Main Body
2 Trauma-informed Assessment
Performing an objective assessment involves the nurse physically touching the client. This touch can make clients feel vulnerable, particularly if they have experienced in their life. Clients may also be anxious, fearful, and/or uncertain about undergoing a physical assessment for many other reasons: it may be their first time undergoing a physical assessment; they may be experiencing physical ailments that they consider embarrassing; they may be self-conscious or have body image concerns; they may identify as transgender or gender-diverse; they may be children who are fearful of unfamiliar people; and they may have had a previous assessment conducted by a healthcare professional who was judgemental, prejudiced, not compassionate, or not accepting.
Because you will not necessarily know whether the client has experienced trauma or is fearful or self-conscious, it is important to use a trauma-informed approach with every client when performing an objective assessment.
Steps to inform a trauma-informed objective assessment include:
- Introduce yourself and your role.
- Explain why you are there.
- Use the client’s identified name and pronouns.
- Ask permission to touch.
- Give the client choices about how to proceed.
- Explain what you are doing as you proceed.
- Provide privacy by closing the door and using a drape so that you only need to expose the areas that you are assessing.
Clinical Tip
For each client, but particularly clients who have experienced trauma, you will need to modify your objective assessment based on their needs. For example, pay attention to cues or signals that notify you when they are feeling discomfort and distress. Cues may include becoming quiet, breathing fast or holding their breath, facial grimacing, and muscle contractions. It is good practice to continually obtain permission before touching areas of the body and narrate your steps aloud for clients so that they can anticipate touch and know what to expect and for how long. For example, you could state “I’m going to listen to valves of your heart by placing my stethoscope in four locations over your chest, I will listen for a few heart beats over each location. Feel free to stop me at anytime, if you need to take a break or if you have questions. Is it okay if I begin?”
Activity: Check Your Understanding
Trauma is the response or outcome of a distressing experience or event that affects a person’s sense of self and overwhelms a person and their ability to function and cope (e.g., violence, accident, natural disaster).
