Assessment of Patients I – LSU Health New Orleans

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Assessment of Patients I

1. Question:--Ask Patient                         Answer:

Describe your involvement in planning your        Patient should describe that the plan of care
  care.                                            was discussed with them; that they are
                                                   working to improve health status by..., etc.


2. Question:                                      Answer:

What is your discipline's scope of assessment?    Staff should verbalize what assessments they
 Is it defined in writing?                          perform and locate a policy that reflects this.

                                         Social Services

3. Question:                                      Answer:

When do you request a social service/case         Refer to Hospital Social Service Policy 5.38.
 management consult on patients?                  All patients are screened for Social Service
                                                   Risk factors (discharge planning,
                                                   abuse/neglect, etc.) within 8 hours of admit.
                                                   Those meeting high-risk criteria are referred
                                                   to social services for a more in-depth
                                                   assessment. These patients receive in-depth
                                                   social services assessment within 48 hours
                                                   of admit, if deemed necessary by the
                                                   administrative house manager. An
                                                   administrative house manager is available
                                                   for emergency consults after hours,
                                                   weekends & holidays.


4. Question:                                      Answer:

What are high-risk criteria that would indicate   Education related to speech  language
 a referral to Speech-Language Pathology is         disorder
 required?                                        Swallowing evaluation  (Bedside and
                                                    Videoflouroscopy)
                                                  Head and neck cancer preoperative
                                                    counseling.
                                                  Voice restoration following total
                                                    laryngectomy
                                                  Fitting voice prostheses
                                                  Stroke evaluation/rehabilitation
                                                  Traumatic brain injury / Closed head injury
                                                   evaluation /Rehabilitation
                                                  Other concerns within the scope of practice of
                                                   Speech-Language Pathology
                                                  The physician must order the consult.
                                                  Refer to Hospital Speech-Language Pathology
                                                   Services Policy 5.36.

5. Question:                                      Answer:

What are high-risk criteria that would indicate   Decreased hearing
 a referral to Audiology Services is required?    Decreased speech understanding
                                                  Failed hearing screening
                                                  Tinnitus
                                                  MD must order consult. Refer to Hospital
                                                   Audiology Services Policy 5.28.


6. Question:                                      Answer:

a) Which waived/point of care tests do you        a) Answer may include urine ketodiastix,
   perform on this unit?                            urine ketostix, urine dipstick, blood glucose,
                                                    clinitest, fecal hemoccults, gastric ph,
                                                    gastroccults, Strep A screens, or urine
                                                    pregnancy tests. Other point of care tests
b) How were you trained/retrained to perform        may include hemachron (ACT) or I-stat.
   these tests?                                   b) Oriented and annual reassessment of
                                                    competence.
c) Where are policies/procedures located?
                                                  c) Polices/procedures should be available for
d) Explain the quality control you perform for      all tests performed.
   each test. Show me your quality control
   logs.
                                                  d) Staff should explain quality control and
                                                    show logs. I-stat, ACT and blood glucose
                                                    do not have manual logs  the logs are
                                                    automated and maintained in the Point of
                                                    Care Office.


7. Question:                                      Answer:

How would you identify possible victims of        -Discrepancies between history and/or
  abuse/neglect?                                     injury
                                                  -Physical Abuse
                                                    -Inconsistencies in the history in
                                     conjunction with the criteria listed
                                        -unusual or unexplained bruising
                                        -head injuries, especially in infants
                                        -retinal hemorrhages infants/children
                                        -fractures
                                        -burns
                                        -repeated injuries
                                      -Sexual Abuse
                                        -genital injuries
                                        -unexplained loss of developmental
                                          milestones
                                        -repeated UTI unrelated to other causes
                                        -depression
                                        -STD's in child
                                        -pregnancy in the very young
                                        -sexual knowledge that exceeds the level
                                     of
                                          maturity
                                      -Neglect
                                         -poor hygiene and/or lack of appropriate
                                           clothing
                                         -lack of heat/running water
                                         -undernourished
                                         -malnourished/dehydrated
                                         -over/under medicated
                                         -lack of immunization
                                         -failure to thrive
                                         -lack of medical care
                                       -Emotional
                                         -withdrawn
                                         -suicidal
                                         -excessively aggressive
                                         -conduct disorder
                                         -inappropriate parent/child interaction
                                         -depression
                                         -Domestic violence - Refer to criteria
                                            listed above as appropriate to the
                                            situation.
                                            Refer to Hospital Abuse/Neglect Policy
                                            5.5

8. Question:                        Answer:

What should you do if you suspect   Document findings. Notify MD. Report as
 abuse/neglect?                      mandated by law to appropriate authorities
                                     and LSUHSC Social Service Department.
                                                  Refer to Hospital Abuse/Neglect Policy 5.5.


9. Question:                                     Answer:
What would you do if you identified a patient    Document findings. Notify MD and Case
   with possible drug/alcohol dependence?         Management. Case Management will
                                                  inform patient of local agencies/treatment
                                                  programs and assist patients to contact
                                                  agencies if they so desire. Refer to Hospital
                                                  Substance Abuse Policy 5.29. Note:
                                                  LSUHSC has no identified treatment
                                                  program for substance abuse.


10. Question:                                    Answer:

What would you base the scope of intensity of    The patient's condition/diagnosis, the care
 further assessment on?                           setting, the patient's desire for care, the
                                                  patient's response to previous care, and the
                                                  patient's consent for treatment.


11. Question:                                    Answer:

a) What special assessments and interventions    a) Social, spiritual, and cultural factors that
   are made for terminal patients?                 influence the perceptions and expressions of
                                                   grief by the patient, family, and significant
                                                   others. To the extent possible, as
                                                   appropriate to the patient's and family's
                                                   needs and the hospital's services,
                                                   interventions address: patient and family
                                                   comfort, dignity, and psychosocial,
b) Who would you consult if needs were             emotional, and spiritual needs about death
   identified?                                     and grief.

                                                 b) Pastoral Services or Social Services, Case
                                                   Manager, Pain Services, or others as needed.


12. Question:                                    Answer:

What special assessments are required prior to   -assessment of mental status
 moderate (conscious) sedation?                  -examination specific to the procedure and
                                                   any co-morbid conditions
                                                 -examination of the heart and lungs by
                                                   auscultation
                                               -airway evaluation
                                               -allergies
                                               -family history of anesthesia/sedation
                                                problems
                                               -medication history
                                               -abnormal lab results
                                               -pain level and assessment
                                               -evaluation of blood/blood component
                                                requirements, as applicable
                                                Refer to Medical Records
                                                Content/Documentation Policy #6.5. and
                                                Moderate (Conscious) Sedation Policy
                                                5.26.

                          Advanced Practice RN/Physician Assistant

13. Question:                                  Answer:

What is your discipline's scope                The assessment includes, but is not limited to,
of assessment?                                  performing an initial/ongoing patient
                                                assessment to determine need for medical
                                                attention, obtaining patient histories,
                                                performing exams and requesting and
                                                interpreting laboratory/diagnostic studies.
                                                In addition, the Advanced Practice
                                                RN/Physician Assistant identifies normal
                                                and abnormal findings, monitors the
                                                effectiveness of therapeutic interventions,
                                                and takes actions within their scope of
                                                practice.

                                               Refer to Hospital Patient Assessment Policy
                                                5.9.



14. Question:                                  Answer:

What is the role of the staff physician in     A duly licensed and credentialed staff
 patient assessment?                            physician will either perform or supervise
                                                the performance of a patient assessment as
                                                outlined in the Medical Staff Bylaws, Rules
                                                and Regulation Section on Health
                                                Information Management and the Hospital
                                                Patient Assessment Policy #5.9.
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