Baseline Assessment STUDENT (1)

Baseline Assessment

• Fundamentals of Nursing Care

Objectives

• Identify the techniques and elements used when performing a physical assessment.
• Explain how to perform a baseline assessment.
• Identify expected findings on a physical assessment.
• Differentiate between the various focused assessments.
• Identify abnormal findings on a baseline physical assessment.

What is an Assessment

• Collection of Data
• Comprehensive Assessment
• Physical Assessment
• Health History Assessment

Comprehensive Assessment

• Objective Data (Physical Assessment)
  • Uses your senses
    • Vision
    • Hearing
    • Smell
    • Touch
  • FACTS
• Subjective Data (Health History)
  • What the pt. says
  • Can verify objective data
  • “OPINION”

Difference Between Assessments

• Health assessment - comprehensive assessment
  • Medical assessment
    • Focus is on disease and pathology
  • Nursing assessments
    • Focus is on the patient’s responses to illness and stressors
    • Health History
    • Physical Assessment

Purpose of the Physical Examination

• Why is a physical examination necessary?
  • To collect data
  • To identify problems/form plan of care
  • To monitor previous problems
  • To screen for health problems

LPN Scope of Nursing - UTAH

• LPN shall:
  • Conduct a FOCUSED nursing assessment and plan for and implement nursing care within limits of competency
  • Conduct patient surveillance and monitoring; assist in identifying patient needs; assist in evaluating nursing care; participate in nursing management by:
    • Assigning appropriate nursing activities to other LPNs
    • Delegating care for stable patients to unlicensed assistive personnel in accordance with these rules and applicable statutes
    • Observing nursing measures and providing feedback to nursing managers
    • Observing and communicating outcomes of delegated and assigned tasks
      *Nurse Practice Act Rule/Scope of Nursing Practice Implementation
• R156-31b-703b

Delegation of Assessments

• UAP (unlicensed assistive personnel)
  • Vital Signs
  • Pain report
  • Blood glucose
  • Height and Weight
• Licensed Professional
  • Verify collected data
  • Interview
  • Physical Assessment

Types of Physical Assessments

• Comprehensive physical assessment (usually by RN)
  • Head to Toe
  • Body systems approach
  • Includes the physical assessment and health hx.
• Focused physical assessment (e.g., head injury)
  • Focus on the problem
  • Narrow approach
• System-specific assessment
  • Focused
  • Specific one body system
• Ongoing assessment
  • As needed AFTER INITIAL ASSESSMENT
  • Mini assessments every time you encounter the patient.
  • Follow up on current problems or identify new ones

Initial Versus Ongoing Assessment

Initial Assessment

• When Performed: Completed when the client first comes to the healthcare agency.
• Purpose of Data:
  • Are related to the person's reason for seeking nursing or medical assistance
  • Provide guidance for care
  • Help determine need for further assessment
  • A comprehensive assessment can be completed as the client's condition permits.

Ongoing Assessment

• When Performed: Performed as needed, at any time after the initial database is completed.
• Purpose of Data:
  • Help identify new problems
  • Follow up on previously identified problems
  • The data points reflect the ever-changing state of the client; for example, vital signs may change rapidly, which is an important indicator of developing or resolving health problems.

How to Prepare for a Physical Examination

• Prepare Yourself (Knowledge)
• Equipment and Techniques
• Therapeutic Communication
• Documentation
• Be familiar with the pt. situation
• Prepare the Environment
  • Privacy
  • Sound, Lighting and Temperature
  • Supplies
• Prepare the Patient
  • Timing
  • Rapport
  • Cultural Differences

Modifications for Different Age Groups

• Infants
• Toddlers
• Preschoolers
• School-Age Children
• Adolescents
• Young and Middle Age Adults
• Older Adults
• Disabilities

Position of the Client for Physical Examination

Physical Assessment

• Physical assessment
  • Using our senses/techniques to gather objective data about the body
• 5 Senses
  • Sight
  • Hearing
  • Touch
  • Smell
  • Taste

Techniques to Use During a Physical Examination

• Inspection = sight
• Palpation = touch
• Percussion = touch
• Auscultation = listening
• Olfaction = smell

Assessment Techniques Order

$I.P.P.A.Q$

Inspection
Palpate
Percuss
Auscultate
Question

Inspection

• General Survey
  • Use of sight
  • Observation and visual examination
  • Starts as soon as you encounter the patient (general survey)
  • Equipment: otoscope, ophthalmoscope, or penlight
• Observe general characteristics
  • Age, gender, race
  • Facial characteristics
  • Body type and posture
  • Gait
  • Speech patterns
  • Mental State and affect
  • Grooming/hygiene
• Perform:
  • Vital signs
  • Height and weight

Vital Signs

Palpation

• Use of touch
• Dorsal part of hand to assess skin temp
• Used to evaluate
  • temperature, skin texture, moisture, anatomical landmarks, and abnormalities
• Examine areas of discomfort last

Percussion

• Usually done by advanced practice health care providers

Auscultation

• Use of hearing to collect data
  • Direct auscultation: listening without a tool
  • Indirect auscultation: listening with a stethoscope
    • Diaphragm: high pitched sounds
      • heart, lungs, bowel
    • Bell: low pitched sounds
      • murmurs and bruits

Olfaction

• Use of smell to gather data
  • Alcohol
  • Urine
  • Fruity breath
  • Clostridium difficile
  • Infection

Taste

• Taste is never going to be used in an assessment!

Brief Bedside Assessment

• Note: This assessment is not as detailed as in Procedures 19-1 through 19-19. You might perform such an assessment when admitting a patient to a hospital unit. You can also use it for ongoing assessments. For daily patient assessments, you will modify the procedure to fit the patient’s health status. You may be able to omit some portions, and you may need to add in-depth, focused assessments of some body systems. The entire assessment should take no more than 15 minutes after you become skilled.

Baseline Physical Assessment Rubric

Preliminaries

• Washes hands, introduces self, ID's patient with two patient identifiers, provides privacy, explains procedure
  • (5 points Possible)

Vital Signs

• Verbalizes checking VS
  • (1 point Possible)

Neurological

• Demonstrates checking LOC using person/place/time/situation
• Demonstrates checking PERRLA (direct & consensual)
• Verbalizes checking for deficits
  • (8 points Possible)

Cardiovascular

• Names and demonstrates location of all 5 heart sites (on self or partner)
• Demonstrates checking for the following in all 4 extremities: pulses, capillary refill, temperature, edema, color
• Demonstrates asking about chest pain
  • (8 points Possible)

Pulmonary

• Verbalizes visually inspecting for rhythm and effort
• Demonstrates correct placement of stethoscope on patient
• Identifies where to auscultate bronchial, bronchovesicular, and vesicular breath sounds (on self or partner)
• Demonstrates a voice transmission test (bronchophony, egophony, whispered pectoriloquy, chosen by instructor)
• Demonstrates checking for secretions and oxygen therapy
• Demonstrates asking patient about discomfort, cough
  • (8 points Possible)

Musculoskeletal

• Demonstrates checking muscle strength (grips and plantar flex)
• Demonstrates assessing gait and movement
• Describes neurovascular checks for orthopedic patients (CMS)
  • (8 points Possible)

Abdominal

• Demonstrates inspecting the abdomen FIRST
• Demonstrates auscultating in 4 quadrants
• Demonstrates light palpation in 9 regions, describes deep palpation
  • (8 points Possible)

Gastrointestinal

• Demonstrates asking patient about diet, percent of meals ingested, nausea/vomiting
• Verbalizes to observe for a feeding tube
• Demonstrates asking pt to describe BM and if passing flatus
  • (8 points Possible)

Genitourinary

• Verbalizes to observe urine for color, transparency, and odor
• Demonstrates assessing for signs of dysuria
• Verbalizes to assess for a catheter and assess patency, urine color/amount, position of bag
  • (8 points Possible)

Pain

• Demonstrates asking patient to rate pain using scale of 0-10
• Demonstrates assessing all steps of COLDERRA
  • (8 points Possible)

Skin

• Demonstrates assessing for color, turgor, integrity
  • (5 points Possible)

Wound

• Verbalizes to assessing type and location, site condition, dressing, and drainage systems
  • (5 points Possible)

IV

• Verbalizes to assess type and location, site condition, patency, and fluid type and rate
  • (5 points Possible)

Psychosocial

• Verbalizes to assess for mood, affect, and interactions
  • (5 points Possible)

ROM

• (10 points Possible)

Baseline Physical Assessment Documentation Tool

General

• Include on all assessments:
  • Gender
  • Age
  • Vital Signs
    • TPR BP
    • $O_2$ Sat
  • Neurological
    • LOC
    • Pupillary exam
    • Assess for Deficits
  • Cardiovascular
    • Rate & Rhythm
    • Pulses
    • Cap Refill Time
    • Skin Temp
    • Edema
    • Skin Color
  • Pulmonary
    • Rhythm
    • Effort
    • Breath Sounds
  • Musculoskeletal
    • Muscle strength
    • Gait
  • Abdominal
    • Inspection
    • Auscultation
    • Palpation
  • Ability to perform ADLs
• Include if applicable
  • Allergies
    • (If pt is on $O_2$ also check sats on RA)
  • GCS
    • (if pt is comatose)
  • Mini Cog if >65 yrs
  • Describe any deficits
  • Chest Pain (CP)
  • $O_2$ rate & route
  • Adventitious breath sounds
  • Secretions
  • Cough
  • Dyspnea
  • Chest Tube
  • CMS check (for orthopedic patients; note area distal to injury)
  • Limited ROM
  • Assisted devices
  • Colostomy
  • Ileostomy
• How to describe "Normal"
  • 75 yo M, NKDA
  • 9 mo F infant
  • $O_2$ sat 98% RA
  • A&O X 4
  • PERRLA
  • "No deficits noted"
  • "RRR $S<em>1S</em>2$ auscultated"
  • "+2 Pulses noted in AE"
  • "CRT <3 sec AE"
  • "No edema noted"
  • "Pink nailbeds noted"
  • Skin W&D
  • Denies CP
  • RRR
  • BS CTA all lobes
  • unlabored resp
  • No cough or secretions
  • "Strong grip strength bilat noted"
  • "Moderate plantar flexion, equal bilat noted"
  • "Steady gait noted"
  • "Full ROM, able to do ADLS"
  • "No assistive devices"
  • CMS intact (note location checked)
  • Abd soft & nondistended
  • "BS active X 4"
  • "no tenderness or masses noted X 9 regions on light palpation"
• Examples of Abnormal Findings (not all-inclusive)
  • Allergic to PCN, iodine
  • "$O_2$ sat 88% on 4L per NC, 82% on RA"
  • "A&O X 1 (to person)"
  • GCS =6 (eyes 2, motor 2, verbal 2)
  • Slurred speech
  • $S_3$ (lub-dub-ta)
  • $S_4$(ta-lub-dub)
  • "Murmur noted"
  • +1 Pulses (thready)
  • +3 Pulses (bounding)
  • CRT > 3 sec
  • "1+ pitting pedal edema noted"
  • "Expiratory wheezes"
  • "Ronchi heard near R bronchus, clears with coughing"
  • "Vesicular Crackles noted A&P bilat"
  • "Labored breathing observed"
  • "Bronchophony noted LLL"
  • "pt c/o productive cough, mod amt of gray sputum observed"
  • Walks w/ shuffling gait
  • "R-sided weakness noted"
  • "decreased ROM noted L elbow with flexion < 90 degrees"
  • "CMS check L foot shows decreased sensory awareness"
  • Abd Distended
  • "Ascites noted"
  • "BS hypoactive per auscultation in upper quadrants"
  • "Abd mass noted per palpation in RL region"
• Abbreviations
  • pt-patient
  • NKDA—no known drug allergies
  • RA-Room Air
  • NC-nasal cannula
  • LOC-Level of Consciousness
  • A&O-Alert & Oriented
  • X4-person, place, time & situation
  • GCS-Glasgow Coma Scale
  • RRR-regular rate & rhythm
  • $S<em>1S</em>2$-lub dub
  • CRT-Capillary refill time
  • AE-all extremities
  • UE-upper extremities
  • LE-lower extremities
  • W&D-warm and dry
  • BS-breath sounds
  • CTA-clear to auscultation
  • Resp--respirations
  • A&P-Anterior & Posterior
  • Bilat-bilaterally
  • LLL-left lower lobe
  • RLL-right lower lobe
  • CMS-circulation, motor, sensation
  • ROM-range of motion
  • R-right
  • L--left
  • BS X 4-Bowel sounds all 4 quadrants
  • RL-right lower

Gastrointestinal

• Include on all assessments
  • Diet & % eaten
  • BM (last occurrence & description)
• Include if applicable
  • N&V
  • Feeding Tube
• How to describe "Normal"
  • "Ate 75% of Reg diet for breakfast"
  • "tolerates ADA diet well"
  • "pt reports passing flatus"
  • "last BM was last night, firm & brown"
  • "Denies N&V"
• Examples of Abnormal Findings (not all-inclusive)
  • "c/o nausea"
  • "NG tube to suction"
    • (If "bowel sounds absent" is charted, document notifying MD)
  • "Emesis of 150 mL after breakfast, brownish color"

Genitourinary

• Include on all assessments
  • Urine color, odor, transparency
  • Quality of urination
• Include if applicable
  • Foley / Ileal conduit
  • Symptoms of dysuria
  • unable to fully empty
  • I&O
  • Incontinence
• How to describe "Normal"
  • "pt reports clear yellow urine"
  • "no foul odor noted"
  • "pt denies s/s dysuria" "pt voids without difficulty"
  • "Foley patent to down drain"
• Examples of Abnormal Findings (not all-inclusive)
  • "c/o burning, urgency"
  • "pt states unable to fully empty bladder"
  • "urine dark amber, clear with strong odor"

Pain

• Include on all assessments
  • Pain scale 0-10
• Include if applicable
  • COLDERRA for pain greater than 0/10;
  • pt's pain goal
• How to describe "Normal"
  • "pt rates pain 0/10 at present" "pt denies pain"
• Examples of Abnormal Findings (not all-inclusive)
  • "pt c/o pain 7/10: C-sharp O-surgery L-abd incision, (etc); pt states pain would feel under control at 3/10"

Skin

• Include on all assessments
  • Color
  • Turgor
  • Integrity
• How to describe "Normal"
  • "Skin tones appropriate for ethnicity"
  • "Skin intact"
  • "Turgor check shows elastic recoil" OR "no tenting noted with turgor check"
• Examples of Abnormal Findings (not all-inclusive)
  • Pallor; Inflamed; Flushed; Mottled
  • Ecchymosis
  • "Hemosiderin noted in LLE"
  • "Tenting noted with turgor check"
  • "pressure point noted on R heel"

Wound

• Include if applicable
  • Type & location
  • Site condition
  • Dressing
  • Drainage system
• How to describe "Normal"
  • Dressing on R thigh CDI
  • "4 cm incision R thigh well-approximated, healing by primary intention"
• Examples of Abnormal Findings (not all-inclusive)
  • "Abd incision closed w/ steri-strips"
  • "Fresh drainage noted and circled on abd drsg"
  • "old drainage observed on drsg"
  • "stage 3 pressure ulcer noted on coccyx"

IV

• Include if applicable
  • Location & gauge
  • Site condition & drsg
  • Patency
  • Fluid & infusion rate Saline locked
• How to describe "Normal"
  • "PIV patent, 21 g in RAC infusing NS @ 125 ml/hr, no s/o infiltration or phlebitis"
  • "18 g in LFA, SL, patent per RN"
  • IV site without s/o infiltration or phlebitis, drsg CDI
• Examples of Abnormal Findings (not all-inclusive)
  • "IV LFA site infiltrated, RN notified"

Psychosocial

• Include if applicable
  • Mood/response
  • affect/interactions
  • Social History
  • Social support
  • Employment
  • Substance use
  • Home environment
• How to describe "Normal"
  • "mood appears appropriate for the situation"
  • "pt interacts well with visitors and nurses"
  • "pt cooperative with treatments"
  • "Married with 2 young children"
  • "Lives alone at home"
  • "Retired electrician"
  • "denies substance use"
• Examples of Abnormal Findings (not all-inclusive)
  • "pt appears agitated"
  • "pt c/o depression 5/10"
  • "pt refuses care"
  • 2 PPD smoker
  • "pt states spouse just left him asking for a divorce"
  • "Resides at SNF"
• Abbreviations
  • N&V-nausea & vomiting
  • c/o-complains of
  • ADA-American Diabetes Assoc diet
  • NAS-no added salt diet
  • FLACC scale-face, legs, activity, cry, consolability
  • CDI-clean, dry & intact
  • RAC-right antecubital
  • LFA-left forearm
  • g-gauge
  • PIV-peripheral IV
  • SL-saline lock
  • PPD-packs per day

Before you begin…WIIPPE

• W WASH YOUR HANDS + WEAR gloves
• I Introduce self
• I Identify Patient
• P Provide Privacy
• P Position Patient
• E Explain Procedure

Patient ID Check

• Patient Verbalization
• ID Band Check
  • Name
  • Date of Birth
• Patient Identification “2 Identifiers” means completing this “2 by 2” grid to ensure all information matches:

The Physical Assessment - Body Systems Approach

• Vital Signs
• Neurological
• Cardiovascular
• Pulmonary
• Musculoskeletal
• Abdominal / Gastrointestinal
• Genitourinary
• Pain (COLDERRA)
• Integumentary – Wounds / IV
• Psychosocial

Neurological System

• WHAT IS ASSESSED?
  • Mental status
  • Level of consciousness and orientation (LOC)
    • OR
    • Glasgow
  • Pupillary responses PERRLA
  • Deficits

Level of Consciousness (LOC)

• A&O x4 = Alert and Oriented to
  1. Person
  2. Place
  3. Time
  4. Situation

Glasgow Coma Scale (GCS)

• First sign of neurological deterioration is often a diminished LOC
• Score for eye, motor, and verbal responses
• May be done as part of a focused assessment for head trauma
• ***Document LOC or GCS (not both)

Assessing PERRLA

• Pupils equal, round, reactive to light and accommodation
  • Direct and Consensual
  • They should accommodate equally
  • Pupils should constrict and eyes cross as a person attempts to focus on an item moving toward them
    • Distant = Dilated
    • Close = Constricted
  • Need a penlight to assess

Neurological Check

• When a patient has a head trauma, a focused assessment (neuro check) needs to be performed
  • Assess LOC (Glasgow Coma Scale)
  • Vital Signs
  • PERRLA
  • Assess strength of hand grip and movement of extremities
  • Determine sensation to touch/pain in extremities

Deficits

• Facial Drooping
• Drooling
• Slurred speech
• Balance issues
• Muscle weakness
• Partial or complete paralysis
• Confusion

REMEMBER…. DSC (for deficits)

• D Drooping/Drooling
• S Slurred Speech
• C Confusion

Cardiovascular System

• WHAT IS ASSESSED?
  • Listen to Rate/Rhythm
  • 5 Names/landmarks and location each heart site (A.P.E.T.M.)
  • Check pulses, capillary refill, temperature, edema, color in ALL 4 extremities
  • Chest pain???

Landmarks

• Erbs point: best place to hear $S<em>1$ and $S</em>2$ equally.
• PMI: most accurate reading of heart rate AT MITRAL SITE
• Inspect position patient sitting to observe pulsations (heaves or lifts)
• Palpate for vibrations
  • Thrill is a pulsation felt in any area except the PMI
  • Associated with abnormal blood flow and usually has an associated murmur
• Auscultate rate and rhythm
  • Identify normal and abnormal heart sounds
  • A quiet room is essential

Heart Sounds Listen For

• Rate
• Rhythm
• Murmurs
• Extra heart sounds
• Heart sounds and rhythm
  • First Heart Sound-$S_1$ or “lub” results from the closure of the valves between the atria and ventricles
    • Dull-low-pitched sound
    • Loudest over the mitral and tricuspid areas
    • Marks the beginning of systole (contraction, or emptying of the ventricles)
  • Second Heart Sound- $S_2$ or “dub” corresponds with closure of the semilunar valves
    • Higher in pitch and shorter than the $S_1$
    • $S_2$ is the loudest at the aortic and pulmonic areas
    • Marks the beginning of diastole (relaxation, or filling of the ventricles)
• Peripheral Circulation
• Five Finger Cardiovascular Assessment

Pulses to check (bilaterally)

• Radial
• Pedal
• Pulse description (amplitude = how strong)
  • + 1 Thready
  • +2 Expected (normal)
  • +3 Full (strong)
  • +4 Bounding
  • ***Feel for strength of pulse, symmetry and regularity of pulse in all ext. comparing side to side and upper/lower
• Capillary Refill Time (CRT)
  • Amount of time for color to return to the capillary bed after pressure is applied to causing blanching.
  • Should be less than 3 seconds (<3 sec.)
  • Perform on upper and lower extremities
• Skin Temperature
  • Use the dorsum of the hand or fingers to assess
  • Compare the temperature of the hands with the feet
  • Compare right side to left side
  • The skin should feel warm
• Edema
  • Body parts swell from injury or inflammation.
  • Affects a minor area or the whole body.
  • Causes: Medications, pregnancy, infections, and many other medical problems can cause edema.

Edema Scale

• 0+ No pitting edema 0 mm
• 1+ Mild pitting edema. 2 mm depression that disappears rapidly.
• 2+ Moderate pitting edema. 4 mm depression that disappears in 10-15 seconds.
• 3+ Moderately severe pitting edema. 6 mm depression that may last more than 1 minute.
• 4+ Severe pitting edema. 8 mm depression that can last more than 2 minutes.
• Skin color
  • Indicates how well blood is being oxygenated and circulated.
  • Paleness (pallor) shock or blood loss.
  • Cyanotic (blue-gray) poor oxygenation.
  • Mottling blotchy discoloration often indicative of shock or blood pooling.
• QUESTIONS:
  • Ask patient if he/she is experiencing any chest pain

Respiratory System - Pulmonary

• What is assessed?
  • Inspect rhythm and effort
  • Correct Placement of stethoscope
  • “Normal” breath sounds
  • Adventitious breath sounds
  • Voice transmission tests
  • Secretions
  • Oxygen
  • Discomfort
  • Cough
• Inspect
  • Rhythm and effort of breathing
  • Retractions, belly breathing
  • Secretions
  • Use of Oxygen
  • Cough or Discomfort (observe and ask)
  • Auscultate ALL LOBES
  • Normal Breath Sounds
  • Adventitious Breath Sounds
  • Voice Transmission
• Note if the patient is on Oxygen ($O_2$)
  • Delivery method
    • Mask
    • Nasal Cannula
  • Rate of delivery

Auscultation

• Bronchial breath sounds
  • Loud, high, pitched sounds
  • Expiration is longer than inspiration
  • Heard best over the trachea on the anterior chest and below the nape of the neck on the posterior chest
• Bronchovesicular Breath Sounds
  • Medium-pitched
  • Equal inspiratory and expiratory phase
  • Air moving through the large airways of the bronchi
  • Heard best over the 1st and 2nd ICS next to the sternum and between the scapula
• Vesicular Breath Sounds
  • Soft, low pitched, breezy sounds
  • Longer inspiratory phase and shorter expiratory phase
  • Air moving through the smaller airways
  • Heard best over the lung fields

Lung Sounds