Episode #9 THE PRE ASSESSMENT ASSESSMENT
○ In this episode I’ll cover
● The Observation phase of your assessment
● What you can assess during the interview portion of visit
● How you can use this portion of the assessment to guide you in patient care
By now, you know that I have a lot of tips and tricks for patient evaluation and examination to streamline the process of patient care. I have been doing this for a little over 20 years now and have picked up on a few valuable observations that can help you in the management of your patient.
We are all very well trained in the physical examination. You know how to do a neurological exam, tracking on movements, sensation and motor function. You know how to listen to the heart and lungs. You can quickly assess for murmurs, adventitious breath sounds, bowel sounds, palpate the abdomen for tenderness and organ enlargement, evaluate range of motion in all planes, do the Rhomberg test, straight leg raise, etc. etc. You understand what I’m talking about. This is typically the phase of the exam that occurs after you have spent a few minutes speaking with your patient about their chief complaint, or discussion of their lab results, studies that have been obtained since the last visit, psychosocial factors and lifestyle tendencies. The part where you either get up from your chair to begin or step closer to actually touch the patient and perform the hands on portion of the examination. I am sure that you are all one of those providers that are rising up from your seat to get closer to the patient for the physical examination, since we discussed that in the last podcast.
If you have missed out on that discussion, you can go back to podcast number 7.
Today’s episode is all about the parts of the examination that can happen from the moment you walk in the door, prior to taking that sit down time with your patients. I am going to review some of the observations that you can make from across the room, that are quite valuable.
You see, when I say that every piece of interaction with that patient is valuable, including those first few minutes that you take to create familiarity and the connection, I truly mean it.
When you first walk into the exam room, you will be able to gauge the mood of the patient and their general physical state. Are they angry, are they sitting with their arms crossed, do you startle them when they walk in? Are they open with you? Are they sitting with minimal emotional response? Do they appear to be depressed? What are you observing?
Now aside from personality, as you make your interaction, smiling upon entering, and trying to engage with that patient, their psychiatric evaluation has begun. Not only that but imagine if the face is kind of rigid and blunted. What would you take from this?
Well, one of the things that you can take from that presentation is potentially a Parkinson’s disorder. This one is often missed. You may think that the patient just does not have much of a personality, if you do not continue on with a more in-depth examination. So, this is another one of your mental notes that you jot down to do a full neurological evaluation to assess for other signs of hypertonicity, tremor, cogwheeling, etc.
Does the patient make eye contact with you? When they do, are both eyes in alignment? Take a good look at the face. As they are speaking to you, is one side of the face less mobile than the other? Could there possibly be any sign of a neurologic event, flattening of the nasal labial folds? Cranial nerve assessment is happening here.
The nervous system is very intriguing and often overlooked. This is why I say, “do not get in a hurry that initial visit, establish that relationship with your patient and be aware of those little things.” If they see you regularly and you notice that there’s been a change in their personality and their response to you as you enter the room, you should be on alert.
Now let’s continue with the interaction. Are you noticing their speech? How is their voice? Is it monotone? Is it slow? Do they have the appropriate inflections when they speak to you? Is there any dysarthria? Are they able to speak in full, complete sentences? You can assess a lot about their cognitive function just through a simple conversation. All of this is just as you enter the door and say hello how are you today! When you ask about them directly, and you get diversion techniques, there may be some kind of psychosocial area that you need to look a bit more into as you are questioning.
You can continue to note vital parts of your assessment as you’re entering the room by looking at their comfort level. Do they appear to be comfortable? Are they sitting relaxed in the exam room? Or are they sitting upright and appearing to be in discomfort. Are they leaning to one side or the other? Do they turn to sit on the edge of the bed? Are they standing and pacing? This is often a sign of a back pain or other physical impairments, that they either would like to tell you about, or are afraid to tell you about or maybe they’re just waiting to see if you even notice.
Let’s keeps going. What is their coloring? Do they look pale, do they appear to be a bit dusky or in distress? How do their lips look? Are they gray or jaundice? This could be part of an evaluation for anemia, liver impairment or a respiratory condition.
That leads to what is their effort of breathing? Are they able to converse with you without becoming short of breath? Are the respirations even and unlabored? Or do they seem to get winded with your discussions? You could also consider the appearance of their chest at this point, but I kind of put that more into my physical, hands on evaluation to look at characteristics such as a barrel chest. You can however note at this point if they are cachectic. But again, that could be rolled more into the actual physical piece of the examination. This current podcast is more so on what you’re assessing as you walk into that room in about a minute or less.
We have not yet even touched on their grooming. Are they well-dressed? Are they clean? Do you notice any odors? Odors can lend into maybe some other issues with hygiene that need to be addressed. Is there incontinence of urine? Because a lot of times they will not actually speak to you about this unless you ask specifically. What else about body odor? Could this be a sign of depression and decrease in self-care? Or maybe they really just came to you after they got off work. Not sure, investigate in a tactful manner.
Does the patient appear to be tired? Or are they alert and oriented and engaged in the conversation. If someone appears to be fatigued, I will bring that to attention for sure! Often times, patients are so used to being chronically fatigued that they don’t even mention it. Or maybe if they haven’t been seeing you for very long, they are used to that being dismissed when they bring it up. Chronic fatigue is very important to follow through on. You’re not going to be one of those providers that dismisses it, because you know it could be key to so many things in this patient’s health. You’re going to be an awesome Nurse Practitioner that is at the top of your game and follow through with the appropriate questions and make that patient feel as if their concerns are valid, because they are.
Remember in a previous podcast, I discussed that patient connection and actually listening to your patient. If you just sit to listen, it will bring so much more to light. They desperately want and need your help. They just may not always know how to bring up the things that are bothering them. Heck, they may not even know that it’s a problem if they’ve been dealing with it forever.
When someone appears to be extremely fatigued, I will jot that down as well. I will ask questions about their sleep. I will consider things like restless leg syndrome, obstructive sleep apnea, nocturia, stress, maybe some children at home that don’t sleep through the night. You need to be the detective. You need to address these observations.
Are you feeling pretty good about yourself right now? Are you feeling like super smart about everything that you can take in from just walking into the room? I know that often times patients wonder what they even come into the office for. What you really are doing for them if you just sit and talk. But all these things that I have just addressed are quite thorough and I’m not even done yet. The complexity of observation in this examination is evident and you are still just asking them about their children or their well-being since your last encounter!
I will continue to engage with them a bit and try to learn a little more about them. As I am asking about their work life and maybe commenting on their fatigue or some other detail that I have noted when coming in, I am looking for other things. When they are distracted, do they have a tremor of the head or the hands? A tremor at rest can be a sign of Parkinson’s disease. Do they make eye contact with you? Do they twist their hands in their lap?
I have to say that I also really like warmer weather, when patients come in in shorts and sandals, because I can see a ton more while we are talking.
Is there any skin discoloration of the lower extremities, is there fungus of the toenails, are there any ulcers, is there edema? I know I know, that is more the physical examination but, when the season is right, that’s also part of that first two minutes.
With the observations that you have made to this point on the patient, you should take a quick peek back at the review of systems and see if any of it was brought up. If it were not, then carry this into the physical assessment questioning as you go from head to toe. If you continue to interact with a patient during the physical exam, you can also observe much more because they are in a relaxed state.
Remember, if you tuned into episode #8, I am recording a physical examination video for you guys. This is one that will show the way that I have streamline things, to get the maximum information in the shortest amount of time. If you haven’t already done so, go to the website nphealthinterventions.com/assessmentpearls to get that emailed to you. It’s totally free. No worries. This is not a sales pitch. This is a true me giving it back and paying it forward. I have been very blessed in my life to have been with some great colleagues that have helped me to excel in some of my assessment skills.
Does the patient appear to be overweight or underweight? If the patient is either, you could have a delicate conversation ahead of you. You have to be very sensitive about addressing either. If someone is overweight, obviously they know they are overweight and they’ve been told on many occasions that they need to lose weight. That is not a revelation to them and should not be the generic thing that you should put into your plan of care with them. If they are underweight, you could very well have some type of a problem with an eating disorder, maybe drug abuse or even a cachectic date associated with a malignancy. It’s your job to see it and address it.
If the patient is overweight and you are at a loss on how to address this and how to treat this by saying more than just eat less and move more, go ahead and check out my weight management program for clinicians. This is not for you to lose weight, although if you need to, it’s all good! You may find some value in it for yourself. This is a program that has been designed from beginning to end to help you to address the patient’s Obesity to improve their outcomes. We go over why you should introduce weight management into your practice, how to implement it into your practice, the appropriate lab evaluations and diagnostic studies to help you find ways to address things that may be contributing to the weight gain beyond nutritional habits. Nutrition and sedentary lifestyle are very important, but often there’s much much more to the etiology. If you’d like to learn more about that go on over to nphealthinterventions/providercourses
I am truly not a pushy, sales kind of person, but I really believe that every provider needs to have this program in their life and in their practice. It’s really the core of managing so many disease states.
And that’s all I’m going to say about that!
We will move forward!! One last thing that I try to do with all of my patients, is walk them out of the room to the checkout window. When I do this, I am able to see how they stand up. Do they need assistance? Do they need to push off to get up out of the chair, is it uncomfortable for them to get up out of the chair? Again, I’m going to touch on Parkinson’s as a cause for difficulty with rising out of the chair or maybe there is a rheumatologic problem, a musculoskeletal issue that keeps them from rising out of the chair correctly or with ease.
As we walk out of the room, I can see how their stance is. Is it wide-based, is it narrow, is it shuffled? Do they run into the walls? How is the balance? Do they use a cane or a walker? So many details! And they think that I am just simply being kind and walking them out to the checkout window to bid them a good day until the next time. Not that that isn’t the case, but the entire time I am interacting with a patient I am assessing. That is the lesson I am trying to give here. Always be assessing your patients for the subtleties they might not know to mention they have, it will help you to help them.
Oh my, I do talk a lot, don’t I!? Let’s start closing out this podcast today. I have went through a lot of stuff. I’ve probably missed a few key points, but I think we’ve covered a nice chunk of material. Was this helpful to you? Is there anything else that you would like to have had me include in this podcast? Don’t be shy. If I don’t know the answers, I will find a way to get them!
I do have intentions in future podcast, to go into some specifics of each system, as well as some common complaints you may get in practice and how to evaluate those. For instance, Parkinson’s disease, as I have touched on a few times today and migraines. Providers find many things in the nervous system challenging and therefore I want to bring a bit more of that to you to help you in clinical practice. This is so you know when to use your excellent primary care skills to manage or to refer out to a specialist. The patient’s time is quite valuable and if they don’t need to take more time to go to a specialist, it’s a win all around. Because there truly are not enough specialists to go around and often times specialists are located in areas that not all patients have easy access to. For instance, in my area, the closest facility with a neurologist is 45 minutes away, minimum. And transportation is an issue because we do not have much in the way of public transportation here in rural West Virginia. There is no Uber, there are no cabs, no transits and no regularly running bus schedule.
How do you feel about all of this? How do you feel about some neurologic topics? With an evaluation attached to it of course. Let me know!
I want to thank you again for taking your time to listen to this podcast. And if you’re loving it, give me a review! That will help others find this podcast to help with their practice also!
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Have a great week! May it be filled with many Health Interventions!