UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS PROFESSIONAL NURSING ORGANIZATION 

POLICY STANDARDS

ADDENDUM:           I.1c
EFFECTIVE:       4/97
REVISION:         5/08
APPROVAL:      5/08

SUBJECT: BIOPHYSICAL ASSESSMENT STANDARDS FOR THE ADULT PATIENT

Standards Based Documentation requires standardized criteria against which all assessments are compared. These standards outline what is consistent with a normal or expected biophysical finding. If a patient meets the standard a check, "Ö ", is placed in the appropriate box. If a patient’s assessment varies from the norm, the deviation is noted with an asterisk, "* " and documented with a Focus Note.

Standards Based Documentation System

  1. Neurological Assessment
  1. Patient is alert and oriented to person, place, and time.
  2. Pupils are equal and reactive to light.
  3. There is symmetry of strength in all extremities; without parathesia.
  4. Speech is clear.
  5. Patient swallows without coughing or choking on liquids or solids.
  6. Visual, auditory acuity sufficient. No obvious  EENT deformities.

 

  1. Cardiovascular Assessment
  1. Apical pulse rate is regular and within normal limits for patient.
  2. Peripheral pulses are palpable and equal bilaterally.
  3. Blood pressure is within acceptable limits for patient.
  4. There is no calf tenderness.
  5. Extremities without edema.
  6. Capillary refill is less than 3 seconds after blanching nailbeds for several seconds.
  7. Neck veins are flat at 45 degrees HOB elevation.

 

  1. Respiratory Assessment
  1. Respirations are quiet and regular at 12-20/minute at rest.
  2. There are no abnormal breath sounds.
  3. Sputum, if present, is clear.
  4. Nailbeds and mucous membrane are pink.

 

  1. Gastrointestinal Assessment

1.      Abdomen is soft, non tender, and without distention.

2.      Bowel sounds are active in all quadrants.

3.      Patient tolerates prescribed diet without nausea or vomiting.

4.      Stools consistent with patient’s usual pattern.

 

 

  1. Genitourinary Assessment
  1. Patient is able to void without difficulty.
  2. Patient is voiding adequate amounts of clear yellow to amber urine without  dysuria or complaints of discomfort.
  3. Bladder is not distended after voiding.
  4. Patient is continent.
  5. There is no penile or vaginal discharge.

 

  1.  Psychosocial Assessment

1.      Behavior/appearance/mood/affect are appropriate to situation.

2.      Patient is able to participate in 2-way communication.

 

G.     Integumentary Assessment

1.      Skin color is within patient’s norm.

2.      Skin is warm, dry, and intact.

3.      Turgor is elastic (returns to normal in less than 3 seconds after pinching skin for several seconds).

4.      Mucous membranes are moist.

5.      Braden Scale is greater than 14.

  1. Musculoskeletal Assessment

1.      There is no joint swelling and tenderness.

2.      Equal and smooth movement of joints is noted.

3.      There is no muscle weakness.

4.      Surrounding tissue is free of erythema or pain.

5.      Falls Risk Assessment:  Patient does not have any of the following risk factors:

a.                   General data:  >60years of age; history of falling before admission

b.                  Physical condition:  vertigo, unsteady gait, weakness, paralysis, seizure disorder, impaired vision, impaired hearing, diarrhea, urinary frequency/urgency/nocturia

c.                   Mental status:  lethargic, confused or disoriented, inability to understand or follow directions

d.                  Medications:  diuretics, anti-hypertensives, central nervous system depressants, chemotherapy

e.                   Ambulatory devices used:  cane, walker, crutches, wheelchair, braces

  1. TB Assessment

1.      Patient has no personal history of TB.

2.      There is no family history of TB.

3.      There is no hemoptysis.

4.      There has been no recent fever.

5.      Patient has not experienced night sweats.

6.      There are no visible deformities.

  1. Maternal (Pregnancy) Assessment (See I.1d Obstetrical Biophysical Assessment standard)

Obstetrical Biophysicall Assessment Standards

1.      Patient is over 18 years of age.

2.      Patient received pre-natal care.

3.      There is no history of complications of pregnancy.

4.      Baby feeding arrangements are known.

    K.  Pain Assessment

Patient reports LOP=0 based on pain scale of 0-10 (0=no pain, 10=severe pain).  The Non-Communicative Pain Scale is a tool for use in patients who are unable to self-report pain due to cognitive impairment relating to disease process, injury, procedure or chemical sedation.

GuidelineXX

  1. Absence of facial grimacing, tightening, tearing or tenseness
  2. Absence of body language - restless, agitated, bracing, fidgeting, tensed
  3. Absence of vocalizations - moaning, grunting, calling out
  4. Absence of increase in heart rate, blood pressure or respiratory rate
  5. Absence of mechanical ventilation, paralytics or sedatives
  6. Absence of fighting ventilator, excessive coughing, biting on endotracheal tub

 

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