Patient Assessment

Conducting a thorough patient assessment is critical for ensuring that we get the most clinical information from our patients. It is one of those skills that we need to be concise and thorough with and it is also one of those skills that we are taught when we are training and often forget how to thoroughly and effective conduct an assessment of patients. E Advanced Healthcare can help you with your patient assessment by providing you with a free resource that you can keep at the point of care on any electronic device.

We provide a great free resource on performing a patient assessment

As mentioned above, you can get a free resource on the subject of conducting a medical assessment that is still very valid for nurses as well as doctors. It is an invaluable healthcare resource that you can keep with you on your iPhone, iPad, Kindle, e-book reader, android phone, mac, pc, laptop etc. You name the electronic resource and you can view it on there with the help of the Amazon Kindle free reading apps.Patient Assessment Book

In addition to the e-book version of this great health assessment resource we also have a paperback version available should you prefer a “hands on” copy.

The books cover the reasons why we assess a patient, factors that affect patient assessments and how to perform one.

We go in-depth into neurological assessments and include topics such as mental status, cranial nerves and their assessment, motor function, reflexes, sensation, arousal, attention and concentration, memory, language, visual spacial perception, praxis and much more. Respiratory assessments are explored and reasons for the respiratory compromise are also discussed. A thorough cardiac assessment strategy is given including auscultation of the heart assessing the ECG and jugular venous pressure assessments. The gastrointestinal and renal systems are also examined in depth to give you the necessary tools to perform a thorough assessment of a patient.

Here at E Advanced Healthcare we believe that healthcare education is a right and should not be made either complicated, inaccessible or expensive. We have put this resource together on the assessment of a patient that is fully referenced throughout with recent journal, government and medical book sources that are trusted in the specialty of healthcare. We have published these resources on Amazon, which means they are available to you from an outlet that you trust and that you can rely on. As mentioned you can get this e-book for free by being an Amazon prime member. However don’t worry if you are not, as the e-book will not cost you a fortune. Yes it is true that most of the current patient assessment books are going on sale for about $50 – $100, however you do not need to pay this! Again E Advanced Healthcare mission statement is to provide you with educational resources that are both useful, informative and accessible. Our e-book is going to cost less than a cup of coffee, so you have nothing to lose apart from some increased knowledge, improved patient care and enhanced professionalism. Should you not want to get the e-book version or the paperback version of this great resource it is still one of the cheapest paperbacks available in the topic of medical assessments.

What else can we offer you before you look at our patient assessment resource?

As you have read this far down the page, I am going to give you a sneak peak of the book itself. As with all the other resources that we have on offer on E Advanced Healthcare the formatting is better in the book itself, this is just for illustration purposes only.

Patient Assessment BookPatient Assessment
by
Jamie Bisson
(Dip. H.Sc., Dip. N.Sc., B.Sc. (Hons.) Crit. Care)

Copyright © 2012 Jamie Bisson
All images are public domain images, unless otherwise stated. As such they are free to be used for any purpose without conditions, unless such conditions are required by law.
All rights reserved.

Table of Contents
Foreword
Why Assess The Patient?
Factors That Affect Patient Assessments
How To Perform A Patient Assessment
Neurological
Mental Status
Cranial Nerves
Motor Function
Reflexes
Sensation
Mental Status
Arousal
Attention And Concentration
Memory
Language
Visual Spacial Perception
Praxis
Calculations
Executive Functioning
Mood And Thought Content
Cranial Nerve Assessment
Cranial Nerve 1 [Olfactory] ⟹ (Smell)
Cranial Nerve 2 [Optic] ⟹ (Vision)
Cranial Nerve 2 [Optic] and 3 [Oculomotor] ⟹ (Pupillary Light Reflex)
Cranial Nerve 3 [Oculomotor], 4 [Trochlear] and 6 [Abducens] ⟹ (Eye Movements)
Cranial Nerve 5 [Trigeminal] ⟹ (Facial Sensation and Mastication Muscles)
Cranial Nerve 7 [Facial] ⟹ (Facial  Expression Muscles)
Cranial Nerve 8 [Vestibulocochlear] ⟹ (Hearing and Vestibular Function)
Cranial Nerve 9 [Glossopharyngeal] and 10 [Vagus] ⟹ (Palatal Movement)
Cranial Nerve 11 [Spinal Accessory] ⟹ (Head Rotation and Shoulder Elevation)
Cranial Nerve 12 [Hypoglossal] ⟹ (Tongue Movement)
Respiratory
Causes Of Respiratory Compromise
Cardiac
Cardiac History
Cardiac Physical Assessment
Listening To Heart Sounds
Jugular Venous Pressure
Gastrointestinal
Renal
Completion Of The Patient Assessment
Bibliography

Foreword
Patient assessment is a crucial part of any healthcare activity. We constantly assess our patients and as such our assessments need to be thorough, systematic and accurate.

My experience in healthcare is mostly within critical care, however I also have extensive experience of working in ward environments. Obviously as working in critical care it is imperative that patient assessments are conducted both formally at the beginning of a shift and when significant changes are detected with the patient. Patient assessments are also performed non-formally during our continual contact with the patient.

Why Assess The Patient?

Why Assess The Patient?

Patient assessments are necessary to gain a baseline evaluation of the patient’s clinical condition in order to aim our treatments towards a positive change, improved care and an expedited discharge from our care.

Patient assessments are the most important skill any healthcare professional can learn as these assessments are the basis of all the decisions that we make regarding the care we provide for our patients.

By undertaking patient assessments we are able to prioritise our care so that the most urgent need  gets attended to first. This is done very formally when starting our career, however as time passes this skill becomes a lot more natural and fluent.

These assessments start very generalised, but as issues are identified the assessments begin to focus in greater detail on the smaller and more precise issues that the patient is presenting or complaining of.

Factors That Affect Patient Assessments
Experience of the practitioner
This can be improved upon by providing education and mentorship into how to prioritise care. This skill is generally learnt during our training, however when working in new areas there will be some new challenges that present themselves. As such, we need to be able to react to the situations and respond appropriately, giving the attention to the most urgent need. The only way of doing this is by undertaking thorough medical assessments.

Assessment education is also often needed, which again is normally learnt during our training, however when working in new environments clinical supervision and mentorship will help the clinician thoroughly assess their patients.

Risk scoring tools and prompting for action
There are many risk scoring tools that we use in our industry, for example in the nursing field there is the Waterlow score for the risk of pressure areas developing with the patient. There are also moving safely assessment, which help us assess how to best mobilise the patients. In the medical speciality there are risk factors that are associated with their past medical history that may have an impact on upon their presenting complaint. There are also APACHE scores, which aim to help us assess the severity of the patients’ illness.

Communication and handover capabilities
Communicating and handing over care effectively will help us relay our assessments onto the rest of the multidisciplinary team so that our observations can be attended to by the necessary personnel. An initiative that is being used in Australia to improve communication is known as an acronym “ISBAR”. This relates to:
Introducing the healthcare professional providing the communication / handover;
Situation being communicated about;
Background of the patient;
Assessments made of the patient’s condition
Recommendations for further care.

There are many other assessment tools available in the workplace regarding patient assessments. Examples of these have been mentioned previously.

Assessment education
To be able to assess a patient effectively, the correct training needs to be given. This book will provide some of that training which needs to be consolidated with practical “hands-on” clinical exposure.

Patient load / workload
Australia has recently been working very hard to establish the correct number of nursing staff for patients they are caring for. In the past the numbers of nurses related to the number of patients has been less than adequate. This has been supported by a multitude of sources, so Australia and other international areas have been working hard to establish the correct “ratio” for safe and effective patient care. This initiative has helped ensure that there are enough nurses available at certain times of the day to help ensure a safe and effective caring facility. With the correct number of nurses working on any particular shift it allows for more concise care and greater opportunities to be more thorough and as such provides the time necessary for a thorough assessment of a patient.

Value of health professionals contribution to care provision
Medical opinion has always been regarded as superior to any other speciality in healthcare, however times are changing and more emphasis is being put into the value of other members of the multidisciplinary team. For team members to gain respect and feel valued we need to be showing that we are able to provide thorough, accurate, appropriate and effective care – consistently. Patient assessment is no different from this. If we learn a thorough and accurate method of performing a patient assessment and are able to communicate this effectively to members of the multidisciplinary team then we are more likely to be valued with regard to our impression and assessment. Providing a concise and appropriate rationale for our assessment is also another important factor when communicating our findings to team members.

How To Perform A Patient Assessment
Performing a thorough patient assessment needs to be completed in a systematic manner, so that all areas are covered and nothing is missed. For this to be done it is best that the patient’s body systems, or main organs are isolated and worked though in a progressive and logical order, as described shortly.

Before entering the patient’s area we need to adhere to what is commonly known as the “five moments of hand hygiene”. These five “moments” are related to using alcohol gel where our hands are not visibly soiled, or using soap and water when soiling is visible, which should be followed with the alcohol gel to reduce the risk of spreading bacteria and viruses by over 1000 times[1]:
Before touching the patient;
Before a procedure;
After a procedure or body fluid exposure risk
After touching the patient;
After touching the patient’s surroundings.
Undertaking a patient assessment would be classified as a “procedure”

In keeping with the five moments of hand hygiene: putting on personal protective equipment is also necessary. The equipment may include gloves, apron, eyewear and possibly a mask.
To assess the patient we need to approach them, however as with advanced life support training it is essential that we assess if it is safe to approach.

Once we have approached them we need to explain to the patient that we are going to perform an assessment.

Checking their vital observations is the first step. As I have mentioned it is best to perform a health assessment in a logical and progressive manner and I advocate performing a “top-to-toe” method. This involves starting the assessment as the patient’s head and progressively moving down to their toes. Besides assessing the patient’s “systems” or organs, it is also important to thoroughly visualise their skin. This should follow the “top-to-toe” method of starting from the head and moving down to their toes. For example looking at their head, face, ears, neck, etc., and then assessing their neurological function before moving down to their chest and respiratory assessments.

Neurological

Neurological assessment

Assessing a patient’s neurological function is fundamental for the following patient groups:
Head injuries;
Chronic renal failure;
Hyper and hypoglycaemia;
General tiredness;
Severe sepsis that is affecting the brain;
Hepatic failure which may lead to encephalopathy;
Hypo and severe hyperthyroidism;
Dementia and Alzheimer’s disease
Seizures;
Strokes or cerebral vascular accidents;
Hypo and severe hyperthermia;
Hypoxaemia;
Severe cardiac arrhythmia’s;
Hypo and very severe hypertension;
Hyponatraemia;
Hyperuraemia;
Severe heart failure;
Severe pulmonary disease;
Alcohol;
Exposure to heavy metals, hydrocarbons and other toxic gasses;
Medications such as opiates, benzodiazepines, anti-psychotics, antidepressants or other sedatives.
This list is extensive and is not fully inclusive, it just demonstrates the wide scope of causes for a decrease in level of consciousness[2].

To make a thorough neurological assessment of the patient we need to assess the patient’s Glasgow Coma Scale, which is a scale ranging from 3 – 15. The scoring system is defined as follows[3]:
Eyes:
4 = Opens spontaneously;
3 = Opens to speech;
2 = Opens to painful stimuli;
1 = Remain closed.
Voice:
5 = Comprehendible and oriented to time and place;
4 = Confused and disoriented;
3 = Inappropriate sounds;
2 = Incomprehensible sounds;
1 = Aphasic (not making any sound).
Motor:
6 = Obeys commands;
5 = Localises to painful stimuli;
4 = Flexes to painful stimuli;
3 = Abnormal (decerebrate) flexion;
2 = Abnormal (decerebrate) extension;
1 = Akinetic (not moving).

Painful stimuli appears a cruel thing to do to a patient who we are supposed to be caring for, however providing this stimuli if the patient does not respond is the only way that we can really tell if there is a severe problem occurring when undertaking our medical assessments. If we were not to give the painful stimuli then the patient may further decrease their level of consciousness and have a greater risk of other complications, miss treatment opportunities and have an increase risk of mortality.

There are two main areas for eliciting pain, central and peripheral pain. The preferred method is central by either pressing firmly on the supraorbital region, rubbing the sternum or pinching the trapezius. Sternal pain, to be accurate, is not really central as the nerve pathways enter the spinal cord lower than is necessary to be classified as central in origin. Peripheral painful stimuli is often applied by applying firm pressure on the top of the finger nails or by pinching the web between the thumb and index finger.

The normal physiological response to pain is this:
Pain is applied to the patient;
Pain is felt by the receptors and the impulse passes to the spinal cord through the afferent (sensory) nerve pathway;
The impulse passes up the spinal cord and into the brain through the spinothalmic tract;
This impulse is interpreted by the brain and another impulse is transmitted back down the spinal cord through the cerebral cortex;
The corticospinal tract allows the impulse to continue down to the efferent (motor) nerve pathways;
This causes the patient to move.

If painful stimuli is applied peripherally then a spinal reflex may occur, which is when the stimulus passes up the afferent pathway and arcs at the spinal cord, passing back down the efferent pathway without ever reaching the brain. This is why the preferred method of assessing the patient’s response to pain (if necessary) is by central stimulation.

A torch light should be shone into the patient’s eyes to hopefully observe a pupillary constriction. Failure to produce pupillary constriction when a light source is applied could be indicative of the following:
Optic nerve damage;
Oculomotor nerve damage;
Brain stem death;
Certain drugs (barbiturates and other sedatives, amongst others).

Further neurological assessments may be necessary. They can be asked if they feel any difference in hot and cold sensations, or getting objects which are out of sight, for example coins out of their pockets, or knowing which feet are on which pedal when driving. This will help to assess the temperature sensation, fine touch sensation and position sensations.

For a patient without any obvious neurological signs they can be assessed on the following headings:
Mental status
Assess the patient’s orientation to time and place;
Assess their ability to comprehend and follow a complex command, whilst not helping them achieve this.
Cranial nerves
Testing the patient’s field of view in one eye;
Bilateral pupillary response;
Eye movements in all directions;
Facial muscle strength;

If you like what you have just read, please get your copy of either the e-book version of the patient assessment resource or purchase the paperback version. As mentioned this can be obtained for free, but if you are not an Amazon prime member, then it will cost less than a cup of coffee. Please feel free and look at the other free resources that we have to offer on E Advanced Healthcare.

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