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116 LAYING THE FOUNDATION

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UNIT 1

safety in patient record-keeping and interprofessional communication. The Daalbirrwirr Gamambigu Project (Flemington et al., 2022) produced a culturally adapted ISBAR (an acronym for ‘identify, situation, background, assessment and recommendation’) for interprofessional communication, and a cultural safety checklist (see

Figure 4.8). Your hospital or healthcare organisation can also use tools

and checklists to assess organisational-level cultural safety (NSWMoH, 2022). All these forms of evidence are important for your continuing professional development and the accreditation of your healthcare organisation (ACSQHC, 2017).

CULTURAL SAFETY CHECKLIST FOR CLINICIANS

Use of clinical yarning with families

Yes No

i. Have I engaged in social yarning? e.g. asked where their familly is from, what

school the children attend, etc.

ii. Have I engaged in diagnostic yarning? (engaged in a two-way information exchange

to gather information used to help diagnose)

iii. Have I engaged in management yarning? (management plan is clearly explained and

formulated in consultation with family)

iv. Have I used plain language without being condescending?

v. Did I use active listening and allow for silences during conversation?

Incorporation of relationships

i. Was I sincere and authentic when interacting with the family?

ii. Was I respectful to any Aboriginal elders present?

iii. Was an ALO offered (if available)?

iv. Was a family spokesperson/contact person identied?

v. Have I asked the question? (Aboriginal identication)

vi. Was I transparent and inclusive?

3 Considerations incorporated into use of ISBAR

i. Were family dynamics, access to transport and carer information included?

ii. Was the ALO, social worker and/or community supports included in recommendation

section of ISBAR?

iii. Were Child & Family Services included in the process?

FIGURE 4.8 Cultural safety checklist for health professionals

FLEM INGTON E T AL. (202 2)

Yes No

As a nurse, you will spend most of your time with people during hospitalisation or medical treatment, so it is to your advantage to familiarise yourselves with all aspects of their social and emotional wellbeing. It will make your job easier and benet the person, who will feel that you understand something about their cultures, concerns and issues. When initiating a health assessment and physical examination, you are not expected to be the ‘expert’ but to have some familiarity with the individual’s culture and a willingness to learn about their lives.

There is an increasing number of First Nations’ nurses and doctors entering the healthcare arena. While it is not and should not be their responsibility to only care for Aboriginal and Torres Strait Islander peoples, or to share their knowledge,

ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLES’ HEALTH 117

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you can respectfully ask them for assistance if the issue you are dealing with is culturally related. Choose your questioning moment with care and ensure that you have already built up a relationship of trust and professionalism so they are not going to interpret your questions as bothersome and taking them away from what they should be doing. Remember, there are First Nations healthcare professionals who can assist you (in addition to nurses and doctors, there are interpreters and community health workers). This will in turn impact on the individual’s health and rate of healing, and/or their willingness to comply with what you are requesting of them.

‘I’m scared of saying or doing the wrong thing’ – My letter to you

At the heart of this journey is your ability to genuinely share your time and spirit. Inthe busy-ness and clinical-ness of the system and its demands, you can see how our two worlds can clash. You may feel awkward doing this at work, perhaps even scared that you are crossing professional boundaries in some way or fearful that you are going to say or do something wrong. Our fear of doing or saying the wrong thing often holds us back. We doubt whether we could really add value or make a difference to the person sitting in front of us.

When we remove the idea that we are there to x someone’s problems and focus instead on the importance of building a trusting relationship (which can still respect professionalism), we often nd not only do we have something to offer but that we will gain something beautiful in return.

CHAPTER 4

It is important to emphasise that we need your genuine and meaningful time so that we can read your heart, connect with you our way and this leads to us understanding you. How does anyone trust someone they don’t understand? If anything, fear sits there and that is why so many of our people are scared of hospital, health or anything to do with the dominant system. Then, when we have non-Indigenous health professionals coming from that system and mimicking its busy, process-oriented, disconnected and individualistic ways that essentially lack heart, it only further exacerbates our fears. Naturally, we will do everything to avoid anything that makes us feel that way, as any human would.

So, you can see how important each and every one of you is in this dream to create equitable access for our people. You have read this far so clearly you want to be the best nurse you can be, to all people, regardless of cultural background.

When you have the ultimate privilege of connecting with an Aboriginal or Torres Strait Islander person, I encourage you to give the gift of your time and spirit; regardless of whether this environment is clinical, work-related or social. Use the time to share your spirit by offering a bit of your story, not your professional or educational one; strip away that privilege and let us connect with you and better understand your weave in this world. Where did you come from? Who is your family? What makes you, you?Then tell me that you know nothing about my journey, but you are here to listen and learn. And I promise you, every time you speak to an Aboriginal or Torres Strait Islander person, you will learn something deep, something that will move your spirit and change your heart in some special way; but you need to be open to that transformative learning and understand that you don’t have to have the answers and we do not expect you to. Just listen and listen deeply so, together, wecan walk and dream in solidarity.

Nicole Hewlett (2023)

118 LAYING THE FOUNDATION

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CHAPTER RESOURCES

REVIEW QUESTIONS

UNIT 1

1. What thoughts and assumptions come up for you when you

think of Aboriginal and Torres Strait Islander peoples? How has the content in this chapter impacted on those thoughts and assumptions?

2. If a person identies as having First Nations heritage, why

is it important not to assume that person is automatically connected to Country, kinship or culture?

3. Why is understanding Australia’s history so important to being

a culturally-responsive nurse?

FURTHER RESOURCES

Continuing your culturally safe learning journey

> Acquire new knowledge from the IAHA’s online cultural

safety training modules, which use a cultural responsiveness framework: https://iaha.com.au/iaha-consulting/culturalresponsiveness-training/

> Learn from the CATSINaM cultural safety training e-learning

modules: https://anmj.org.au/a-new-cultural-safety-and-culturalhumility-training-program-for-nurses-and-midwives-launched/

> Discover these clinical yarning e-learning modules: https://

www.clinicalyarning.org.au/

> Explore Aboriginal and Torres Strait Islander peoples’

experiences and learn about local cultures near you: https:// www.welcometocountry.com/

> Learn about and practise dadirri: https://www.

miriamrosefoundation.org.au/dadirri/

4. In your opinion, what are ve strengths of First Nations cultures?

5. What are some ways that you can build trust and connection

with Aboriginal and Torres Strait Islander peoples and co-workers?

6. Why is your role as a nurse critical to creating access to health

care among Aboriginal and Torres Strait Islander peoples?

7. How will you continue your culturally-responsive journey?

> Visit the Healing Foundation website to learn more about the

Stolen Generations and how to educate all age groups: https:// healingfoundation.org.au/

> Learn more about Aboriginal kinship systems from Sydney

University: https://www.sydney.edu.au/about-us/vision-andvalues/our-aboriginal-and-torres-strait-islander-community/ kinship-module.html

> Watch this video to understand intergenerational trauma:

https://healingfoundation.org.au/intergenerational-trauma/

> Explore more about the history of stolen wages: https://www.

creativespirits.info/aboriginalculture/economy/stolen-wages/ stolen-wages

> Invest in learning First Nations words: https://www.abc.net.au/

radionational/programs/wordup; https://australianaudioguide. com/podcast/word-up/

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G., Minniss, F. R., Armao, J., van de Mortel, T., Kain, V. J., CoronesWatkins, K., Elder, E., Wardrop, R., Mansah, M., Hilton, C., Penny, J., Hall, K., Sheehy, K., & Rogers, G. D. (2022). Indigenous-led First Peoples health interprofessional and simulation-based learning innovations: Mixed methods study of nursing academics’ experience of working in partnership. Contemporary Nurse, 58(1), 43–57. https:// doi.org/10.1080/10376178.2022.2029518

Woolyungah Indigenous Centre (WIC). (2019). You can’t say that! Hints and

tips. Retrieved from https://documents.uow.edu.au/content/groups/ public/@web/@eed/documents/doc/uow272408.pdf

UNIT

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PHYSICAL EXAMINATION

CHAPTER 5 PHYSICAL EXAMINATION TECHNIQUES

CHAPTER 6

CHAPTER 7

CHAPTER 8

CHAPTER 9

CHAPTER 10

CHAPTER 11

CHAPTER 12

CHAPTER 13

CHAPTER 14

CHAPTER 15

CHAPTER 16 MUSCULOSKELETAL

CHAPTER 17 GENITOURINARY AND REPRODUCTIVE GENITALIA

CHAPTER 18 ANUS, RECTUM AND PROSTATE

EXAMINATION REQUIREMENTS FOR EVERY CONSUMER

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES

INTEGUMENTARY

HEAD, NECK AND REGIONAL LYMPH NODES

EYES

EARS, NOSE, MOUTH AND THROAT

BREASTS AND REGIONAL NODES

RESPIRATORY

CARDIOVASCULAR

GASTROINTESTINAL

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CHAPTER

PHYSICAL EXAMINATION TECHNIQUES

LEARNING OUTCOMES

By the end of this chapter you should be able to: 1 describe how to maintain standard precautions and transmission-based precautions during

the physical examination

2 establish an environment suitable for conducting a physical examination 3 describe how to perform inspection, palpation, percussion and auscultation, and identify

which areas of the body are assessed with each technique

4 demonstrate inspection, palpation, percussion and auscultation in the clinical setting.

BACKGROUND

Inspection, palpation, percussion and auscultation are the techniques used by the nurse to assess the consumer during a physical examination. This chapter introduces the assessment techniques and equipment used to conduct physical examinations. Before commencing your physical examination, always remember the signicance of utilising infection control practices during every encounter involving the consumer. It is important to be aware of the Australian Commission on Safety and Quality in Health Care national priorities that promote, support and encourage the implementation of safety and quality in healthcare provision (ACSQHC, 2019) and the second edition of the National Safety and Quality Health Service Standards (ACSQHC, 2017). Further, in New Zealand, the Health Quality & Safety Commission (2022) works with clinicians, providers and consumers to ensure quality and improvement in health care.

The severe acute respiratory syndrome coronavirus (SARS-CoV-2) that causes coronavirus disease (COVID-19) and the subsequent worldwide pandemic have created signicant challenges and changes to many healthcare practices. To date, there have been over 515 million cumulative cases of COVID-19, and over six million cumulative deaths worldwide (World Health Organization (WHO), 2022a). Practice changes to physical examination of persons requiring health care have been considerable. Practice changes include increased use of standard and transmission-based precautions, telehealth, and the use of articial intelligence to diagnose respiratory sounds. The use of standard precautions and transmission-based precautions will be explored in this chapter and should be applied in the context of the physical examination.

PHYSICAL EXAMINATION TECHNIQUES 123

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CONSIDERATIONS PRIOR TO COMMENCING PHYSICALEXAMINATION

Physical examination of a consumer serves many purposes:

1. screening of general wellbeing; the ndings will serve as baseline information

for future examinations

2. validation of the reason/s that brought the consumer to seek health care

3. monitoring of current health problems

4. identication of health problems/medical diagnoses and treatments.

The need for physical examination depends on factors such as the consumer’s health status, contact with healthcare providers, and accessibility to health care. For example, a person with diabetes mellitus, arthritis and glaucoma is likely to access health care more often than a healthy teenager or adult.

Standard precautions

The transmission of hepatitis, human immunodeciency virus (HIV), severe acute respiratory syndromes (SARS), and other infectious diseases is a primary concern for the nurse and for the consumer. as ‘universal precautions’, were developed by the Centers for Disease Control and Prevention (CDC) to protect healthcare professionals and consumers. Australia and New Zealand have developed national guidelines underpinned by the principles of the CDC and WHO guidelines for standard and transmission-based precautions (National Health and Medical Research Council (NHMRC), 2019; Ministry of Health, 2022a). The primary goal of standard precautions is to prevent the exchange of blood and body uids ( every consumer throughout the entire encounter, whether or not the consumer has a known or suspected infectious process.

Standard precautions are the minimum infection control practices that are practised in all healthcare settings ( control guidelines are published on a living guideline by the National Health and Medical Research Council (NHMRC, 2019); in New Zealand, the recommendations for standard precautions (Health Quality & Safety Commission, 2022) include:

> hand hygiene > personal protective equipment (PPE) > handling and disposing of sharps > routine management of the physical environment > reprocessing of reusable instruments and equipment

> respiratory hygiene and cough etiquette.

Figure 5.1). Standard precautions should be practised with

Standard precautions, formerly known

FIGURE 5.1 The nurse is using standard

precautions to draw blood.

Figure 5.2). In Australia the current infection

CHAPTER 5

Hand hygiene

The single most important infection control practice is effective hand hygiene. Hand hygiene includes hand washing with soap and water and alcohol-based hand rub (ABHR). Hand hygiene should be performed according to the ve moments of hand hygiene (WHO, 2009). Hand washing with soap and water should occur when hands are visibly dirty, soiled with blood or body uids or after using the toilet (NHMRC, 2019). In addition, hand washing with soap and water is preferred following exposure to specic microorganisms (e.g. Clostridium difcile, norovirus) (NHMRC, 2019). Hand hygiene using ABHR can be used at all other times (WHO, 2009, p. 155).

You must consider the ve moments of hand hygiene during every physical examination (see Figure 5.3). Some nurses perform hand hygiene in the examination area with the consumer present. It is a nonthreatening way to start the physical assessment, and allows the patient time to ask questions concerning the process. For further information refer to the NHMRC’s Australian guidelines for the prevention and control of infection in healthcare, 2019, v.11.10 (2021), Living guideline (NHMRC, 2019).

124 PHYSICAL EXAMINATION

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UNIT 2

DEVE LOPED BY T HE AUSTR ALIA N COMMISSI ON ON SAFE TY AND Q UALIT Y IN HEALT H CARE (AC SQHC). AC SQHC: SY DNEY (20 23)

SOURC E: REPRO DUCED WI TH PERMIS SION FROM T HE INFEC TION PRE VENTI ON AND CON TROL POS TER – COMB INED AIRB ORNE AND CO NTACT PRE CAUTIO NS,

FIGURE 5.2 Standard precautions

SOURC E: REPRO DUCED WI TH PERMIS SION FROM T HE INFEC TION PRE VENTI ON AND CON TROL POS TER – COMB INED CONTA CT AND DRO PLET PR ECAUTI ONS, DEVE LOPED BY

THE AUS TRAL IAN COMM ISSION ON SA FET Y AND QUAL ITY IN HE ALTH CAR E (ACSQH C). ACSQH C: SYDNE Y (2023)

PHYSICAL EXAMINATION TECHNIQUES 125

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The NHMRC (2019) supports existing WHO (2022b) guidelines that recommend the use of an alcohol-based hand rub (see

Figure 5.4), as it is more effective against

most common infectious agents on hands than hand hygiene using plain or antiseptic soap and water.

FIGURE 5.3 Hand washing using soap and water FIGURE 5.4 Hand washing using an alcohol-based

hand rub

REFLECTION IN PRACTICE

CHAPTER 5

Five critical moments of hand washing

Can you remember what the ve critical moments of hand washing are? You might like to refresh your memory through the Hand Hygiene Australia website: https://www.hha.org.au/hand-hygiene/5-moments-for-hand-hygiene

Figure 5.5 depicts these critical moments. It is based on the ‘Your 5 moments for Hand Hygiene’, World Health Organization.

FIGURE 5.5 Five moments for hand hygiene

SOURC E: REPRO DUCED WI TH PERM ISSION FR OM 5 MOMEN TS FOR HAN D HYGIENE P OSTER , DEVEL OPED BY TH E AUSTR ALIAN C OMMISSI ON ON SAFE TY AND Q UALIT Y IN HEALT H CARE (A CSQHC). A CSQHC: S YDNEY ( 2021)

In New Zealand, hand hygiene guidelines are also available, and these are based on the same WHO critical moments, and can be

accessed via https://www.hqsc.govt.nz/resources/resource-library/hand-hygiene-nz-hand-hygiene-a-guide-for-healthcare-staff/

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