NU2ICU General Physical Assessment

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GENERAL PHYSICAL ASSESSMENT

To perform a high standard assessment a nurse should use every known records of patient history and to fill in the blanks needs to be able to professionally enquire and, importantly, engage with the patient.  Being adept at making the patient feel comfortable and safe is an absolute priority and great skill to learn.  Whether in ICU or general wards your assessment skills are your most powerful tool to ensure the best care for your patient and peace of mind for you

DATA

Review the patient notes and observation chart prior to performing your assessment.  Note the patient’s name, age and religion (some religions would initially preclude opposite sex assessment). Being culturally aware in the 21st century is mandatory and obviously formally ask for the patient’s permission prior to any assessment or interview

 

HISTORY

Patients Own Health Concern

Patients should be asked (if able) their reason for seeking medical help on this occasion / what brought them into hospital. It is important to get the chief complaint in the patient’s own words to assess their understanding of their own health. In chronic illness, they should be questioned as to what changes in their condition prompted them to seek help,  as some patients ‘normal’ is so far from what we expect that this is a good time to try to gauge this

 

ALLERGIES

The patient should be questioned as to environmental, food, drug, and contact allergies. Reactions to allergens should be established.  Assess type and effectiveness of past and current treatment for allergic reactions

 

MEDICATIONS

Name, dosage and frequency of medications should be listed; include over-the-counter and herbal medicines


RAPPORT

Always greet the patient in a friendly, non-threatening manner.  Use “Mr.”, “Mrs.” or their first name if you feel confident.  Explain your relationship to the patient’s care.  During introductions many patients are trying to figure out what you think of them – do you have a preconceived opinion of them?  They are looking at your facial expressions, tone of voice and general manner

One example of an introductory statement in relation to nursing assessment is, “Good Morning, my Name is Jess and I’m your nurse for this shift.  If it is all right with you I will be going through a complete history with you today and performing a physical assessment to help better meet your health care needs. This assessment will also provide a baseline snapshot of your health status right now so that we can notice any changes in your condition during this or perhaps your next admission.”

Use targeted language during your patient assessment interview,

  • listen to the patient’s level of communication and talk to that level and avoid medical “jargon”
  • speak slowly and clearly
  • use all of your listening skills and allow the patient to think and, especially, to talk
  • maintain safe body language even if frustrated with time taken
  • always confirm patient statements to ensure correctness
  • avoid being judgemental – a 70 year old that still smokes probably well understands the damage and the life choice involved in continuing to smoke – offer any recommended assistance, advice or referral and move on
  • end with an open framed opportunity like “do you have any questions or is there anything else”

These methods help avoid miscommunication and encourage you to take the most easily understood and most easily repeated line of questioning

 

ENVIRONMENT

Ensure maximum privacy by use of curtains and closed blinds at all times. Ask the family to leave, if possible, so the patient can provide candid responses to all questions

Always bear in mind curtains are not soundproof and kindness and respect must be shown when dealing with aspects of the patient’s care that may cause embarrassment or discomfort.  Many a neighbouring patient has heard far more than they ever needed to in error

At all times observe infection control processes and procedures – hand hygiene and personal protective equipment

 

We have assembled our tools, time to put them to work.  Keep up the great work!

NU2ICU

 

REFERENCES

Clinical Examination : a systematic guide to physical diagnosis 6th Edition 2010 by Nicholas J. Talley, Simon O’Connor.

Oxford Handbook of Clinical Examination and Practical Skills, 1st Edition 2007 by James Thomas, Tanya Monaghan

 

More reading

NU2ICU PRIMARY ASSESSMENT

NU2ICU SECONDARY ASSESSMENT

NU2ICU KNOWLEDGE ADJUNCTS

NU2ICU AUSCULTATION SKILLS

NU2ICU NORMAL VALUES

NU2ICU RRS / MET VALUES

NU2ICU BONDY ASSESSMENT SCALE

NU2ICU ASSESSMENT PRACTICE TOOL