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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