General health assessment and history taking

Health Assessment

1. GENERAL HEALTH ASSESSMENT AND HISTORY TAKING Princy Francis M I st Yr MSc (N) JMCON

2. DEFINTIONS AND TERMINOLOGIES HEALTH “Health is a state of complete physical mental and social well –being and not merely the absence of disease or infirmity” - World Health Organization “Assessment is a systematic ,dynamic process by which the nurse through interaction with client, significant others and health care provides, collect and analyze data about client” – American Nurses Association

3. HEALTH HISTORY Health history is a collection of subjective data that includes information on both the client’s past and present health status. PHYSICAL EXAMINATION Physical examination provides objective data for identifying problems and making diagnosis.

4. Assessment : It is a systematic and deliberate process of gathering the information regarding client’s health. Inspection: It is one method of physical examination which involves the visual examination of the body. Palpation : it is the use of tactile sensation foe identifying the characteristics of skin and superficial tissues. Percussion : It is method of physical examination by tapping with the fingers on the body to determine the quality of sound. Auscultation : It is a method of physical examination that involves listening the sounds within body either by ears or stethoscope.

5. PURPOSES OF HEALTH ASSESSMENT To obtain baseline data about the client’s functional abilities. To supplement, confirm, or refute data obtained in the nursing history. To obtain data that will help establish nursing diagnoses and plans of care. To evaluate the physiological outcomes of health care and thus the progress of a client’s health problem. To make clinical judgements about a client’s health status. To identify areas for health promotion and disease prevention.

6. TYPES OF ASSESSMENT Comprehensive health assessment . It includes complete physical examination and health history. Ongoing partial assessment: is one that is conducted at regular intervals during care of the patient. Focused assessment : Examination of a body area Emergency assessment : is a type of rapid assessment conducted to identify the potentially fatal conditions.

7. PREPARING THE CLIENT

8. PREPARING THE ENVIRONMENT

9. CULTURAL SENSITIVITY A client’s health beliefs, use of alternative therapies, nutritional habits, relationship with family and comfort with the nurses physical closeness during an examination and history taking must be considered.

10. COMPONENTS OF A NURSING HEALTH HISTORY Biographic data. Reason for seeking health care/ chief complaint. History of present Illness Past health history Family history Review of systems Lifestyle Socio-cultural History Psychological History Occupational and environment History

11. Biographic data Personal data including name, address, age and date of birth, gender, religion, race/ethnic origin, bed number, ward, medical diagnosis, Surgery (if performed), occupation, education and type of health plan/insurance

12. Reason for seeking health care/ chief complaint. It should be written in client’s statement. In case of multiple problems, ask client to indicate the priority of complaint. Avoid using medical terminology. Write problems in chronological order

13. History of present Illness Expansion of chief complaints. Chronological order Location, quality, quantity, chronology, setting, exaggerating and relieving factors, associated symptoms, effect on sleep, daily activities.

14. Past health History Allergies Medical disease such as Hypertension, Diabetes, TB, Anemia , Seizures, Arthritis, Heart Disease, Glaucoma etc. Trauma, Injury: Fracture, abdominal trauma, burns, blunt/penetrating injury, altered consciousness level. Hospitalization Childhood disease and immunization Obstetric History Drug history

15. Family history Family composition Sl. No Name of the family members Age/ sex Relationship with client Marital status Educational status Occupational status Health status                        

16. FAMILY HISTORY - Family Health history The family history should include: causes and age of death of parents, details about the health of siblings and children and information about heart disease, hypertension, diabetes, asthma, allergies & ethnic origin.

17. Review of systems The review of systems (ROS) is a brief account from the client of any recent signs or symptoms associated with any of the body systems.

18. Respiratory History Presenting Problem/Complaint : Cough, Sputum, Hemoptysis, Wheeze, Chest Pain, Shortness of breath, Systematic symptoms, Drug History : Allergies, inhalers, nebulizer, home oxygen Social History : Smoking history-measured in pack years Contact with animals/pets Presence of stairs in or leading into flat/house Hobbies. Family history : e.g. asthma/hay fever

19. Cardiovascular History 4 main cardiovascular symptoms: Chest pain, Shortness of breath, Presence and extent of edema, Palpitations Main risk factors for Ischemic Heart Disease: Smoking, Hypertension, Diabetes mellitus, Hyperlipidemia, Family history Past Medical History : e.g. angina, myocardial infarction, bypass operation, rheumatic fever, stroke, intermittent claudication Social History : Smoking alcohol, stairs Family History Drug History: Allergies

20. LOCOMOTOR HISTORY Evolution of condition - Acute or chronic, Associated events and Response to treatment Current symptoms - Pain, Stiffness, Swelling. Pattern of joint involvement Involvement of other symptoms - Skin, lung, eye or kidney symptoms, Malaise, weight loss, fevers or night sweats Impact of lifestyle- Patient’s needs/ aspirations, Ability to adapt with functional loss Pain History S -site, O -onset, C -character, R -radiation, A – associations, T -timing, E -exacerbating & relieving factors , S -severity (mnemonic ‘SOCRATES’) Use of medication for pain relief

21. Personal data/Life style Habit Diet Elimination pattern Sleep and rest pattern Activity and exercise pattern

22. Obstetric History Menstrual Pattern-regular/ irregular History of pregnancy, labor , puerperium and complications if any

23. Socio cultural history Home environment, family situation, and client’s role in the family

24. Psychosocial History Psychosocial history refers to assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the client’s ability to cope. Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should be explored

25. Occupational and Environmental history It includes collecting data regarding client’s occupation, life style in job, working environment etc. Collecting information includes designation, location of work, exposure to hazardous material, residing near mines, farms, factories or shipyard. Congestion, overcrowding, may spread communicable diseases.

26. PHYSICAL EXAMINATION PURPOSE To make direct observations of any deviations from normal To validate subjective data gathered through the interview Baseline measurements are obtained, Physical examination techniques are used to gather objective data

27. COMPONENTS OF PHYSICAL EXAMINATION General physical examination General observations and examinations of head , scalp, skin and hair, eyes, mouth and pharynx, ear , noise and throat, neck, breasts and axillae and extremities. Specific examinations Examination of chest for cardiovascular and respiratory system. Examination of abdomen for GI tract , biliary system and urogenital system. Other systematic examinations eg : CNS , locomotor , and neurological system.

28. PREPATION FOR HEALTH ASSESSMENT Preparing the environment:- Preparing the equipment:- Preparing the client a) Physical preparations B) psychological preparations

29. GENERAL PHYSICAL EXAMINATION METHODS OF ASSESSMENT Five primary techniques Inspection (look –inspect) Palpation ( feel with hand) Percussion ( tap with hand) Auscultation ( listen) Olfaction (Smell / odours)

30. GENERAL OBSERVATIONS : Observe Note the finding/abnormalities Facial Expression Puffiness ,smiling , gloomy/depressed , blank (mass – like), apathetic, etc Position/posture Stopped or erect , supine or prone , rigid or flaccid Complexion Normal or flushed, dark or fair Body size and built Obese/overweight , thin , emaciated , asthenic , hypoasthenic . Mental status Confused , comatosed (unconscious)

31. Observe Note the finding/abnormalities Gait and abnormal movements Involuntary movements (tremors , chorea, athetosis, twitching), gait abnormalities (short shuffling, hemiplegic, waddling , high – stepping, scissor shaped) Sound/vocal speech Aphasia , dysphasia , stridor, hoarseness , wheezing. Smell /Odour   Bad (lung abscess), fishy (hepatic coma), urine like (uraemia), sweety (diabetic ketoacidosis) Nutrition status Normal or poor

32. GENERAL EXAMINATION Consciousness: Conscious / Semi – conscious / Unconscious Orientation: Oriented to time / place /peers Nourishment : Well nourished / moderate nourished / malnourished Health: Healthy / Unhealthy Body built: Thin/moderate / obese Activity : Active /dull Look: Pleasant/ happy/alert / sad /depressed/ fearful / anxious / tired / drowsy Hygiene: Good / Bad Speech : Clear / slurring / stammering / not clear / maintains eye contact Height , Weight, BMI Vital signs – Temperature , Pulse, Respiration, B.P

33. Integumentary System (Skin) Color : Fair / brown / dark in complexion Texture : Normal / dry Skin turgor: Normal / decreased Hydration: Good / moderate / dehydrated Discoloration : Absent / yellowish / cyanosis / vitiligo / pallor / increased pigmentation.

34. Erythema/ Jaundice/ tan- brown Subjective symptoms: No complaints / pain / feeling of cold/ warmth tingling / numbness

35. Lesions/Masses : Absent / macule / papule/ nodule/ vesicle/ pustule

36. Nails On Observation : Intact / onycholysis / peeling or cracking / paronychia Nail beds : Pinks / cyanosed /pale

37. Nail plate : Absent /flat / clubbing / whitening/ Beau’s lines/Koilonychia(Spoon nail)/Splinter haemorrhage Scharmroth’s window test: Normal /abnormal

38. Hair and scalp Color : Black / brown / red / grey / dyed Texture : Normal / dry Grooming : Not groomed / well groomed Distribution: Normal / scanty / bald / alopecia

39. Head Shape : Normocephalic / micro / macro / hydrocephalic Scalp : Clean / pediculosis / presence of dandruff / any scar Face : Puffiness / moon face / Bell’s palsy / no complaints

40. Eyes Eye brows : Symmetrical / equally distributed / asymmetrical / scanty Eye lashes : Absent / equally distributed / presence of dandruff Eye lids : Normal / oedematous / ptosis Pupillary reflex : Reacting to light / unequal reaction (specify which eye)

41. Pupil size : Pin pointed / 2mm / 3mm / dilated Sclera : White / reddish / yellowish Conjunctiva : Normal / pale / yellowish / conjunctivitis Vision : Normal / abnormal (specify including use of spectacles)

42. Ears Pinna : Normally placed / anotia / microtia / melotia Cerumen: Absent / packed with Ottorhoea : Absent / purulent / serous /bloody / sangiunous Hearing: Normal / decreased (specify)

43. Nose Nasal septum: Midline / deviated Nasal pathway : Patent / obstructed / nasal polyp Smell : Normal / absent Rhinorrhoea: Absent / watery / purulent / mucoid / epistaxis Frontal & maxillary sinuses : Painful / tender / sinusitis / no complaints

44. Mouth & Pharynx Lips: Dry / cracks ; symmetrical / asymmetrical Color : Pink / pale / dark Gums : Color – pink / pale dark ; bleeding / pus/ leukoplakia Tongue : Moist / dry / coating / lesions / ankyloglossia Position : Midline / deviated Mobility : Voluntary / not possible Color : Pink / pale / reddish /dark

45. Neck Size and symmetry: A symmetrical because of mass edema . Range of motion: Lateral head back, side to side. Position of Trachea Place index finger in the suprasternal notch and slide it to right and then left of trachea to note the space on either side. Normally, space between trachea and sternocleidomastoid muscle is same in both sides. T hyroid gland

46. Palpation Pulsation in neck region Jugular vein distension Tracheal rings, cricoid cartilage and thyroid cartilage. Abnormal findings: Tenderness, non-midline position .

47. Lymph Nodes: Inspect the superficial lymph nodes for – Edema , Erythema, Red streaks Palpate. Nodes for size, consistency, mobility border, tenderness and warmth. Large, warm, tender, firm, free movable lymph node – Head or throat infection. Unilateral, hard, asymmetric, fixed, non-tender node – Malignancy Palpation of Lymph Nodes

48. CHEST – RESPIRATORY SYSTEM Inspection Breathing: With efforts, normal without efforts Chest wall symmetry: Anterior – Posterior angle (AP angle): anteriorly should be less than 90 o . Breathing rate: Normal, tachypnea , bradypnea, apnea . Breathing pattern Chest expansion Apical impulse: Can be seen in hyperthyroidism. Chest configuration: Barrel Chest/Funnel Chest (pectus excavatum)/ pigeon chest (pectus carinatum)/ Kyphoscoliosis

49. Palpation Chest wall: Crepitus, pleural friction rub Symmetry: Normal, Asymmetry reflects atelectasis, pneumonia, fail chest, pneumothorax Thoracic expansion/ respiratory excursion Tactile fremitus Curvature: Scoliosis or Kyphosis. Vocal(Tactile) Fremitus: Bilaterally equal.

50. Abnormal findings Increased Fremitus: Consolidation, lobar pneumonia Decreased Fremitus: Obstruction to transmit vibrations, emphysema, pleural thickening, pulmonary edema . Pleural effusion, bronchial obstruction. Rhonchi, Fremitus: Bronchial secretions are thick. Pleural friction fremitus: Inflammation of parietal or visceral Pleural, causing decrease in normal lubrication. Presence of masses/ tenderness

51. Percussion of Thorax Tone: Resonance, hyperresonance, hypo resonance. Intensity: Loud, soft, Medium. Pitch: Very Low, Low, high pitch.

52. Auscultation for breath sounds Bronchial, vesicular, broncho vesicular, adventitious sounds, vocal sounds Abnormal breath sounds Crepts (fine short interrupted sound) Rhonchi (Low pitched continuous musical sound) Wheeze (High pitched continuous musical sound) Pleural friction rub (grating type of sound)

53. Breast and Axilla Inspection Breast size, shape and symmetry Skin of Breast: Appearance of colour, pigmentation, vascularity surface characteristics. Other signs/symptoms: None / if any________________ Areola: Color , surface characteristics. Nipples: Position, symmetry, intactness, discharge, bleeding, lesions, scaling. Axillae: Rashes, lesions, masses

54. Palpation Breast and axillae surface characteristics, nodules and tenderness. Nipples Surface characteristics, discharge.

55. HEART (Cardiovascular system) Inspection : bulging or pulsation at aortic and pulmonic areas, chest abnormalities Palpation : Thrill / Pulsation. Thrill indicates cardiac murmur. In mitral area palpate for apical beat. Percussion: cardiac dullness is located in the third to fifth intercoastal space

56. Auscultation S1 (apex of heart {left 5 th intercoastal space midclavicular line}) S2 (Aortic area of heart {Right 2 nd intercoastal space}) S3 ventricular gallop (mitral area{left 5 th intercoastal space}) S4 atrial gallop (mitral area in left lateral position)

57. Heart murmur Heart murmur (harsh, rumbling, blowing sound caused by blood flow across a defective valve or shunting through an abnormal passage). Grading: Grade I : very faint Grade II : Quiet but audible Grade III: moderately loud Grade IV: Loud Grade V: very Loud Grade VI : Very loud without stethoscope.

58. EXAMINATION OF THE ABDOMEN ( GastroIntestinal ) Inspection Initially look for general signs such as weight loss. Shape/symmetry, Abdominal distension ( 5Fs – flatus, faeces , foetus , fat, fluid), Scars and striae, Prominent veins, Hernia, Visible peristalsis

59. Auscultation Bowel sounds Place the diaphragm of your stethoscope on the mid-abdomen and listen for gurgling sounds. Normally occur every 5-10seconds Absent bowel sounds indicate intestinal ileus. Increased bowel sounds indicate bowel obstruction. Arterial bruits Place diaphragm of stethoscope over aorta and apply moderate pressure. If a systolic murmur is heard this indicates turbulent flow caused by atherosclerosis or an aneurysm. Listen for renal bruits 2.5cm above and lateral to the umbilicus.

60. Percussion Liver Begin by establishing lower liver edge. Place hands parallel to the right costal margin starting at the same point of palpation. Repeat in a stepwise manner moving the fingers closer to the costal margin until the note becomes duller. This is the position of the lower liver edge. Next find the upper margin of the liver. It can be located by detecting a change in note from the dullness of liver to resonance of lungs.

61. Spleen Begin by percussing the ninth intercostal space anterior to the anterior axillary line (Traub’s space). If the spleen is not enlarged the sound will be tympanic. If it is dull continue to percuss in a stepwise manner moving hands towards right iliac fossa.

62. Ascites If fluid is suspected percuss across patients abdomen (from midline to right flank) until the percussion note changes from tympanic to dull. Mark that spot and then ask your patient to turn onto their right side (if you are standing on left of patient). After 30seconds repeat percussing from the midline towards the right flank. If fluid is present it will have redistributed secondary to gravity and therefore the area previously marked as sounding dull to percussion will now be tympanic.

63. Bladder If the bladder is distended the suprapubic area will be dull rather than tympanic. Percuss from the level of the umbilicus, parallel to the pubic bone

64. Palpation Light palpation of the nine segments Observe patient’s face throughout palpation to ensure that you are not causing pain. Light palpation is used to assess tenderness and guarding (a sign of irritation of the peritoneum). Deep palpation is used to assess for masses. If appropriate, test for rebound tenderness (a sign of intra-abdominal pathology)

65. Palpation of organs Live r A normal liver extends from 5th intercostals space to costal margin. It may be palpable in normal individuals. Position your hand in the right iliac fossa with fingers in an upward position facing the liver edge (alternatively you can use the radial aspect of your index finger). Press your fingertips inward and upward and hold this position while your patient takes a deep breath. As the liver moves downward with inspiration the liver edge will be felt under fingertips. If no edge is felt repeat the procedure closer and closer to the costal margin until either the liver is felt or the rib is reached.

66. Spleen The normal spleen cannot be felt and only becomes palpable It enlarges from under the left costal margin towards the right iliac fossa. The fingertips of right hand are then positioned obliquely across the abdomen pointing to the left costal margin towards the axilla. Press your fingertips inward and upward and hold this position while your patient takes a deep breath. As the spleen moves with inspiration the edge may be felt under your fingertips. If no edge is felt repeat the procedure closer and closer to the left lower rib cage until the costal margin is reached

67. Kidneys To examine left kidney, place the palmar aspect of left hand posteriorly under left flank. Position the middle three fingers of right hand below the left costal margin, lateral to the rectus muscle (opposite position of left hand). Ask patient to take deep breath and press both fingers firmly together. If the kidney is palpable it will be felt slipping between both fingers.

68. Aorta In thin patients or those with a dilated aorta, the aorta can be palpated by placing both hands on either side of the midline at a point half way between the xiphisternum and the umbilicus. Press your fingers posteriorly and slightly medially and the pulsation should be present against your fingertips.

69. MUSCULOSKELETAL SYSTEM Postural curves: Normal / kyphosis / lordosis / scoliosis Muscle tone: Normal / hypertonia / hypotonia / flaccid / spastic / rigid Muscle strength: Normal / weaker than normal / hyperactive

70. Upper Extremities Symmetry: Symmetrical / asymmetrical Finger nails: Capillary refill _______ seconds Range of motion: Possible / if impossible (specify)_________ Peripheral pulses: Radial – rate, rhythm, volume (normal /abnormal) Brachial: Rate, rhythm, volume – (normal / abnormal) Reflexes: Biceps - normal / abnormal

71. Triceps: Normal / abnormal Edema / swelling: Absent / if present (specify area) ____________ Cyanosis: Absent / if present (specify area) ____________ Joints: No complaints / swollen /stiff / tender /crepitus__________ Deformity: Absent / if present (specify)________________

72. Lower Extremities Peripheral pulses: Dorsalis pedis – rate, rhythm volume (normal / abnormal), if abnormal (specify)__________ Posterior tibial: Rate, rhythm, volume (normal/ abnormal), if abnormal (specify)_______ Popliteal: Rate, rhythm, volume (normal / abnormal) if abnormal (specify)_________ Reflexes: Patellar – normal / abnormal Plantar: Normal / abnormal

73. GALS Screen Check changes in appearance (swelling, deformity, abnormal posture) and movement (restricted, pain). Gait: - Ask the patient to walk a few steps, turn and walk back. Observe gait for symmetry, smoothness and ability to turn quickly. Stand patient. Inspect from behind, from side and in front. Look for bulk and symmetry of shoulder, gluteal, quadriceps and calf muscles; limb alignment, alignment of spine; level iliac crests; ability to fully extend elbows and knees; popliteal swelling; abnormalities of feet.

74. Arms: - Ask patient to put their hands behind their head. Assess shoulder abduction and external rotation and elbow flexion. With patient’s hands held out, palms down, fingers outstretched, observe the back of the hands for joint swelling and deformity. Ask patient to turn their hands over. Look for muscle bulk and deformities. Ask patient to make a fist. Visually assess power grip, hand and wrist function and range of movement in fingers. Ask patient to bring each finger in turn to meet the thumb. Gently squeeze MCP joints for tenderness (ask about pain first). Pronator Drift test: Ask the patient to stretch out their arms (palms UP) and close their eyes. Look for any drifting down of the arms, especially unequal drifts-suggests pyramidal lesion in brain such as stroke-a good screening test to do at the start of an exam.

75. Legs: - While standing inspect from the front, side and behind paying special attention to the popliteal fossa. Lie patient on couch. Assess full flexion and extension of both knees, feeling for crepitus. With hip flexed to 90 degrees, holding the knee and ankle, assess internal rotation of each hip in flexion. Muscle power Grading 0 No movement 1 Flicker of movement 2 Movement with gravity eliminated 3 Movement against gravity 4 Movement against resistance but incomplete 5 Normal power

76. Reflexes Biceps (C5, C6): Ask the patient to flex their elbow to 90° and rest their forearm on their abdomen. Locate the biceps tendon and rest your finger on it. Strike your finger and watch the biceps muscle for contraction. Triceps (C7): Ask patient to resume the position as above. Strike the triceps tendon directly, just above the olecranon process and watch the triceps muscle for contraction. Supinator (C5, C6): Ask the patient to maintain the position described above, making sure their hand is in the mid prone position. Rest your finger on the lower radius on the extensor aspect of the arm and strike it with the tendon hammer. Observe the movement in the brachioradialis muscle.

77. Reflex grading 0 Absent +/- Present with reinforcement + Just present ++ Brisk normal +++ Exaggerated response

78. GENITO – URINARY SYSTEM Inspects for: Lesions/scar , Discharge/infection, Voiding by self, Continent, Incontinent / Catheterized, Colour of urine Male Inspect penis and scrotum for swelling Palpate: any mass, inguinal hernia, enlargement of prostate gland. Female Discharge, swelling, redness Pelvic mass.

79. RECTUM & ANUS Perianal skin integrity: Intact / excoriation / rashes / lesions / haemorrhoids / bleeding Bowel elimination pattern: Normal / constipation / loose stools / diarrhoea Subjective symptoms: Pain before or while passing stools / blood or mucus in stools / rectal mass

80. NEUROLOGICAL SYSTEM Coordination Ask patient to slide the heel of one foot in a straight line down the shin of the other leg. When the heel has reached the bottom of the shin, ask the patient to flex the leg then bring the heel back down on to the shin just below the knee. In a person who does not have any problems with co-ordination these steps are completed in smooth manner- Gait Romberg’s test : - Ask the patient whether they can stand with both feet close together, then put a hand behind & in front to prevent the patient from falling. Instruct them to close their eyes

81. Ask to stand on tip-toes (with your hands lightly supporting their shoulders) for a true test of ankle plantar flexion power. Ask the patient to stand back on their heels and lift their toes to test for foot drop. Sensory Assessment Five modalities of the sensory system- light touch, pain, temperature, proprioception and vibration.

82. Proprioception This is examined by testing the joint position sense in the big toe. First isolate the joint by holding it apart from the other toes. Hold the distal phalanx of the patient’s large toe at the sides to avoid giving information from pressure. Demonstrate the movements of ‘up’ and ‘down’ to the patient. Ask the patient to close their eyes and to say whether the movement is up or down. Proprioception can also be assessed by Romberg’s test: ask the patient to stand with feet together with both eyes open (be in a position in which to catch patient if required- ie hand behind & in front of the patient). Then ask the patient to close their eyes. If they are more unsteady with their eyes closed this is a sign of difficulty with proprioception. Remember that proprioception (and vibrational sense) is conveyed by the dorsal column/medial lemniscal pathway.

83. Vibration Use a 128 Hz tuning fork. Demonstrate the sensation on the sternum. To ensure that you are testing vibration rather than sensation ask the patient first ‘if they feel buzzing sensation’. If they answer yes; ask them to tell you when ‘it stops’. Vibration is tested on bony prominences, initially on the medial aspect of the big toe. If vibration is absent here then the tuning fork should be moved proximally to establish the level at which it can be appreciated. Start at a bony part of the toes, the medial or lateral malleolus, then the upper part of the tibia, then the iliac crests.

84. GLASGOW COMA SCALE Action Response Score Eye response Spontaneously To speech To pain None 4 3 2 1 Best Verbal Response Oriented Confused Inappropriate words Incomprehensible sounds None 5 4 3 2 1 Best Motor Response Obeys commands Localized pain Flexion withdrawal Abnormal flexion Abnormal extension Flaccid 6 5 4 3 2 1 Total score Best Response Comatose patient Totally unresponsive 15 8 or less 3

85. GLASGOW COMA SCALE Minor Brain injury : 13- 15, moderate brain injury : 9-12, Severe brain injury : 3- 8 Action Response Score Best Motor Response Obeys commands Localized pain Flexion withdrawal Abnormal flexion Abnormal extension Flaccid 6 5 4 3 2 1 Total score Best Response Comatose patient Totally unresponsive 15 8 or less 3

86. Cranial Nerve Examination I - Olfactory nerve: Test the sense of smell in each nostril with coffee or some other distinct smell II -Optic nerve: Perform visual field assessment comparing your visual fields to the patient’s o It is important to test all four quadrants. Examine the pupils for pupillary light responses. Look for asymmetry; reactivity to direct & indirect light; and to accommodation.

87. III/IV/VI- Oculomotor, Trochlear & Abducens nerves Near and light reaction– the efferent pathways of the accommodation reaction pass through the oculomotor nerve. IIIrd nerve palsy (gross ptosis and eye down and out) or myasthenia (variable ptosis which is worse on prolonged looking up) Ask the patient to follow your finger with their eyes and assess eye movements. Hold the finger at the extremes and observe for the presence of nystagmus

88. V- Trigeminal nerve There are three components: Sensory – using cotton wool touch each of the 3 divisions (ophthalmic, maxillary and mandibular) comparing side to side Motor – examine muscles of mastication – temporalis and masseter. Ask the patient to open their mouth against resistance (lateral pterygoids) and note jaw deviation towards the side of the lesion. Reflexes - The afferent part of the jaw jerk is formed by the motor root of the trigeminal nerve. In the corneal reflex the afferent limb is contained in the ophthalmic division

89. VII -Facial: - Examine the muscles of facial expression (including buccinator). The upper half of the face is innervated by both cerebral hemispheres: thus, in upper motor neuron lesions there is sparing of the frontalis muscle and unilateral, lower facial weakness. Examine (or ask about) taste- note this is only for anterior 2/3 of tongue. VIII-Vestibulocochlear: - Examine hearing by rubbing fingers together or whispering numbers

90. Rinne’s test -Place a 256 or a 512Hz fork on the mastoid process and then move it in front of the pinna. A patient with no hearing problems should hear sounds transmitted via air conduction louder than those via bone. In a conductive hearing loss, bone conduction will be louder than through air. Weber’s test -Place a 256 or a 512Hz tuning fork on top of head and ask which ear the buzzing is loudest. Normally both are same. If different it should be heard loudest in the ear affected by conductive deafness and quieter in the ear affected by perceptive deafness.

91. IX/X-Glossopharyngeal and Vagus : - Test the gag reflex. To do it, place a round tongue depresser lightly on the soft palate on each side. IX is the sensory and X is the motor component. For vagus , assess movement of soft palate and NOT the uvula (it can go anyway it likes) (ask the patient to say ‘ aahh ’). The palate will not lift up on the side of the lesion

92. XI- Accessory: - Examine the sternomastoid and upper fibres of the trapezius by asking the patient to shrug their shoulders and to turn their head against resistance (feel for the strength in the contralateral sternocleidomastoid). XII-Hypoglossal: - Examine the tongue for wasting and fasciculations Assess tongue movements and note any deviation. The tongue deviates to the side of the lesion

93. AFTERCARE OF ARTICLES AND DOCUMENTATION Be sure the patient is safe and comfortable. Article should be sent for sterilization. Disposable articles should be disposed off immediately and replacement of all other articles should be done and to be stored in an area specified. Document the time of examination, name of examiner, specimens collected and observations made that may contribute to plan nursing care.

94. JOURNAL ABSTRACT Teaching physical assessment skill to international students in New Zealand In New Zealand physical assessment skills are routinely taught as a part of the UG bachelor programme . Due to changes made by the nursing council of New Zealand in 2012, a group of internationally qualified nurses, predominantly GNM diploma nurses from India, who were then studying in the New Zealand, were required to complete a degree level paper in simulated Physical assessment. For each presenting problem the student used the acronym “OLDCART” to ask questions about the problem. O - Onset, L – Location, D- Duration, C – Characteristic, A- Aggravating Factors, R – Relieving Factors, T – Treatment. The physical assessment skill enhances nurse’s self confidence and may improve patient health outcomes and patient experience.

95. Development of nursing assessment tool : An application of Roy’s adaptation theory The study aims to examine the Roy adaptation theory as a basis for development of nursing assessment tool for the assessment of cardiac patients. Author found a congruence between concepts old cardiac nursing and Roy adaptation theory after in-depth review. This assessment tool was developed based on Roy’s adaptation theory, in which the health problems of patients in all four modes and the relevant stimuli can be identified.

96. The nursing assessment tool is divided into 3 sections. First section covers the baseline information include biodata, history, diagnosis, information regarding lifestyle, lab investigation / examination and medications. Second section of nursing assessment tool covers the first level assessment of patient in all four modes: physiological , self-concept, role function, interdependence mode and identifying nursing problems. Third section covers the assessment of environmental stimuli i.e , Focal, contextual and residual stimuli related to the problems identified.

97. Importance Of Thorough Physical Examination: A Lost Art - Asif et al Several recent studies have described a deterioration in physical examination skills among modern physicians. Reasons hypothesized for this change are improvements in technology and time constraints. Poor physical exam skills are a noteworthy threat to patient safety as they can lead to incorrect as well as missed diagnoses, causing delays in timely implementation of life-saving treatments.

98. Here, they present a case of extensive acute embolic strokes secondary to infective endocarditis. The patient was initially misdiagnosed as having Bell’s palsy due to incorrect physical examination. Through this case, they highlight the importance of management guided by a thorough history and physical examination to minimize diagnostic errors.

99. Why the history and physical examination still matter The history and physical examination (H/PE) have been the foundation of medical diagnosis for centuries. However, as laboratory tests and diagnostic imaging has expanded, physical examination skills have been deemphasized in medical education, and clinicians have become more reliant on tests and imaging. This article describes the historical contributions of the H/PE and its resurgence in a refined form to improve diagnosis.

100. ASSIGNMENT Write an assignment on history and physical examination of a patient with Cirrhosis of Liver.

101. BIBLIOGRAPHY https://www.gcu.ac.uk/media/gcalwebv2/hls/content/History%20Taking.pdf Potter AP, Perry GA. Basic nursing essentials for practice. 6 th edition. India: Mosby Elsevier; 2007 Taylor C, Lillis C, Lemone P. Fundamentals of nursing art and science of nursing care . fifth edition. India: Wolter Kluwer; 2006. Smeltzer CS, Bare GB, Hinkle LJ, Cheever HK. Brunner & Suddarth’s textbook of Medical-surgical nursing. Volume I. Twelvth edition. NewDelhi:Wolters Kluwer (India) ; 2011.