Alexa-Rae P.

Zagado
BSN-III
NCM 104 – RLE
Sir Ronald Ramo RN, MAN
March 30, 2020

Quiz

1) Explain the importance of the Head-to-Toe assessment and what technique is

used for each system.

Importance of Physical Assessment:

 To detect and treat diseases and disorders early.

 To identify actual and potential health problems.
 To establish a data based from which the subsequent phases of the nursing
evolve.
 To assess the client’s impact of activity and exercise on the client’s overall level of
health.
 To assess the client’s routine exercise pattern and observe how the client’s body
system response to activity and exercise.
 To establish the client-nurse relationship
 To obtain information about the client’s health including, physiologic, psychologic,
sociocultural, cognitive, developmental and spiritual aspects.
 To identify the client’s strength and weaknesses.

Purpose of Physical Assessment:

 To supplement, confirm or refute data obtained in the nursing history.

 To confirm and identify nursing diagnosis.
 To make clinical judgments about a client’s changing health status and
management.
 To evaluate the physiological outcome of care.
 To obtain and gather data about the client’s health basis of data for future
assessment.
 An excellent way to evaluate an individual’s current health status.

The nursing assessment and its components:

This is a major factor of nursing care. It is a process in which includes both physical
and psychological aspect to evaluate client’s condition. This enables the nurse to
make a judgment about the client’s health status, ability to manage his/her health
care and need for nursing.
The Physical Assessment:
This is a process by which a nurse obtains a data that describes a person’s
response to actual or potential health problems which is analyzed to form pertinent
diagnosis. It Is a head to toe review of each body system that offers objective
information about the client and allows the nurse to make clinical judgment.

Reflexes:
- Bent, turned or directed back; or produced by a reflex without intervention
of consciousness.
- Is an involuntary and nearly instantaneous movement in response to a
stimulus.

Visual Acuity:
- The degree of detail the eye can discern an image.
- Is a quantitative measure of the ability to identify black symbols on a white
background at a standardized distance as the size of the symbols is
varied.
- The acuteness or clearness of vision, especially form vision, which is
dependent on the sharpness of the retinal focus within the eye and the
sensitivity of the interpretative faculty of the brain.

The Interview:
- An interview is a conversation between two or more people (the
interviewer and the interviewee) where questions are asked by the
interviewer to obtain information from the interviewee.
- Therapeutic interaction that has a purpose.

Signs:
- A sign is the physical manifestation of an illness, injury or other bodily
disorder. A sign is objective and can be observed.
- Signs can be felt, heard, seen, and measured by the diagnostician or
nurse. These include pulse, respirations, blood pressure, and physical
evidence such as bleeding, broken skin, bruising etc.

Symptoms:
- Subjective evidence of a disease of physical disturbance observed by the
patient.
- Is a departure from normal function or feeling which is noticed by a
patient, indicating the presence of disease or abnormality. A symptom is
subjective, observed by the patient, and not measured.

Four Basic Techniques in a Physical Assessment:

- Inspection:
It is the use of one’s senses of vision and smell to consciously observe the
patient. It is also known as concentrated watching. It is a close, careful scrutiny; first
of the individual as a whole and then of each body system. Inspection begins the
moment you first meet the individual and develop a “general survey”. Then as you
proceed through the examination, start the assessment of each body system with
inspection.

- Palpatation:
It is the act of touching a patient in a therapeutic manner to elicit specific
information. It follows and often confirms points you noted during inspection.
Palpation applies your sense of touch to assess these factors: texture, temperature,
moisture, organ location and size, as well as any swelling, vibration or pulsation,
rigidity or spasticity, crepitation, presence of lumps or masses and presence of
tenderness or pain. Two distinct types of palpation:

 Light palpation - It is superficial, delicate and gentle. In light palpation, the finger
pads are used to gain information of the patient’s skin surface to a depth of
approximately ½ - 1inch below the surface. Light palpation reveals information on
skin texture and moisture; overt large or superficial masses; and fluid, muscle
guarding and superficial tenderness.

 Deep palpation - It can reveal information about the position of organs and
masses, as well as their size, shape, mobility, consistency, and areas of discomfort.
Deep palpation uses the hands to explore the body’s internal structure to a depth of
1 to 2 inches or more. This technique is most often used for the abdominal and male
and female reproductive assessments. Variations in this technique are single handed
and bimanual palpations.

- Percussion:
It is the technique of striking or tapping the person’s skin with short, sharp
strokes to assess underlying structures. The strokes yield a palpable vibration and a
characteristic sound that depicts the location, size and density of the underlying
organ. These sounds also are diagnostic of normal and abnormal findings. Any part
of the body can be percussed, but only limited information can be obtained in
specific areas such as heart. The thorax and abdomen are the most frequently
percussed location. Four types of percussion techniques:

 Immediate or Direct Percussion - The striking hand directly contacts the body
wall. This produces a sound and is used in percussing the infant’s thorax or the
adult’s sinus areas.

 Mediate or Indirect Percussion - It is used more often and involves both hands.
The striking hand contacts the stationary hand fixed on the person’s skin. This
yields a sound and a subtle vibration.
 Direct Fist Percussion:
It is used to assess the presence of tenderness in internal organs, such as the
liver or the kidneys. The presence of pain in conjunction with direct fist percussion
indicated inflammation of that organ or a strike of too high in intensity.

 Indirect Fist Percussion - Its purpose is the same as direct fist percussion. In fact,
the indirect method is preferred over the direct method. It is because in this
methods. The non-dominant hand absorbs some of the force of the striking hand.
The resulting intensity should be sufficient force to produce pain in the patient if
organ inflammation is present. Percussion elicits five types of sounds:

1) Flatness (dull) – bone and muscle

2) Dullness (thud like) – liver, spleen, heart
3) Resonance (hollow) – air-filled lung/ normal lung
4) Hyperresonance – emphysematous lung
5) Tympany – stomach filled with gas (air)

- Auscultation:
It is the act of active listening to the body organs to gather information on patient’s
clinical status. Auscultation includes listening to sounds that are voluntarily and
involuntarily produced by the body such as the heart and blood vessels and the
lungs and abdomen. Auscultated sounds should be analyzed in relation to their
relative intensity, pitch, duration, quality, and location. Two types of auscultation:
Indirect and direct auscultation:

 Direct of Immediate auscultation - It is the process of listening with the unaided

ear. This can include listening to the patient from some distance away or placing the
ear directly on the patient’s skin surface. And example is the wheezing that is
audible to the unassisted ear in a person having a severe asthmatic attack.

 Indirect or Mediate auscultation - It is the use of stethoscope, which transmits the

sounds to the nurse’s ear.

2) Explain what the GCS is and its importance in a neurologic assessment (LOC, NVS,
Cranial Nerve Assessment).

The Glasgow Coma Scale (GCS) is a neurological scale which aims to give a
reliable and objective way of recording the state of a person's consciousness for
initial as well as subsequent assessment. A person is assessed against the criteria of
the scale, and the resulting points give a person's score between 3 (indicating deep
unconsciousness) and either 14 (original scale) or 15 (more widely used, modified
or revised scale).

The GCS was used to assess a person's level of consciousness after a head
injury. The scale is used by emergency medical services, nurses, and physicians as
being applicable to all acute medical and trauma patients. In hospitals, it is also used
in monitoring patients in intensive care units.

GCS is used as part of several ICU scoring systems, including APACHE II, SAPS
II, and SOFA, to assess the status of the central nervous system. The initial indication
for use of the GCS was serial assessments of people with traumatic brain injury and
coma for at least six hours in the neurosurgical ICU setting, though it is commonly
used throughout hospital departments.

The tool we use to assess the level of consciousness is the Glasgow Coma
Scale (GCS). This tool is used at the bedside in conjunction with other clinical
observations and it allows us to have a baseline and ongoing measurement of the
level of consciousness (LOC) for our patients.

The cranial nerve exam is a type of neurological examination. It is used to

identify problems with the cranial nerves by physical examination. It has nine
components. Each test is designed to assess the status of one or more of the twelve
cranial nerves.

3) Explain how diagnostic tests are important in a physical assessment and how
relevant it is (EEG, MRI, Ultrasound, LP, CT Scan, Central Angiography,
Ventriculogram, GCS, Apgar Scoring).

The scope of diagnostic tests ranges from the signs and symptoms elicited
during clinical examination, imaging tests, to biochemical, pathologic, and
psychological tests. Tests that are capable of fully discriminating between the
presence and/or absence of a disease are uncommon. Diagnostic testing is generally
performed to screen for, detect, and monitor diseases. To optimize the use of
diagnostic testing, clinicians should be aware of how the results of testing will affect
determination of the probability of the presence of disease.

The EEG test is a graphic recording of the electrical activity of the brain. EEG
electrodes are placed on the scalp overlying multiple areas of the brain to detect and
record electrical impulses within the brain. This study is invaluable in the
investigation of epileptic states, in which the focus of seizure activity is
characterized by rapid, spiking waves seen on the graph. Patients with cerebral
lesions (e.g., tumors, infarctions) will have abnormally slow EEG waves, depending
on the size and location of the lesion. Because this study determines the overall
electrical activity of the brain, it can be used to evaluate trauma and drug
intoxication and also to determine cerebral death in comatose patients.

Magnetic resonance imaging (MRI) of the body uses a powerful magnetic

field, radio waves and a computer to produce detailed pictures of the inside of your
body. The MRI is a widely used imaging technology. Besides its noninvasiveness, its
humongous ability to generate different contrasts in soft tissues gives rise to the
increasing importance in diagnosis of different diseases. In addition to its ability to
provide high-resolution anatomical images it is also possible to directly obtain
molecular information.

The Ultrasound test has found widespread application in anatomical imaging,

blood-flow measurement, and evaluation of physiology in almost all aspects of
medicine. As ultrasound instruments have become smaller, less expensive, and
easier to use, diagnostic ultrasound has become increasingly popular among a wide
variety of physicians. Ultrasound imaging technique has replaced or complemented
a large number of radiographic and nuclear medicine procedures and has opened
new areas of diagnostic investigation. For example, in many cardiovascular diseases
diagnostic ultrasound has replaced invasive methods as the primary means of
evaluation. In obstetrics, where radiography is no longer generally used, diagnostic
ultrasound has provided an important means of assessing fetal viability and age,
evaluating fetal development, and diagnosing fetal, uterine, and placental
abnormalities. An Ultrasound is considered as the primary imaging modality for the
detection of most gynaecological, hepatic, biliary, pancreatic, splenic, and renal
diseases and for examination of the scrotal contents, bladder, and prostate.

Also known as a spinal tap, an LP is a procedure whereby spinal fluid is

removed from the spinal canal for the purpose of diagnostic testing. It is particularly
helpful in the diagnosis of inflammatory diseases of the central nervous system,
especially infections, such as meningitis. It can also provide clues to the diagnosis of
stroke, spinal cord tumor and cancer in the central nervous system.

CT scan images allow radiologists and other physicians to identify internal

structures and see their shape, size, density and texture. This detailed information
can be used to determine if there is a medical problem as well as the extent and
exact location of the problem, and other important details. The images can also
show if no abnormality is present.

An Angiography remains as an important tool for evaluating aneurysms and

outlining AVMs with detail, showing feeding and draining vessels. For patients in
which surgery is being considered for either of these entities, angiography is often
necessary. An angiography may be performed before evacuation of an intracerebral
hematoma, in an attempt to demonstrate an aneurysm or AVM before surgery. An
angiography demonstrates small vessels well and is the best imaging method
available for outlining the beading of vessels seen with vasculitis.

A ventriculogram is a test done during cardiac catheterization. that evaluates

the main pumping chamber of your heart (left). A ventriculogram can show:

- The movement of your heart muscle as your left ventricle fills and pumps blood.
- The size of your left ventricle.
- How efficiently your left ventricle pumps blood (ejection fraction).
- How well blood flows through your heart valves (aortic and mitral valves).
 The Glasgow Coma Scale provides a practical method for assessment of
impairment of conscious level in response to defined stimuli. Based on motor
responsiveness, verbal performance, and eye opening to appropriate stimuli, the
Glascow Coma Scale was designed and should be used to assess the depth and
duration coma and impaired consciousness. This scale helps to gauge the impact of a
wide variety of conditions such as acute brain damage due to traumatic and/or
vascular injuries or infections, metabolic disorders.

The Apgar score provides an accepted and convenient method for reporting
the status of the newborn infant immediately after birth and the response to
resuscitation if needed. It is obtained by adding points (2, 1, or 0) for heart rate,
respiratory effort, muscle tone, response to stimulation, and skin coloration; a score
of ten represents the best possible condition. The American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists encourage use of an
expanded Apgar score reporting form that accounts for concurrent resuscitative
interventions.