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HEALTH ASSESSMENT

 History taking ASSESSMENT NURSE’S ROLE


 Physical examination  Accurate and holistic  Data collector
 Psycho-social  FIRST and most critical step of the nursing process and accuracy of
 Objective and subjective
Assessment assessment data affects all other phases of the nursing process.
data to determine client’s
 Interpretation of  Gathering of information about a patient’s physiological, psychological,
overall level of
laboratory findings sociocultural, developmental and spiritual status.
functioning in order to
make a professional

TYPES OF ASSESSMENT
clinical judgement.

4. INITIAL 3. ONGOING/ PARTIAL 2. FOCUSED/ PROBLEM- 1. EMERGENCY


COMPREHENSIVE ASSESSMENT BASED ASSESSMENT ASSESSMENT
ASSESSMENT  After initial  Thorough assessment of  Very rapid assessment
 Client’s perception of comprehensive a PARTICULAR client performed in life-
ALL body parts assessment problem and does not threatening situations
 Past health hx, family hx,  Problems initially cover areas not related (e.g. choking, drowning)
lifestyle & health detected are reassessed to the problem  Immediate diagnosis is
practices in less-depth to  Referral to a specialist needed to provide
 Objective data during a determine any major  Ex. Specialist does this prompt treatment.
step-by-step physical changes from the kind of assessment like  Ex. Assessment of
examination baseline data. ophthalmologist or if the ABC’s (Airway,
 FIRST COMPLETE  Ex. Next nurse to handle patient who have a Breathing, Circulation)
ASSESSMENT the patient does this kind particular problem, the
 When: every time nurse of assessment. nurse tries to assess
receives a patient/ more specifically to that
admission of patient area thus being focused
 Purpose: to establish or problem based
baseline data assessment.
FOUR MAJOR STEPS OF HEALTH ASSESSMENT
1. COLLECTION OF 2. COLLECTION OF 3. VALIDATION OF DATA 4. DOCUMENTATION OF
SUBJECTIVE DATA OBJECTIVE DATA DATA
 Process of confirming/
 Data personal info that  Directly obtained by verifying that the  Primary Reason
can be elicited and nurse examiner subjective data &  Provide the HC
verified only by the client.  Includes data: objective data you have team with a
(sensations/symptoms, a. Directly obtained by gathered are reliable & database that
feelings, perceptions, the nurse/examiner accurate as well as becomes the
desires, preferences, through observation complete. foundation of care
beliefs, ideas, values) & P.E  Methods for the client.
 Method: client interview b. Observed by family  Recheck your  Helps to identify
 Major Areas or SOs about the own data health problems,
 Biographical info client  Clarify data with formulate nursing
 Physical c. Client’s health record the client (ask diagnosis & plan
symptoms related  Major Areas additional
to each body part  Physical questions)
or system characteristics  Verify with
 Past health (e.g. skin color) another HC
history  Body functions  Compare
 Family history (e.g. HR, RR)
 Health& lifestyle  Appearance
practices  Behaviour
 Measurements
(e.g. Ht, Wt.)
 Laboratory
Results
CRITICAL THINKING IN
HEALTH ASSESSMENT
PREPARING FOR THE ASSESSMENT
CRITICAL THINKING
 Gather information before actually meeting the client – biographical data
 Purposeful mental activity (problem-solving &
(age, sex, religion, occupation & important documentation)
decision making) that guides beliefs & actions.
 Keep an open mind & avoid premature judgement that may alter your ability
 ‘Thinking about your thinking while you’re thinking in
to obtain accurate data.
order to make your thinking better’
 Educate yourself about client’s medical diagnosis
 Is self-DIRECTED, self-DISCIPLINED, self-
 Obtain & organize materials needed for assessment. MONITORED, & self-CORRECTIVE THINKING
 Creative thinking- is a MAJOR COMPONENT of
critical thinking
 Goal directed thinking that leads to better solutions by
EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT using new ideas/ methods.

1. PAST
 Assessment integral part of nursing even since the days of Nightingale
 Nurses relied on their natural senses UNIVERSAL INTELLECTUAL STANDARDS
2. PRESENT
 Role of nurses in health assessment more prevalent today
OF CRITICAL THINKING
 Depth & scope of nursing assessment has expanded 1. Clarity 2. Relevance
3. FUTURE
 Increased specialization & diversity of assessment skills
3. Accuracy 4. Breadth
 Nurses’ roles to vastly grow with nurses who have strong assessment 5. Precision 6. Depth
& client teaching abilities. 7. Fairness 8. Logic
[CRAB PDF L]
CLARITY RELEVANCE
 ‘Could you elaborate further?’  ‘How is that connected to the question?’
‘Could you express that point in another  ‘Is the diarrhoea related to the patient’s
way?’ complaint of being tired?’
‘Could you give me an example?’

BREADTH (Generalizing)
ACCURACY  ‘Do we need to consider another point of
 ‘Is that really true?’ view?’
 ‘How could we find out if that is true?  ‘Is there another way to look at this
question?’

PRECISION DEPTH
 ‘How does you answer address the
 ‘Could you give me more details?’
complexities in the question?’
 ‘Could you be more specific?’
‘Is that dealing with the most significant
factors?’

FAIRNESS
LOGIC
 ‘Do I have a vested interest in this issue?’
 ‘Does this really make sense?’
 ‘Am I sympathetically representing
 ‘Does that follow what you said?’
viewpoints of others?’
THE CLIENT IN CONTEXT: CULTURE,
SPIRITUALITY, FAMILY & COMMUNITY
CONTEXT & HEALTH
ACCULTURATION
 Health Assessment involves assessment of the individual as
a whole.  The process where people adapt to or borrow traits from
 The individual is part of a CULTURAL context, FAMILY another culture.
context, SPIRITUAL context & a COMMUNITY context, all of
which affect the client’s health status. CULTURE SHOCK
 A disorder that occurs in response to transition from one
CULTURE cultural setting to another.
 Totality of socially transmissible behavioural patterns, arts,
beliefs, values, customs, lifeways. ETHNOCENTRISM
 The tendency to view your own way of culture as the most
SUBCULTURE desirable, acceptable, or best, and to act in a superior manner
 Composed of people who have a distinct identity & yet are toward other cultures.
related to a larger cultural group.
CULTURAL IMPOSITION
RACE  The tendency to impose your beliefs, values, & patterns of
 Classification of people according to shared biologic behaviour on individuals from another culture.
characteristics, genetic markers or features.

CHARACTERISTICS OF CULTURE
LEARNED SHARED ADAPTED UNIVERSAL
Transmitted from generation to By all As environmental ALL HUMANS HAVE
generation; learned through life members of the circumstances change, the CULTURE.
experiences within one’s cultural group group changes to improve its
group. ability to survive.
THE ROLE OF CULTURE IN ILLNESS
CULTURE-BOUND SYNDROMES MIDDLE EASTERN
 Are culturally-defined conditions which may have no equivalent
 Men & women do not shake hands, touch each other or go
from a biomedical/scientific perspective.
together in public, unless they are married/belong to same
 EX. Empacho – Hispanic ; Panuhot – Cebuano immediate family.
 Physically robust person considered healthy
 Culture is male-dominated
CHINESE  Health care provider should only be of the same sex
 Eye contact may be considered disrespectful  Culture is highly influenced by Islamic religion
 Hesitant to ask questions; nodding may not mean agreement  CBS: ‘ZAR’ (apathy & withdrawal believed to be caused by spirit
 Respect elders & authority figures possession) [MULTIPLE IDENTITY DISORDER]
 The word ‘no’ may be interpreted as disrespectful for others
 Touching unacceptable with members of opposite sex
 Female patient – female nurse HISPANIC AMERICAN
 Family involvement is preferred  Tend to be verbally expressive, yet values confidentiality
 Health beliefs: Illness is an imbalance between yin (cold/low (sensitive to open discussions regarding sex)
caloric food) and yang (hot/high caloric food like meat)  Believes illness to be caused either by the supernatural, as a
 Health practices: punishment from God / as an imbalance between the
 Acupuncture CALIENTE (HOT) & FRIOS (COLD) – similar to yin and yang.
 Medicinal herbs  Health practices:
 Ventosa  When ill, first seeks advice from older women in family
 Acupressure/massage  Then goes to either an JERBERO (HERBS HEALER) or
CURANDERO (HOLISTIC HEALER)
 If no relief, may go to physician
KOREAN  CBS:
 Similar cultural characteristics with the Chinese  MAL OJO ‘EVIL EYE’
 Touching someone’s head is considered disrespectful.  EMPACHO ‘BALL OF FOOD’
 CBS: ‘HWA-BYUNG’ ( a mental illness common in married;  SUSTO ‘SOUL LOSS’ following extreme flight
middle-aged woman, triggered by life crises) [SOMATIC  CAIDA DELA MOLLERA (‘depressed fontanelle’ due to
DISORDER] improper handling of infant)
AFRICAN AMERICAN DOs & DONTs FOR
 Menstruation is believed to rid the body of dirt & excess
blood CULTURAL ENCOUNTERS
 Have rich tradition of herbal remedies
 CBS: DOs
 VOODOO ILLNESS ( as a result of witchcraft)  Become sensitive to nonverbal cues & communication
 FALLING OUT ( sudden collapse, fainting/blacking out;  Engage in many direct cultural encounters
normal reaction)  Appreciate differences, but build on similarities

FILIPINO DONTs
 Need to engage in ‘small talk’ before discussing more serious  Stereotyping
matters
 Personalizing all perceived negative communication
 Respect the elderly & people older than you
 Judging others based on your personal values & rules
 Sex & socioeconomic status too personal to discuss
 Expressing pain/ crying is a sign of weakness (especially
among males)
 Cultural Beliefs: Believes that illness may be caused by evil
SPIRITUALITY RELIGION
spirits; may see folk/ faith healers.  A search for meaning &  Refers to rituals, practices, &
 Health Practices: purpose in life, which seeks experiences involving a
 FLUSHING (stimulating perspiration) to understand life’s search for the sacred that
 PROTECTION (use of amulet, religious medals, pictures, questions in relation to the are shared within a group.
statues) sacred.  Each religion has different
 CBS:  SPIRITUAL ASSESSMENT views on health & illness
 ‘PANUHOT’ ‘NABUYAGAN’ ‘PASMO’ ‘KABUHI’ – will help the nurse address  Formal, organized,
‘BARANG’ client’s spiritual needs to ritualistic & group-
maintain well-being. oriented
 Informal, Non-organized,
CULTURAL COMPETENCE Self-reflection &
experienced
 Refers to an ability to interact effectively with people of
different cultures.
BUDDHISM CHRISTIANITY
 Prayer & meditation are used for cleansing & healing  Jesus Christ is the saviour & miracles can happen through
 Death is associated with rebirth into another form prayers.
(reincarnation)  Extreme unction for the dying
 Many are strict vegetarian  Emergency Baptism for dying/dead newborns.

HINDUISM JUDAISM
 Restrictions related to work on holy days are removed to save
 Illness is a result of past & current life actions (KARMA)
a life [PIKUACH NEFESH]
 The RIGHT HAND – holy; thus, eating & interventions needs to
 Psalms & last prayer of confession (vidui) are held at bedside
be with the right hand to promote clean healing
 At death, arms are not crossed & any clothing/bandages
 Many but not all are vegetarians
should be buried with the person
 NO BEEF
 DIET: No mixing of meat & dairy; KOSHER LAWS include
special slaughter & food handling; unleavened bread only
during PASSOVER WEEK
ISLAM
 Prayer occurs 5 times/ day; at dawn/sunrise, noon, afternoon,
sunset & evening JEHOVAH’S WITNESSES
 Prayers are done facing the EAST on a rug; it is preceded by  Prohibits consumption, storage & transfusion of blood
WASHING HANDS & FEET
 Ladies are not to view men other that their husbands, naked
 All outcomes in life are seen as predetermined by ALLAH
 It is important for dying clients to face EAST & die facing EAST CHURCH OF JESUS CHRIST OF LATTER –
 Consumption of PORK & ALCOHOL is prohibited DAY SAINTS (Mormons) & SEVENTH DAY
 RAMADAN: month of fasting; refraining from eating, drinking,
having sex, & indulging in anything in excess/ ill-natured from ADVENTIST
dawn until sunset.  Prohibits alcohol, coffee, tea & tobacco/smoking
FAMILY COMMUNITY
 Consist of individuals you consider to be your significant  Geopolitical communities determined by natural boundaries
others  Organized based on the relationship between people
 Role of family in illness: the family’s belief about health,  Role of family in illness: communities affect the emotional &
illness & related behaviours & the meaning of health & physical health of individuals & families.
illness have for the family tend to affect each member’s
behaviour.
 Family assessment is IMPORTANT.

2: NURSING DATA COLLECTION,


& ANALYSIS
FACTORS INFLUENCING THE INTERVIEW
1. Approach
A. Interview
2. Environment
B. Collecting Subjective Data
3. Confidentiality
C. Collecting Objective Data
4. Note-taking
D. Validation of Data
5. Time, Length & Duration
E. Documentation of Data
6. Biases & Preconceptions
[AEC-NTB]

NURSING INTERVIEW STAGES OF THE INTERVIEW


 PURPOSEFUL, TIME-LIMITED verbal
interaction between the nurse & the STAGE I (Introductory Stage)
patient/ his/ her significant other
 Done to collect subjective data about the
STAGE II (Working Stage)
patient STAGE III (Termination Stage)
FACTORS INFLUENCING THE INTERVIEW
APPROACH Process
 gather all appropriate information before  Check the biographical data
approaching the patient  Approach patient
 begin by introducing your name & title  Introduce yourself
 Initially, call the patient by his/ her  Ask patient’s name & ask how should you address him/her
formal name & ask how the patient to be  State your purpose
addressed.  State the confidentiality clause
!!! For suicidal patients: ask patient where, when, how, who. Nurses have
ENVIRONMENT the DUTY TO WARN!!!
 Has direct influence on the amount &
quality of information gathered
 Ideal setting for interview: Private room,
NOTE-TAKING TIME, LENGTH, & DURATION
less distractions/ interruptions, &
 Advisable but may cause patient
increase comfort level for the patient.  Interview times should be least
discomfort
disruptive to patient’s daily routine &
 Explain the necessity of jotting
try to accommodate patient’s request.
down pertinent information
CONFIDENTIALITY  Show to patient the form you will
be using
 Essential in developing trust
 Pay attention to patient & defer
 Verbal assurance of confidentiality often
recording if patient discusses
BIASES & PRECONCEPTION
eases the patient’s concerns
sensitive issues  Be sensitive to personal as well as
 Reasons for sharing confidential
 Jot down phrases, words & dates patient contexts in order to treat all
information
that can be used. patients fairly & respectfully
 Patient poses danger to self/
 Ask permission sa patient if it’s fine  Avoid faulty assumptions by continually
others
if dli then don’t, listen nalang. validating information & personal
 Institutional Policy (inform the
Nurses adjust. impressions (use effective interview
patient prior when the info should
techniques)
be shared)
FACTORS AFFECTING
THE INTERVIEW
ACTIVE LISTENING
 GOAL: decode the patient’s messages in order to understand the situation/
STAGES OF THE problem as the other person sees it.
 Always pay particular attention & formulate an appropriate response
INTERVIEW  feedback

STAGE I (Introductory Stage)


NONVERBAL CUES
 The nurse & patient establish trust &
get to know each other.  Communicating a message without words
 May include: body position, nervous repetitive movements of the hands/ legs,
rapid blinking, lack of eye contact, yawning, fidgeting, excessive smiling/frowning,
STAGE II (Working Stage) repetitive clearing of the throat, etc.

 Bulk of the patient data is collected


DISTANCE/ PROXEMICS PERSONAL SPACE
 The amount of space a person  the space over which the person
STAGE III (Termination Stage) considers appropriate for claims ownership (e.g. pt’s
interaction is a significant factor hospital room & bathroom)
 Information is summarized & validated
in the interview process & is  Pt may be protective over this
 during this stage, give the pt an
determined in part by cultural space & consider unauthorized
indication of the amount of time left
influences use of it as an invasion of privacy.
a. Intimate zone
b. Personal (18 inches – 4 ft.)
c. Social (4ft – 12ft)
d. Public (12ft – more)
EFFECTIVE INTERVIEW TECHNIQUES
USING OPEN-ENDED USING CLOSE-ENDED
QUESTIONS QUESTIONS
 If you want the client to expound,  Restrict/ regulate pt response to a
FACILITATING
explain ‘yes’, a ‘no’/ a response less than  Encourages pt to continue
 Encourages pt to provide general 3 words. talking
rather than more focused  Used to focus the interview,  Coupled with nonverbal cues-
communication. pinpoint specific areas of eye contact, nodding, & learning
 E.g. what caused you to believe concern & elicit valuable slightly forward
that you might be drinking too information quickly & efficiently  E.g. “Go on” / “Uh-huh”
much?  Can disrupt communication if  Ensures a lot of data, not limited
 Validating the right patient before frequently used to assessment tool
giving the drug: “May I know your  E.g. “Are you thinking of hurting
name Sir?” yourself?”
RESTATING
 Involves repeating/ rephrasing
the main idea expressed by the
USING SILENCE MAKING OBSERVATIONS patient & lets the patient know
 Helps structure & pace the that you are paying attention.
 The nurse verbalizes perceptions  Pt: I don’t sleep well anymore. I
interview, convey respect &
about the patient’s behaviour, find myself waking up frequently at
acceptance, & prompt additional
then shares them with the night
patient data
patient. N: Do u have difficulty sleeping
 On the part of the patient, may
 E.g. “Speaking about those
convey anxiety, confusion, or
symptoms seems to make you
embarrassment.
tense. I notice that you are
clenching your fists & grimacing”
EFFECTIVE INTERVIEW TECHNIQUES
REFLECTING INTERPRETING
 The nurse directs the pt’s own  Enables the nurse to link events
questions, feelings & ideas back to that perhaps the patient was not
the patient & provides opportunity able to piece together.
for the patient to reconsider & or CLARIFYING  Non-therapeutic: Base on your
expand on what was said.  Used by the nurse to make clear own understanding sa nurse
something the patient says or to  Therapeutic: based on prior data
SEQUENCING pinpoint something in the of the patient.
message when the patient’s
 Involves asking the patient to words & nonverbal cues do not
place a symptom, a problem, or SUMMARIZING
agree.
an event in its proper sequence.  Especially useful at the end of the
 Facilitating the conversation such health assessment interview
that occurrence of ENCOURAGING  Summarize data, tell him about
symptoms/events are pieced what you’ve gathered, verify and
COMPARISONS
together chronologically by pt. ask if there’s more
 E.g. “what specific events led you  Helps the patient to deal more
to feel overwhelmed & suicidal?” effectively with unfamiliar
situations by placing the
EXPLORING
symptoms/ problems in the  Enables the nurse to develop, in
FOCUSING (REDIRECTING)
context of something else that is more detail, a specific area of
 Allows the nurse to concentrate familiar content/ patient concern
on/ track a specific point the  E.g. “In what way was this allergy  Helps the nurse identify patterns/
patient has made. attack different from/ the same as themes in symptom
 Useful to pts with heightened your previous ones?” presentation/ in the way
anxiety & altered concentration  Assess for allergies patients handle problems/
or jumping from topic to topic health concerns.
 E.g. “Tell me more about the chest  E.g. “Tell me more about how you
pain you experience when you feel when you do not take your
begin to exercise” medication”
EFFECTIVE INTERVIEW TECHNIQUES
INFORMING
 Providing the patient with needed
PRESENTING REALITY CONFRONTING information, such as explaining the
 Typically used with psychiatric/  A verbal response the nurse nature and/or the reasons for any
confused patients, or to patients makes to some perceive necessary tests & procedures.
who exaggerate or make discrepancy/ incongruency in  Allows the nurse to help patients
grandiose statements the pt’s thoughts, feelings, become aware of all possible
 Done in a non-argumentative way, behaviour choices.
encourages patient to rethink a  Can be used to focus the pt’s
statement and perhaps modify attention on some aspect of
it. behaviour that if changed could LIMIT SETTING
 E.g. Hallucination – feeling, lead to more efficient functioning  When the patients exhibit
seeing, hearing that it is not there.  Done in a caring, empathetic inappropriate/ unacceptable
manner, rather than a critical/ behaviour
accusatory one.  Setting specific limits on
COLLABORATING inappropriate patient behaviour,
NORMALIZING like: sexually aggressive pt.,
 The nurse & patient work hostile pt., talkative pt.
together, rather than the nurse  Allows the nurse to offer  Structure  clear statement of
taking control of the interaction. appropriate reassurance that the rules set
 Pt has important knowledge & pt.’s response may be quite  Safetyfor pt, nurses, hc
information to share & common for the situation &  Consistency  applied 24 hrs.
encourages active involvement helps decrease patient’s anxiety duty
of patient in their own health care. & fear of being misunderstood.  Provide guidance by calmly,
clearly & respectfully telling the
patient what behaviour is
expected
NON-THERAPEUTIC HEARING-IMPAIRED
 Face the client
REQUESTING ON PROBING  Often lip read
EXPLANATIONS  Repeated/ persisted questioning  Hearing aid is in working order.
 Personal beliefs, feelings, of the pt about a  Minimize background noise
thoughts & behaviours & imply statement/behaviour.  Avoid speaking loudly & slowly
criticism and may make the  Prevention:  Use nonverbal cues (e.g. facial
patient feel inadequate, defensive/  Going onto the next part of expression & body movements)
angry the interview
 Why?  Asking permission to get
back to the subject SPEECH-IMPAIRED
ADVISING  Just sitting quietly until
 Ask simple questions
patient begins to speak
 Consistently telling a patient what  Allow additional tissue
 Repeat/ rephrase
to do
 Be patient
OFFERING FALSE
 Use a written format
REASSURANCE  Nurse speak directly patient
USING PROBLEMATIC
 Giving vague, simplistic
QUESTIONING TECHNIQUES responses that question the
 Posing Leading Questions patient’s judgement, devalue, and
 Interrupting the Patient block patient’s feelings & NON-ENGLISH
 Engaging in Talkativeness communicate a lack of
 Using Multiple Questions understanding & sensitivity on  Interpreter/translator
 Using Medical Jargon the part of the nurse which often  Direct questions to the patient
 Being authoritative increases pt’s anxiety.  Nurse should not assume that the
interpreter can answer questions
for the pt.
GIVING APPROVAL/ DISAPPROVAL  Does not take into account
 Telling a patient what is right/wrong is demoralizing & may limit phrases
patient’s freedom to verbalize/ behave in certain ways & hinder the
nurse’s attempts to establish rapport.
LOW LEVEL OF
UNDERSTANDING OLDER ADULT
 Requires time & patience  Avoid ELDERSPEAK
 Don’t hurry ANXIOUS & ANGRY  Schedule more than one interview
 Interview SO’s for supplemental  Require additional time for
 Let the client express emotions & questioning
info. understand the emotional outburst
 Direct questions to patient  Client is obviously angry,
 Observe nonverbal recognize & acknowledge the
communication HOSTILE
emotion
 Don’t reciprocate with anger &
hostility
UNDER THE INFLUENCE  Minimize aggression through limit-
SEXUALLY AGGRESIVE
OF ALCOHOL/ DRUGS setting refocusing
 Firm but kind and consistent  Position yourself near an easily
 Place yourself at a safe distance,  Set limits appropriately accessible exit
remain calm & provide care in a
 Do not turn your back
non-threatening manner  Watch for signs of high tension in
ILL the patient

VISUALLY-IMPAIRED  Go through the entire interview


 Collect personal data CRYING
 Look directly at the patient  Interview SO
 Avoid speaking loudly  Empathy & allow patient to cry
 Touch is important but ask  Tissues – empathy
permission first
 Use clock hours to indicate the
direction/position
COLLECTING SUBJECTIVE DATA
Health History
 A collection of information
obtained from the patient/ other
sources.  Ambulatory: pt can walk on his Correct Syntax
 PURPOSE: own In for complaints of (main
 Provide the subjective  Co-management: multiple symptoms) noted (onset)
database doctors accompanied by (associated
 Identify patient strength  Internal Med – Blue symptoms)
 Identify patient health Surgery – Red
problems, both actual and Family Med – Pink
potential Optha & ENT – orange For MAIN SYMPTOMS:
 Identify supports Pedia – yellow
Obgyne – white Describe character of s/s,
 Identify teaching needs
location [or specific body landmark] &
 Identify discharge needs
other additional landmark.
 Identify referral needs  Chief complaint – main reason pt
got admitted For ONSET:
 Character
Components of the Health Onset
Mention how many years,
months, weeks, days, hour/ minutes
History Location PTA (prior to admission)/ PTC (prior to
1. Biographical Data Duration consultation) in which main symptoms
2. Source of History Severity was 1st noted.
3. Present Health Pattern
Associated Signs & Symptoms For ASSOCIATED SYMPTOMS:
a. Chief Complaint/ Reason for
seeking care [COLDSPA] Also describe, same as main
b. History of Present Illness symptom if possible
4. Past Health History
5. Gordon’s Functional Health
Patterns
[BSPchPG]
COMMON CHIEF COMPLAINTS &
IMPORTANT DATA TO INCLUDE
FEVER In for complaints of intermittent PAIN
fever with the highest recorded body
DURATION: Remittent? Intermittent? MANNER OF OCCURRENCE:
Relapsing (Tick Borne, temperature of 39 degrees Celsius per
Sudden/Abrupt?
constant and last for days)? axilla noted 2 days PTA accompanied
Gradual/Progressive?
Constant? by loss of appetite & fatigue. No SEVERITY OF PAIN:
SEVERITY: Mild (37.5 – 38.3)? Moderate-
episode of chills noted. Mild? Discomforting?
grade (38.3 – 39.4)? High- [Pertinent negative – possible Distressing? Horrible?
grade (39.4 – 41.7)? Excruciating?
symptoms pero wala na feel sa patient]
CHARACTER OF PAIN:
COMMON ACCOMPANYING SYMPTOMS: Dull? Sharp? Stabbing? Burning?
Chills, fatigue, weakness, pain, Gnawing? Cramping?
rashes In for complaints of sudden Throbbing?
stabbing constant excruciating pain DURATION OF PAIN:
Continuous/Steady/Constant?
@ RLQ abdominal area with
Rhythmic/Periodic/Intermittent?
observed facial grimacing, profuse Brief/Momentary/Transient?
sweating (diaphoresis) & abdominal LOCATION OF PAIN:
guarding noted 3H PTA accompanied Specific Body Landmark,
by dizziness & nausea quadrant or region?
Radiating to: (specify)
COMMON CHIEF COMPLAINTS &
IMPORTANT DATA TO INCLUDE
COUGH In for complaints of severe
CHARACTER OF COUGH: dyspnea & productive cough with
Productive ‘kagalkal’? Non- yellowish, thick, copious sputum
productive ‘gahi’? Barking
noted 1 week PTA. No episode of
VOMITING
‘hutoy’? Dry? Brassy ‘metallic
cough’?
fever and coryza noted. Pt is a known CHARACTER:
SPUTUM AMOUNT: asthmatic. Projectile?
Scant? Moderate? Copious? CHARACTERISTIC OF VOMITUS:
SPUTUM ODOR: Bile-stained or greenish?
Foul-smelling? Putrid? Bloody? Brown with fecal odor?
SPUTUM COLOR: Coffee-ground? Undigested
Blood-tinged (Bloody sputum – food?
HEMOPTYSIS)? Whitish (viral QUANTITY:
infections)? Greenish/yellowish
In for complaints of vomiting q Exact amount of vomitus per
(bacterial infections)? Rust- after feeding composed previously episode?
tinged? ingested milk approximately COMMON ACCOMPANYING SYMPTOMS:
Nausea, abdominal pain,
SPUTUM CONSISTENCY: accounting ½ to 1 cup per episode
Tenacious/Thick? anorexia, weight loss, change in
noted 4 days PTC accompanied by bowel habits, excessive belching/
Thin/Watery/mucoid? Frothy? excessive crying & difficulty to
OTHER RESPIRATORY PROBLEMS: flatus, bloating/fullness,
pacify. dizziness, vertigo
Dyspnea

!!! MELANPTYSIS – black sputum, CORYZA –


colds, wheezing – asthma, laryngotracheitis –
inspiratory stridor!!!!
COMMON CHIEF COMPLAINTS &
IMPORTANT DATA TO INCLUDE
INJURIES
D I A R R H E A / LBM MASSES QUANTITY:
Single? Multiple?
CHARACTER OF STOOLS: CHARACTER: USUAL INJURIES:
Loose & water? Grossly bloody? Tender? Pulsating? Gunshot Wound? Stab wound?
Black & tarry? With pus present, Fixed/movable (mobility)? Laceration? Fractures? Burns?
copious, mucus & blood present? Soft/Hard & firm (consistency)? LOCATION:
ODOR: Well-defined/irregular shape? Mention exact body landmark
Foul-smelling? Fishy odor? SIZE: ACCOMPANYING SYMPTOMS:
QUANTITY: Exact diameter in centimetres / Frank, severe, bleeding?
Exact amount per episode? about the size of …? (Ruler in Decrease Levels of
COMMON ACCOMPANYING SYMPTOMS: cm.) consciousness (LOC)?
N&V, abdominal pain, fever, LOCATION: MECHANISM OF INJURY:
abdominal distention, Exact body landmark, region or Motor Vehicular Accident (MVA),
bloating/fullness quadrant where mass can be Falls, Occupational/industrial
seen/ palpated? accident, house fire, etc.
In for complaints of severe In for complaints of tender soft
loose watery mucoid stool with round mass about a size of a 25
fishy-odor amounting to centavo coin located @ right axilla In for complaints of excruciating
approximately ½ to 1 cup per noted 4 months PTC accompanied by pain with observed shortened left
episode noted a night PTA discomfort upon movement of right leg suspected for possible fracture
accompanied by bloating & belching. arm. due to MVA noted moments/___
No episodes of fever & abdominal PTA. No bleeding & No LOC noted.
pain noted.
OTHER CHIEF HISTORY OF PRESENT
COMPLAINTS ILLNESS
 Procedures such as blood transfusion, Expounded of CC
contemplated surgery (you may start each paragraph with ‘___PTA/PTC’ write a chronological
specify), diagnostics test & the like act of the pt’s CC & the events surrounding it until time of
[NOTE: mention medication for a certain
procedure/ simplify the s/s that led to
admission; note progression & any increase in severity
performing the said procedure] include consultations the pt had & any medications [indicate
 Labor & delivery (observe proper generic & brand name, dosage & timing] taken/ management
syntax) done by the pt to manage the chief complaint before being
admitted (also indicate if such medication/management afforded
relief - & if temporary/ permanent relief)
In for complaints of If DIAGNOSTIC TESTS were taken, mention the date it was
contemplated surgery due to taken, who ordered it & if possible, the results of such tests.
presence of myoma seen in the If you believe that the CC may be direct extension of his
ultrasound & vaginal bleeding with ongoing chronic problem, then begin the HPI with the
blood clots noted 5 years PTA. No chronic problem/ with the Past Health History, making sure
associated abdominal pain noted. to include previous hospitalization related to condition,
maintenance, medications, treatment, dx texts, etc.
COLLECTING OBJECTIVE DATA
Non-invasive Procedures
DIAGNOSTIC PROCEDURES X-RAY/ RADIOGRAPHY BARIUM SMALL BOWEL
Client’s vital signs are always No jewelry, belts FOLLOW-THROUGH
obtained before, during & after C/I: pregnancy PREPARATION: same with
a procedure. For ALL procedures, client barium swallow, but continuous
should lie still & if with injected ingestion of BaSO4
contrast media, assess IODINE X-rays are taken every 20-30
DIAGNOSTIC PROCEDURES ALLERGY. min over the next hour/ 2 until
1. NON-INVASIVE PROCEDURES the entire small bowel is
 Informed consent only when opacified.
there is injection of a contrast UPPER G.I. SERIES/
medium/ dye. BARIUM SWALLOW
LOWER G.I. SERIES/
2. INVASIVE PROCEDURES PRE-Procedure:
Always require an informed BARIUM ENEMA
 NPO – Post midnight
consent PRE-Procedure:
 Client drinks BaSO4
3. LABORATORY TESTS  1-2 days low residue diet
(causes white stool and
(fibrous diet); NPO – PM
constipation) during
 Cleansing enema then
procedure
BaSO4 enema before
POST-Procedure:
procedure
 EOF (encourage oral
POST-Procedure:
fluids)
 EOF, laxative as ordered
Non-invasive Invasive Procedures
 Blood coagulation parameters are obtained before the procedure
Procedures  Client’s vital signs are always obtained before, during & after a procedure
 Bedside @ patient’s room
ULTRASOUND ABDOMINAL
Full bladder for UTZ – KUB LUMBAR PUNCTURE or PARACENTESIS
NPO – PM for UTZ – WA SPINAL TAP Specimen: PERITONEAL FLUID
(Whole Abdomen) To diagnose meningitis or ASCITIC FLUID
Need full bladder min. prior. Get CSF PRE-procedure:
‘FETAL’ position (KNEE-  Weigh client, measure
CHEST position) during abdominal girth
COMPUTED procedure. (abdominal circumference)
TOMOGRAPHY (CT) SCAN POST-procedure: & empty bladder
Same with x-ray  FOB (Flat on Bed) for 6-8  Position: HIGH-
hrs. w/o pillow to prevent FOWLER’s (45-90
hypertension degrees)
 Local anaesthesia - POST-procedure:
MAGNETIC RESONANCE
LIDOCAINE  Weigh client & measure
IMAGING (MRI)
abdominal girth
More detailed
PRE-Procedure:
 Assess for
THORACENTESIS
PLEURAL EFFUSION – accumulation of fluid in pleural cavity
CLAUSTROPHOBIA
Client instruction:
C/I: metal objects & implants
 No talking, laughing, sneezing, coughing & deep breathing during
 Create artefacts in the
procedure
scan
 Positions: Straddling on a chair, leaning forward on an overbed table,
 Remain motionless
side-lying with HUB elevated (use pillows)
Invasive Procedures Laboratory Tests
BONE MARROW
BIOPSY LIVER BIOPSY COMPLETE BLOOD COUNT
From ILIAC CREST/ PRE-procedure: RBC (Red Blood Cell)
STERNUM  2hrs. NPO WBC (White Blood Cell) with differential
HGB (Hemoglobin)
Large bore needle used  Position:
PRE-procedure: HCT (Hematocrit)
supine
MCV (Mean Corpuscular Volume)
 Empty bladder with RUQ
MCH (Mean Corpuscular Hemoglobin)
POST-procedure: exposed
MCHC (Mean Corpuscular Hemoglobin
 Assess complications POST-procedure:
Concentration)
(bleeding and  Right side-
RDW
hematoma formation) lying with small
PLT (Platelet)
DURING procedure: opposite pillow under bx
side mo lie down site for 8 hrs.
POST procedure: on the side [strictly follow] SERUM ELECTROLYTES
mo lie down Potassium – KALEMIA
Sodium – NATREMIA
Calcium – CALCEMIA
DIRECT VISUALIZATION PROCEDURES
Magnesium – MAGNESEMIA
Endoscopy
Phosphorus - PHOSPHOTEMIA
Bronchoscopy/ Laryngoscopy
PRE-procedure:
 NPO – PM ARTERIAL BLOOD GAS
POST-procedure: From PULSE SITES
 Check GAG REFLEX Check BLOOD PH (7.35 – 7.45)
 Never let pt eat, if wala pa GAG REFLEX
VITAL SIGNS
 Provide data that reflect the status of several body systems
SPECIMEN COLLECTION
1. STOOL SPECIMEN including but not limited to the cardiovascular, neurological,
S/E of occult blood/ Guaiac Test peripheral vascular, and respiratory vascular.
For S/E – OPEH (Ova-Parasite  Sequence: TEMP  PR  RR
Entamoeba Hystolitica) – an amoebiasis TEMPERATURE PULSE
test NORMAL: 36.5 – 37.5 Shockwave produces when the
For S/E – fat analysis degrees Celsius heart pumps blood out of the
 MELENA – black tarry stool; bleeding ELDERLY: 35 – 36.4 ventricles into the aorta
upper G.I. degrees Celsius A.k.a arterial/ peripheral pulse
 HEMATOCHEZIA – fresh blood in stool; Diurnal variation: (time of the NORMAL: 60 – 100 bpm
bleeding lower G.I. day affects temperature) SITES: temporal, carotid, apical
 STEATORRHEA – fatty stool/ rich in fats - Lowest (4 – 6 a.m.) (pinaka accurate), radial, brachial,
2. URINE SPECIMEN - Highest (8 – 12 m.n) popliteal, femoral, dorsal pedis
a. Mid-stream clean catch (MSCC) ROUTES/ SITES: oral, Babies – brachial pulse; Adults –
specimen axillary, rectal, tympanic, carotid pero radial is easily
- Clean genitalia (more on bacteria rectal for newborns accessible
test)
RHYTHM
b. Timed specimen (e.g. 24H collection) RESPIRATION a. REGULAR
- Test for protein & kidney function Done without alerting the b. IRREGULAR
c. Specimen for Urine Culture & Sensitivity client by watching chest - REGULARLY IRREGULAR
- Finding what kind of bacteria; how before removing the - IRREGULARLY
sensitive antibiotic is to bacteria stethoscope after counting IRREGULAR
3. SPUTUM SPECIMEN the apical beat. AMPLITUDE
a. Random Specimen Also done by placing client’s 0 absent pulse
b. AFB (Acid Fast Bacilli) smear arm across chest while +1 weak pulse
- Test for Tuberculosis palpating radial pulse +2 normal pulse
- Mycobacterium tuberculosis NORMAL: 12 – 20 cpm +3 bounding pulse
PHYSICAL ASSESSMENT
BLOOD PRESSURE PHYSICAL EXAMINATION TECHNIQUES
Inspection, Palpation, Percussion, Auscultation
Measured on dominant arm first
In abdomen: Inspection, Auscultation, Palpation, Percussion
Taken on both arms if done on
client for the first time
NORMAL: INSPECTION PALPATION
90 – 140 mmHg (systolic) Using senses of vision, smell & Involves the use of hand to touch &
60 – 90 mmHg (diastolic) hearing to observe & detect any feel
Pulse pressure = S – D normal/ abnormal findings CDS3M2T2
-NORMAL: 30 – 50 May use special equipment (e.g. - Consistency (soft/hard/fluid filled)
-less than 30 -> pt. having shock opthalmoscope) - Degree of Tenderness
KOROTKOFF SOUNDS GUIDELINES: - Size (small/medium/large)
- Auscultatory Method - Room at comfortable - Shape (well-defined/irregular)
temperature - Strength (strong/weak/thread)
PHASE I – faint, clear, repetitive,
- Use good lighting - Moisture (dry/wet)
tapping sound (SYSTOLIC)
- Look & observe before - Mobility (fixed/movable/still/vibrating)
PHASE II – muffled/swishing - Temperature (hot/cold)
touching because doing so may
PHASE III – return of distinct sound alter appearance - Texture (rough/smooth)
- Expose the body part while PARTS OF THE HAND TO USE
PHASE IV – muffled, less distinct FOR PALPATION
draping properly
PHASE V – disappearing sound - NOTE FOR: color, patterns, 1. FINGERPADS – sensitive to the
(DIASTOLIC) size, location, consistency, discriminations (pulse, texture,
symmetry, movement, size, consistency); cremitus
Palpatory method -> SYSTOLIC
behaviour, odor, sounds 2. ULNAR/PALMAR SURFACES –
only
- Compare appearance of vibration, thrills, fremitus
symmetric body parts 3. DORSAL SURFACE –
temperature
TYPES OF PALPATION PERCUSSION
Involves tapping of body parts to produce
1. LIGHT
sound waves/ vibrations to: AUSCULTATION
- Little or no depression (1
- Elicit pain Requires the use of a stethoscope
cm.), used to feel for
- Determine location, size & shape to listen for heart sounds,
pulses, tenderness, skin
- Determine density (if organ is fluid/air- movement of blood through
texture, temperature &
filled) vessels, movement of the bowel, &
moisture
- Detect abnormal masses movement of air through the
2. MODERATE
- Elicit reflexes respiratory tract.
- 1-2 cm. depression; used
TYPES GUIDELINES:
to feel for size, consistency
1. DIRECT - Eliminate distracting noises
& mobility of masses
- Tapping body part with 1 / 2 fingertips; - Explore the body part
3. DEEP
may also use reflex hammer - Use the:
- 2.5 cm – 5 cm.
2. BLUNT  DIAPHRAGM – high-pitched
depression; used to feel for
- Placing 1 hand flat on the body surface sounds (e.g. normal heart
very deep organs covered
& using the fist of the other hand to sounds, bowel sounds,
by thick muscle; check for
strike the back of the hand flat on the breath sounds
tenderness
body surface; KIDNEY PUNCH TEST
4. BIMANUAL  BELL – low-pitched sounds
3. INDIRECT/MEDIATE
- Using 2 hands (one hand (e.g. murmurs)
- Commonly used method; detects
applies pressure & other USING THE STETHOSCOPE:
density of underlying structures
feels structure examines) - Warm diaphragm/ bell before
placing it
- Explain to client what you are
PERCUSSION TONES
listening
RESONANCE (Hollow) ----> Normal Lung
- Don’t apply too much pressure
HYPERRESONANCE -----> Lung with Emphysema
when using the bell.
TYMPANI (Drum – like) ----> Puffed-out cheek; G.I. organs
DULLNESS -----> Diaphragm, Liver, Pleural Effusion
FLATNESS -----> Muscle, Bone
VALIDATING DATA DOCUMENTATION
 DOCUMENTING DATA
 PURPOSE: confirm or verify that subjective &
- Crucial part of health assessment
objective data are reliable & accurate.
- Is required by:
 STEPS: decide if data require validation; use  Nurse Practice Act
methods/ways to validate data; identifies area of  Accreditation/
missing data Reimbursement Agencies
 DATA REQUIRING VALIDATION  Institutional Policy/
- Discrepancies between subjective & objective data Procedure
- Discrepancies in what the client says at one time  PURPOSES
then at another time - Provide chronological source of
- Abnormal/ inconsistent findings
data
 METHODS OF VALIDATION - Prevent fragmentation/repetition
- Repeat assessment - Establish basis for screening
- Clarify data with client - To help diagnose new problems
- Verify with another Health Care professional - Determine educational needs of
- Compare findings client, family & significant others
 AREAS WHERE DATA ARE - Eligibility of care & reimbursement
MISSING ARE IDENTIFIED THROUGH: - Legal record of care
- Grouping Data - Access to epidemiological data
- Establishing initial database - Compliance on legal & professional
standard requirements
 FORMS ( I F F)
 GUIDELINES 1. INITIAL ASSESSMENT FORM
- Arrives in the hospital
- Document legibly/print neatly in non-erasable ink
2. FREQUENT/ ONGOING ASSESSMENT
- Use correct grammar & spelling
FORM
- Use only abbreviations that are acceptable to and
a. Frequent Vital signs sheet (TPR every
approved by the institution serving the client
4hrs. monitoring of vital signs)
- Maintain confidentiality
b. Assessment Flow charts (I & II)
- Avoid wordiness that creates redundancy. Like for ex.
Vital signs in I&O
“gurgly bowel sounds in all abdominal quadrants
Flow sheet I – max. 2hrs.
at 36 per minute”.
Flow sheet II – hourly monitoring to 15
- Use phrases instead of sentences. Like for ex.
minutes monitoring
“bilateral lung sounds clear”
c. Nurse’s/ Progress Notes (Nursing
- Record data findings, not how they were obtained.
Diagnosis)
Like for ex. “Client is 3 years hypertensive with left
d. CFAC Sheet (Color, Frequency,
arm BP 120/80”.
Amount, Characteristic)
- Write entries objectively without making premature
3. FOCUSED/SPECIALTY AREA
judgements/diagnosis like for ex. “Client seen
crying, have not changed clothes, alone in the
room and does not talk to anyone” SHIFT
- Record the client’s understanding, the perception of 7 – 3 (6A – 2P) BLUE
problems 3 – 11 (2P – 10P) BLACK
- Avoid recording the word “normal” for normal findings 11 – 7 (10P – 6A) BLACK
- Record complete info. & details for all client symptoms/ VELEZ 4 hrs. MONITORING
experiences 2A – 6A – 10A – 2P – 6P – 10P
- Include additional assessment content when CONVERSION
applicable 1 glass = 240 ml
- Support objective data with specific observation 1 cup = 180 ml
obtained during the physical examination 1 oz. = 30 ml
GUIDELINES IN CONDUCTING HEALTH ASSESSMENT
1. Preparing Oneself PREPARING ONESELF
2. Preparing the Self-assessment
Equipment & Practice
Environment Standard precautions
3. Approaching & - HAND HYGIENE – inside patient’s room & nursing station
Preparing the  Alcohol-Based Hand rub
Client  Antimicrobial Soap Wash
4. Client Positioning 5 MOMENTS
5. Ethico-legal 1. Before touching a patient
2. Before clean/aseptic procedure
Considerations
3. After body fluid exposure risk
6. Aftercare 4. After touching a patient
7. Documentation 5. After touching patient surroundings
[ P – PACE – AD] - PPE (PERSONAL PROTECTIVE ENVIRONMENT) – contact with blood and other body fluids;
prevent contamination to body; discard before leaving the room; instituted to all patients (private
room ideal)
 GLOVES: if contact with body fluids ( except tears and sweat); non-intact skin & mucous
membranes
 GOWN: contamination of clothing & exposed skin anticipated
 MASK & GOGGLES: sprays & splashes
- WASTE MANAGEMENT
 SHARPS: disposed on puncture-proof container
 SOILED LINENS: requires proper handling GREEN – wet, non-infectious BLACK – dry,
non-infectious YELLOW – gloves, cottons
 DISINFECTION: done routinely on patient equipment & surroundings
PREPARING THE  FOR SKIN, HAIR, & NAIL
EQUIPMENT & ENVIRONMENT EXAMINATION:
1. RULER (cm. markings)
PREPARING THE EQUIPMENT 2. MAGNIFYING GLASS
- Gather necessary equipment 3. WOOD’S LIGHT
- Check if functioning
- Place in accessible area during P.E.  FOR HEAD & NECK EXAM:
(physical examination) 1. SMALL CUP OF WATER

 EQUIPMENT NEEDED FOR P.E.  FOR EYE EXAMINATION:


1. GLOVES 1. PENLIGHT – for pupillary reflex
- Assess for latex allergy prior to P.E. by 2. SNELLEN CHART (20ft. distance)
assessing if he/she is allergic to avocado, 3. OPTHALMOSCOPE
banana, apple & tomato 4. COVER CARD
DERMAPRIN- alternative to latex 5. NEWSPAPER/ ROSENBAUM POCKET
SCREENER to assist vision at near distance
 FOR VITAL SIGNS:
1. SPHYGMOMANOMETER  FOR EAR EXAMINATION:
2. STETHOSCOPE 1. OTOSCOPE
3. THERMOMETER (oral, rectal, & tympanic)
2. TUNING FORK
4. WATCH with second hand

 FOR ANTHROPOMETRIC  FOR MOUTH, THROAT, NOSE &


MEASUREMENTS: SINUS EXAMINATION:
1. PENLIGHT
1. SKINFOLD CALIPERS
2. TONGUE DEPRESSOR
2. FEXIBLE TAPE MEASURE 3. OTOSCOPE
3. PLATFORM SCALE with height attachment
 FOR THORAX, LUNGS, HEART, PREPARING THE EQUIPMENT &
NECK & VESSEL: ENVIRONMENT
1. STETHOSCOPE PREPARING THE ENVIRONMENT
2. MEASURING TAPE & PENCIL - Comfortable
3. SPHYGMOMANOMETER - Quiet
- Privacy
 FOR FEMALE GENITALIA: - Adequate Lighting (sun- ideal source of light)
1. VAGINAL SPECULUM & LUBRICANT - Firm exam table
2. SPECIMEN CONTAINER, SLIDES, - Bedside tray/table
COTTON TIP APPLICATOR
APPROACHING & PREPARING THE CLIENT
 FOR MUSCULOSKELETAL: - Establish rapport during the interview
1. GONIOMETER - Describe what the physical examination will involve
2. TAPE MEASURE - Respect the client’s desires & requests
- Obtain consent. If client asks for certain body part not to be
 FOR NEUROLOGIC EXAM: assessed, explain the importance of the examination.
1. TUNING FORK - Instruct to empty bladder (IF urine sample is not needed)
2. COTTON WISP, PAPER CLIP - Instruct patient to undress & exam to exam gown
3. SOAP, COFFEE - Assess patient for allergy to latex
4. SALT, SUGAR, LEMON, PICKLE JUICE - Stand on the right side of patient
5. TONGUE DEPRESSOR - Be systematic & use head-to-toe approach
6. REFLEX HAMMER - Always compare symmetry as applicable
7. COIN/ KEY (assess for stereognosis – the - Least invasive procedures FIRST
ability to assess objects) - Continue explaining procedure throughout P.E & integrate
health teaching & promotion as necessary.
CLIENT POSITIONING
SITTING ETHICO-LEGAL CONSIDERATIONS
- For evaluating the head, neck, lungs, chest, back, Be vigilant in nursing practice
breasts, axilla, heart, vital signs & upper extremities Establish a trusting & caring relationship with the patient
- If client is too tired/weak: lay down with head Execute nursing assessment correctly
elevated While performing each step, inform the pt. WHAT to expect,
SUPINE WHERE to expect it, & HOW it will feel.
- Difficulty breathing: Raise the head Address questions, protests & requests PRIOR to the
- Allows the abdominal muscles to relax examination
- Same areas of assessment as sitting but already Document all assessments, procedures & even injuries in
includes the lower extremities. the Nurse’s Notes
DORSAL RECUMBENT
- Areas of assessment: head, neck, chest, axillae,
lungs, heart, extremities, breast, peripheral pulses AFTERCARE
- Abdominal muscles contracted in this position Convey gratitude for the client’s cooperation
- Preferred by clients who have lower back pain & Dispose/ clean equipment
abdominal pain Document findings on designated forms
STANDING
- assess posture, balance & gait & male genitalia
PRONE DOCUMENTATION
- To assess hip joint & back Make notes as you perform the P.E; but document as
- C/I: cardiac & respiratory problems CONCISELY as possible
KNEE-CHEST DON’T document general non-descriptive/ non-
- to asses rectum measurable terms
LITHOTOMY DO use specific descriptive & measurable terms
- Feet supported by stirrups where it supports the calf
- Examine female genitalia, reproductive tract &
rectum.
GENERAL SURVEY
First step in a head-to-toe assessment  ASSESSING LEVELS OF CONSCIOUSNESS (LOC)
Provides clues about the OVER-ALL health of the GLASGOW COMA SCALE (GCS)
patients EYE OPENING RESPONSE
INCLUDES: 4 spontaneous
 Over-all impression of client 3 to speech
 Mental status (conscious/ unconscious, drowsy, 2 to pain
confused) 1 no response
 Vital signs VERBAL RESPONSE
COMPONENTS: 5 oriented to time, person & place
 General Appearance (body, symmetry, obvious 4 confused
anomaly/deformity, apparent level of wellness) 3 inappropriate words
 Client’s stated age vs. apparent age & developmental 2 incomprehensible sounds
stage 1 no response
 Dress & hygiene (acc. To occasion/ weather) MOTOR RESPONSE
 Stature, posture & gait (coordination of arms to walking) 6 obeys command
TRIPOD position – COPD 5 moves to localised pain
 Body build, muscle mass & fat distribution 4 flex to withdraw from pain
 Level of consciousness 3 abnormal flexion (decorticate)
“Client is alert & oriented to person, place, time & 2 abnormal extension (decerebrate)
events, responds to questions & interacts 1 No response
appropriately. Maintain eye contact & conversation”  Behavior, body movements, mood & affect (facial
 Obvious signs of distress (e.g. labored expression)
breathing/speech, painful facial expression, sweating)  Hygiene (odor, grooming)
SERIOUS OCCURENCES: seizures, bleeding, fracture.  Facial expression
SIGNS OF EMOTIONAL DISTRESS: tearfulness, cold  Speech (pace of patient’s talking, odor)
clammy hands, inability to pay attention
SKIN ASSESSMENT
PERFORMING THE ASSESSMENT PALPATION
1. NURSE PREPARATION - MOISTURE
Client preparation – position, privacy, proper  NORMAL: smooth, well-moist, clear, no
instruction, therapeutic communication lesions
2. PERFORM THE ASSESSMENT TECHNIQUE  Skin folds can be area of excessive moisture
CORRECTLY & SYSTEMATICALLY (Head-to-  Assess skin folds since it can be an area
toe) where microorganisms can thrive in
3. REPORT OF FINDINGS  Odors – skin folds
Able to report objectively - TEMPERATURE
Avoid “abnormal” “normal” “good”  Warmer part – reddish, swelling might mean
Document at patient’s chart a possible infection
Use COLDSPA  Colder part – bluish/pale/white might mean
poor perfusion of blood in that area; arterial
SKIN ASSESSMENT insufficiency
- TEXTURE
INSPECTION
 NORMAL: smooth
- Skin color & pigmentation
- THICKNESS
- PATIENT PREP: change to hospital gown
- Maybe from race  NORMAL: thin
- There are related to melanin production  Angiomas – visible ‘ugat-ugat’
(hyper/hypopigmentation)  Callous – fingertips, palm, soles of foot
- Note BIRTHMARKS, SKINFOLDS - MOBILITY & TURGOR
- Use GLOVES: suspected lesion on that part  POSITION: lie down supine, pinch clavicular
- Hand hygiene BEFORE & AFTER area
- Ask permission to touch  Ability of the skin to be pinched & turns back
- Inspect also for tattoos to original position
 NORMAL: intermediate recoil
SKIN ASSESSMENT SCALP & HAIR ASSESSMENT
PALPATION
 INSPECTION
- MOBILITY & TURGOR
- COLOR
If recoil < 2 sec. – moderate dehydration
Note chemically colored hair
If recoil > 2 sec. – severe dehydration
- DISTRIBUTION
If recoil > 3 sec. – tenting of the skin
 NORMAL: evenly distributed
If slower than intermediate – dehydration
 Note hair baldness/ alopecia
As age increases, recoil becomes slower
INSPECTION & PALPATION
- EDEMA (HUPONG)
- At 1 in. interval, separate the hair from the scalp
 Usually feet/legs (bipedal edema)
- Condition include cleanliness, dryness/oiliness,
 Use thumb when assessing
parasites, lesions
 Press edematose area; note pitting/indention
o PITTING EDEMA
Vascular/venous insufficiency – DVT/ NAIL ASSESSMENT
systemic problems  INSPECTION
GRADE - COLOR
+1 , +2, +3, +4 (very deep, very slow recoil,  Remove if there is nail polish
bigger area)  Indicate possible peripheral cyanosis – arterial
o NON-PITTING EDEMA insuffiency/poor blood circulation
Lymphedema  Assess Capillary refill test – gives idea of how
Blockade lymph vessels properly oxygenated peripheries are
Faster to recoil back  NORMAL: after blunching the nail, pinkish color
Problems in lymph circulation returns before 2 seconds.
PALLOR – no color - SHAPE
CYANOSIS – blue  NORMAL: Should be at least 160 degrees
PERIPHERAL – cyanosis @ extremities  If super flat nails (180 degrees) – nail clubbing sign
CENTRAL – cyanosis @ lips/ buccal mucosa of poor oxygenation of extremities, visible for
which points out possible cardiopulmonary patients with heart disease
problems.
NAIL ASSESSMENT ASSESSMENT OF EXTERNAL EYE
 INSPECTION & PALPATION STRUCTURES
- Condition includes nail grooming, & cleanliness,  INSPECTION
texture, nail markings, & nail plate attachment to nail - PALPEBRAL CONJUNCTIVAE
bed
 NORMAL: pinkish
 Upper part: use cotton buds
ASSESSMENT OF EXTERNAL EYE  Note color & presence of lesions
STRUCTURES INSPECTION & PALPATION
 INSPECTION - LACRIMAL GLANDS
- Symmetry (note symmetry of eyeballs & any  Note pain, tenderness, swelling
protrusion/ sinking)  Palpate nasolacrimal duct
- Assess external eye structures  Minimal tears are normal
 NORMAL: upper eyelid cover 2/3 in. of iris INSPECTION
- EXOPTHALMUS – associated with hyperthyroidism - CORNEA & LENS (note appearance)
eyelids are at the edge of the iris  COLOR: clear & transparent
- EYEBROWS (note color, symmetry, distribution)  CATARACT: can be removed through LASIC
- EYELIDS (note position & appearance of eyelids & surgery, replacement of lens
eyelashes, color changes & blinking) - IRIS (note shape & color)
 PTOSIS – drooping of eyelids  Dark brown/ light brown
 NORMAL: Directed outward - PUPIL (note shape, size, direct & consensual reaction to
- BULBAR CONJUCTIVE & SCLERAE (note for clarity, light & accommodation)
color, & texture)  Gives idea that cranial nerves are functioning
 NORMAL FOR SCLERA: clear, white, no foreign  DIRECT RXN – constrict with light
bodies  CONSENSUAL RXN – constrict other eye without
 Check for pink eye (conjunctivitis) light when the other eye is subjected to light
 Check for episcleritis ( reddish of sclera) - PUPILLARY GAUGE FOR MEASURING PUPIL SIZE
 PTERYGIUM – covers iris & other parts of the  Same time, size, rate of constriction
eye
ASSESSMENT OF EXTERNAL EYE ASSESSMENT OF EXTRAOCULAR
STRUCTURES MUSCLE FUNCTION
 INSPECTION  INSPECTION
- TESTING ACCOMODATION OF PUPILS - COLOR VISION – assess possible color blindness
 Pupils should be able to converge at the center using ISHIHARA PLATE
- SAMPLE DOCUMENTATION  CORRECT: 25, 45, 6
NORMAL FINDING: “Equally round about 3 mm in size,  RED & GREEN BLINDESS: 29, 56, 8
illuminated pupil constricts & pupil opposite of the one - VISUAL ACUITY – distant vision
illuminated constricts simultaneously; pupils converge  Snellen’s chart is used in 20 ft. (6 meters)
& constrict as objects moves in toward nose; pupil  Alternative: nameplate in 2-3 ft. away
response uniformly”  Snellen E chart – for people who can’t read
- VISUAL ACUITY – near vision
ASSESSMENT OF EXTRAOCULAR  Pocket snellen chart/Rosenbaum pocket card in
a distance of 14 inches
MUSCLE FUNCTION
- PERIPHERAL VISION (CONFRONTATION TEST)
 INSPECTION
 Check whole face
- CORNEAL LIGHT REFLEX TEST
- COVER TEST (4’’ x 5’’)  Regions
- OPTHALMOSCOPE
 Assess ocular muscles
 Client have no unnecessary movements while
focusing on distant objects
- CARDINAL GAZE (positions test)
6. UL 1. UR

5. FL 2. FR

4. LL 3. LR
Pt. is able to move smoothly and symmetrically