What does a physical assessment entail?

Outcomes 

1. Students will develop a working knowledge and understanding of what constitutes effective communication.

2. Understand the importance of patient assessment.

3. Students will know how to perform a patient assessment 

     in a systematic way.

4.  Develop a clearer understanding of documentation.

5.  Participate in peer discussions and self-reflection.

Signposting to useful and evidence based resources and providing interventional education and offer refferals to a specialised professional eg psychiatrist

Thoughts were she was undergoing in and out body experience consequently.

She is entering into reality

Protect the patient from other patients

History from the age of 22 when condition was triggered by relationship breakdown and cannabis use

Reassessment, review, evaluate care.

Assess risk of relapse.

Fearing family may die and may be relating to her stress factors and could contribute to her mind racing resulting in possible heart palpitations

Sleeping patterns would also need to be assessed, as well as monitoring fluid and dietary intake as this could be a reason for memory loss

risk assessment could be carried out due to the fact that she works with children in a school. Safeguarding referral may be a possible option considering she has had 5 episodes of psychosis

auditory hallucinations of being spoken to by God and her father praying for her

mixed thoughts

In case the patient relapses

To safeguard the patient

Important to provide person centered care

To aid the patient in decision making

It helps for interventions

Time management to help allocate appropriate care

Good communication skills

Observation skills inc none verbal cues

Working in a MDT

Assessment tools-

MSE

ABC

News chart

Camberwell assessment of needs

DASS

To establish what is time sensitive.

Ensure the patient safety.

Speak clearly and maintain eye contact, give the patient time to respond.

Active listening

Do not stand over the patient

Ask open questions to encourage the patient to give more than one word answers

Control our emotions

Pay attention to none verbal cues

When we find a good pathway to the patient, create a hospital passport to aid other members of staff

Effective communication strategies-

To pass and gain information

Interact with the patient

To gain better understanding of the patient

For continuation of care

We communicate to express our feelings and concerns

Paramount for good teamwork

It helps to meet the needs of the patient

For update purposes

4 types of communication are Verbal, none verbal, visual and written

BAV-Q

Using open questions.

Tone of voice.

Repeat a summary of what you've understood from the conversation, avoiding noisy environment

A-E stands for

A- airway

B- breathing

C- circulation

D- disability

E- exposure

A physical assessment involves

Inspection

Vital signs

Skin assessment

Height and weight

many others

Breathing.

Circulation.

Disability.

Danger.

Exposure.

Blood pressure range 120/80 is the normal rate

Respiratory range 12-18

Pulse range 60-100 per minute

Temperature range 36.1 to 37.2 degrees c

Saturation 95-100

1. Airway

   referring to nose, mouth

2. breathing

   possibly monitoring chest movement for regular breathing and the rate

3. circulation

   heart rate, blood pressure, ECG monitoring and capillary refill time

4. disability

   level of consciousness, limb movement, blood glucose

5. Exposure and environment

   temperature,

   
   

   Physical assessments entail checking skin for bruising, vital signs, patient weight, vision, checking ear, nose and throat, blood sugar levels

1. Airway

   referring to nose, mouth

2. breathing

   possibly monitoring chest movement for regular breathing and the rate

3. circulation

   heart rate, blood pressure, ECG monitoring and capillary refill time

4. disability

   level of consciousness, limb movement, blood glucose

5. Exposure and environment

   temperature,

   
   

   Physical assessments entail checking skin for bruising, vital signs, patient weight, vision, checking ear, nose and throat, blood sugar levels

active listening

maintaining good eye contact

good non verbal communication and body language

Asking questions and reaffirming to establish understanding

a gentle touch depending on the situation and the patient

Giving patient time to respond

Breathing- Breathing is shallow with a respiration of 10

Circulation- Hands and fingers responsive to pain only.

Disability- None verbally responsive but she is responsive to pain in her hands and fingers.

Exposure- We have inspected the woman's body for any injuries or visual clues

She could suffering post-natal depression, further assessment needs to be done, therapy needed, social services to be informed, if there is a partner in her life, explore her social life, confirm if she uses alcohol, does she feel like harming herself or the baby.

Refer Katia to her health visitor as this will aid in safeguarding the baby if risk are present.

The health visitor can also refer to social services to provide help to Katia and her baby