Nursing Physical Assessment Using a Body System Approach

CNE/Preceptor assessed

Y/N

Identify indication or rationale for medication administration (Oral)

Confirm patient identity

Determines need to undertake a nursing physical assessment

Identify appropriate timing for performing the assessment

Therapeutic relationship

Initiate communication by introductions and clarification of patient’s immediate needs and problems

Clarify patient knowledge and provide education where necessary

Explain actions and potential discomfort at all stages of the procedure

Gain patient consent

Assess patient

Assess patient comfort and provide analgesia where appropriate

Performs a rapid visual assessment of the patient and their environment for important cues.

The primary survey below may assist with this rapid review and should be performed every time you attend to your patient, but it does not need to be included in the Assessment 3a -ePortfolio Semester 1.

Primary survey

Airway – Is the airway clear?

Listen for noisy or obstructed breathing

Feel for airflow over the mouth

Breathing – Is the patient breathing spontaneously?

Look for rise and fall of the chest

Circulation – Does the patient have adequate circulation?

Observe skin colour

Feel for a pulse

Disability – What is the patient’s level of consciousness?

Determine if the patient is alert, responsive to voice, responsive to pain, or unresponsive (unconscious)

Exposure– Performs a quick head-to-toe scan of the patient and their environment:

Does the patient look well, sick or critical?

What treatments are in progress and how might these affect your assessment findings (e.g. medications, infusions, oxygen)?

Performs Hand Hygiene

Performs social handwash

Adheres to ‘5 moments for hand

Wear appropriate PPE

Gather equipment

Blue/black pen, relevant documentation

Penlight torch

Pulse oximeter

Stethoscope

Sphygmomanometer

Thermometer

Prepare Equipment

Consider privacy and appropriateness of setting (Inclusion of family, friends, NOK)

Position patient comfortably

Perform Clinical Procedure- Neurological

Assesses level of consciousness and mental status

Perform a focused neurological assessment including Glasgow Coma Scale, pupil size and reaction, limb strength

If indicated, perform a mental state assessment

Assesses for pain or discomfort

If indicated, performs a focused pain assessment using a pain assessment tool/acronym

Perform Clinical Procedure- Cardiovascular

Inspect and palpates skin colour, temperature and capillary refill

Palpates peripheral pulses for rate, rhythm and strength

Measure blood pressure

Auscultate apical pulse

Palpate calves for tenderness

Palpate for oedema in feet and dependent areas (e.g. sacrum)

Complete neurovascular observations if indicated

Complete an electrocardiogram (ECG) if indicated

Observe for/apply compression stockings and sequential compression devices

Perform Clinical Procedure- Respiratory

Inspect chest and work of breathing

Measure respiratory rate, rhythm and depth

Assess ability to cough; examines sputum if indicated

Auscultate lung sounds

Measure oxygen saturation

Does the patient require any oxygen? Liters per minute and how is the oxygen delivered?

Is your patient on inhalers?

Peak flow

Perform Clinical Procedure- Gastrointestinal

Inspect the abdomen for symmetry, masses, or distension

Auscultate for bowel sounds

Palpate the abdomen lightly noting any tenderness, guarding or rigidity; feels for any masses or pulsations

Assess the most recent and frequency of bowel action

Assess mucous membranes, teeth/dentures (e.g. redness, ulceration, dental cavity)

Assess for nausea and vomiting

Assess weight (recent gain/loss)

Check if the patient is nil by mouth (NBM)? If oral diet: normal soft, smooth/minced? Assesses percent of meal eaten. Is the patient on a food and/or fluid balance chart

Is assistance in feeding required?

Perform Clinical Procedure- Renal

Observe and maintain current intake and output, 24-hour fluid balance if indicated

Assess and interpret fluid status

Measure and observe urine output, colour, presence of sediment

If indicated, palpates bladder for distension

If indicated, performs urinalysis

Observe for urostomy, indwelling urinary catheter (JDC), suprapubic catheter (SPC)

Perform Clinical Procedure- Musculoskeletal

Inspect major joints for range-of-motion

Assess muscle strength and compare sides

Observe safe use of mobility aids

Observe ability to transfer and mobilise

Assessment of falls risk

Assistance in activities of daily living (ADL’s)

Perform Clinical Procedure- Integumentary

Inspect and palpate the skin for general colour, temperature, moisture and turgor and capillary refill

Inspect and palpate for signs of pressure injury such as non-blanchable redness, localised heat, oedema and induration

Complete a pressure injury assessment

Observe any wounds, dressings and drains for warmth, redness, swelling, exudate and odour

If indicated, performs a focused wound assessment

Perform Clinical Procedure- Analysing data

Compare assessment findings with patient’s baseline assessment data

Analyse for important changes or trends over time

Review medications

If appropriate analyse other investigations and tests (e.g. Xray, blood results)

Clean and dispose of equipment appropriately

Dispose of used equipment in appropriate reciprocal

Place call bell within reach

Leave room clean and clear of clutter

Perform hand hygiene

Clean any equipment used

Complete Documentation

Document assessment findings in patient’s healthcare record following a structured nursing assessment framework

Reports any significant abnormal data to senior nurse and/or medical officer