Patient assessment is the process of collecting information about an individual patient’s physiological, psychological, mental status before any regular checkup, surgery or in the case of an accident. It is usually done by a licensed and registered nurse. Patient assessment is usually conducted to identify and address the existing and future patient care needs. This article provides information regarding a few aspects of patient assessment.
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Patient Assessment Tools
Patient assessment tools are developed to help healthcare providers check for various injuries, possibilities of other health conditions and pain identification. There are numerous tools out of which a few examples are given ahead:
- ABCDE of total physiology check:
A: Airway check
B: Breathing
C: Circulation of blood and air
D: Disability to any organ
E: Exposure
- AVPU is used to measure the levels of consciousness
A: Alertness levels
V: Voice
P: Pain levels as expressed by the individual
U: Unresponsiveness
Assessment of Stroke Patient
Stroke can become a sudden cause of death, disability and patient assessment in stroke are very necessary. A few tools used for assessment of a stroke patient are:
- CPSS refers to the Cincinnati Prehospital Stroke Scale
- FAST stands for Face Arms Speech Test
- LAPSS stands for Los Angeles Prehospital Stroke Screen
While these three tools are easy to conduct, they don’t measure stroke sensitivity.
A few other tools that do measure stroke sensitivity are:
- LAMS stands for Los Angeles Motor Scale
- RACE is for Rapid Arterial Occlusion Evaluation
- MEND means Miami Emergency Neurological Deficit
Cognitive Assessment for Stroke Patients Scoring: CASP, which refers to Cognitive Assessment for Stroke Patients scoring is the tool used to measure the cognitive functions affected in stroke. The CASP consists of nine items that measure six cognitive functions like language comprehension and formation, praxis, short term memory functions, the orientation of the temporal portion, spatial neglect, and executive functions.
Postural Assessment Scale for Stroke Patients: PASS, which is the abbreviation for Postural Assessment Scale for Stroke patients, is designed to evaluate the control of the body and posture after stroke. The PASS consists of 2 sections divided into maintaining posture and changing posture and contains 12 fours level items in total.
Psychological Assessment for Stroke Patients: Psychological assessment for stroke patients is necessary because many aspects of cognition like memory, consciousness, thinking, perception, and affective factors like mood and temperament are likely to be affected in stroke. Psychological assessment for stroke patients can be done by tools like
- CAM-ICU: Confusion assessment method for ICU
- CES-D: Centre for Epidemiological studies for Depression
- MoCA: Montreal Cognitive Assessment
- NIHSS: National Institute Health Stroke Scale
Respiratory patient assessment
Respiratory patient assessment is a form of external assessment of ventilation and oxygen supply of the patient, which includes observations of the rate, depth, and pattern of the respirations performed by the patient. Respiratory patient assessment methods involve noting complaints by the patient of breathlessness, bluish appearances of the nails, lips, skin, restlessness, confusion, pain and effort during respiration process, abnormal breathing sounds, etc.
Health assessment questions to ask the patient
The normal health assessment questions to ask a patient can be divided into the following sections:
- Asking about the chief complaint
- Asking about the history of present illnesses
- Inquiry about the past medical history
- Asking about allergies
- The medications that the individual is currently using
- Family history of the patient related to medical and diseases
- Social history of the patient
- Taking a review of the various organs and systems
Confused Patient Assessment
CAM- Confusion Assessment Method is used to measure whether the patient is suffering from delirium which is a mental condition characterized by disturbances of consciousness and attention, perception, etc.
To look for other potential causes of confusion, a range of tests are included in the confused patient assessment like:
- Blood tests like FBC, U&Es, LFTs, TFTs, Calcium, etc.
- Urinalysis as UTI can cause delirium
- Imaging techniques like CT head, chest X-ray
Assessment of a patient with hypertension
The steps of assessment of a patient with hypertension include:
- Checking the Blood pressure levels
- Focusing on the presence or absence of TOD-target organ damage
- Physical examination includes measurement of electrolytes, urinalysis, blood urea, ECG and others
- Assessment of cardiovascular risk factors
- Examining the history of the patient
- Chemical checkup of glucose, cholesterol, triglycerides, levels
- Hypertension tools like Hypertension Control Package for Clinicians, Hypertension Prevalence Estimator Tool, Tools for Community Health Workers for Hypertension, etc.
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