Jarvis’s Physical Examination & Health Assessment

Chapter Thirty Focused assessment

Written by Helen Forbes, Elizabeth Watt

In a hospital setting, the patient does not require a complete head-to-toe physical examination every day. However the patient does require an assessment at least every 8 hours that focuses on certain parameters, usually in response to current symptoms, signs or potential risks to health. Measurements, such as vital signs, daily weights, abdominal girth, neurological observations or the circumference of a limb, must be taken very carefully. The validity of such measurements depends entirely on the consistency of the procedure from nurse to nurse. Also remember that many assessments must be done frequently throughout the course of a shift with the purpose of detecting subtle changes in the person’s health state that could indicate deterioration of their condition. This chapter outlines the initial assessment that will allow you to get to know your patient when you first greet them at the start of a shift, as well as brief focused assessments that will assist you to quickly appraise the person’s current health situation. Take note of anything that will need continuous monitoring, such as a blood pressure or pulse oximetry reading that is not what you expect, or breath sounds that suggest a difficult respiratory effort. If there is no protocol in place for a particular assessment situation, then decide for yourself how often you need to check on the person’s status—it is very easy to be distracted by ringing bells and alarms as the shift progresses, but your own judgment about a patient’s needs is just as important as any electronic alert or alarm. If you identify a change in the person’s condition, you must then continue with a more comprehensive investigation of the symptoms and signs (both subjective and objective data collection) which has been described in detail in the previous chapters.

The need for multiple assessments of each patient highlights the need for efficiency in the hospital setting. Your assessments must be thorough and accurate, yet you must be able to complete them rapidly without seeming hurried. The only solution to this paradox is practice. Remember that practising in a laboratory setting, with simulated patients or with classmates, may feel artificial but it is the quickest route to feeling confident in the presence of hospitalised patients.

The focused assessment applies to adults in medical and surgical wards. Each assessment must be specialised to each patient situation, and the findings must be integrated into your complete knowledge base regarding the patient. This includes what you read in the progress notes and charts including notes from other health professionals, what you hear in the nursing handover and the results of any laboratory tests and diagnostic imaging that are available.

Sequence	Selected photos
Many of the assessments can be done with the person sitting in a chair. For some you may need to assist the person into bed. Make sure that the bed is at a comfortable level for the physical examination.
GENERAL SURVEY
On your way into the room, verify that any necessary markers or flags are in place at the doorway regarding such conditions as isolation precautions, latex allergies or fall precautions. Once in the room, introduce yourself as the patient’s nurse for the shift. Make direct eye contact and do not allow yourself to be distracted by IV pumps or other equipment as you ask how they are feeling, how they spent the previous shift and whether they are currently having any pain or discomfort (including chest pain). Refer to what you have heard from the previous shift in the process of your own questioning—this alleviates the person’s frustration at answering the same questions every time a new staff member walks through the door.
Offer water (if the patient is not nil orally) as a courtesy and note the data this gives you: the person’s ability to hear, follow directions and, especially, ability to swallow. As you collect this and subsequent history, note data on the general appearance. Complete your initial overview by verifying that the correct name band has been applied to the wrist. At this time conduct a general check of equipment attached to the patient. Check: • The IV bag/s against the medical orders including the solution type and rate of infusion • The IV site for redness and swelling • Oxygen/suction administration and equipment • Drains/catheters and drainage equipment/containers • Location and function of emergency equipment.
GENERAL APPEARANCE
1 Facial expression, appropriate to the situation 2 Body position, relaxed and comfortable or tense, in pain 3 Level of consciousness, alert and oriented, attentive to your questions, responds appropriately 4 Skin colour, mucous membrane colour 5 Nutritional status, weight appears in healthy range, even fat distribution, hydration appears healthy 6 Speech: articulation clear and understandable, pattern fluent and even, content appropriate 7 Hearing, responses and facial expression consistent with what you have said 8 Personal hygiene, ability to attend to hair, make-up, shaving
MEASUREMENT
Done at prescribed time intervals—note changes from previous assessment or trends in the assessment findings. 1 Temperature 2 Pulse 3 Respiration 4 Blood pressure (note to avoid an arm because of surgery or venous access on that side) 5 Pulse oximetry 6 Rate pain level on 1 to 10 scale, and note ability to tolerate pain 7 If pain medication given, note response in 15 minutes for IV administration to 1 hour for oral administration.
MENTAL STATUS
Commonly performed postsurgery/anaesthetic on return to ward; following head injury, stroke or neurological surgery or after any change in conscious state; where there is a history of mental illness, confusion or delirium. 1 General appearance and demeanour 2 Behaviour 3 Thought processes and perceptions
NEUROLOGICAL AND SENSORY FUNCTION
Commonly performed postsurgery/anaesthetic on return to ward; following head injury, stroke or neurological surgery or after any change in conscious state. This may involve the recording of frequent assessments using the Glasgow Coma Scale on a neurological assessment chart. 1 Eyes open spontaneously to name 2 Motor response 3 Verbal response 4 Pupil size in mm and reaction, R and L 5 Muscle strength, R and L upper 6 Muscle strength, R and L lower 7 Any ptosis, facial droop 8 Sensation 9 Communication (including vision and hearing) 10 Ability to swallow
RESPIRATORY FUNCTION
Commonly performed postsurgery/anaesthetic on return to ward; following chest surgery or trauma; in the person with a chest infection, asthma or chronic lung disease; or in the person who is at risk of ineffective airway clearance. 1 Oxygen by mask, nasal prongs, check fitting 2 Note FIo₂ 3 Respiratory effort 4 Auscultate breath sounds comparing side to side: Posterior lobes: left upper, right upper, left lower, right lower Note: if not able to sit up, have another nurse hold patient side to side Anterior lobes: right upper, left upper, right middle and lower, left lower 5 Cough and deep breath; any mucus? Check colour and amount.
CARDIOVASCULAR FUNCTION
Commonly performed postsurgery/anaesthetic on return to ward; in the person with chest pain or myocardial infarction; postcardiac or vascular surgery; vascular assessments are also performed post orthopaedic surgery or trauma. 1 Auscultate rhythm at apex: regular, irregular? 2 Check apical pulse against radial pulse, noting perfusion of all beats 3 Assess apical heart sounds 4 Check capillary refill for prompt return 5 Check pretibial oedema 6 Palpate posterior tibial pulse, right and left 7 Palpate dorsalis pedis pulse, right and left Note: Be prepared to assess pulses in the lower extremities by Doppler imaging if you cannot find them by palpation 8 Assess fluid intake and output balance.
SKIN
Commonly performed postsurgery/anaesthetic on return to ward; as part of an assessment of fluid balance, wound assessment and to assess risk of skin breakdown. 1 Note skin colour 2 Palpate skin temperature; expect warm and dry 3 Pinch up a fold of skin under the clavicle or on the forearm to note mobility and turgor 4 Note skin integrity, any lesions and the condition of any wound/dressings 5 Complete any standardised scales used to quantify the risk of skin breakdown 6 Verify that any air loss or pressure loss surfaces being used are properly applied and operating at the correct settings
NUTRITION AND METABOLISM
Commonly performed postsurgery/anaesthetic on return to ward; and to monitor nutritional intake and blood sugar levels. 1 Assess type and amount of food and fluid intake 2 Assess appropriateness of diet for person’s situation 3 Check nasogastric feeds/drainage 4 Perform blood sugar monitoring if relevant.
ABDOMEN/BOWEL FUNCTION Commonly performed postsurgery/anaesthetic on return to ward; to assess bowel sounds prior to commencement of food and/or fluids; to assess risk for constipation. 1 Assess contour of abdomen: flat, rounded, protuberant 2 Listen to bowel sounds in all four quadrants 3 Check any tube placement for drainage and insertion site integrity 4 Assess bowel or urinary stoma (if applicable) for colour and moisture, size and shape, oedema, periostomal skin integrity, protrusion (spouting) and output 5 Inquire whether passing flatus or stool and rating according to the Bristol stool form scale.
RENAL/BLADDER FUNCTION
Commonly performed postsurgery/anaesthetic on return to ward; to assess bowel sounds prior to commencement of food and/or fluids. 1 Assess fluid intake compared with output in the last 24 hours. Check fluid balance over past days 2 Inquire about voiding frequency 3 Check urine for colour, clarity and amount 4 If urine output is below the expected value, perform a bladder scan according to agency protocol. Is the problem in the production of urine or its retention?
MUSCULOSKELETAL FUNCTION
1 Assist patient to sitting up level, move to chair 2 Note any assistance needed, how tolerates movement, distance walked to chair, ability to turn 3 Need for any ambulatory aid or equipment 4 Complete any standardised scales used to quantify the patient’s risk for falling 5 Note patient’s need for rest/sleep, presence of fatigue.

BIBLIOGRAPHY

Australian Commission on Safety and Quality in Health Care, 2010a. Clinical handover. Available at http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/PriorityProgram-05#Tools.

Australian Commission on Safety and Quality in Health Care. Recognising and responding to clinical deterioration. Available at http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/prog-patientsrisk-lp, 2010.