Planning

Planning is the term used to describe a complete plan created by a nurse that starts with the first patient interaction and lasts until the patient is discharged from the health agency. It is the decision-making phase in the nursing process. A nursing action plan should be created to help the patient resolve his condition once the patient and nurse have reached an understanding regarding the diagnosis. The patient should be included in the process of creating the strategy, and his preferences should be considered as much as is practical.

Purposes

• To achieve a greater level of performance and wellness.
• To determine if the client's health has changed in any way. (Repeated Planning)
• Maintain the patient's present level of health and functionality (in case of potential problems.)
• To adapt to a lesser level of health and functioning when a treatment is not possible.
• Should have a plan in place in case a patient develops a fatal illness and their life is in risk.

Types of Planning

Initial planning: The nurse who conducts the admission evaluation typically develops the initial comprehensive plan of care. The client's body language is visible to the nurse, and she also has access to certain intuitive knowledge that would not otherwise be available. Standardized care plans specify the nursing diagnoses and supporting therapies. The nurse performing the admission, nursing history, and physical assessment should start making plans as soon as feasible due to the trend toward shorter hospital stays.

Ongoing planning: Every nurse who interacts with a patient is in charge of continual planning. Nurses can further customize the initial care plan as they gather more details and monitor the client's response to treatment. In addition, the nurse plans the care that will be given that day as part of ongoing planning at the beginning of a shift. The nurse performs daily planning for the following objectives using data from ongoing assessments:

• To see if the client's health state has changed.
• To establish priorities for the client's care throughout the shift.

Discharge planning: This is the procedure for foreseeing and making plans for post-discharge requirements. Due to the usual length of stay of clients, who are occasionally discharged while still needing care, it is a crucial component of comprehensive health care and should be addressed in each client's care plan. Such care is increasingly provided in the home, even if many clients are discharged to other organizations (such nursing homes).

Steps of planning

• Setting priorities
• Writing nursing goals
• Planning nursing actions

Setting Priorities

Prioritization refers to the process of ranking nursing diagnoses or patient problems in order of priority and urgency in order to establish a preferred sequence for nursing interventions. It comprises ranking the nursing issues or choosing which of the issues that have been identified requires immediate attention and which can wait. When a patient has numerous diagnoses and associated concerns, priorities help in anticipating and timing nurse intervention. Diagnoses made by nurses are given a high, medium, or low priority.

• High priority nursing diagnoses: High-priority nursing diagnoses are ones that are life-threatening and must be addressed immediately. Priority is given to nursing diagnoses that, if left untreated, could cause harm to a patient or others. High-priority nursing diagnoses include "high risk for aspiration," "high risk for violence- self-directed or directed at others," "impaired gas exchange," and "decreased cardiac output." In an emergency or critical care setting, people can develop multiple high-priority nursing diagnoses at the same time.
• Intermediate priority: These are non-emergency and non-life threatening conditions such as altered bowel habits, impaired skin integrity, knowledge deficits, and decreased mobility.
• Low priority: Nursing with a low priority The patient's well-being is affected by a diagnosis that is not necessarily directly tied to a specific condition or prognosis. i.e. altered sleep pattern, risk of chronic respiratory infections due to a 20-year smoking history

Prioritization may be conducted to:

• Determine which health condition to address first based on the critical need determined by a review of available data.
• Prepare a plan for addressing health needs based on the resources available.
• Determine which health conditions are most likely to be impacted successfully by accessible evidence-based therapies.

The following points should be considered while setting priority.

• Make use of Maslow's hierarchy of requirements.
• Consider the urgency of his/her concerns, such as hemorrhage, breathing difficulty, and so on.
• When possible, consider the client's priorities.
• Consider the client's health ideals and beliefs.
• Priority setting includes ethical care. When ethical considerations cloud priorities, it is critical to have open communication with the patient, family, and other health care providers.
• Consider the availability of time and resources, such as time, cost, person, and equipment.
• Priorities shift as a patient's condition changes, sometimes in a matter of minutes.
• Consider the patient's potential impact of future issues.
• Medical treatment strategy

Writing Nursing Goal 

The nurse should list the nursing goal for each issue after ranking the patient's worries in order of importance. It also acts as a schedule for the test. A goal is a broad declaration that identifies intended changes in a patient's condition or behavior. In order for the nurse and client to evaluate the client's progress toward the desired objectives as well as the effectiveness of nursing intervention, the goals must also be measurable and realistic. A goal is to lessen or completely eradicate the challenges identified in the patient's assessment. Depending on how long it takes to accomplish a goal, it might be long-term or short-term.

• Short term goals: When the goals are likely to be achieved fairly e.g. within few hours or days they are called short term goals. 
• Long term goals: When the goals are likely to take many days or months to achieve, they are considered to be long-term goals.

Goals are essential for the nursing-care plan because a goal gives direction to the nursing intervention.

• Serves as a guide for nursing action
• Motivates the patient as well as the nurse to continue their effort.
• Serves as a criterion to evaluate the effectiveness or nursing intervention. 

Guidelines for Writing Goals

Goals should be: 

• Related to the trauma response.
• Client-centered.
• Address what the client will do, when and what extent it will be accomplished.
• Clear and concise. Ambiguous of abstract wording should be avoided.
• Observable and measurable
• Time limited.
• Realistic.
• Determined by client and nurse together
• Specific.
• Assignable- specify who will do it.
• Achievable
• Relevant

An expected outcome is a quantifiable shift in a patient's condition that you anticipate happening as a result of nursing care or a metric to gauge goal achievement. For a single aim, there may be multiple expected outcomes that must be achieved. Additionally, a list of the desired outcomes broken down into steps might help you organize actions in a practical way. Always include time frames and a chronological list of expected results.

Planning Nursing Action

Nursing actions are particular nursing tasks that are intended to carry out in order to accomplish the objective. After nursing diagnoses are determined and goals and outcomes are chosen, you decide on an intervention tailored to the patient's circumstances. When deciding on nursing interventions, the patient should be consulted. When planning nursing interventions, the following factors should be taken into account:

• The planned nursing action must be safe for the patient.
• It must be realistic.
• It must be based on scientific principles.
• It must accomplish the stated goal.

Types of nursing interventions:

• Independent interventions: activities that are nurses are licensed to initiate e.g.: back care, catherization, counseling, health teaching, emotional support etc.
• Dependent interventions: activities carried out under physicians order eg: medication, diagnostic procedure etc. 
• Collaborative interventions: activities carried out in collaboration with other health team members such as: physiotherapy, nutrition therapy etc.

After choosing appropriate nursing interventions the nurse writes those on the plan on nursing orders. Choosing suitable nursing interventions involves critical thinking and your ability to be competent in three areas:

• Knowing the scientific rationale for the intervention
• Possessing the necessary psychomotor and interpersonal skills
• Being able to function within a particular setting to use the available health care resources effectively.

Components of nursing order 

Implementation

The fourth step in the nursing process is this. officially starts once the nurse creates a plan of care based on a precise and pertinent nursing diagnosis. The nurse then launches interventions that are intended to achieve the targets and anticipated results required to maintain or enhance the patients' health state. A nursing intervention is any procedure carried out by a nurse to improve patient outcomes that is supported by clinical judgment and expertise. The stated goal is what implementation tries to achieve. In order to ensure continuity of care for the patient during hospitalization and in the lead-up to discharge, nursing care is provided in accordance with the care plan.The solutions a nurse employs should ideally be evidence-based, offering the most recent, cutting-edge, and efficient techniques to managing patient concerns. Implementation may take hours, days, weeks, or even months to complete. Before, during, and after interventions, the nurse must continue to evaluate the client's condition. The nurse receives baseline information from the assessment before the intervention. The nurse can gauge the client's reaction—whether good or negative—through assessment before, during, and after the intervention. The nurse must take necessary measures if there are bad reactions while doing the procedure. If there are favorable results, the nurse enters this data into the database to assess the effectiveness of the intervention.

To carry out the intended nursing interventions, the nurse must also have psychomotor abilities, interpersonal skills, and critical thinking abilities. Even if the planning is done correctly, there are various variables that could emerge and prevent the plan from being implemented. The nurse should be adaptable when delivering the care. For instance, it could be challenging to carry out the care according to the plan if the equipment isn't ready, the doctor is on his rounds, visitors show up, or the patient experiences another emergency. Interventions consist of both direct and indirect care methods for people, families, and the community.

• Direct care: Direct care interventions are treatment performed through interactions with patients. For example, a patient receives direct intervention in the form of medication administration, insertion of intravenous infusion and counseling during a time of grief.
• Indirect care: Interventions are treatments performed away from patient but on behalf of the patient or group of patients. For example, indirect care measures include actions for managing the patient's environment eg. Safety and infection control, and documentation.

Use critical thinking to determine whether a planned intervention is still appropriate for the patient's clinical state before putting it into action. Always pause before acting. The circumstances of patients frequently vary minute by minute. You must take into account the nursing unit's activity schedule, which frequently determines when and how to conduct an intervention. Your choices regarding whether and how to intervene are influenced by a variety of circumstances. It is your responsibility to possess the knowledge and clinical proficiency required to carry out interventions for your patients in a safe and efficient manner. Following are some suggestions for making decisions during implementation:

• Review the set of all possible nursing interventions for the patient's problem.
• Review all possible consequences associated with each possible nursing action.
• Determine the probability of all possible consequences.
• Make a judgment of the value of the consequence to the patient

When implementing interventions, nurses should follow these guidelines:

• Based nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible.
• Clearly understand the order to be implemented and questions any that are not understood.
• Adapt activities to the individual client, a client's beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action.
• Implement safe care.
• Provide teaching, support and comfort to enhance the effectiveness of nursing care plans.
• Be holistic; view the client as a whole.
• Respect the dignity of the client and enhance the client's self-esteem. 
• Encourage the client to participate actively in implementing the nursing interventions. 
• Documenting Nursing Activities.

Process of Implementation 

The process of implementation normally includes:

• Assessing or reassessing the client:
  • Assessment is a continuous process that occurs each time you interact with a patient. While providing care, nurses must continue to collect data about changes in the patient's level of wellness, health problems as well as reactions, feelings and strengths. Reassessment often focuses on one primary nursing diagnosis, or one dimension of  the patient such as level of comfort, or one system such as the cardiopulmonary system. The reassessment helps to decide if the proposed nursing actions are still appropriate for the patient's level of wellness. 
• Reviewing and revising the existing nursing care plan:
  • After the reassessing the patient, review the care plan and compare assessment data to validate the nursing diagnosis and determine whether the nursing interventions remain the most appropriate for the clinical situation. If the patient's status has changed and the nursing diagnosis interventions are no longer appropriate, modify the nursing care plan. 
• Organizing resources and care delivery:
  • The resources of the facility include equipment and skilled personnel. Organization of equipment and personnel makes timely, efficient, skilled patient care possible. It is also important to prepare the environment and patient for a nursing intervention. Before performing an intervention, decide which supplies you need and determine their availability. Always place equipment in a convenient location to provide easy access during a procedure. As a nurse you are responsible for deciding whether to perform an intervention or delegate it to another member of the nursing team. When the intervention are complex or physically difficult probably need assistance from co colleagues or patients family. The patient care environment needs to be safe and conductive to implementing therapies.

Determining the nurse's need for assistance: When implementing nursing strategies, the nurse may require assistance for one of the following reasons:

• If the nurse is unable to implement the nursing strategies safely alone for one example turning an obese patient in bed.
• The nurses also need assistance if they lack the knowledge or skills to implement any particular nursing activity.

Implementing nursing intervention:

To assist the client in achieving his or her health goals, nursing strategies are put into practice. Nursing tasks can be performed independently, with another person, or in a group. Implementing nursing strategies should take into account the following:

• The client in individual.
• The client's need for involvement.
• Prevention of complication.
• Preservation of the body defenses.
• Provision of comfort and support to the patient 
• Accurate and careful implementation of all nursing activities.

Documenting nursing activities:

Nursing action plans and care guidelines are frequently presented verbally as well as in writing. By documenting the interventions and the client's reactions in the nurse's notes, the nurse completes the implementing phase. The senior nurse or the doctor may want to stay up to speed with verbal reports regarding the patient when their health is changing quickly. At the conclusion of the shift, the nurse may enter recurring or routine tasks in the client's record. In nursing, immediate recording is crucial.

Evaluation

The fifth step in the nursing process is evaluation. Based on the client's behavioral responses, nursing care effectiveness is assessed in relation to the client's goals. It's a continuous process. The nurse conducts an assessment to establish whether the objectives for the patient's wellbeing have been fulfilled after all nursing interventions have been carried out. In order to make wise decisions at subsequent stages of the nursing process, nurses regularly examine data. The care plan must be continually assessed for both the patient's condition and the nursing staff's efficacy. It is a crucial part of discharge planning because it enables the nurse to consult with patients and families to determine whether more medical attention is required, and then to make the appropriate referrals.

Purposes

The purposes of evaluation as described by the Open University publication (1984) are:

• To determine whether patient's goals/expected outcomes have been achieved.
• To measure standards of nursing care.
• To measure the quality of nursing care.
• To discover which nursing actions are most consistently effective in solving a particular patient problem.
• To measure staff performance.

Process of evaluating client responses

• Collecting data related to the desired outcomes.
• Compering the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying or terminating the nursing care plan.

The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilized, and patient's condition deteriorated, died, or discharged. It involves determining whether client's goals have been met, partially met or not met.

• Goal met: if the patient is able to demonstrate the behavior within the date and time specified in the goal statement, the goal is met 
• Goal partially met: if the patient is able to demonstrate the behavior but not at the extent the nurse had specified in the goal statement, the goal is partially met.
• Goal not met: if patient is unable or unwilling to perform the behavior at all, the goal is not met.

If the goal has been met, the nurse must then decide whether nursing activities will cease or continue in order for the client's status to be maintained. If the goal has been partially met or not been met, the nurse must reassess the situation. for example:

Goal- Pain will be relieved within 1/2 an hour after administration of pain relieving medicine.

Evaluation- Done after 1/2 an hour of administration of pain relieving medicine.

• Pain was relieved - Goal was achieved.
• Pain was slightly reduced - Goal was partially achieved. 
• Pain was not at all reduced - Goal was not achieved.

Data are collected to determine why the goal has not been achieved and what modifications to the plan of care are necessary. There are a number of possible reasons that goals are not met or are only partially met, including.

• The initial assessment data were incomplete.
• The goals and expected outcomes were unrealistic.
• The time frame was too optimistic.
• The goals and nursing interventions planned were not appropriate for the specific clients.

Nursing Care Plan

A nursing care plan is a documented plan or directive for nursing action (activities), developed in response to an evaluation of changes in the patient's health status. Priorities, goals, planning, nursing interventions, reasoning, and evaluation are all included in the nursing diagnosis. The final step of the planning phase is the creation of the nursing care plan. The full care plan serves as a blueprint for nursing action, offering guidance for carrying it out and a framework for assessing the client's reaction to nursing action.

Purpose of the Written Care Plan

• Care plans provide direction for individualized care of the client. A care plan flows from each patient's unique list of diagnoses and should be organized by the individual's specific needs.
• Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient's needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.
• Care plans help keep documentation. The care plan should specifically outline which Pre observations to make, what nursing actions to carry out, and what instructions the client or Poss family members require.
• They serve as a guide for assigning staff to care for the client. There may be aspects of the 01 patient's care that need to be assigned to team members with specific skills.
• Care plans serve as a guide for reimbursement. Medicare and medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.

Guidelines for writing Nursing care plans

• Date and signature should be mention.
• Use category headings assessment, nursing diagnosis, planning, implementation and evaluation.
• Use standardized medical symbols and key words rather than complete sentence complete sentence to communicate ideas e.g. BD, HS, SOS etc.
• Prioritize nursing diagnosis
• Be specific in action.
• Include collaborative and cooperative activities in the plan.

Example of Nursing Care Plan

Patient's identification                                  Student's identification

Name of Patient:                                          Student's Name:

Age:                                                             Year:

Sex:                                                              Clinical Area:

Date of admission:                                       Date of Nursing Care Plan began:

Diagnosis: Encephalitis                                Date of Nursing Care Plan evaluated:

Bed No.:

Patient's assessment

16 years, Mr. Ram was admitted in medical ward yesterday with the two days history of unconsciousness. Now he is still unconscious. Can't move his body himself, smelly secretion + + in mouth, oral care has not given for 3 days. Intravenous fluids 5%, dextrose 8 hourly going on, can't eat himself, has not passed stool for 3 days, decrease bowel sound on auscultation, temperature 39°C, dirty body and hair.

Patient's health problems

• Temperature 39°C
• Can't turn his body himself
• Smelly secretion + in mouth
• Can't eat himself
• Constipation
• Dirty body and hair

Actual nursing diagnosis

• Alteration in body temperature, 390c related to inflammation of brain tissue.
• Poor oral hygiene related to inability to take care himself.
• Poor personal hygiene: dirty hair and body related to inability to take care himself.
• Alteration in elimination: constipation related to immobility.

Potential nursing diagnosis

• Risk of nutritional deficit related to lack of intake.
• Risk of pressure sore related to immobility.
• Risk of oral infection related to lack of oral care.
• Risk of urinary tract infection related to indwelling catheter.
• Risk of joint contracture related to immobility of joints.

Pre and post-operative nursing care plan

Possible pre-operative nursing diagnosis

• Fear related to surgery/unknown cause. 
• Anxiety related to knowledge deficit/effect of surgery on ability to function.
• Post-operative nursing diagnosis.
• Ineffective airway clearance related to anaesthesia.
• Ineffective breathing pattern related to pain, general anaesthesia and decreased energy.
• Pain related to surgical incision.
• Hypothermia related to exposure to cool environment.
• High risk for altered urinary elimination related to decrease bladder tone secondary to effect of general anesthesia.
• Potential for wound infection related to surgical incision.
• Risk of chest infection related to anesthesia and immobility.
• Potential for constipation related to surgical manipulation of intestine, pain medication and immobility.
• Potential altered nutrition: less than body requirements related to nausea and diminished peristalsis.
• Knowledge deficit follow-up care and home care related to change in health status

Method of Physical Examination

Equipment Required for the Physical Examination

• Screen
• Weight machine.
• Top sheet/ blanket to cover the patient during examination.
• Dress for patient
• A tray containing
  • Paper bag with cotton swab
  • Vitals sign tray including Sphygmomanometer, Stethoscope, Thermometer and Tape measure
  • Flashlight
  • Lubricating jelly
  • Oto-ophthalmoscope
  • Tissues
  • Paper towels
  • Tongue depressors
  • Pocket eye chart
  • Tuning fork (128 Hz)
  • Rectal gloves
  • Reflex hammer

Procedure for Doing a Physical Examination

• Explaining the purposes and procedure for physical examination.
• Wash hands
• Prepare the patient for physical examination.
• Take clinical measurements like height, weight and vital signs.
• Tell the patient how long the examination will take.
• Asking him to urinate.
• Arranging for a quiet, private area for assessment.
• Asking the patient to remove his clothes and giving him a drape to cover.
• Inspect the patient's general appearance.
• Assess the physical status of the patient in a systematic way by using various methods of physical examination.
• After completing the physical examination, allow the patient to put on his clothes.
• Wash hands.
• Explain the findings to the patient.
• Record the relevant findings of physical examination on the patient's assessment form.

Positioning

• Have the client seated as you begin the examination
• If the client is unable to sit, use fowler's or semi flower's position.

Steps of Doing a Physical Examination

• Measurement:
  • Take Height, weight and vital signs.
• General appearance:
  • Use inspection and observe the behaviour

• Skin:
  • Use inspection and palpation. Start from the head then proceed down the body to the soles of the feet.

• Lymph nodes:
  • Use inspection and palpation

• Head:
  • Use inspection and palpation

• Sinuses:
  • Use inspection and palpation

Examination	normal data	abnormal data
Palpate the sinuses Palpate for frontal sinuses tenderness by pressing up from under the bony brow on each side. Avoid pressure on the eyes. Then press up on each maxillary sinus.	No tenderness in frontal and maxillary sinuses	Local tenderness, together with symptoms such as pain, fever, and nasal discharge, suggest acute sinusitis involving the frontal or maxillary sinuses.
the Transillumination of the sinuses -Transillumination is not routine, it is often helpful when sinus tenderness or other symptoms suggest sinusitis. The room should be thoroughly darkened. Using a strong, narrow light place the light source, place snugly deep under each brow, close to the nose. Shield the light with your hand. Look for a dim red glow as light is transmitted through the air-filled frontal sinus to the forehead.		Absence of glow on one or both sides suggests a thickened mucosa or secretions in the frontal sinus, but it may also result from developmental absence of one or both sinuses.
Ask the patient to open the mouth wide and tilt the head back. [An upper denture should first be removed.] Shine the light downward from just below the inner aspect of each eye. Look through the open mouth at the hard palate. A reddish glow indicates a normal air- filled maxillary sinus.

• Eye:
  • Use inspection and palpation

Look for weakness or imbalance of the extra-ocular muscles

To assess the extra-ocular movements, stand or sit 3 to 6 feet in front of the patient. Ask the patient to follow your finger or pencil as you sweep through six cardinal directions of gaze. Making a wide H in the air leads the patient's gaze.

• Extreme right.
• To the right and upward.
• Down a right.
• To the extreme left.
• To the left and upward.
• Down on the left.

Asymmetry of the corneal reflection indicates a deviation from normal ocular alignment which may be caused by muscle weakness.

Inspect for normal conjugate or parallel, movements of the eyes in each direction, or any deviation from normal.

Convergence test

Ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose. Note convergence of the eyes. This is normally sustained to within 5 cm to 8 cm. Poor convergence in hyperthyroidism

Cover test

A cover test may bring out a latent muscle imbalance not otherwise seen.

Testing vision

Visual acuity is a test of central vision. If possible use a snellen eye chart and light it well. Position the patient 20 feet from the chart. Patients who use glasses other than reading glasses should wear them. Ask the patient to cover one eye with a card and to read the smallest line of print possible. Record the smallest line the patient read successfully. Normal finding is 6/6. Unexpected loss of acuity is a sign of serious ocular pathology.

Visual fields by confrontation

It is rough clinical test of peripheral vision. This procedure is usually omitted in a routine examination but should be included whenever a neurological problem is suspected.

Method

Ask the patient to cover one eye without pressing on it, and to look at your eye directly opposite. Close your other eye. Slowly bring a pencil or other small test object from the periphery into the field of vision from the 8 direction and ask the patient to say 'now' as soon as it appears. During most of this examination keep the test object equidistant between your eye and the patient's so that you can compare the patient's visual field your own. Repeat with the other eye.

• Ear:
  • Use inspection and palpation

Test for lateralization (Weber test): Place the base of the lightly vibrating tuning fork firmly on top of the patient's head or on the mid-forehead. Ask where the patient hears it: on one or both sides. Normally the sound is heard in the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly on the head.

Compare air (AC) and bone conduction (BC) (Rinne test): Place the base of lightly vibrating tuning forks on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the forks close to the ear canal and ascertain whether the sound can be heard again. Here "U" of the forks should face forward, thus maximizing its sound for the patient. Normally the sound is heard longer through air than through bone (AC>BC).

Weber test                                                                   Rinne

Voice test: whispered is a high frequency sound and is used to detect high tone loss. Test one ear at a time.

• Nose:
  • Use inspection and palpation

• Mouth and Throat
  • Use inspection and palpation and smelling

• Neck use inspection and palpation

• Chest and Lungs:
  • Use inspection, palpation,percussion and ausculation

• Heart:
• Use inspection and auscultation

Male Breast: A firm dise of glandular enlargement in a male in called gynecomastia

• Abdomen:
  • Use inspection, ausculation, percussion and palpation

• Anus:
  • Use inspection

• Male genitals:
  • Use inspection, palpation

• Female genitals:
  • Use inspection

• Muscular-Skeletal System:
  • Use inspection and palpation

• Nervous System:
  • Use inspection and palpation

• Reflexes
  • Biceps reflex (C5-C6)
    • Partially flex the patient's arm at the elbow, and rest the forearm over the thighs placing the palm of the hand down.
    • Place the thumb of your non- dominant hand horizontally over the biceps' tendon.
    • Deliver a blow (slight downward thrust) with the percussion hammer to your thumb.
    • Observe the normal slight flexion of the elbow and feel the biceps contraction through your thumb.
  • Triceps reflex (C7-C8)
    • Flex the patient's arm at the elbow, and support it in the plan of your non-dominant hand.
    • Palpate the triceps tendon about 2-5cm above the elbow.
    • Deliver a blow with the percussion hammer directly to the tendon.
    • Observe the normal slight extension of the elbow.
  • Brachioradialis reflex (C3-C6)
    • Rest the patient's arm in a relaxed position on your forearm or on the client's own leg.
    • Deliver a blow with the percussion hammer directly on the redius 2-5 cm above the wrist (the bony prominence on the thumb side of the wrist. *
    • Observe the normal flexion and supination on the forearm. The fingers of the hand may also extend slightly.
  • Planter reflex (L2-L4)
    •  Ask the patients to sit on the edge of the examining table so that the legs hang free.
    • Locate the patellar tendon directly below the patella.
    • Deliver a blow with the percussion hammer directly to the tendon.
    • Observe the normal extension or kicking out of the leg as the quadriceps' muscle contract.
  • Achilles reflex (ankle jerk) (S1-S2)
    • With the patient in the same position as for the planter reflex, slightly dorsiflex the client's ankle by supporting the foot lightly in the hand.
    • Deliver a blow with the percussion hammer directly to the Achilies tendon just above the heel.
    • Observe and feel the normal planter flexion of the foot.
  • Planter reflex or babinski reflex (L4-S1)
    • It may be absent in the adults without pathology or overridden by voluntary control.
    • Use a moderately sharp object e.g. key, dull end of pin, the handle of the percussion hammer.
    • Stroke the lateral border of the sole of the patient's foot, starting at the heel, continuing towards the big toe.
    • Observe the response normally all five toes bend downward; this reaction is negative babinski. In the abnormal babinski response, the toe spread outward and the big toe moves upward.

After completing procedure

• Allow the patient to put on clothes and manage.
• Explain the relevant findings to the patient.
• Replace the articles and perform hand washing.
• Record and report the important findings of physical examination.