Download adult or child

File 10 Patient assessment and transport
Patient presentation (adult or child)
When a patient presents for health care the clinician is required to gather an orderly
collection of information to identify the patient’s health status. This information forms the
basis of patient assessment and is gained through:

Taking a patient history

Performing clinical observations

Performing a physical examination

Use of diagnostic and pathology services

Collaboration with other members of the team
It is a requirement that all clinicians document their findings in a clear and concise way.
Quality professional documentation is the cornerstone of effective communication [1].
This section is set out to assist with documentation. It is recommended that clinicians
document the page number of HMP/CCG referred to.
Presenting concern/s
The first priority is to assess whether the person is:

seriously ill and needs immediate management or,

is a non urgent presentation, and there is time for a complete patient history and
health education to occur
Where possible use a private setting for the patient interview.
Use open ended questions to begin with to provide general rather than more focused
information. For example, “how do you usually deal with an asthma attack?” [2].
Closed questions can be used to focus the interview, pinpoint specific areas of concern
and gain information quickly and efficiently. For example, “has this type of allergic
reaction happened before?” [2].
Commence by introducing yourself and;
1. Asking the person what brought them to the facility / clinic today? The person may
be presenting at the invitation of a health professional.
2. Ask about the length of time the patient has had the illness / symptoms / problem and
the exact details of the signs and / or symptoms. For each of these ask: [2]

Have they had this before? If so when and what happened?

Location of problem / symptom – original site of presenting concern, where does
it hurt? point to the area

Radiation – does it spread from the original site? If so where

Quality – ask the patient to describe the way it feels to them? sharp, stabbing,
burning (use patients own words)

Quantity – is it mild, moderate or severe? can use a pain score 0-10

Associated manifestations – are there any signs or symptoms associated with
the presenting concern? e.g. nausea and vomiting, photophobia and headache.
Document relevant negative symptoms that are not present

Aggravating factors – what things make the problem worse?

Alleviating factors – what makes it better? sleeping, lying down, taking
medication?

Setting – what were you doing when it started? where you at home? At work?

Timing – when did it start? onset? duration and frequency
File 10 Patient assessment and transport

Meaning and impact – what does this problem mean to the patient and what
impact does it have on their life? e.g. relative may have died at a young age
having experienced a similar problem or the person may have withdrawn from
social contact
Always ask the patient specifically if they have

Fever?

Pain?

Shortness of breath?

Diarrhoea?

Weight loss?
Patient history (adult or child)
There are four types of history taking [2]
1. Complete patient history – comprehensive history of the patients past and present
health status. Usually done at initial visit in a non-emergency situation
2. Episodic history – is shorter and specific to the patients current presenting concern
3. Interval or follow-up history – builds on a preceding visit. It documents the followup required from the prior visit
4. Emergency patient history – only information required immediately to treat the life
threatening condition is gathered from patient or witnesses. Once this has past a
more comprehensive history may be taken once the patient has stabilised
This section outlines what is required for a complete patient history. The history may be
given by the patient, parent or carer in the case of a child, or legal guardian where
appointed. Consider that the patient may be visually or hearing impaired or may not
speak English. In Aboriginal and/or Torres Strait Islander communities Health Workers
will be the cultural and linguistic interpreters.
Consent is always required. The circumstances of the presentation will determine the
extent of patient history taken.
Demographic
information
Medical history
Surgical history
Name, address, date of birth, gender, alias, occupation, next of kin, emergency
contact details, Medicare number, ethnic status
Have you had any illnesses / sickness in the past?
Do you have diabetes? high blood pressure? high cholesterol?
Any big worry problems? depression?
Have you ever had chest pain? heart attack? epilepsy? asthma?
For detail of special medical history such as obstetric, sexual health see related
section
Have you had any operations? Do you know what it was for? Were there any
complications? When and where did you have the operation?
File 10 Patient assessment and transport
Medication
 Is the patient on any medication? (regular; occasional; prescription, non-
history
prescription, complementary, or bush medicine)
 For each medicine the patient is taking, the following details are important:
Allergies
 the generic name, strength and form (often patients are unable to recall or
are unaware of the full details, in which case ask the patient what they are
taking the medicine for, ask if they have their medicines with them as these
details can be obtained from the containers)
 dose and frequency
 duration of therapy, i.e. when therapy started
 are they taken as prescribed? (does the patient have difficulty
remembering or do they miss taking their pills for any reason? Remember
that non-adherence may be the reason why the patient appears to be not
responding to prescribed medication.)
 ask the patient to demonstrate use of puffers, or describe how they use eye
drops, or ear drops for example
 Patients often don’t mention medicines they think are not relevant. Therefore
using a checklist to prompt specific questions e.g. asking females whether
they are on the oral contraceptive pill, will assist in obtaining a comprehensive
medication history. See Appendix 1 Medication History Checklist
 Document medications on Medication Action Plan form
 Ask the patient if they have recently ceased or changed any of their
medications?
 Ask the patient if there is any medication they have tried for their illness which
has not worked
 It may be necessary to contact the referring facility, other primary health care
facilities, guardian or other health care providers to confirm or obtain the
medication information required
Medication allergies / adverse drug reactions (ADR)
 Try to be specific. Find out the name of drug/substance, type of reaction
suffered and its severity e.g. rash, nausea, swelling of the lips, tongue or
breathing difficulties and date that reaction occurred or approximate
timeframe e.g. “20 years ago”. Document this information on the adverse drug
reaction (ADR) section of the medication chart according to the Statewide
Medication Chart Guidelines and Non-inpatient rural and remote medication
chart guidelines. Also attach an “adverse drug reaction” sticker to medication
chart
 All Queensland Health non-inpatient facilities (and facilities discharging
patients to non-inpatient facilities, who document medication for supply on
discharge) are required to use the Non-inpatient rural and remote medication
chart and the Non-inpatient rural and remote Warfarin medication chart
 See Appendix 1 Mediation History Checklist
 Medication Services Queensland for Medication Action Plan training and
competency on Medication History
http://qheps.health.qld.gov.au/qhmms/home.htm or phone 07 36369095 Fax
07 36369098
Besides medicines, is there anything else you are allergic to?
For example - bee stings? sticking plaster for dressing? nuts?
What happens? Do you carry an Epi-pen / medication?
File 10 Patient assessment and transport
Injuries
Family history
Social history
Cultural history
Have you been involved in an accident? What happened? Did you lose
consciousness? Have you ever tried to hurt yourself on purpose?
Have you ever been assaulted?
Are there any health problems in your family? heart trouble, kidney? diabetes?
high blood pressure? TB, suicide? stroke? mental health problem – such as
depression or schizophrenia? alcohol problem? or problem with drugs?
smoking? obesity? weight loss? skin infections? cancer?
What is your position in the family? Do you have extra / any responsibility
because of your position? How does that affect you?
Do you work? Are you married? Live at home? Where do you live? Who else
lives there? Do you smoke? Do you drink alcohol? On a typical day / week how
much would you drink?
Do you use drugs? smoke, inject? snort? swallow?
Are you worried about these? Have you ever tried to give up?
How long have you lived here? Where were you born? What cultural group do
you identify with? What health problems did / have you experienced or exposed
to when you were in the different place/s? Did anything make it better?
Consider - Major beliefs and values. Health beliefs and practices. Language
barriers and communication styles. Role of the family, spouse / partner, and
parenting styles. Religious influences. Dietary practices. Seasonal influences.
[2] What does being healthy mean for you?
Physical examination of patient (adult or child)
Ensure patient privacy. For a comprehensive physical examination a patient maybe
required to remove some or all of their clothing and change into a gown. Consent is
required. Skills to perform physical examination are: [2]
Inspection
- is the use of the senses of vision and smell to consciously
observe the patient.
Auscultation
- the act of active listening to body organs to gather information on
a patient’s clinical status. Body sounds can be voluntary (deep
breaths) or involuntary (heart sounds). Sounds are described by
their intensity, pitch, duration, quality and location. Equipment
used to assist in auscultation includes – blood pressure machine,
stethoscope (adult and paediatric), pinard’s stethoscope (to listen
to fetal heart in pregnant woman), doppler ultrasound.
Palpation
- uses touch in a therapeutic manner to identify specific information.
The palms, fingertips and back of the hands are used. Light and deep
palpation is used.
Percussion
- is the technique of striking one object against another to cause a
vibration that produces sound. Identification of air, fluid or solids
can be confirmed and the size, shape and position of an organ.
Percussion sounds are reported according to intensity – loudness or
softness of the sound, duration – the time period over which a
sound is heard and pitch – the highness or lowness of the sound.
Have a systematic approach to physical examination. Know what is normal then it is
easier to identify variations. Document your findings.
File 10 Patient assessment and transport
Standard clinical observations
To be performed on each patient who presents for acute care (minimum)
Normal range
Normal range
adult
child
Pulse rate (heart
60 – 100 bpm
Age
Beats per minute (mean)
rate) beats per
<1day
93 to 154 (123)
minute
1 to 2 days
91 to 159 (123)
3 to 6 days
91 to 166 (129)
1 to 3 weeks
107 to 182 (148)
1 to 2 months
121 to 179 (149)
3 to 5 months
106 to 186 (141)
6 to 11 months
109 to 169 (134)
1 to 2 years
89 to 151 (119)
3 to 4 years
73 to 137 (108)
5 to 7 years
65 to 133 (100)
8 to 11 years
62 to 130 (91)
12 to 15 years
60 to 119 (85)
Blood pressure
<140 systolic / 90 diastolic For gender BP breakdown see Acute Post
(BP) systolic and
Streptococcal Glomerulonephritis
diastolic
50th percentile blood pressures
Age
systolic
diastolic
1year
90
60
5 years
95
60
10 years
105
65
15 years
115
65
18 years
120
70
90th percentile blood pressures
Age
systolic
diastolic
1year
110
75
5 years
115
75
10 years
125
80
15 years
135
85
18 years
140
90
Respiratory rate
12-20 bpm
Age
Breaths per minute
(resps) breaths
0 to 1 year
24 to 38 bpm
per minute
1 to 3 years
22 to 30 bpm
4 to 6 years
20 to 24 bpm
(One breath in
7
to
9
years
18 to 24 bpm
and out = 1
10 to 14 years
16 to 22 bpm
breath)
14 to 18 years
14 to 20 bpm
Temperature
Oral 36 -38 °C
(temp) – axilla,
Axilla 35.4 -37.4 °C
under tongue, ear,
Ear 36 -38 ° C
in degree celsius
Rectal 36.7-38 ° C
°C
File 10 Patient assessment and transport
If indicated also perform with standard clinical observations
Blood glucose level
4-8 mmol / L (random capillary)
(BGL)
Urinalysis (U/A)
Record results of dipstick
Specific gravity, pH, protein, leucocytes, blood ketones
Oxygen saturation
PaSO2 > 94%
(PaSO2)
PaSO2 90 – 92% for patients with COPD and chronic hypoxia
Body measurements
Normal range - adult
Normal range - child
Height
Plot on growth chart for age and gender
Plot on growth chart for age and
gender
Weight
Plot on growth chart for age and gender
Plot on growth chart for age and
Record on medication chart
gender AND on medication chart
Waist circumference
Adults
Not applicable for children
Men
Women
Risk
< 94 cm
< 80 cm
Low
94-101 cm
80-87 cm
High
≥ 102 cm
≥ 88 cm
Very high
General appearance
Inspection
 Identify if patient meets stated versus apparent age
 Body fat / distribution?
 Stature – their posture, body proportions (are their limbs in proportion to
body)
 Facial features – is there anything significant? (consider foetal alcohol
spectrum disorder). Facial expressions?
 Motor activity – the way the person walks (gait and speed), weight bearing
– are they favouring or guarding parts of their body? Is there decreased
movement in any part of the body?
 Body and breath odours
 How is the person groomed? dressed? personal hygiene?
 What is the persons mood? manner?
 Verbal and non-verbal body language?
 Is the person distressed? physically? psychological or emotionally?
File 10 Patient assessment and transport
Neurological
system
(mental and
conscious state)
For detailed mental status examination (MSE) see Mental Health section.
Conscious state:
1. AVPU - A – alert / V – responds to verbal statement / P – responds to
painful stimuli / U – no response (unresponsive)
2. Glasgow coma scale (adult, child, infant)
Glasgow coma scale (GCS)– adult, child and infant
Adult
Child
Infant
Child > 5 years
2-5 years
0-23 months
Eyes Open
4. Opens eyes spontaneously
3. Opens eyes on command or to speech
2. Opens eyes with pain (pinching)
1. No eye opening/no response
Best Verbal
5. Fully orientated
5. Appropriate
5. Smiles, coos, cries
Response
4. Confused,
words and
appropriately
disorientated:
phrases
4. Cries but consolable
not sure of their name
4. Inappropriate
3. Persistent cries and/or
or where
words
screams
they are or what
3. Cries and/or
2. Grunts
happened
screams
1. No response
3. Inappropriate:
2. Grunts
meaningless words
1. No response
2. Incomprehensible
noises: grunts, moans
1. No sounds
Best Motor
6. Obeys commands
6. Obeys commands
Response
5. Localises to pain
5. Localises pain
4. Withdraws to pain
4. Withdraws to stimuli
3. Flexor response to pain (bends arm or leg)
3. Abnormal flexion
2. Extensor response to pain (straightens arm or 2. Extensor responses
leg)
1. No response
1. No response
Score
Maximum score= Eyes 4 + Verbal 5 + Motor 6 = 15 (fully alert, conscious)
Minimum score = Eyes 1+Verbal 1+Motor 1 = 3 (unconscious)
Always act - on score less than 14 / act immediately on a score of 13 or
less in a child / drop of 2 or more from last assessment / if less than 8
consider intubation
GCS not valid if – patient has - direct eye injury or periorbital swelling after head trauma; intubated
patients; immobilised limbs. In these situations it is appropriate to record the individual scores for each
measurable response (motor, verbal or eyes) [3]
Skin
Inspect
Palpate
Through out physical examination note:

Colour, bleeding, bruising, rashes

Vascularity (presence of lesions – skin tags, sores, scabies, fungal
infection, skin cancers

Moisture - sweating, dry

Temperature - cool, warm, hot?

Texture - is the skin thin / thick?

Turgor - (elasticity / amount of fluid in skin), normal turgor is when fully
File 10 Patient assessment and transport
Head and face
Inspect
Palpate
Eyes
Inspect
Test
If skilled
Ears
Inspect
Palpate
Test if skilled
Nose and sinuses
Inspect

hydrated and skin snaps back to normal position; decreased skin turgor is
a late sign of dehydration. It is normal for skin turgor to decrease as skin
ages.
Oedema - excessive fluid in subcutaneous tissues






The shape of the head
Head and scalp
Colour and distribution of hair – note any head lice, nits
Face – eyes (position), eyebrows, ears, nose and mouth
Head and scalp
Lymph nodes






Eye lids, conjunctiva, sclera, cornea, iris, pupil, lens
Visual acuity – near and distant
Corneal reflexes
Cover test
Red eye reflex
Look at the back of the eye with ophthalmoscope


External ear – alignment, shape, colour, size and any lesions of pinna
Ear canal, tympanic membrane (ear drum), middle ear with otoscope.
Note discharge, swelling, signs of infection, fungal infections, lumps or
bony growths, foreign body, wax
External ear
Mastoid bone
Lymph nodes of neck
Hearing with audiometer
Middle ear function with tympanometer





Palpate





Percuss

Mouth and throat
Inspect
Palpate







The external surface of the nose
Is the nose patent? (can the patient breath through their nose?)
Frontal and maxillary sinuses
Is there any discharge / foreign body?
Frontal and maxillary sinuses (above eyebrow and each side of nose to
cheeks)
Frontal and maxillary sinuses (above eyebrow and each side of nose to
cheeks). Tap middle finger of one hand to the middle finger of other hand
placed over the sinus. Does it make a dull or hallow sound?
Note breath odour
Lips, mucosa of mouth
Gums, hard and soft palate (if applicable)
Tongue – ask the patient to stick their tongue out
Tonsils – swollen, red?
Ask the patient if they have any trouble with taste? swallow? gagging?
reflux?
Lips and mouth if indicated
File 10 Patient assessment and transport
Neck
Inspect
Palpate
If skilled
Arms & hands
Inspect





Skin of neck – colour, lesions
Muscles of neck – are they extended?
The trachea – is it central? to one side?
The thyroid – is it enlarged?
The lymph nodes / glands– in front of the ears, behind the ears, under
jaw, chin, lower jaw, tonsillar area, above and below clavicle

Muscles of the neck, is there any swelling? can the patient lift their
shoulders?

The trachea

The carotid arteries – one at a time

The thyroid – stand in front or behind patient and feel

The lymph nodes / glands– in front of the ears, behind the ears, under
jaw, chin, lower jaw, tonsillar area, above and below clavicle
Inspect the jugular vein for distension, and estimate the venous pressure (JVP)
if indicated

Nail bed – colour – pink, blue? Shape – clubbing can occur as a result of
long term hypoxia

Muscle size, upper and lower arm

Presence of lesions
Palpate

Texture of nail bed or nail

Joints of fingers, writs, elbows and shoulders

Temperature

Radial and brachial pulses
Assess

Range of motion and strength of fingers, wrists, elbows and shoulders
If skilled

Assess capillary refill on nail bed as an indication of peripheral circulation

Check capillary refill by pressing on the nail until blanching occurs.
Capillary refill
Release the nail and count the time for the nail to return to its previous
colour. Check capillary refill on all extremities

Normal capillary refill is 2- 3 sec. A delayed capillary refill may occur with
heart failure, shock or peripheral vascular disease
Upper back of chest (posterior thorax)
Inspect

Cervical, thoracic, lumbar spine

Size and shape of chest wall

Size, shape and position of shoulders, scapula
Auscultate

The posterior thorax and lateral thorax (chest)
Palpate

Cervical, thoracic, lumbar spine
Percuss

The posterior thorax and lateral thorax (chest)
If skilled

Palpate the thyroid (posterior approach)

Perform diaphragmatic expansion -is there equal expansion of both sides
Upper front of chest (anterior thorax)
Inspect

Size, shape of chest wall

Angle of ribs, intercostal spaces

Muscles used for respiration, is the sternum being retracted? muscles
between ribs? muscles of neck?

Respirations

Count the respirations (One breath in and out = 1 bpm)
File 10 Patient assessment and transport
Auscultate
Palpate
Percuss
If skilled
Heart
Inspect
Auscultate (with bell
of stethoscope)




The anterior thorax (chest wall)
The anterior thorax (chest wall)
The anterior thorax (chest wall)
Perform anterior thoracic expansion-is there equal expansion of both
sides?

Chest wall, pulses in neck

The apical (apex) of the heart

Describe, sounds – rhythm, rate

Count the pulse
If skilled

Palpate the cardiac landmarks for pulsations, thrills, and heaves
Female breasts as appropriate to presentation by skilled practitioner
Inspect

Breasts for colour, size, shape, equal on both sides? Any obvious
discharge?

Lesions / thickening / oedema
Palpate

Both breasts and

Lymph nodes – under arm, pectoral, clavicle
If skilled

Teach breast self examination
Male breasts as appropriate to presentation by skilled practitioner
Inspect

Breasts for colour, size, shape, equal on both sides? Any obvious
discharge?

Lesions / thickening / oedema
Palpate

Both breasts

Lymph nodes – under arm, pectoral, clavicle
If skilled

Teach breast self examination
Abdomen
Inspect

The size, shape, colour and pigmentation

Note – scars, stretch marks, visible peristalsis, masses, pulsation

Umbilicus
Auscultate

Bowel sounds - describe
Percuss

Quadrants of the abdomen

Note – liver span and descent

Spleen, stomach and bladder
Palpate

Palpate lightly all quadrants of the abdomen

Note any guarding

Palpate (deeply) if skilled

Liver, spleen, kidney, aorta and bladder
Inguinal area
Inspect

Inguinal lymph nodes

For inguinal hernias
Palpate

Inguinal lymph nodes

Femoral pulses
Legs and feet
Inspect

Colour, oedema, lesions, scars, hair distribution, varicose veins

Muscle size upper and lower leg and feet – are they equal?
Palpate

Temperature, oedema,

Texture skin and nails

Pulses – popliteal, dorsalis pedis, posterior tibial pulses
File 10 Patient assessment and transport

Muscles legs and feet

Joints of the hips, knees, ankles and feet
Assess

Range of movement – hips, knees, ankles and feet
If skilled

Check capillary refill (as per arms & hands)
Female genitalia, anus and rectum as appropriate to presentation by skilled practitioner
See Health Check – Women
Male genitalia as appropriate to presentation by skilled practitioner
Inspect

Hair distribution, penis, scrotum

Urethral meatus for discharge, location on head of penis
Palpate

Penis, urethral meatus and scrotum

Inguinal area for hernias
If skilled
Teach testicular self examination
Male anus, rectum and prostate as appropriate to presentation by skilled practitioner
Inspect

The perineum, sacrococcygeal area, anal mucosa
Palpate (if skilled)

The anus, rectum and prostate
Diagnostic and pathology services
Diagnostic and pathology services are limited in rural and remote facilities.
Patients may be required to travel in order to access some diagnostic services.
Visiting outreach services including those provided by the RFDS may also bring portable
diagnostic devices to the patient.
Refer to the current edition of the Pathology Handbook for Rural and Remote Queensland
for information on ordering of pathology tests, labelling, collection of specimens,
pre-laboratory processing, transport of specimens and accessing of results.
It is very important when diagnostic tests have been performed that the results are
followed up, the patient informed of the results and abnormal results acted on. Consult a
Medical Officer for advice if unsure about results. MO must review all abnormal results.
Collaboration with other members of the team
To ensure the patient receives the appropriate care for their condition, collaborating with
other members of the team, often by remote consultation, is required.
Collaborative practice is the term used to describe the practice relationship between Registered
Nurses, Medical Practitioners, Aboriginal and Torres Strait Islander Health Workers and other
health professionals who use the PCCM as a guide to practice. The collaborative practice
relationship incorporates the dual notions of collaboration and delegation.
The defining characteristics of the collaborative practice relationship are:

Mutual respect and acknowledgment of each profession’s role, scope of practice and
unique contribution to health outcomes

Clearly stated protocols and guidelines for clinical decision-making which comply with
relevant legislation and are supported by the health facility and the health organisation

Clearly defined levels of accountability with an acceptance that joint clinical decisionmaking is an integral component of collaborative practice

A belief that the best health outcomes are achieved when well prepared health
professionals work in collaboration and partnership in both the practice and
educational setting