Chapter 2. Patient Assessment
Sometimes the nurse will not have time to complete a detailed assessment on every client at the start of the shift. Quick priority assessments provide a guide for the nurse to quickly gather information to help in determining relative client stability and priorities for care. This approach is also helpful each time the nurse interacts with the client and in the event of an emergency. Any concerns are followed up with a more focused assessment and, if necessary, activation of the agency’s emergency response system.
The QPA assessment includes the steps in Checklist 23.
Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.
|A||Airway. Does the patient’s position allow their airway to be patent? For example, if someone has slumped down in the bed or wheelchair, they may require repositioning.|
|B||Breathing. What is the quality of the breathing? Are there any suggestions that breathing is compromised? Any concerns require further investigation.|
|C||Circulation. What is the patient’s colour. Quickly palpate extremities for warmth. Any concerns require further investigation.|
|I||In. What is going in? Identify every solution going into the patient. Follow all tubes from their source to the patient. Are the volumes adequate? Are the rates accurate? Are the tube insertion sites intact and free of complications? Is the safety equipment (i.e., pumps) plugged in and working? Is there any evidence of complications?|
|O||Out. What is coming out? Are dressings dry and intact? Are any drainage tubes present? If so, what is the nature of the drainage? Follow all tubes from their source to the patient. Are the tubes patent? Are the tubes secured to avoid accidental or unintentional removal? Is there any evidence of complications?|
|P||Pain. Is the patient comfortable? Are analgesics given previously still effective? Does the patient need repositioning? Are they too warm or too cold? Do they need to use the washroom?|
|Adapted from: Christensen & Kockrow, 1999|
Critical Thinking Exercises
- Initial assessment of your patient reveals that the patient is having trouble speaking. What would be your next steps?
- Your patient is returning from surgery following an appendectomy. Outline an assessment plan using a systems approach