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• DAR(P)


  Data, actions, response, plan
• SOAP(IEP)


  Subjective data, objective data, assessment, plan, intervention, evaluation
• ADPIE


  Assessment, diagnosis, plan, intervention, evaluation
• SBAR


  Situation, background, assessment, recommendations
• Anatomical surfaces


  • Anterior (ventral) - front
  • Posterior (dorsal) - back
  • Distal - farther from trunk
  • Proximal - closer to trunk
  • Superior - above
  • Inferior - below
• General survey begins at the first moment of meeting a patient and continues through the history, assessment, and every subsequent interaction
• Components of general survey

  • Physical appearance
  • Body structure
  • Mobility
  • Behaviour
• Physical appearance


  Age, sex, level of consciousness, skin color, facial features
• Body structure


  Stature, nutrition, symmetry, posture, position, body build and contour
• Mobility


  Gait, range of motion
• Behaviour


  Facial expression, mood and affect, speech, dress, personal hygiene
• Weight


  Remove shoes and heavy outer clothing, ensure weighing at same time of day for repeated measurements
• Height


  Remove shoes, stand straight, look ahead. If unable to stand, use arm span as an approximation
• BMI


  Marker for optimal weight per height and indicator of obesity. BMI = weight (kg)/height (m) squared
• Reasons to assess vital signs

  • Establish a baseline
  • Monitor condition
  • Evaluate response to treatment
  • Evaluate health issues
  • Assess risks for alterations in health
• Temperature


  Controlled by the hypothalamus. Normal is 35.9-37.5 degrees Celsius. Influenced by diurnal cycle, menstrual cycle, exercise, age
• Temperature measurement methods


  • Oral
  • Axillary
  • Rectal
  • Tympanic membrane
  • Temporal artery
• Pulse


  Reflects the stroke volume. Assessed for rate, rhythm, amplitude, and elasticity
• Respirations


  Measures the rate of one inspiration and expiration cycle. Assessed for rate, rhythm, depth, quality, and use of accessory muscles
• Blood pressure


  Reflects the force exerted by the flow of the blood against arterial walls. Systolic, diastolic, and mean arterial pressure
• Factors causing false high blood pressure readings

  • Anxiety
  • Arm level below heart
  • Patient supporting own arm (high diastolic)
  • Patient supporting legs
  • Cuff too narrow for arm
  • Deflating cuff too slowly (high diastolic)
  • Re-inflating cuff midway (high diastolic)
  • Repeating BP too soon (high diastolic)
• Factors causing false low blood pressure readings


  • Arm level above heart
  • Cuff wrap is loose or uneven
  • Pushing stethoscope too hard on brachial artery (low diastolic)
  • Deflating cuff too quickly (low systolic)
• Preparation for assessment


  Collect equipment, introduce yourself, give an overview, drape appropriately, use a logical sequence
• Assessment techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Inspection


  Concentrated watching, first of the patient as a whole, then of each body system. Observing for overall characteristics using sight, hearing, and smell
• Palpation


  Applying sense of touch to assess texture, temperature, moisture, and organ location and size, as well as swelling, vibration or pulsation, rigidity, presence of lumps, and present of tenderness or pain
• Percussion


  Tapping skin with short, sharp strokes to assess underlying structures, the strokes yield a palpable vibration and characteristic sounds that depict the location, size, and density of the underlying organ
• Percussion notes


  • Resonant
  • Hyper-resonant
  • Tympany
  • Dull
  • Flat
• Auscultation


  Listening to sounds produced by parts of the body, such as lungs, heart, blood vessels, and abdomen via stethoscope
• Developmental considerations for physical examinations

  • Infants
  • Toddlers
  • Preschoolers
  • School-age
  • Adolescents
• Initial pain assessment questions

  • Onset
  • Provocative/palliative
  • Quality of pain
  • Region of body/radiation
  • Severity of pain
• Patients


  • Realistic and amenable to health teaching
  • Don't want to be treated as a child
• Initial Pain Assessment


  1. Onset

  2. Provocative/palliative

  3. Quality of pain

  4. Region of body/radiation

  5. Severity of pain

  6. Treatment/timing

  7. Understanding of pain

  8. Values
• Onset


  • When did the pain start?
  • Identify onset of pain
  • Is it acute or chronic
• Provocative/palliative


  • Does your pain increase with movement or activity?
  • Are the symptoms relieved with rest?
  • Where any other tx effective?
  • Identify quality of pain and differentiate b/w neuropathic and nociceptive
  • To identify alleviating and aggravating factors
  • To evaluate effectiveness of current tx
• Quality of pain


  • What does your pain feel like?
  • What words would you use to describe your pain?
  • To identify mechanisms of pain
• Region of body/radiation


  • Where is your pain?
  • Does the pain radiate or move to other areas?
  • To identify one or more areas of the body that are affected by pain
• Severity of pain


  • How would you rate your pain on a scale of 0-10?
  • To identify intensity of pain
  • To identify degree of impairment and effect on quality of life or ability to perform ADL's
• Treatment/timing


  • What tx have worked for you in the past?
  • Is it a constant, dull, or intermittent pain?
  • To identify tx which have been successful in the past
  • To identify the timing of pain so that tx can be focused on spikes in pain
• Understanding of pain


  • What do you believe is causing the pain?
  • To understand pt hx of pain
  • To be able to set achievable pain and functional goals when reviewing the plan of care