Health Assessment - BLUEPRINT SLIDES PDF

## Health Assessment - BLUEPRINT SLIDES ### Types of Assessment - Initial assessment: Performed within specified time after admission to a health care agency. - Problem-focused assessment: Ongoing process integrated with nursing care. - Emergency assessment: During any physiological or psychologic...

## Health Assessment - BLUEPRINT SLIDES ### Types of Assessment - Initial assessment: Performed within specified time after admission to a health care agency. - Problem-focused assessment: Ongoing process integrated with nursing care. - Emergency assessment: During any physiological or psychological crisis of the client. - Time-lapsed reassessment: Several months after initial assessment ### Collecting Data: Gathering Information | Subjective (Symptom) | Objective (Signs) | | :--------------------------------------------------------- | :------------------------------------------------------------------------------------ | | Verbal statement by the patient Eg… Nausea, pain, fatigue, itching | Detected by an observer - can be measured over an accepted standard | | What patient says | What we can see | ### PURPOSE OF HEALTH ASSESSMENT - To obtain baseline physical and mental health data - To supplement, confirm, or question data obtained - in the nursing history. - To obtain data - that will help the nurse establish nursing diagnoses and plan patient care. - To evaluate - appropriateness of the nursing action - To evaluate - the physiological outcome of care. - It helps nurses identify deviations from normal and potential health problems. - It serves as a foundation for developing a patient-centered care plan. ### Open Questions - Always start with an open question and listen to the patient's story. - Open questions begin with: "What" "Why" "When" "How" "Which" - Main features of open questions: - They encourage conversation. - They are good for finding out details. - They give 'control' to the responder during conversation. - They often start with 'what', 'when' 'why', 'tell me', 'describe', etc. - But, they take longer time, and one needs to be an active listener. ### Closed Questions - Closed questions have single short answers like, "yes", "no", "don't know." - They force a person to give a brief answer. - They usually provide a factual answer. - Used to gain clarification. - But, a misplaced question can stop conversation and lead to silence. - Examples of closed questions: - "What is your name"? - "Do you smoke"? - "What do you prefer, tea or coffee"? ### Leading Questions - Questions based on your own assumptions that leads the patient to the answer you want to hear. - This should not be used at all. - This type of questions are used when the questioner wants to get something confirmed. - These are commonly used in legal cases. - Leading question can help you get the answer you want. - Disadvantage: Biased leading question can render your data unusable and open to question. ### Components of health history - Menstrual and Obstetrical history [if applicable]: - Length of cycle: - Duration of cycle: - Pain and other associated symptoms: - Number of children: - Type of childbirth/s: - Abortion/Still birth: - Any ante/intra/post natal complications: - Personal history: - Hygienic habits - Smoking/ Substance abuse - Dietary pattern: - Dietary preferences: - Frequency and amount of food intake: - Food Allergies: - Functional history: - Rest and sleep patterns - Bowel and bladder habits ### Development of Empathy - Nurse must be receptive to the patients feeling and perceptions - Nurse must understand the patients communication - Nurse should be able to put himself/herself in the patient's place and understand patients needs which they may not be able to communicate freely sometimes. - For eg: After a painful experience the patient may not feel to have food. The nurse understands this and doesn't force the patient. - Empathy should not be confused with sympathy ### Some examples of Subjective & Objective data - Tachycardia- O - Dizziness- S - Unconsciousness- O - Fatigue- S - Nausea- S - Hyperthermia- O - Shortness of breath- S (can also be O if severe) - Wheezing- O - Vomiting- O - Cough- O - Itching- S - Pain- S - Tenderness- O ### Light palpation: To perform light palpation place your dominant hand lightly on the surface of the structure. There should be very little or no depression (less than 1 cm). Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture. ### Auscultation **Stethoscope Part** | **Purpose** | **Technique** --- | --- | --- DIAPHRAGM | To detect high-pitched sounds. <br/> Ex: breath sounds <br/> Normal heart sounds <br/> Bowel sounds | Press firmly on body part BELL | To detect low-pitched sounds. <br/> Ex: Abnormal heart sounds (murmur) | Press lightly over body part ### Legal and Ethical Aspects of Health Assessment - Confidentiality and Patient Privacy: - HIPAA regulations, maintaining patient dignity. - Informed Consent: - Explanation of procedures and obtaining consent. - Professional Boundaries and Ethical Conduct: - Respecting patient rights and cultural differences. ### Assessment Sequencing - Head-to-Toe Examination: - Systematic approach from head down to toes - System Wise Examination: - Assessing one system at a time (e.g., cardiovascular, respiratory) - Emergency Assessment: - Rapid assessment focusing on life-threatening conditions (e.g., ABCs: Airway, Breathing, Circulation) ### PULSE - **Tachycardia**: - The pulse is faster than 100 beats per minute. - Result from shock, hemorrhage, exercise, fever, acute pain, and drugs. - **Bradycardia**: - The pulse is slower than 60 beats per minute. - Result from unrelieved severe pain, drugs, resting, and heart block. ### Precautions with BP measurement - Allow the patient to rest for at least five minutes in a quiet room before beginning BP measurement. - Patients should be asked to refrain from smoking, drinking tea/coffee or exercise for at least 30 minutes before measuring the BP. - Patient should sit calmly with back support, feet flat on floor for 5 minutes before taking a reading or patient should be in supine position. - Use the correct BP cuff size and the cuff should fit snugly on the arm, about 2-1 inch above the elbow crease. - BP should not be measured on an arm which has, and IV fluid connected, arteriovenous shunt, fistula or graft (for hemodialysis) ### Factors Affecting Pulse Rate - Age. As age increases, the pulse rate gradually decreases overall. - Gender. Males lower than females - Exercise. The pulse rate normally increases with activity. - Fever - Elevated - Medications. Some medications decrease the pulse rate, and others increase it. - Hypovolemia/dehydration.. - Stress. - Position. - Pathology. ### Types of Pulses - **Absent pulse**: Having difficulty feeling a person's pulse. Cannot detect a pulse at all. - **Weak pulse**: Abnormally slow heart rate that is less than 60 beats per minute. - **Thready pulse**: Irregularities in strength or rhythm. - **Bounding pulse**: Strong throbbing felt over one of the arteries in the body. ### Pulse Assessment Techniques - Primary pulse assessment site: - Radial artery located at inner (thumb) side of the wrist - Apical radial rate: - Number of sounds heard at heart's apex and the rate of radial pulse during the same period. - The pulse deficit: - Difference between the apical and radial pulse rate ### Jaundice - Yellowing of the skin and eyes due to elevated levels of bilirubin, often indicating liver dysfunction. ### Abnormal condition of nail - Paronychia: inflammation of tissue surrounding the nail ### Rash - A noticeable change in the texture or color of the skin, often accompanied by redness, bumps, or itching. ### Lesion - An abnormal area of tissue that can be flat or raised, varying in size, shape, and color. It includes macules, papules, nodules, etc. ### Vesicle - A small, fluid-filled blister that forms on the skin, commonly seen in viral infections like herpes or chickenpox. ### Visual Acuity - The Snellen chart, which is composed of a series of progressively smaller rows of letters, is used to test distance vision. - The fraction 20/20 is considered the standard of normal vision. - The patient is positioned at the prescribed distance, usually 20 feet, from the chart. - Right eye is tested and recorded first. - Completely occlude the left eye using palm. ### Pupillary reaction to light - The pupillary response is checked with a penlight - A normal pupil is black. Size is 2-6mm - Pupillary reaction - It should be round and equal in diameter ### Cranial nerve testing -extra ocular muscles movements - Examiner can observe eye movements in all directions. - Stand in front of the patient. - Place an object - 12 to 14 inches away from nose. - Ask them to follow your finger with there eyes while keeping there head in one position. - Using your finger, trace an imaginary "H" or rectangular shape in front of them. ### Ectropion: Outward turning of an eyelid margin ### Techniques & Tools for Ear Assessment - **Tuning Fork Tests**: - **Weber Test**: Assesses lateralization of sound. - **Rinne Test**: Compares air conduction vs. bone conduction. - **Whisper Voice Test**: - Assesses hearing acuity by asking the patient to repeat whispered words. ### Whisper Test - Whisper Test: Simple and accurate screening test to detect hearing impairment. Administration takes one to two minutes. - **Sensorineural hearing loss (SNHL)** is caused by damage to the structures in your inner ear or auditory nerve. - **Conductive hearing loss** results when there is any problem in delivering sound to cochlea, the hearing part in the inner ear. Common reasons for conductive hearing loss include blockage of ear canal, a hole in ear drum, problems with three small bones, or fluid in the space between ear drum and cochlea. ### Tuning Fork Test - Used to differentiate between conductive and sensorineural hearing loss. - Test can be performed with 128, 256, 512, 1024 2048 hertz. - Larger forks vibrate at slower frequency. - Tuning fork is activated by striking against examiner's elbow, heel of hand and placed 2 cm away from ear for air conduction and on mastoid for bone conduction. - **Air conduction** – Tuning fork is placed vertically in line with meatus about 2 cm away. - **Bone conduction** - Foot place of vibrating tuning fork is placed on the mastoid bone. ### Techniques & Tools for Ear Assessment - **Otoscopic examination:** - using an otoscope, we are able to observe the internal structures of the ear. ### NORMAL BREATH SOUNDS - **Bronchial breathing**: - The bronchial breath sounds over the trachea has a higher pitch, louder. - Inspiration is shorter than expiration. - There is a gap between inspiration & expiration. - **Bronchovesicular breathing**: - Heard over 1st and 2nd interscapular space. - Inspiration and expiration are equal. - There is no pause between inspiration and expiration. ### Vesicular breathing: The vesicular breathing is heard over the chest wall. It is lower pitched and softer than bronchial breathing. Inspiration is longer & louder than expiration. There is no gap or pause between inspiration and expiration. It is heard best at the bases of lungs. ### Auscultation - Evaluate for adventitious sounds or abnormal breath sounds - **Crepitation** - Crackles/ Soft (fine) – non-musical, brief sound - Rales Loud (coarse) - non-musical, brief sound - **Wheeze** - Continuous musical sounds - **Ronchi** - Continuous snoring sounds - **Pleural or Friction Rub** - discontinuous creaking or brushing sounds - **Stridor** - Continuous, crowing sound ### Adventitious Breath Sounds/ Abnormal sounds - **CRACKLES/RALES**: - are the interrupted sounds; you will hear in a lung field that has fluid in the small airways. - **Fine crackles** sound cellophane being crumpled or like salt heated on a frying pan. - **Coarse crackles** sound like pouring water out of a bottle or like ripping open Velcro. - **Lung Diseases** - asthma, bronchiectasis, chronic bronchitis, consolidation interstitial lung disease, pulmonary edema - **WHEEZE**- - Wheezes are continuous, high pitched, hissing sounds heard normally on expiration but also sometimes on inspiration. - They are produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions. - **Lung Diseases**:- asthma chronic bronchitis COPD pulmonary edema - **Pleural friction rub**: - when thickened, roughened pleural surfaces rub together as the lungs expand and contract, a continuous or intermittent grating sound may be audible - **RHONCHI;-** - Wheezes and rhonchi are actually very closely related. Rhonchi are low pitched, continuous, musical sounds that are similar to wheezes. - They usually imply obstruction of a larger airway. - Rhonchi are caused by blockages to the main airways by mucous secretions, lesions, or foreign bodies.. ### Breath sounds | Type | Duration | Expiration | Location | |---|---|---|---| | Vesicular | > expiratory <br/> inspiratory <br/> Insp louder <br/> No gap | soft <br/> low pitch | over the whole lungs <br/> bottom of lungs | Bronchovesicular | > inspiratory <br/> expiratory <br/> Ins & Exp same loudness <br/> No gap | medium loud <br/> medium pitch | peristernal <br/> interscapular | Bronchial | > inspiratory <br/> expiratory <br/> same loudness <br/> Exp longer <br/> Gap | loud, strong <br/> high pitched | above clavicle <br/> manumbrum <br/> sterni | Tracheal | > expiratory <br/> inspiratory <br/> Insp louder <br/> Gap | very loud <br/> high pitched | above trachea ### Evaluate for normal sounds - Tracheal - Bronchial - Bronchovesicular (1st & 2nd ICS lateral to sternum) - Vesicular - all over the chest wall ### Laboratory Investigations: - **Electrocardiogram (ECG):** - An ECG records the electrical signals/impulses of heart to show how fast the heart is beating, the rhythm of the heart beats (steady or irregular), and the strength and timing of the electrical impulses as they move through the different parts of the heart. - **Echocardiogram:** - A test of the action of the heart using ultrasound waves to produce a visual display/ sound waves to produce images of heart, for the diagnosis or monitoring of heart disease. - Echocardiogram will show how blood flow through the heart and heart valves ### Cardiac Markers - Cardiac Markers are used for diagnosis of patients with chest pain and suspected acute coronary syndrome (ACS) and for management and prognosis in patients with acute heart failure, pulmonary embolism, and other disease states. - **Cardiac troponin (Muscle protein) Troponin T and Troponin I** Are known as Myocardial Infarction indicators. - **Creatinine kinase (CK) - Enzyme**. - **CK-MB (Heart- skeletal muscle)**. - **Myoglobin (Oxygen-storing protein)**. ### Locating And Palpating Apical Pulse - This apical pulse is generally located in the 5th intercostal space, about 7-9 cm to the left of the midline. ### Pulse Deficit - It is the difference between the apical pulse and radial pulse when counted for one full minute simultaneously. - Increased anxiety, Heavy blood loss, Situations of extreme or chronic pain, Low blood pressure or hypotension, Heart disease, Heart failure, Overactive thyroid gland ### Auscultate for bowel sounds: - Use the diaphragm of the stethoscope. - Start in the RLQ and move through the other quadrants. - Note the character and frequency of the sounds. - Count the sounds for at least 60 seconds. - Normal bowel sounds are irregular, clicking, gurgling, and high-pitched. Heard approximately every 5 to 15 seconds. - They occur from 5 to 30 times per minute. - Listen to bowel sounds for a full minute before determining if they are normal, hypoactive, or hyperactive. ### Murphy's Sign - A positive Murphy's Sign indicates potential cholecystitis or inflammation of the gallbladder. - To test, firmly palpate the RUQ subcostal region, pushing under the ribs. Ask the patient to take a deep breath. - A positive sign is when significant pain is elicited by this maneuver, usually stopping them mid-breath. ### Findings on Auscultation - Complete absence of any bowel sounds over a 4-minute period indicates paralytic ileus. - Borborygmi -Intestinal hurry or rush, which occurs in diarrhoeal states, causes loud gurgling sounds, often audible without the stethoscope. - Findings that should be reported: - Bruit over the aorta (swishing, swirling sound of blood flowing at high pressure) - suggests abnormal turbulence in the aorta. Can indicate abdominal aorta aneurysm, and must be notified immediately. - Continuous bowel sounds over the ileocecal valve. - A completely irregular pattern of bowel sound. ### Palpation - Lightly palpate the abdomen: - Place the palmar surface of your hand on the abdomen and extend your fingers. - Lightly press into the abdomen with your fingers. - Move your hand over the four quadrants by lifting your hand and then placing it in another area. - The abdomen should be soft, smooth, Non tender, and pain-free. ### PSOAS sign - This is a test for appendicitis. - Place your hand above the patient's right knee. - Ask the patient to flex the right hip against resistance. - If pain in iliopsoas muscle (the right lower quadrant of the abdomen) is present, Iliopsoas sign is positive ### Patient History - **Review Chief Complaint:** Document any complaints related to the GI system (e.g., pain, nausea, vomiting, changes in bowel habits). - **Collect health history** (past GI disorders, surgeries, medications, family history). - **Inquire about dietary habits** (daily diet, food intolerances, fluid intake). - **Assess bowel habits** (frequency, consistency, colour of stools, use of laxatives). ### EVALUATING NUTRITIONAL DISORDERS | System/Region | Sign or Symptom | Implications | |---|---|---| | General | Weakness and fatigue <br/> Weight loss | Anemia or electrolyte imbalance <br/>Decreased calorie intake, increased calorie usein, or inadequate nutrient intake or absorption | | Skin, hair, and nails | Dry, flaky skin <br/> Dry skin with poor turgor <br/> Rough, scaly skin with bumps <br/> Petechiae or ecchymoses <br/> Sore that won't heal <br/> Thinning, dry hair <br/> Spoon-shaped, brittle, or ridged nails | Vitamin A, vitamin B-complex, or linoleic acid deficiency <br/> Dehydration <br/> Vitamin A deficiency <br/> Vitamin C or K deficiency <br/> Protein, vitamin C, or zinc deficiency <br/> Protein deficiency <br/> Iron deficiency | | Eyes | Night blindness; corneal swelling, softening, or dryness; Bitot's spots (gray triangular patches on the conjunctiva) <br/> Red conjunctiva | Vitamin A deficiency <br/> Riboflavin deficiency | | Throat and mouth | Cracks at the corner of the mouth <br/> Magenta tongue <br/> Beefy red tongue <br/> Soft, spongy, bleeding gums <br/> Poor dentition <br/> Swollen neck (goiter) | Riboflavin or niacin deficiency <br/> Riboflavin deficiency <br/> Vitamin B12 deficiency <br/> Vitamin C deficiency <br/> Iodine deficiency | | Cardiovascular | Edema <br/> Third and fourth heart sounds <br/> Shortness of breath <br/> Cough <br/> Tachycardia, murmur, hypotension | Protein deficiency, thiamine deficiency <br/> Fluid volume deficit; anemia | | GI | Ascites | Protein deficiency | | Musculoskeletal | Bone pain and bow leg <br/> Muscle wasting | Vitamin D or calcium deficiency <br/> Protein, carbohydrate, and fat deficiency | | Neurologic | Altered mental status <br/> Ataxia <br/> Paresthesia, neuropathies | Dehydration and thiamine or vitamin B12 deficiency <br/> Vitamin B12, pyridoxine, thiamine, or niacin deficiency | ### Laboratory Studies - Can detect preclinical nutritional deficiencies and can be used to confirm findings - **Plasma glucose -** - Normal 60-110mg/dl - **Hemoglobin**- less in iron deficiency anemia, increased dehydration, decreased anemia - Normal M:14-18; F:12-16. - **Hematocrit**- measures cell volume, also an indicator of iron status. - Normal M: 37%- 49%; F: 36%-46%. - Low value indicates insufficient hemoglobin formation. - **Cholesterol**- to evaluate fat metabolism and to assess risk for CVD. - Normal 120-200 (200-239 moderate risk, 240 or more- high risk) ### Laboratory Studies - **Triglycerides**- screen for hyperlipidemia and determine risk of CAD. - Normal 150mg/dl - **Serum protein, serum albumin**- measure of visceral protein status. - Normal 3.5-5.5 g/dl - Low serum albumin level occurs with protein calorie malnutrition, altered hydration status, decreased liver function. - **Vitamins and Minerals levels** - **Serum transferrin**- iron transport protein, more sensitive indicator of visceral protein status. - Normal 170-250 mg/dl ### Mid Upper Arm Circumference - Estimates skeletal muscle mass and fat stores. - The normal MAC for 20 years old female range from 23 to 34.5 cm and male range from 27.2-37.2 cm. - Difficult to obtain and interpret in older adult because of sagging skin, changes in fat distribution, and declining muscle mass. ### Common Symptoms of Urinary Disorders - **Dysuria:** - Definition: Pain or discomfort during urination. - Potential Causes: UTIs, bladder infections, STIs. - **Urinary Frequency:** - Definition: Increased need to urinate more than normal. - Possible Conditions: Cystitis, diabetes, prostate issues. - **Urinary Urgency:** - Definition: Sudden, compelling urge to urinate. - Associated Disorders: Overactive bladder, inflammation. ### Diagnostic Investigations - **Urinalysis:** - Purpose: Screening for various conditions, including infections and kidney disease. - **Culture and Sensitivity:** - Purpose: Identifies specific pathogens causing infection and their antibiotic sensitivity. - **Imaging Studies:** - Ultrasound: Non-invasive; used to visualize kidney size and structure. - CT Scans: Detailed imaging for diagnosing stones, tumors, or structural issues. - **Cystoscopy:** - Purpose: Direct visualization of the bladder and urethra for diagnosis. - **Post-Void Residual Measurement:** - Assessing bladder emptying efficiency. ### Cystoscopy - **Description and Indications:** - Procedure for visualizing the bladder and urethra using a cystoscope. - **Procedure Overview:** - Informed consent and explanation to the patient. - Insertion of cystoscope through the urethra. - Direct visualization of the bladder interior, allowing for biopsy or removal of tissue if needed. - **Post-Procedure Care:** - Monitoring for complications such as bleeding or infection. - Providing patient education regarding potential symptoms to watch for. ### Cystoscopy: - Procedure for visualizing the bladder and urethra using a cystoscope. ### Percussion - **Percussion of the Bladder:** - Assess for dullness in the suprapubic area indicating distended bladder. - **Costovertebral Angle (CVA) Tenderness:** - Gently tap the area where the kidneys are located. - Positive tenderness may indicate kidney inflammation or infection (e.g., pyelonephritis). ### How to assess a patient's pain history: the 'PQRST' approach | Category | Question | |---|---| | P: Provokes and Palliates | What causes the pain? <br/> What makes the pain better? <br/> What makes the pain worse? | | Q: Quality | What does the pain feel like? <br/> Sharp? Dull? Stabbing? Burning? Crushing? | | R: Region and Radiation | Where is the pain located? <br/> Is it confined to one place? <br/> Does the pain radiate? If yes, where to? <br/> Did it start elsewhere and now localized to one spot? | | S: Severity | How severe is the pain? | | T: Time | When did the pain start? <br/> Is it present all the time? <br/> Are you pain-free at night / day? <br/> Are you pain-free on movement? <br/> How long does the pain last? | ### Types of ROM Evaluation - **Passive ROM** – Movement is produced entirely by an external force. - **Active-Assistive ROM**- Assistance is provided manually or mechanically because the prime mover needs assistance to complete the motion. - **Active ROM** – Movement without assistance and is the prime mover. ### Equipment Used for ROM Testing - **Goniometer** - measures the angle at a joint. Goniometers measure range of motion in degrees, from zero to 180 or 360, and come in various shapes and sizes to be used on particular joints. - **Inclinometer** - measure the angle of the cervical, thoracic, or lumbar spine ### Body Movements - **Abduction** - **Adduction** - **Circumduction** - **Rotation** - **Lateral flexion** - **Flexion** - **Hyperextension** - **Opposition** - **Extension** - **Pronation** - **Supination** - **Dorsiflexion** - **Plantar flexion** - **Inversion** - **Eversion** ### Diagnostic Tests - **Arthrocentesis:** - A needle is inserted through the joint capsule and fluid is aspirated. - Diagnostic: done to obtain synovial fluid. - Therapeutic: to remove excess fluid. - **Post-procedure:** - Maintain dressing, - ambulation as soon as awake. - mild soreness of joint for 2 days. - joint rest. - **Arthroscopy:** - is the internal inspection of a joint using an instrument called an arthroscope. Arthroscope is a thin fiber-optic viewing instrument that is inserted into the joint a small incision in the knee. - **Nursing Management:** - After the arthroscopy procedure. - Leg is elevated without flexing the knee. - A cold pack is placed over the bulky dressing covering the site where the arthroscope was inserted. - Administer analgesic as necessary. - Maintain non-weight bearing on affected leg for 48 hours. - **Dual energy x-ray absorptiometry (DEXA) –** - Bone density examinations are done to evaluate bone mineral density and to evaluate degree of osteoporosis. Painless procedure, non-invasive. Need to remove jewelry. - **Skeletal X-Ray, CT and MRI -** - help to identify traumatic disorders, such as fractures and dislocations, and other bone disorders, such as malignant bone lesions, joint deformities, calcification, degenerative changes, osteoporosis and joint disease. ### Muscle Strength Scale - 0 - No muscle contraction - 1 - Trace muscle contraction, such as a twitch - 2 - Active movement only when gravity eliminated - 3 - Active movement against gravity but not against resistance - 4 - Active movement against gravity and some resistance - 5 - Active movement against gravity and examiner's full resistance ### Glasgow Coma Scale (GCS) - **Definition:** - The Glasgow Coma Scale is a neurological assessment tool that measures the severity of brain injury based on a patient's response to stimuli. - **Components:** - **Eye Opening (1-4):** Spontaneous, to verbal command, to pain, none. - **Verbal Response (1-5):** Oriented, confused, inappropriate words, incomprehensible sounds, none. - **Motor Response (1-6):** Obeys commands, localizes pain, withdraws from pain, flexion to pain, extension to pain, none. - **Scoring Interpretation:** - Total Scores: Scale ranges from 3 (deep coma) to 15 (fully awake). - **Clinical Use:** Discuss how GCS aids in evaluating the severity of head injuries. - **Interpretation: GCS Score:** - 13-15: Mild injury. - 9-12: Moderate injury. - 8 or less: Severe injury. ### Pupillary Assessment | S. N. | Items/Procedure | Yes | No | Remarks | |---|---|---|---|---| | 1 | Direct pupillary reflex | | | | | 2 | With the patient seated, dim the lights. | | | | | 3 | Shine the light from your pen torch into the patient's pupil and observe for pupillary restriction in the ipsilateral eye. | | | | | 4 | Consensual pupillary reflex | | | | | 5 | Once again shine the light from your pen torch into the same pupil, but this time observe for pupillary restriction in the contralateral eye. | | | | | 6 | A normal consensual pupillary reflex involves the contralateral pupil constricting as a response to light entering the eye being tested. | | | | ### Deep Tendon Reflexes (DTRs) - **Definition:** Reflexes elicited by tapping on a tendon, causing a muscle contraction. - **Common DTRs:** - **Biceps Reflex:** C5-C6 spinal segments. - **Triceps Reflex:** C6-C7 spinal segments. - **Patellar Reflex:** L2-L4 spinal segments. - **Achilles Reflex:** S1-S2 spinal segments. ### Grading Reflexes | Reflexes | Scale | Clinical shorthand to summarize reflex findings | |---|---|---| | Deep tendon reflexes <br/> Biceps reflex C5/C6 <br/> Brachioradialis reflex C6 <br/> Triceps reflex C7 <br/> Patellar reflex L4 <br/> Achilles tendon S1 <br/> Plantar response | 0 = absent <br/> 1+ = hypoactive <br/> 2+ = normal <br/> 3+ = hyperactive <br/> 4+ = hyperactive with clonus <br/> 5+= sustained clonus | | ### Techniques for eliciting major reflexes. -(A) Biceps reflex. -(B) Triceps reflex. -(C) Patellar reflex -(D) Ankle or Achilles reflex. -(E) Babinski response. ### Romberg Test | S. N. | Items/Procedure | Yes | No | Remarks | |---|---|---|---|---| | 1 | Position yourself within arm's reach of the patient to allow you to intervene should they begin to fall. | | | | | 2 | Ask the patient to put their feet together and keep their arms by their sides. | | | | | 3 | Ask the patient to close their eyes . | | | | | 4 | Interpretation - Normally patient should be able to maintain balance even when pushed slightly. If patient can't maintain balance, it indicates positive Romberg sign | | | | ### Hyper-Parathyroid Disorders - **Tetany:** - general muscular tremors/involuntary muscle contractions and overly stimulated peripheral nerves. Caused by electrolyte imbalances - often low calcium levels. - **Chvostek sign:** - spasm of facial muscles that occur when muscles of/ facial nerve is tapped. ### Hypoglycaemia - Blood glucose <70 mg/dL (3.9 mmol/L) - Cold, clammy skin - Rapid heartbeat - Headache - Nervousness, tremors - Faintness, dizziness - Hunger - Changes in vision ### Hypersecretion of Adrenal glands - Cushing's Disease or Syndrome Symptoms - Personality Changes. - Red Face - ↑ Susceptibility to Infection - Males: Gynecomastia - Fat Deposition on Abdomen and Back of Neck ("Buffalo Hump") - Hyperglycemia - CNS Irritability - Fat Round "Moon" Face - Fluid Retention (Edema) - Thin Extremities - GI Distress-TAcid - Purple Striae - Females: Amenorrhea, Hirsutism - Thin Skin - Bruises & Petechiae - Osteoporosis (increased risk of fractures) ### Diabetes Mellitus - Signs and Symptoms 1. Polyuria 2. Polydypsia (Increased thirst) 3. Polyphagia (Increased hunger) 4. Glucosuria (Sugar in the urine) 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Acetone breath odor 9. Kussmaul's Respiration (rapid shallow breathing) 10. CNS depression leading to coma