Nursing: Physical And Health Assessment

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Nursing: Physical And Health Assessment

Nursing: Physical And Health Assessment

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.   Assessment of the Neurological System

Randy Adams, 38-year-old male patient of Dr. Joseph Reynolds, was admitted yesterday morning for 24-hour observation for moderate concussion sustained in car accident. 
Randy had lost consciousness during the accident and was extremely disoriented when he arrived at the ER following EMS transfer. 
He is an Iraq war veteran, and he appeared to believe that the event occurred in Iraq. 
Dr. Reynolds is concerned that Randy is still suffering from the effects of handful of explosive accidents that occurred while he was in Iraq. 
The doctor is unsure if Randy’s current problems are the result of the automobile accident or of earlier injuries, so he has referred him to both neurologist and mental health specialist for consultations.

Please discuss the following in light of the foregoing.
The pathophysiology of concussions and their treatment
In your current clinical situation, do you use any neurological assessment tools? (if not presently working, please describe one used during prior employment or schooling)
Current best practices for post-traumatic stress disorder (PTSD) nursing interventions that you would include in this patient’s care plan
Assessment is critical component of nursing practice, as it is essential for the planning and delivery of patient and family-centered care. 
In the national competency standard for registered nurses, the Nursing and Midwifery Board of Australia (NMBA) states that nurses “conducts comprehensive and systematic nursing assessment, plans nursing care in consultation with individuals/groups, significant others, and the interdisciplinary health care team, and responds effectively to unexpected or rapidly changing situations.”
Aim
This guideline’s goal is to guarantee that all RCH patients receive regular and timely nursing assessments.
The goal of the guideline is to provide nurses with:
Indications for evaluation
Approach to evaluation in children
Types of evaluations
Structure for evaluations
Term Definitions
Admission assessment: thorough nurse evaluation that includes the patient’s history, overall appearance, physical examination, and vital signs.
Shift Assessment: brief nurse assessment conducted at the start of each shift or if the patient’s condition changes.
Focused evaluation: detailed nursing examination of specific body system(s) related to the patient’s presenting problem or current concern(s). 
This could include one or more of the body’s systems.
Methodology for physical examination
Consider the child’s age and developmental stage.
Implement behaviors that demonstrate respect for the age, gender, cultural beliefs, and personal preferences of the child.
Change your vocabulary and communication style to meet the demands of your child.
Establish rapport with the child and his or her family. 
For newborns and young children, use play approaches.
First, get as much information as possible through observation.
Use systematic strategy while remaining flexible to meet the child’s behavior.
Examine the least intrusive parts first (e.g., hands, arms), and then the uncomfortable and sensitive areas (i.e. ears, nose, mouth)
Determine which elements of the exam must be completed before any sobbing that may occur in some youngsters (i.e. heart, lungs abdomen)
Encourage the youngster and his or her family to ask questions and express any concerns.
When possible, assessments should be scheduled in conjunction with other services at time when the kid is relaxed and compliant. 
However, the clinical requirement for the assessment should be balanced against the child’s desire for rest. 
It may be reasonable to postpone assessments for stable youngster until the child is awake.
The nurse should refer any major issues to the ANUM and the medical team during the assessment process.
Admission Evaluation
The nurse should do an admission evaluation with parent or care giver, ideally upon arrival to the ward or preadmission, but it must be completed within 24 hours after admission. 
Admission evaluation is completed in the ADT navigator’s admissions page, with extra information placed into the patient’s progress notes. 
The patient’s privacy must be respected at all times.
History of the patient
Nursing personnel should address the current illness/injury history (i.e., reason for current hospitalization), pertinent prior history, allergies and responses, medications, immunization status, implants, and family and social history. 
Recent out-of-country travel should be discussed and documented.
Consider maternal history, prenatal history, delivery type and difficulties, if any, Apgar score, resuscitation necessary at delivery, and Newborn Screening Tests for neonates and babies (see Child Health Record for documentation).
Overall Appearance
The overall physical, emotional, and behavioral state of the patients is evaluated. 
This should happen at admission and then be monitored during the patient’s stay in the hospital.
Looks well or sick, pale or flushed, lethargic or energetic, agitated or quiet, cooperative or aggressive, posture and movement are all factors to consider for all patients.
Infant and Neonate
Interaction between parent and an infant
Asymmetry of the body, as well as spontaneous posture and movement
Symmetry and facial feature positioning
powerful scream
Child in Adolescence
Interaction between parent and child, and between child and a
Mood and impact
Fine and gross motor skills
Milestones in development
Speech that is appropriate
Mood and Affect in Adolescence
Personal cleanliness is important.
Communication
Signs of life
Baseline observations are documented on the patient’s observation flowsheet as part of an admission assessment. 
Ongoing vital sign assessments are conducted for your patient as directed. 
It is necessary to evaluate the ViCTOR graph at least every hours or as patient condition requires in order to observe vital sign trending and help your clinical decision making process.
For children over the age of six months, tympanic temperatures should be taken. 
Use digital thermometer per axilla if you are less than months old.
Respiratory Rate: Take minute to count the child’s breaths. 
Examine for any respiratory discomfort.
Palpate brachial pulse (recommended in neonates) or femoral pulse in infants and radial pulse in older children to determine heart rate. 
Count pulses for full minute to ensure accuracy.
Every patient should have baseline blood pressure measurement taken. 
The size of the cuff is crucial issue. 
rough guideline for selecting an acceptable cuff size is to ensure that it fits 2/3 width of the upper arm. 
Perform blood pressure check on all four limbs on neonates who have not previously been admitted to the hospital.
Monitor oxygen saturation as clinically required. 
Take note of the oxygen need and mode of delivery.
Pain: As suitable for the age group, use FLACC, Faces, numeric scale, or the Neonatal Pain Assessment Tool. 
For intubated and sedated patients, specialized pain scales are used in areas such as the PICU and NICU. 
Modified Pain Assessment Tool (MPAT), for example. 
Examine current pain relief drugs and procedures.
Measurements Not Included
Weight: at the time of admission and/or on weekly/daily basis as clinically required.
Height: as prescribed by the doctor.
Circumference of the head: as clinically indicated.
BSL (blood sugar level): as clinically indicated.
Physical examination: planned physical examination enables the nurse to gain an accurate assessment of the patient. 
Techniques for gathering information include observation/inspection, palpation, percussion, and auscultation. 
Clinical judgment should be utilized to determine the scope of the assessment required. 
Primary assessment (Airway, Breathing, Circulation, and Disability) and Focused systems assessment are examples of assessment information. 
The “Shift assessment” section below contains detailed information on each evaluation criterion.
Change Evaluation
Every patient is assessed at the start of each shift, and this information is utilized to build plan of care. 
The initial shift evaluation is documented on the patient care plan, and any subsequent assessments or adjustments are recorded in the progress notes. 
Clinical judgment should be utilized to determine the scope of the assessment required.
The general look of the patient is the first step in patient assessment. 
Use observation to determine the patient’s overall appearance, which includes the amount of interaction, whether the patient appears well or poorly, whether he or she is pale or flushed, lethargic or energetic, agitated or calm, compliant or aggressive, posture, and movement.
Assessment data may contain, but is not limited to, the following:
Noises, fluids, coughing, and any artificial airways
Breathing: bilateral air entry and movement, breath noises, respiratory rate, rhythm, respiratory work: 
– spontaneous/labored/supported/ventilator-dependent, oxygen need, and manner of delivery
Pulses (location, rate, rhythm, and strength); temperature (peripheral and central), skin color and moisture, skin turgor, capillary refill time (central and peripheral); skin, lip, oral mucosa, and nail bed color 
If the ECG rate and rhythm are being monitored,
Use evaluation methods such as the Alert Voice Pain Unconscious Score (AVPU) or the University of Michigan Sedation Score (UMSS), as well as the Gross Motor Function Classification System (GMFCS) to assess disability. 
Identify any abnormal movement or gait, as well as any necessary aids such as mobility aids, transfer requirements, spectacles, hearing aids, and prosthetics/orthotics.
Observation of vital signs, including pain: as suitable for the age group, use FLACC, Wong Baker Faces, numeric scale, the Neonatal Pain Assessment Tool, and the Comfort scale. 
Examine current pain relief drugs and procedures. 
Please consult the Pain Assessment and Measurement clinical guideline for further details.
Skin color, turgor, blemishes, bruises, wounds, and pressure injuries are all factors to consider.
Hydration and nutrition status should be assessed, as well as feeding type (oral, nasogastric, gastrostomy, jejunal, fasting, and breast fed), food type, and IV fluids.
The paediatric nutrition screening tool* should be completed for all paediatric patients at arrival and is requirement for accreditation standard 5. 
The screening technique consists of four ‘yes/no’ questions that are used to identify patients who need nutritional assessments and interventions. 
Parents/caregivers, medical records, and an examination of the kid can all provide information. 
Children who do not need nutrition assessment should be rescreened every days while in the hospital. 
Regular weight checks and nutritional intake should be part of the rescreening process.
*
Adapted from the ‘Paediatric Nutrition Screening Tool Instructions for Use’ information document at Lady Cilento Children’s Hospital’s Dietetics and Food Service.
Output: 
Examine your bowel and bladder routine(s), incontinence management, urine output, bowels, drains, and overall losses. 
Examine the fluid balance activities
Clinically indicated blood sugar levels
Focused Assessment: evaluation of the presenting problem(s) or additional concerns, such as cardiovascular, pulmonary, gastrointestinal, renal, ocular, and so on.
Risk assessment includes pressure injury risk assessment (link to pressure guideline), falls risk assessment (link to Falls guideline), and identification bands.
Assess for mood, sleeping patterns and outcomes, coping methods, admission reaction, emotional state, comfort objects, support networks, admission reaction, and psychosocial assessments.
It is critical to consider conducting psychosocial assessments in teenage patients since physical, emotional, and social well-being are all intertwined. 
The HEADSS exam is psychosocial screening tool that can help you create relationship with young person while learning about their family, peers, school, and inner thoughts and feelings. 
The HEADSS assessment’s major goals are to screen for specific risk-taking behaviors and to identify areas for intervention, prevention, and health education. 
More information can be found at 
Engaging and evaluating the adolescent patient. 
It is crucial to note that you may need to create rapport with the young person and that the HEADSS exam may involve several shifts.
Social: 
This may include discussing variety of topics such as parents/caregivers/guardians, siblings, housing arrangements, visiting plans, transportation, unique cultural requirements, schooling, discharge plan, and so on. 
Relevant social assessment information, such as court orders, can also be included in the FYI tab to alert all members of the health care team.
Examine the patient’s history as reported in the medical record. 
In order to add more details to the history, it may be essential to ask questions.
Nursing: Physical And Health Assessment
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