ASSESSMENT
Assessment serves as the initial phase within the APIE framework, comprising Assessment, Planning, Implementation, and Evaluation. Various types of assessments, such as NEWS2 Assessment, Neurological Assessment, or Community Assessment, may be encountered. Scenarios presented during assessment stations include Anxiety and Depression, Asthma, Chronic Heart Failure, Community Assessment, Ectopic Pregnancy, Fall and Fracture, Hernia, Homelessness, Pneumonia, and Subdural Hematoma.
This article will delve into the specifics of the NEWS2 Assessment initially, followed by additional considerations for Neurological and Community Assessments. The time allocated for all assessment types is now 20 minutes. Participants will receive a corresponding chart, whether it be a NEWS2 Assessment Chart, Neurological Assessment Chart, or Community Assessment Chart based on the provided scenario.
It is crucial to remain composed, albeit challenging. Taking a moment for deep breaths, proceed to complete the assigned chart. Following the introductory phase, initiate the assessment by posing an open-ended question, such as “What brought you to the hospital?” Observe, document findings, and then proceed with further inquiries. Emphasizing the verbalization of critical scores, such as the NEWS2 score in NEWS2 Assessment, GCS Score in Neurological Assessment, and PHQ9 Score in Community Assessment (typically provided with the scenario), is essential.
PROCEDURE
Upon entering the patient’s room, it is crucial to assess scene safety before proceeding. This involves ensuring that the environment is safe to approach.
To uphold the patient’s privacy and dignity, it is important to close curtains and doors, creating a confidential space.
Conducting a thorough hand rub following the seven steps of hand hygiene is essential. Simultaneously, observe for potential hazards such as a cigarette packet, glass of water, pills, sample bottle, spectacles, etc. If any hazards are identified, seek patient consent before removal, providing a clear explanation of the consequences.
Introducing yourself as the attending nurse, is the next step in establishing rapport with the patient.
Initiate a polite conversation by asking for the patient’s name, preferred form of address, and date of birth.
Verify this information with the patient’s ID tag, which typically includes their name, date of birth, and hospital number.
Inquire about the patient’s current well-being and comfort level.
Encourage the patient to share their chief concern or provide details about the reason for their visit.
To ensure comprehensive care, ask about any allergies the patient may have.
Is there any pain at the moment? If so, please rate it on a pain scale from 0 (least pain) to 10 (worst pain ever experienced). Make sure to note the pain score as expressed by the patient.
On a scale from 0 to 10, where 0 signifies no pain, and 10 represents the most intense pain you’ve ever felt, could you provide your current pain level?
If the patient is using an oxygen mask or if there’s a need to adjust the bed end, inform the patient that you’re here to check their oxygen saturation and temperature. Additionally, ask if they are comfortable talking.
Shall we proceed with taking your observations, including blood pressure, pulse rate, and respiration? I’ll also need to ask you a few questions about your condition later to plan your care accordingly. Is that acceptable to you?
Inform the patient that you’ll be conducting the procedure, which will take approximately 15 minutes.
Have you been at rest for the past 20 minutes?
Let the patient know that initially, you’ll be taking their observations. Request them to remain calm, avoid talking, and not cross their legs during this time.
Before interacting with the observation machine, make sure to rub your hands.
I’m verifying with the examiner that the equipment has been cleaned, calibrated, and is ready for use. (Given the current scenario where the equipment is already cleaned and calibrated, there may be no need for reconfirmation.)
I’m about to measure your blood pressure. Could you please specify which arm you’d prefer?
Have you undergone any surgeries on this arm?
I’m confirming that this arm is free from infections, inflammation, or lesions.
Ensure that the bladder length of the cuff is more than 80% of the patient’s arm circumference, and the bladder width is more than 30% of the patient’s arm circumference.
Before proceeding, I have placed the cuff 2-3 cm above the antecubital fossa, ensuring it is positioned after locating the brachial artery.
Inform the patient that they may feel a pressure sensation while their blood pressure is being measured.
In the meantime, I’ll also be checking your oxygen saturation on your other hand. Is that acceptable to you?
I’m confirming that the finger is free from any infections or inflammation, warm rather than cold and clammy, and that there are no false nails or nail varnish.
I am evaluating capillary refill in the finger by applying gentle pressure to the fingertip for 5 seconds and observing the time it takes to return to its original state. Once completed, I will move on to checking your body temperature.
Capillary refill occurs in less than 2 seconds, indicating a swift return to normal blood flow. It is safe to proceed with the assessment.
While I gather patient information, the blood pressure machine will automatically record your blood pressure. Is this arrangement acceptable to you?
Your blood pressure is within the normal range, and your oxygen saturation is -97%. I utilized the tympanic method, measuring the temperature in your ear. Is this method agreeable to you?
If you are using hearing aids, ideally, wait 20 minutes before obtaining an accurate reading.
The ear examination for signs of infection, inflammation, or cerebrospinal fluid drainage reveals no abnormalities; everything appears clear.
After confirming the temperature with the patient, I will dispose of the disposable cap in the clinical waste and document the temperature on the NEWS2 chart.
Next, I will check your pulse rate for 2 minutes. May I proceed with this assessment?
From this moment onward, first assess the pulse rate for one minute, then respiration for the following minute.
Once the examination is complete, communicate the pulse rate and respiratory rate findings to the patient, specifying that the pulse rate was observed for one minute and respiration for another minute. Document all observations in the NEWS2 chart.
HOLISTIC ASSESSMENT
I will now pose a few additional questions as part of the ongoing assessment. Let’s begin:
Do you engage in any habits such as smoking or drinking alcohol? If applicable, could you share details about your smoking habits and whether you have considered smoking cessation programs?
Do you have any lifestyle-related diseases, such as diabetes, hypertension, or other conditions? If time permits, I’d like to provide information and education about managing these conditions effectively.
Can you describe your sleeping pattern? How many meals do you typically consume in a day, and do you follow a mixed diet? If needed, we may involve a dietitian for further guidance.
Are you currently experiencing any breathing problems or related issues? It may be beneficial to consult with a respiratory nurse for a more detailed assessment.
Have you had a bowel movement today? Diarrhoea or constipation
Have you urinated today or since your arrival at the hospital?
Are you able to perform your daily activities independently, or do you require assistance, particularly in terms of mobility? Any regular exercise?
Do you have one to support you at home?
Do you have any spiritual needs with regards to your health?
Furthermore, it’s crucial to inquire if there’s anything else you would like to share. This open-ended question serves as a trigger to capture any information we might have missed. If time constraints prevent further questioning after observations, please feel free to express any additional concerns or details.
Thank you for your cooperation. I will continue to monitor and escalate your care as needed. Should you require assistance, simply press the call bell, and I’ll be available. Please take the observation machine with you.
Additionally, if you have any specific requests, let me know, and I’ll ensure the room is ready for your comfort, including opening the curtains and providing a hand rub using the seven steps of hand hygiene before leaving the room.
A-E Assessment in Holistic Approach
While making observations, you can employ the ABCDE method of assessment with the following steps:
Airway: Ensure clarity with no visual obstructions.
Breathing: Evaluate respiratory rate, rhythm, and depth; assess oxygen saturation level; observe for respiratory noises (such as rattle, wheeze, stridor, coughing); check for unequal air entry; look for visual signs of respiratory distress (such as the use of accessory respiratory muscles, cyanosis, sweating see-saw breathing);
Circulation: Monitor heart rate, rhythm, strength and assess blood pressure, capillary refill, pallor, and perfusion.
Disability: Examine the conscious level using ACVPU (alert, confusion, voice, pain, unresponsive); check for the presence of pain; urine output, and blood glucose.
Exposure: Record temperature; inquire about the presence of bleeds, rashes, injuries, or bruises; gather a medical history.
Example:
Pre-operative Inguinal Hernia care
Candidate briefing
You are a registered adult nurse working in the surgical assessment unit. Please conduct a holistic assessment of the patient’s physical, psychosocial, spiritual and sexual care needs.
As part of your assessment, please complete an A to E assessment (airway, breathing, circulation, disability, exposure), and take and record the patient’s vital signs (blood pressure, temperature, pulse rate, oxygen saturations, respiratory rate) and calculate a national early warning score (NEWS 2) score.
Depending on the patient’s circumstances and condition, you may wish to focus on some areas of assessment in more depth than others.
Please note that there is no need to remove the patient’s clothing to assess exposure. Please ask the examiner for any additional clinical information you require.
All equipment has been checked, calibrated and is cleaned.
An observation chart is provided and must be completed within the station.
This document must be completed using a GREEN PEN.
You have 20 minutes to complete this station, including the completion of the following documentation: NEWS 2 chart.
Assume it is TODAY and it is 10:00 hours.
Assessment: Pre-operative Care for Inguinal Hernia
Patient Details:
Name: Scooby Doo
Date of Birth: 20/02/1970
Hospital Number: 65034286
Address: Pepperrell Road, Highbridge
General Practitioner (GP): Dr Kumar, Highbridge Surgical Centre, Highbridge
Date of Admission: 05/12/2021
Chief Complaint:
Scooby reports a noticeable bulge on either side of the pubic bone, exacerbated during activities such as coughing. He experiences a burning sensation at the bulged area, along with pain or discomfort, particularly when bending over or lifting. He has reduced intake of fluids and diet due to nausea. Additionally, he mentions feeling unusually warm and fatigued.
Diagnosis and Treatment Plan:
Diagnosed with inguinal hernia.
Referred to the surgical team, with hernia repair scheduled for tomorrow.
Past Medical History:
Diabetic since 2017.
Social History:
Co-resides with a partner who has Alzheimer’s disease.
Resides in a two-story house.
Occasional alcohol consumption.
Daughter provides meals during her visits every other day.
Medication History:
Glucophage: 1 gm, once a day.
Paracetamol: 1 gram as needed.
Non-smoker.
Presenting Complaint:
John has experienced a reduction in dietary and fluid intake due to nausea. Looking anxious and worried
Allergies:
Allergic to penicillin.
HOW TO ANSWER
Your allotted time for the station is 20 minutes, inclusive of reading. We recommend candidates to employ skimming and scanning techniques to complete the reading within the initial minute and review the information in the subsequent minute. Consequently, you will have a total of 18 minutes for conducting your assessment.
Upon perusing the first page of the scenario, you can ascertain the following details:
Charts necessary for your assessment
A brief understanding of the setting
Current date and time
The second page typically contains the subsequent details:
Patient information
Presenting complaints
Past medical history
Allergies
Social history
Drug history
During the remaining 2 minutes, your task is to quickly skim and scan through the provided information. Focus on identifying answers to the following questions:
Does the patient have any conditions such as asthma, diabetes, hypertension, depression, etc.?
Where is the patient currently located, and what is their current situation?
Does the patient experience any pain, breathing difficulties, mental disorders, wounds, fractures, or infections? How is he managing their nutritional requirements?
What is the patient’s elimination pattern?
What concerns might the patient have regarding their social situations or their current health conditions?
Now, let’s explore how to utilize this information to fulfil our marking criteria through a sample role play.
Role-play Script for a Patient with Inguinal Hernia
Nurse: As I step into the room, my first priority is ensuring a safe environment. Confirming scene safety, I check that it’s secure for me to approach.
Nurse: To respect your privacy and dignity, I close the doors and draw the curtains.
Nurse: Prior to our interaction, I perform hand hygiene using the 7-steps recommended by the WHO.
Nurse: Good morning, I’m Moana, your nurse for today. How are you feeling?
Patient: I’m fine, thank you.
Nurse: Could you please share your full name?
Patient: I’m Scooby Doo.
Nurse: What do you prefer I call you?
Patient: Scooby is fine.
Nurse: Alright, Scooby. Can you confirm your date of birth for me?
Patient: It’s 20/02/1970.
Nurse: May I cross-check that with your ID?
Patient: Of course.
Nurse: Thank you. (Verifying Name, DOB, and hospital number with the scenario and ID band) I’ve confirmed that I’m with the correct person.
Nurse: Scooby, any known allergies?
Patient: Yes, I’m allergic to Penicillin.
Nurse: Could you describe the reaction you have when exposed to Penicillin?
Patient: I develop rashes on my body.
Nurse: May I check your allergy band on your hand?
Patient: Certainly.
(Nurse checks the allergy band)
Nurse: I assure you that I will avoid using any substances causing allergies during your hospital stay. Is that acceptable?
Patient: Yes, thank you.
Nurse: Scooby, are you comfortable, or are you experiencing any pain?
Patient: Yes, I’m in pain.
Nurse: I’m sorry to hear that. On a scale from 0 to 10, where 0 is no pain and 10 is severe pain, how would you rate it?
Patient: It’s a 4.
Nurse: I understand. I’ll complete my assessments in 15 to 20 minutes, then check your prescription and administer any prescribed painkillers or escalate to the prescriber if needed. Can you manage your pain until then?
Patient: Yes, I can.
Nurse: Thank you. Would you like a change in position for more comfort?
Patient: I’m comfortable as I am.
Nurse: Alright, Scooby. Today, I’m here to conduct your A-E assessment, covering airway, breathing, circulation, disability, and exposure. Before we begin, I’ll gather the necessary equipment. Is that okay with you?
Patient: Yes, go ahead.
Nurse: Feel free to use the call bell if you need anything while I’m away. (Performs hand rub after leaving the patient)
Nurse: Assessor, please is the equipment cleaned and calibrated within the last 24 hours?
Assessor: Yes.
Nurse: Thank you. (Performs hand hygiene, wears gloves and apron)
Nurse: Scooby, I’m back with the equipment. Can I proceed with your observations?
Patient: Yes, please.
Nurse: Great. Starting with your airway, I observe your inhalation and exhalation. Since our communication is clear, and you’re breathing comfortably, your airway appears clear with no obstructions.
Nurse: Now, let’s check your oxygen saturation. May I see the middle finger of your right hand?
Patient: Certainly.
(Nurse checks oxygen saturation) Now I am going to check the capillary refill by pressing the finger nail for few seconds, (1,2,3,4,5). It is less than 2 seconds, its normal and I am happy to apply the saturation probe.
Nurse: Your oxygen saturation is 98%, indicating good perfusion.
Nurse: Moving on, I’ll assess your pulse rate for 2 minutes. Any hand preference for checking?
Patient: Left hand.
(Nurse checks pulse rate and respiratory rate)
Nurse: Your heart rate is 74 beats/min, and your respiratory rate is 18 breaths/minute with good rhythm and depth, both within normal ranges. No respiratory abnormalities observed eg; respiratory distress like using the accessory muscle to breath or sign of cyanosis or unequal air entry and no sweating. No respiratory noises like stridor or wheeze
Nurse: Any recent coughing?
Patient: No.
Nurse: Now, I’ll check your blood pressure. Is your left hand okay for this?
Patient: Yes.
(Nurse checks blood pressure) I can confirm that there are no signs of infection, inflammation or cannula.
Do you have any surgeries on this hand?
Patient: no
I can feel the brachial pulse and I am happy to apply the BP Cuff. (Take the BP cuff and verbalize: cuff is adequate for the patient size)
Nurse: I am applying the BP cuff 2 to 3cm above the antecubital fossa. Scooby, while I am inflating the cuff you may feel some pressure and its normal, you won’t experience any pain so don’t worry.
Nurse: Your blood pressure is 130/90, which is normal.
Nurse: I’ll record these observations in the NEWS 2 chart. If you need anything, please use the call bell.
(Removes gloves and apron, performs hand rub, completes NEWS 2 chart, and performs hand rub)
Nurse: Scooby, your NEWS 2 score is 0, indicating normal vital signs. We’ll continue routine monitoring every 12 hours.
Nurse: Is there anything specific on your mind?
Patient: I’m worried about my surgery.
Nurse: Don’t worry; I’ll guide you through everything during your hospital stay.
Patient: Okay, thank you.
Nurse: How about your dietary intake? Are you eating regularly?
Patient: Nausea has affected my eating habits.
Nurse: Any issues with bowel habits like diarrhoea or constipation?
Patient: No.
Nurse: Post-surgery, focus on a diet rich in protein, vegetables, and fruits. Drink at least 2 to 3 litres of water daily.
Nurse: Scooby, do you engage in regular exercise?
Patient: Not consistently.
Nurse: Once you’re getting better, consider light daily walks rather than strenuous exercises.
Patient: Okay.
Nurse: How about your mobility? Do you need assistance with daily activities?
Patient: I’m managing on my own.
Nurse: And your wife, is she receiving support?
Patient: Yes, my sister is with her.
Nurse: Excellent! Any spiritual concerns?
Patient: No.
Nurse: That’s great to hear. Any other concerns or questions from you?
Patient: No.
Nurse: Do you still have pain?
Patient: Yes.
Nurse: I’ll check the prescription and administer pain relief accordingly. I’ll document and escalate as needed. If you require anything, use the call bell.
(Assessor I will clean all equipment and do my final documentation, and then perform my final hand hygiene)
Nurse: Thank you.
