01.03 The 5-Minute Assessment (Physical assessment)

Overview

1. Completing a shift assessment in 5-minutes is all about multi-tasking
2. Below you will find the action steps to take. In italics below that, you will find the OTHER information you can/will be gathering simultaneously
3. Words in BOLD are statements you should make
4. Underlined words are equipment you will need

Nursing Points

General

1. Remember to ALWAYS inspect skin throughout assessment and to remove gown/clothing!
2. Stethoscope should be on bare skin for most accuracy.
3. Equipment Needed
   1. Stethoscope
   2. Pen Light

Assessment

1. 1. Walk in.  Introduce yourself to the patient. If they are asleep, call their name, then gently shake, and progress to deeper stimuli as needed. “I need to do a quick assessment to start the shift, is that okay?”.
      1. General level of consciousness
      2. General appearance
      3. Affect
      4. Verbal response
      5. Speech quality
   2. Orientation questions: “Just a few questions we ask everyone – Can you tell me your name? Can you tell me where we are right now? Can you tell me what month it is? What brought you into the hospital?”
      1. Further idea of affect, emotions, LOC, verbal response, speech quality, etc.
   3. Tell the patient: “I’m going to start the physical part of the assessment, if anything I do or ask you to do causes you pain, just let me know”.
      1. Allows you to be constantly assessing for pain throughout assessment
   4. Pen Light → Assess pupil response (PERRLA) (“Look straight at my nose”). Look quickly in nose and mouth (“Open your mouth, stick out your tongue”). Then ask patient “Turn your head to the left, now to the right” -while you look at/in their ears briefly. Then perform visual fields with the cardinal directions (“Follow my finger with just your eyes”).
      1. Facial symmetry
      2. Conjunctiva color/drainage
      3. Sclera color/moisture
      4. Ability to follow commands
      5. Neck ROM (they should tell you if it hurts)
   5. ASK: “Any pain or issues with your head, neck, jaw, or ears?” If NO – MOVE ON!
   6. Stethoscope ON → Listen AND Inspect simultaneously “I’m going to listen to your heart, lungs, and belly now. Just breathe normally for now.” – “Now take a deep breath in and out when you feel my stethoscope on your chest” for lung sounds
      1. Heart sounds (5) + Lung sounds (10)
         1. Palpate for crepitus (SubQ air)
         2. Chest symmetry
         3. Chest expansion
         4. Retractions/accessory muscle use
         5. SKIN on Thorax!!
            1. Including TURGOR
      2. Bowel sounds (4). If you hear active bowel sounds right away, go to next quadrant – must listen for full 5 minutes to confirm absent.
         1. INSPECT → skin, symmetry, distention, hernias
   7. Palpate abdomen x 4 quadrants looking for obvious masses or tenderness. IF ABNORMAL → percuss (dull or distended may = blood)
      1. Watch for grimacing or guarding that may indicate pain
      2. Feel for tight, firm, or distended abdomen
   8. UPPER EXTREMITIES:
      1. “Can you squeeze my hands?”
         1. Quick way to get both hands in front of them – you can then move to pulses and the rest of strength.
      2. Radial pulses & cap refill
         1. Skin, nails, edema, temperature, moisture
      3. Strength → “Lift your hands up like you’re stopping a bus – push against me” – “now, pull me towards you”.
         1. More command following
         2. Range of motion
      4. Range of motion → “Can you put your arms out to the side? Now over your head?”
         1. Patient should be reporting any pain with movement
         2. Can put hand on joint while this is occurring to assess for crepitus
   9. LOWER EXTREMITIES:
      1. Pedal pulses & cap refill
         1. Skin, nails, edema, temperature, moisture
      2. Strength → “Push down on my hands like a gas pedal” – “Pull your toes toward your head” – “Lift your legs off the bed, don’t let me push them down”
         1. Range of motion
         2. Command-following
      3. Range of motion – “Can you bend your knees?”
         1. Patient should be reporting pain with movement.
         2. A patient who can bend both knees should leave them bent for the next step!
   10. BACK → Have your patient turn to one side. Plan ahead if you need help to turn the patient – get UAP’s in the room.
       1. Stethoscope – Listen to lungs on back
          1. Assess skin, continence, ability to turn self
       2. Alternatively – do this part FIRST when you’re doing bedside shift report, because you will need to do a skin check and will have another set of hands with you.
   11. GU – reserve this for during a bath or incontinence care. But at this point you can ASK → “Have you had any issues with pain or burning with urination?” – if NO, and if they’re not OB or having a primary genital complaint, it is not necessary

Nursing Concepts

1. 1. You should be assessing skin, temperature, eema, and pain throughout the assessment
   2. Finish your assessment with a full set of vital signs and address your patient’s needs
   3. If any findings are abnormal, pause and investigate further
      1. PQRST pain assessments
      2. Wound/dressing assessments, etc.
   4. Document your findings!

Patient Education

1. Purpose for assessment
2. Any abnormal findings – don’t diagnose, but can explain what is happening physiologically