant and vital information is included in the handover, and it can be used for more than just a clinical handover at the start or end of a shift.
  • Stands for:
    • I - introduction: you introduce yourself to the patient
    • S - situation: a short summary outlining the patient situation, why they have presented to the healthcare service and any other facts. Any allergies or infectious status should also be provided here.
    • B - background: the patient's health background, which may also include family history, current situation, psychosocial issues or any other relevant information
    • A - assessment: this is where you assess the patient's current problem or needs based on the information you have collected and/or presented within your handover.
    • R - recommendation: this is where you recommend nursing care or any interventions for the next nurse to undertake on their shift

Communication of Critical Information

  • Communication of critical information is closely linked to clinical handover, and to recognising and responding to acute deterioration.
  • Critical information may include:
    • New diagnostic or test results that require a change to care
    • Changes in the patient's physical or psychological condition (including deterioration)
    • Errors in diagnosis
    • Missed review of test results
    • Predetermined alerts and triggers
  • It’s not important at this stage of your learning that you memorise the deterioration ISBAR format, but it is useful for you to be aware of it for use when communicating critical information

Documentation

  • Essential component of effective communication.
  • Intent: relevant, accurate, complete, and up-to-date.
  • Contemporaneous means "existing at, or occurring in the same period of time".
  • Documentation should occur at the same time, or soon after, the patient event happened.
  • Nursing responsibility: document vital signs and assessment findings.
  • Reporting: prioritize and report findings needing immediate action.
  • Nurses must comply with hospital's documentation requirements.

Documentation Requirements

  • Different health care organizations will have the same forms, such as the observation chart
  • The observation chart, or vital signs form, which you will be using in the clinical nursing laboratories was standardised across Australia in the year 2012.
  • The progress notes - encourage you to read as many health records and progress notes as possible when on placement to develop your understanding

Objective and Subjective Information

  • Documentation should reflect the objective and subjective data obtained during the examination and assessment of the patient and their current condition, as well as from interactions with the patient throughout your shift.

Medico-Legal Requirements

  • Handwriting MUST be LEGIBLE
  • Use black or blue ink only
  • Date format dd/mm/yy and timed using the 24- hour clock
  • If you make an error, you should draw a single line through the written information, write error and initial the error
  • No blank areas in progress notes, if there are, they should have a line drawn through them
  • Only use acceptable abbreviations
  • Should be contemporaneous
  • MUST be signed, with a printed name and designation
  • Progress notes should be dated and timed

Abbreviations

  • Abbreviations within documentation are considered appropriate.
  • Ensure that you only use acceptable and correct abbreviations, and these may vary between different health care organisations.
  • In some instances the same abbreviation can have a different meaning dependent of the environment or discipline.

Digital or Electronic Documentation

  • Digital health has become a vital part of a modern, accessible health care system designed to meet the needs of all Australians.
  • The National Digital Health Strategy and Framework for Action will be implemented in Australia. The framework highlights the evidence-based clinical and economic benefits of evolving health and care to meet the needs of modern Australia.

Assessment Overview

  • Physical assessment is performed in all health care settings, on people of all ages, in order to gather comprehensive objective data and provide a complete picture of the person's physiological functioning.
  • Used to make valuable clinical decisions.
  • Objective data: is observable and measurable data. It can be obtained through physical assessment and includes vital signs, bowel sounds and gait.
  • Subjective data: includes feelings, perceptions and concerns of the patient, and is gathered through therapeutic communication and the health assessment interview. It includes data such as a pain scores, dietary choices and how the patient is 'feeling'.

Physical Assessment Purpose

  • Often it is assumed that physical assessment only occurs on initial admission, or when a patient's condition deteriorates.
  • A physical assessment should be performed at least once a shift by nursing staff to assist in recognition of any deterioration, and to evaluate the effectiveness of treatments and interventions.
  • A physical assessment provides:
    • direct observation of the patient to recognize any deviations from normal
    • validation of subjective data provided by the patient or their family, during the health assessment interview
    • objective data, including baseline observations

Initial Assessment

  • Learn to start your initial assessment when you first have contact with a patient.
  • For example, consider the following:
    • Does the person look sick?
    • How does the person move?
    • Is the person avoiding eye contact, or do they appear withdrawn?
    • Can you smell anything unusual?
    • Is the patient dressed appropriately?
    • Do they answer your questions appropriately?
  • Use your observation skills to collect cues about the patient, and also assess for any risks about patient safety at the same time.

Physical Assessment Considerations

  • Be organised, remain calm and be competent in your physical examination skills.
  • It is important to be prepared, calm, and follow a systematic process.
  • Introduce yourself to the patient, and you MUST gain consent before undertaking any patient assessment - explain to your patient what you intend to do.
  • Environment - Preparation of the environment is equally important as the preparation of the patient
    • Ensure it is undertaken in a room that will provide privacy, with minimal or no interruptions,
    • The room is at a suitable temperature for the patient,
    • Lighting is appropriate,
    • There is minimal noise to allow clear communication and accurate auscultation, and
    • There is an appropriate bed, chair or examination table for the patient.
  • Equipment
    • A stethoscope
    • A sphygmomanometer and appropriate-sized blood pressure cuff
    • Pulse oximeter
    • Penlight
    • Thermometer
    • A watch or clock with a second-hand
    • Relevant documentation charts
    • Alcohol-based hand rub
    • Any PPE that you may need

Systematic Assessments

  • Primary the ABCDE approach, and HIPPA.
  • Several types of physical assessment, all which use a systematic approach, and you may find slight variations within the texts.
  • 4 main categories based on the prescribed textbooks:
    • Primary assessment (ABCDE and HIPPA approach),
    • Secondary assessment
    • Comprehensive assessment,
    • Focused assessment, and
    • Ongoing assessment.
Primary Assessment
  • Primary assessment follows the ABCDE approach, or Airway, Breathing, Circulation, Disability and Exposure
    • Assess airway patency
    • Measure respiratory rate Evaluate work of breathing (depth, rhythm and quality) Measure oxygen saturation
      Airway
    • Palpate pulse rate, rhythm and quality Measure blood pressure Assess urine output
      Breathing
    • Assess level of consciousness (AVPU and/or GCS) Evaluate speech Assess for pain
      Circulation
    • Measure body temperature Inspect skin integrity Inspect and palpate skin for signs of pressure injury Observe any wounds, dressings, drains or invasive lines Observe ability to transfer and mobilise Assess bowel movements
      Disability
HIPPA

Exposure the HIPPA acronym, which allows for a systematic physical assessment and is based on sensory ordering. This sensory ordering incorporates the nurse using their visual (seeing), auditory (hearing), tactile (touch) and olfactory (smell) senses.

  • Inspection involves a careful visual observation and should commence when you first see the patient.
  • Palpation and percussion are more advanced techniques,
  • Auscultation is an important skill to have as a nurse and requires practice and more practice.

Other Types of Assessments

Comprehensive Assessment
  • A thorough assessment that is generally performed on admission.
Focused Assessment
  • Limited in scope and generally is based on the bodily system of the presenting issue.
Ongoing Assessment
  • Systematic monitoring and follow up of any problems identified during the primary, comprehensive or focused assessment.

Vital Signs

  • Vital signs provide objective and subjective data that indicates the effectiveness of circulatory, neurological and respiratory system function, and can be used to assess baseline health status, changes in physiological function, and response to treatment.
  • You are expected to demonstrate understanding and competency in taking the following vital signs:
    • Pulse (heart rate)
    • Blood pressure
    • Temperature
    • Respiratory rate
    • Oxygen saturation
    • Pain assessment
    • Consciousness level
Vital Signs Routine
  • On initial admission
  • Routinely throughout admission
  • Before and after surgery or procedures
  • In conjunction with medications that affect vital signs
  • When the patient’s physical condition changes

Vital Signs: Documentation

  • You must document the vital sign measurement as soon as possible on the appropriate chart.
  • Currently in Australia, each healthcare organisation has an observation and response chart design that has been developed and approved by the Australian Commission on Safety and Quality in Health Care (ACSQHC)
  • This is also referred to as a track and trigger system
    • track and trigger system allows the patient's physiological status to be tracked over time and, if a specific trigger is reached, an escalation pathway for their review is enacted.
    • A single-parameter system means that an escalation for review may be triggered by one vital sign abnormality
    • A multiparameter (aggregate scoring) system assigns a score to each vital sign based on the level of its abnormality that will direct the clinician to the level of medical review required.
Pulse
  • A pulse is the palpable bounding of blood through a peripheral artery as the ventricle contraction ejects blood into the aorta, creating a pulse wave.
  • The normal pulse, or heart rate, for an adult is considered to be between 60 to 100 beats per minute.
Landmarks for Pulses
  • Radial - radial artery on the wrist, at the base of the thumb.
  • Carotid - Along the medial edge of the sternocleidomastoid muscle in the neck.
  • Brachial - Groove between biceps and triceps muscles at antecubital fossa.
  • Ulnar - ulnar artery on the wrist, at the base of the little finger.
  • Femoral - Below inguinal ligament, midway between the symphysis pubis and anterior superior iliac spine (in your groin).
  • Popliteal - Behind knee in popliteal fossa.
  • Posterior tibial - Inner side of the ankle, below the medial malleolus.
  • Apical - Auscultated at the fourth to fifth intercostal space at the left midclavicular line (you cannot palpate the apical pulse).
  • Dorsalis pedis - Along the top of the foot, between extension tendons of the great and first toe.
  • Temporal - The top of the cheekbone up to the hairline, located in front of the tragus.
Factors that may affect the pulse rate
  • The rate can be modified by the autonomic nervous system
  • Age affects the rate, with children and infants having a higher normal heart rate when compared to adults
  • Medications can affect the