5ª AULA FUNDAMENTOS BÁSICOS DA PRÁTICA ASSISTENCIAL

Main ideas / lessons conveyed

• 5th lesson of a course: Basic Fundamentals of Clinical Practice (semiology and semiotechnics in nursing).
• Core nursing responsibility: perform the overall assessment of the patient using the nursing process, with emphasis on the first stage:
  • Initial assessment / nursing history (data collection).

Physical examination as a key instrument

• Collects clinical data to help identify health problems.
• Must be performed with:
  • a systematic structure
  • adaptation to the patient’s needs and the care setting.

Focus vs general exam

• A physical exam can be:
  • General: head-to-toe
  • Targeted: urgent/emergency complaints (e.g., trauma, burns, respiratory issues, postoperative wounds).

From data to nursing decisions

• The physical exam’s value depends on:
  • documentation
  • translating findings into:
    • nursing diagnosis
    • treatment/intervention plan

Nursing vs medical diagnosis

• Medical diagnosis: identifies the disease.
• Nursing diagnosis: focuses on human responses to health conditions (physiological, psychological, etc.) and guides nursing interventions.
• Nursing is essential for:
  • prevention
  • early detection
  • follow-up
  • continuity of care
  • not only treatment.

Using NANDA taxonomy (preview)

• Nursing diagnoses must follow a pattern:
  • Related to (etiology/cause)
  • Characterized by / evidenced by (defining characteristics)
• Example patterns emphasized:
  • “Impaired ambulation”
    • related to: lack of physical conditioning
    • characterized by: inability to walk a necessary distance
  • “Risk of infection”
    • specify risk factors such as:
      • poor skin integrity
      • surgical wound
      • invasive procedures
      • low immunity
• Exams/boards require linking assessment findings to the nursing diagnosis.

Physical exam methodology (4 main techniques)

• Inspection
• Palpation
• Percussion
• Auscultation

These are the “bread and butter” techniques of clinical assessment.

Where the 4 techniques fit in the nursing process

• Primarily in the first stage: initial assessment / nursing history.
• The nursing process is described as circular, but data collection via physical exam is fundamentally anchored to the first stage.

Cephalocaudal (head-to-toe) organization

• Ensures systematic assessment from:
  • head/skin/hair
  • to feet/locomotion
• The term may be updated in literature, but the goal remains: comprehensive coverage.

Importance of environment, lighting, positioning, ethics, and communication

• Position must match the exam (e.g., gynecological/breast positioning).
• Environment affects accuracy:
  • lighting, temperature, privacy barriers (curtains/screens)
• Consent:
  • verbal consent for routine nursing exams
  • written consent may apply in other contexts
• Companion presence:
  • patient may have a companion during the exam
• Women’s health contexts:
  • ensure comfort
  • add a colleague/another professional when relevant for safety and ethics

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Details of each technique

Inspection (observation)

• Visual assessment only (no manual/palpable action).
• Used to observe:
  • skin color (pallor/cyanosis/jaundice)
  • respiratory rate (visually counting when feasible)
  • level of consciousness
  • turgor, elasticity
  • nutrition/hydration cues
• Less intrusive/“natural” observation can improve accuracy (patients subconsciously change behavior when aware they’re being assessed).

Palpation

• Touch-based assessment for:
  • texture, volume, hardness, sensitivity
  • edema, nodules
  • organ findings (e.g., liver)
  • pain response
• Performed with clean, warm hands and trimmed nails (infection control and patient safety).
• Techniques vary by region:
  • one vs two hands
  • superficial vs deeper palpation
  • abdominal quadrants
  • specialized maneuvers (e.g., “sunburst” palpation for breast; Allen test for peripheral perfusion)
  • pressure methods (digital pressure, pen tip when tools aren’t available; compression/“bridge pressure”)

Percussion

• Produces sound to infer what lies underneath (fluid/masses/inflammation-related changes).
• Can be:
  • direct or indirect (difference in how the finger is used on/against the skin)
• Used to detect abnormalities and may relate to pain/inflammation.
  • If palpation worsens a condition, percussion may be preferred.
• Safety/bioethics reminders:
  • gloves in practice for contact precautions
  • demonstrations may omit gloves for visibility

Auscultation

• Uses a stethoscope to listen to internal sounds (lungs, heart, abdomen).
• Performed last because earlier steps may disturb findings (but may be reordered in a focused exam depending on priorities).
• Requirements:
  • quiet environment
  • warm stethoscope
  • avoid controlling patient breathing or speaking into tubing
• Focus points:
  • Lungs: anterior and posterior foci (taught as “six anterior and seven posterior”)
  • Heart: four focal points, assessed systematically

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Example clinical application

• Targeted assessment: postoperative wounds, respiratory symptoms, jaundice color changes, edema/perfusion issues.
• Link to diagnosis and intervention:
  • Example: jaundice + ineffective oxygen supply
    • identify with relevant tests (e.g., described perfusion test, “Aren/Allen-type”)
    • document findings to guide the care plan.

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Methodology / instructional content (detailed bullet list)

A) How nursing links physical exam → nursing diagnosis → plan

• Perform physical exam during initial assessment (nursing history/data collection).
• Use findings (signs/symptoms; physical and behavioral indicators) to:
  • identify nursing diagnoses
  • document properly in nursing progress notes
  • plan interventions (what to do, how, why, when)
• Ensure the nursing prescription is derived from:
  • the diagnosis
  • the evidence/characteristics
  • the related factors

B) How to write nursing diagnoses using NANDA structure

• Required components:
  • Related to (etiology/cause / contributing factor)
  • Characterized by / evidenced by (defining characteristics from assessment)
• Examples emphasized:
  • Impaired ambulation
    • related to: lack of physical conditioning
    • characterized by: impaired ability to walk a necessary distance
  • Risk of infection
    • related factors such as:
      • poor skin integrity
      • surgical wound
      • invasive procedures
      • low immunity

C) Decide general vs targeted physical exam

• Use general head-to-toe assessment when appropriate (cephalocaudal).
• Use focused/targeted assessment when:
  • urgent/emergency complaint exists (trauma, severe burns, respiratory distress, vomiting/nausea, etc.)
  • there’s a known monitored condition (e.g., incision/wound; postoperative follow-up)
• Even in targeted cases, do general assessment as needed, but prioritize the relevant area.

D) Step-by-step physical exam technique sequence (baseline)

1. Inspection (visual)
2. Palpation (touch; superficial + deep as needed)
3. Percussion (tap to infer underlying tissue/fluid/masses)
4. Auscultation (listen with stethoscope)

E) Timing within the nursing process

• Primarily used in initial assessment / nursing history.
• Notes emphasized:
  • interventions (e.g., charting/evaluating vitals at intervals) belong to implementation, not assessment/history.
• The process may be revisited, but physical exam data collection is foundational to the first stage.

F) Practical technique guidance (reliability and safety)

• Inspection
  • Observe naturally to reduce patient behavioral changes
  • Assess consciousness/skin findings/respiratory rate visually when feasible
• Palpation
  • Use clean, warm hands; trim nails
  • Use superficial + deeper palpation when clinically indicated
  • Apply region-specific approaches (abdomen quadrants; specialized breast techniques)
• Percussion
  • Choose direct vs indirect; apply quickly to create vibration
  • Consider technique choice if palpation could worsen certain issues
• Auscultation
  • Do in a quiet environment
  • Warm stethoscope
  • Avoid interfering with breathing/speaking into tubing
  • Use proper anatomical focus points (lungs anterior/posterior; heart four foci)

G) Ethics, consent, and patient-centered communication steps

• Identify patient; ensure privacy (screens/curtains in ICU/ward).
• Explain what will be done and why; obtain consent.
• Use verbal consent for routine nursing physical exams.
• Allow/offer a companion during the exam.
• Women’s health examinations:
  • confirm comfort (especially if performed by a male professional)
  • have a colleague/another professional when needed for safety/ethics

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Speakers / sources featured (as identified in the subtitles)

• Professor Aldo (primary lecturer)
• Professor Renata (host/other instructor)
• Maria (named during an example scenario about calling the nurse; appears as “nurse Maria”)
• Fabíola
• Elina
• Késia
• Professor Andressa (in-house teacher; videos demonstrating techniques)
• Silvia (student/commentary voice)
• Adriana (student/commentary voice; congratulated on pregnancy in the subtitles)
• Marilene
• Maria Leutina
• Guilherme (student/commentary voice; answers a question and explains physical exam stages)
• Fernanda (student/commentary voice)
• Adriano
• Carla
• Alice
• Alvine / “Alice” and “Carla” (student remarks)
• Ministério da Saúde / Ministry of Health (authority referenced regarding instruments/equipment when not available)
• NANDA taxonomy
• Glasgow Coma Scale (referenced for later topics)