PRE-CLINICAL

INSPECTION – an assessment technique in which the

PHYSICAL ASSESSMENT
A systematic, comprehensive, continuous collection,
validation and communication of client’s data using a
variety of methods
PATIENT APPROACH DURING PHYSICAL ASSESSMENT
- When possible, begin with patient in a sitting position,
so front and back and be examined.
- Completely expose the part to be examined but drape
the rest of the body appropriately
- Conduct exam cephalocaudal
- Compare findings on both sides
- Explain all procedures to avoid alarming and encourage
cooperation
- Make the patient as comfortable as possible
PURPOSES
To obtain baseline data and expand the data base from
which subsequent phases of the nursing process can
evolve.
To identify a variety of patient problems (actual and
potential)
To identify factors placing the patient at risk and
determine the areas of preventive nursing.
To evaluate the outcome of treatment and therapy.
To enhance the nurse-patient relationship.
To make clinical judgments.
examiner observes the body surface. The nurse notes the
general body contour, posture, color of skin, presence of
rashes, scars and any external visible pathology.
PALPATION – an assessment technique in which the
examiner feels with his/ her fingers and one or both
hands. The degree of pressure applied during palpation
varies, depending on, for example, the tenderness of the
area and the depth of palpation required. Some organs
are always palpable and changes in size, shape and
location may be felt. Others are palpable only when
enlarged or displaced.
PERCUSSION – an assessment technique in which the
examiner “thumps” or “taps” a body surface with a
percussion hammer or the hand or fingers. Percussion
assesses density of a cavity or organ.
AUSCULTATION – an assessment technique in which the
examiner listens to and assesses the sound produced by
various body organs and tissues such as heart, lung or
bowel with the use of a stethoscope.
Essential Conditions for a Good Physical Examination:
Good lighting and ventilation
Full exposure of the area to be examined
Patient in a relaxed state
Grounded with ethical considerations (consent, privacy,
confidentiality, veracity and voluntarism)

EQUIPMENT: GENERAL PROCEDURE

- Explain the procedure to the patient to avoid
Stethoscope unnecessary anxiety as well as facilitate patient’s
Percussion Hammer cooperation.
Safety Pins And Cotton Swabs - Obtain patient’s consent (written or verbal) to ensure
Watch With Second Hand that patient’s right is respected.
Ophthalmoscope/Otoscope - Gather all equipment to save time and energy.
Snellen’s Chart - Wash hands to deter spread of microorganisms.
Pen Light - Don gloves when necessary to protect from infectious
Tape Measure microorganisms.
Tuning Fork - Close the curtains and doors to provide privacy.
Tongue Depressor - During interview, ask questions tactfully in a non-
Sphygmomanometer judgmental way to avoid patient’s intimidation.
Special Marking Pen - Use open-ended questions oftentimes to explore
patient’s data and history.
TECHNIQUES: - Expose only the area/s being assessed to avoid
A systematic approach to physical assessment is unnecessary exposure.
important to prevent omissions. The usual sequence of - Perform physical assessment appropriately and
assessment activities are (1) look (inspect), (2) feel efficiently.
(palpate), (3) tap or thump (percuss), and (4) listen - Communicate to the patient the result of your
(auscultate). assessment.
- Show gratitude and appreciation to patient after the
procedure.
- Do aftercare.
- Document the procedure with your assessment
findings.
- Notify the physician for any abnormalities noted to
promote collaborative management.
CONTENTS OF A PHYSICAL EXAMINATION
Assessing Appearance and Mental Status
Equipment: Tape measure
1. Explains procedure to the patient (What you are
going to do, why it is necessary, and how he/she can
cooperate).
2. Does hand washing.
3. Provides privacy. Assessment
4. Observes body built, height and weight in relation to
the patient’s age, lifestyle and health.
5. Observes the patient’s posture and gait, standing,
sitting and walking
6. Observes the patient’s overall hygiene and
grooming. Relate these to the person’s activities
prior to the assessment.
7. Notes body and breath odor.
8. Observes for signs of distress in posture or facial
expression.
9. Notes obvious signs of health and illness.
10. Assesses the patient’s attitude.
11. Notes the patient’s affect/mood and the
appropriateness of responses.
12. Listens for quality, quantity and organization of
speech.
13. Listens for relevance and organization of thoughts.
14. Documents pertinent findings in the chart.
ASSESSING THE SKIN PREPARATION
ASSESSING THE HAIR
ASSESSING THE NAILS
ASSESSING THE SKULL AND FACE
ASSESSING THE EYE STRUCTURE AND VISUAL ACUITY
ASSESSING THE EARS AND HEARING
ASSESSING THE NOSE AND SINUSES
ASSESSING THE MOUTH AND OROPHARYNX
ASSESSING THE NECK
ASSESSING THE THORAX AND LUNGS
Assemble equipment and supplies:
stethoscope
Skin marker/pencil
centimeter ruler
1. Inspect the shape and symmetry of the thorax from
the posterior and lateral views.
2. Inspect spinal alignment for deformities. Have the
client to stand from a lateral position. Observe the
standing client from the rear. Have the client bend
forward at the waist and observe from behind.
3. Palpate the posterior thorax. For clients who have no
respiratory complaints, rapidly assess the temperature
and integrity of all chest skin. For clients who do have
respiratory complaints, palpate all chest areas for bulges,
tenderness or abnormal movements. Avoid deep
palpation for painful areas especially if fractured rib is
suspected.
4. Palpate the posterior chest for respiratory excursion.
Place the palms of both hands over the lower thorax,
with your thumbs adjacent to the spine and your fingers
stretched laterally. Ask the client to take deep breath
while you observe the movement of your hands and any
lag in movement.
5. Palpate the chest for vocal (tactile) fremitus, instruct to
say 1, 2, 3. Place the palmar surfaces of your fingertips of
the ulnar aspect of your hand or closed fist on the
posterior chest starting near the apex of the lungs.
6. Ask the client to repeat such words as “blue moon” or
“one, two, three.”
7. Repeat the two steps moving your hands sequentially
to the base of the lungs.
8. Compare the fremitus on both lungs and between the
apex and the base of each lung either:
1) using one hand and moving it from one side of the
client to the corresponding area on the other side
2) using two hands that are placed simultaneously
on the corresponding areas of each side of the chest.
9. Percuss the thorax.
10. Percuss for diaphragmatic excursion.
11. Auscultate the chest using the flat disc diaphragm of
the stethoscope. Warm the diaphragm slow deep breath.
12. Uses the systematic zigzag procedure used in
percussion.
13. Ask the client to take slow, deep breaths through the
mouth. Listen at each point to the breath sounds during a
complete inspiration and expiration.
14. Compare findings at each point with the
corresponding point on the opposite side of the chest.
15. Inspect breathing patterns.
16. Inspect the costal angle and the angle at which the
ribs enter the spine.
17. Palpate the anterior chest.
18. Palpate the anterior chest for respiratory excursion.
Place the palms of both palms of your hand on the lower
thorax with your fingers laterally along the lower rib cage
and your thumbs along the costal margins. Ask the client
to take a deep breath while you observe the movement
of your hands.
19. Palpate tactile fremitus in the same manner as for the
posterior chest. If the breasts are large and cannot be
retracted adequately for palpation this part of the
examination is usually omitted.
Anterior Thorax
1. Percuss the anterior chest systematically. Begin above
the clavicles in the supraclavicular space and proceed
downward to the diaphragm.
2. Compare one side of the lung to the other.
3. Displace female breasts for proper examination.
Auscultate the trachea
1. Auscultate the anterior chest. Use the sequence used
in percussion beginning over the bronchi between the
sternum and the clavicles.
2. Document the findings in the client’s record.
ASSESSING THE HEART AND THE CENTRAL VESSELS
Posterior Thorax
1. Assemble equipment and supplies
2. Simultaneously inspect and palpate the precordium for
the presence of abnormal pulsations, lifts, or heaves. 3.
Inspect and palpate the aortic and pulmonic areas,
observing them at an angle and to the side, to note for
the presence and absence of pulsations.
4. Inspect and palpate the tricuspid area for pulsations
and heaves or lifts Inspect and palpate the apical area for
pulsation. Nothing its specified location (it may be
displaced laterally or lower) and diameter. If displaced
laterally, record the distance between the apex and the
MCL in centimeters.
5. Inspect and palpate the epigastric area at the base of
the sternum for abdominal aortic pulsations
6. Auscultate the heart in all four anatomic sites: aortic,
pulmonic, tricuspid, and apical (mitral).
Carotid Arteries
1. Palpate the carotid artery. Use extreme caution
2. Auscultate the carotid artery.
Jugular Veins
1. Inspect the jugular veins distension. The client is
placed in a semi-Fowler’s position, with the head
supported on a small pillow.
2. The jugular distension is present; assess the jugular
venous pressure (JVP). Assemble equipment and
supplies: millimeter ruler, examination gloves and
magnifying glass.
3. Locate the highest visible point of distension of the
internal jugular vein.
4. Document pertinent findings in the patient’s chart.
ASSESSING THE PERIPHERAL VASCULAR SYSTEM
Peripheral Pulses
1. Palpate the peripheral pulses (except the carotid pulse)
on both sides of the client’s body individually,
simultaneously, and systematically to determine the
symmetry of pulse volume.
Peripheral Veins
1. Inspect the peripheral veins in the arms and legs for
the presence and/or appearance of superficial veins
when limbs are dependent and when limbs are elevated.
2. Assess the peripheral leg veins for signs of phlebitis.
Peripheral Perfusion
1. Inspect the skin of the hands and feet for color,
temperature, edema and skin changes.
2. Assess the adequacy of arterial flow if arterial
insufficiency is suspected. Capillary blanch test
3. Document findings in the client’s record.
ASSESSING THE BREAST AND AXILLAE
1. Assemble equipment. • Centimeter ruler
2. Inspect the breast for size, symmetry, and contour or
shape while the client is in a sitting position.
3. Inspect the skin of the breast for localized
discolorations or hyperpigmentation, retraction or
dimpling, localized hypervascular areas, swelling or
edema.
4. Emphasize any retraction by having the client:
• Raise the arms above the head
• Push the hands together, with elbows flexed
• Press the hands down on the hips - note
movement of the breast
5. Inspect the areola area for size, shape, symmetry,
color, surface characteristics, and any masses or lesions.
6. Inspect the nipples for size, shape, symmetry, color,
surface characteristics, and any masses or lesions.
7. Palpate the axillary, sub clavicular, and supraclavicular
lymph nodes.
8. The client is seated with the arms abducted and
supported on the nurse’s forearm.
9. Use the flat surfaces of all fingertips to palpate the four
areas of the axilla: the edge of the greater pectoral
muscle along the anterior axillary line.
10. Palpate the breast for masses, tenderness and any
discharge from the nipples.
11. Palpate the areola and the nipples for masses.
Compress each nipple to determine the presence of any
discharge. If discharge is present, milk the breast along its
radius to identify the discharge-producing lobe.
12. Assess any discharge for amount, color, consistency
and odor.
13. Note any tenderness on palpation.
14. Document pertinent findings in the client’s record.
ASSESSING THE ABDOMEN
1. Assemble equipment and supplies:
Examine light
Tape measure
Water – soluble skin marking pencil
Stethoscope
2. Ask client to urinate, empty bladder makes assessment
more comfortable.
3. Assist the client to a supine position with the arms
placed comfortably at the sides.
4. Place small pillows beneath the knees and the head to
reduce tension in the abdominal muscles. Expose only
the client’s abdomen from chest line to the pubic area to
avoid chilling and shivering, which can tense the
abdominal muscles.
5. Inspect the abdomen for skin integrity
6. Inspect the abdomen for contour and symmetry.
7. Observe the abdominal contour while standing at the
client’s side when the client is supine.
8. Ask the client to take a deep breath and to hold it.
9. Assess the symmetry of contour while standing at the
foot of the bed.
10. If distension is present, measure the abdominal girth
by placing a tape around the abdomen at the level of the
umbilicus.
11. Observe abdominal movements associated with
respiration, peristalsis or aortic pulsations.
12. Observe the vascular pattern.
Auscultation of the abdomen
Auscultate the abdomen for bowel sounds, vascular
sounds and peritoneal friction rubs.
Percussion of the liver
Percuss the liver to determine its size.
Palpation of the Abdomen
1. Perform light palpation first to deter areas of
tenderness and/or muscle guarding.
2. Systematically explore all four quadrants.
3. Perform deep palpation over all four quadrants. - last i
palpate ang naay pain kay masakitan na sya
Palpation of the Liver
Palpate the liver to detect enlargement and tenderness,
blow R coastal margin.
Palpation of the Bladder
1. Palpate the area above the pubic symphysis if the
client’s history indicates possible urinary retention. - if
2. Document pertinent findings in the client’s record.
ASSESSING THE FEMAL GENITALS AND INGUINAL AREA
1. Assemble equipment and supplies:
Examination gloves
Drape
Supplemental lightning
2. Inspect the distribution, amount, and characteristics of
pubic hair.
3. Inspect the skin of the pubic area for parasites,
inflammation, swelling and lesions. To assess pubic skin
adequately, separate the labia majora and labia minora.
4. Inspect the clitoris, urethral orifice, and vaginal orifice
when separating the labia majora.
5. Palpate the inguinal lymph nodes.
6. Document findings in the client’s record
ASSESSING THE MALE GENITALS AND INGUINAL AREA
Assemble equipment and supplies:
• Examination gloves
Pubic Hair
Inspect the distribution, amount, and characteristics of
pubic hair.
Penis
1. Inspect the penile shaft and glans penis for lesions,
nodules, swellings and inflammation.
2. Inspect the urethral meatus for swelling, inflammation,
and discharge. Compress or ask the client to compress
the glans slightly to open the urethral meatus to inspect
it for discharge. If the client has reported a discharge,
instruct the client to strip the penis from the base to the
urethra.
3. Palpate the penis for tenderness, thickening, and
nodules. Use your thumb and first two fingers.
Scrotum
1. Inspect the scrotum for appearance, general size, and
symmetry. To facilitate inspection of the scrotum during
a physical examination, ask the client to hold the penis
out of the way. Inspect all skin surfaces by spreading the
rugaeted surface of the skin and lifting the scrotum as
needed to observe posterior surfaces.
2. Palpate the scrotum to assess status of underlying
testes, epididymis, and spermatic cord. Palpate both
testes simultaneously for comparative purposes. Inguinal
Area
3. Inspect both inguinal areas for bulges while the client
is standing, if possible. The client remains at rest. Next,
have the client hold his breath and strain or bear down,
as though having a bowel movement.
4. Palpate hernias.
5. Document findings in the client record.
ASSESSING THE RECTUM AND ANUS
1. Position the client. In adults, a left lateral or Sims
position with the upper leg accurately flexed is required
for the examination.
For females: a dorsal recumbent position with hips
externally rotated and knees flexed or lithotomy position
may be used.
For males: A standing position while the client bends
over the examining table may also be used.
2. Inspect the anus and surrounding tissue for color,
integrity, and skin lesions. Then ask the client to bear
down as though defecating. Describe the location of all
abnormal findings in terms of a clock, with the 12 o’clock
position toward the pubic symphysis.
3. Palpate the rectum for anal sphincter tonicity, nodules,
masses, and tenderness.
4. On withdrawing the finger from the rectum and anus,
observe it for feces.
5. Document findings in the client.
ASSESSING THE MUSCULOSKELETAL SYSTEM
1. Inspects the muscle for size. Measures the muscle with
a tape.
2. Compares each muscle on one side of the body to the
same muscle on the other side for any apparent
discrepancies.
3. Inspects the muscle and tendons for contractures and
fasciculation.
4. Inspects any tremors of the hands and arms by having
the patient hold the arms out in front of the body.
5. Palpates muscles at rest to determine muscle tonicity.
6. Palpates muscle while patient is doing active range of
motion. Checks flaccidity, spasticity, and smoothness of
movement. (Flexion and extension movement)
7. Palpates muscle while the patient is doing passive
range of motion.
8. Tests muscle strength. Compares the right side with
left side.
Bones
1. Inspects the skeleton for normal structure and
deformities.
2. Palpates the bone to locate any areas of edema or
tenderness.
Joints
1. Inspects the joints for swelling.
2. Palpates each joint for tenderness, swelling,
crepitation, and presence of nodules.
3. Assesses joints, for range of motion, smoothness of
movement.
4. Documents pertinent findings in the patient’s record
NEUROLOGIC ASSESSMENT
1. Determines the patient’s orientation to time, place and
person by tactful questioning.
2. Determines patient’s level of consciousness Reaction
Level Scale (RLS) Glasgow Coma Scale (GCS). Makes use
of the Neuro Assessment Graphic Sheet.
Biceps Reflex – tests the spinal cord level C5- C6.
1. Partially flexes the patient’s arm at the elbow, and
rests 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.
2. Deliver a blow (slight downward thrust) with the
percussion hammer to your thumb. Observe the normal
slight flexion of the elbow, and feels the bicep’s
contraction through your thumb.
Gra Description
de
0 No muscular contraction detected.
1 A barely detectable trace of contraction.
2 Active movement with gravity eliminated.
3 Active movement against gravity.
4 Active movement against gravity and some 
resistance.
5 Active movement against full resistance.
Triceps Reflex – tests the spinal cord level C7, C8.
1. Flexes the patient’s arm at the elbow level, and
support it in the palm of your non dominant hand.
2. Palpates the triceps tendon about 2-5 cm (1-2 in)
above the elbow. Delivers a blow with the percussion
hammer directly to the tendon.
3. Observes for the normal slight extension of the
elbow.
Brachioradialis Reflex – tests the spinal cord level C3, C6.
1. Rests the patient’s arm in a relaxed position on
your forearm or on the patient’s own leg.
2. Delivers a blow with the percussion hammer
directly on the radius 2-5 cm (1-2 in) above the bony
prominence on the thumb side of the wrist. Observes the
normal flexion and supination of the forearm. The fingers
of the hand may also extend slightly.
Patellar Reflex – tests the spinal cord level L2,L3,L4.
1. Asks the patient to sit on the edge of examining
table so that his/her legs hang freely.
2. Locates the patellar tendon directly below the
patella. Delivers a blow with the percussion hammer
directly to the tendon. Observes the normal extension or
kicking out of leg as the quadriceps muscle contracts
Achilles Reflex – tests the spinal cord level S1; S2.
With the in the same position as for the patellar
reflex, slightly dorsiflex the patient’s ankle by supporting
the foot lightly in the hand.
REFLEXES
Plantar (Babinski’s) Reflex – uses moderately sharp
object, such as the handle of percussion hammer.
Strokes the lateral border of the sole of the patient’s
foot, starting at the heel, continuing to the ball of the
foot, and then proceeding across the ball of the foot
toward the big toe. Observes for the response. Normally,
in adult all five toes bend downward.
Achilles Reflex – tests the spinal cord level S1; S2.
With the in the same position as for the patellar
reflex, slightly dorsiflex the patient’s ankle by supporting
the foot lightly in the hand.
Plantar (Babinski’s) Reflex – uses moderately sharp
object, such as the handle of percussion hammer.
Strokes the lateral border of the sole of the patient’s
foot, starting at the heel, continuing to the ball of the
foot, and then proceeding across the ball of the foot
toward the big toe. Observes for the response. Normally,
in adult all five toes bend downward.
MOTOR FUNCTION
Gross Motor and Balance Test
Walking Gait
Asks the patient to walk across the room and back, and
assess the patient’s gait.
Romberg’s Test
Asks the patient to stand with feet together and arms
resting at the sides, first with eyes open, then closed or
20 to 30 seconds without support.
Standing with one foot with eyes closed
Asks the patient to close his/her eyes and stand on one
foot, then the other. Stands close to the patient during
the test.
Heel-Toe Walking
Asks the patient to walk a straight line, placing the heel of
one foot directly in front of the toes and then on the
heels.
Toe or heel Walking
Asks the patient to walk several steps on the toes and
then on the heels.
Fine Motor Test for Upper Extremities
Finger to Nose Test
Asks the patient to abduct and extend the arms at
shoulder height and rapidly touch the nose alternately
with one index finger and then the other. Have the
patient repeat the test with the eyes closed if the test is
performed easily.
Alternating supination and pronation of hands and
knees
Asks the patient to pat both knees with the palms of both
hands and then with the backs of the hands alternately at
an ever increasing rate.
Finger to Nose and to the Nurse’s Finger
Asks the patient to touch the nose and then your index
finger held at a distance at about 45 cm (18 in) at a rapid
and increasing rate
Fingers to Fingers
Asks the patient to spread the arms broadly at shoulder
height and then bring the fingers together at the midline,
first with the eyes open and then closed, first slowly and
then rapidly.
Fingers to Thumb
Asks the patient to touch each finger of one hand to the
thumb of the same hand as rapidly as possible.
Asks the patient to lie supine and to perform these tests:
Heel Down Opposite Shin
Asks the patient to place the heel of one foot just below
the opposite knee and run the heel down the shin to the
foot. Repeat with the other foot. The patient may also
use a sitting position for this test.
Toe or Ball of Foot to the Nurse’s Finger
Asks the patient to touch your finger with the large toe of
each foot.
Light-Touch Sensation
1. Compares the light touch sensation of symmetric areas
of the body.
2. Asks the patient to close the eyes and to respond by
saying “yes” or “no” whenever the patient feels the
cotton wisp touches his/ her skin.
3. With a wisp of cotton, lightly touches specific spot and
then the same spot on the other side of the body.
4. Tests areas on the forehead, cheek, hand, lower arm,
abdomen, foot, and lower leg. Checks a specific area of
the limb first.
5. Asks the patient to point to the spot where the touch
was felt.
If areas of sensory dysfunction are found,
determines the boundaries of sensation by testing
responses about every 2.5 cm (1 in) in the area. Makes a
sketch of the sensory loss area for recording purposes
Pain Sensation
Equipment: Broken Tongue Depressor
1. Assesses pain sensation as follows:
Asks the patient to close his/her eyes and to say
“sharp”, “dull”, “don’t know” when the sharp or dull end
of the broken tongue depressor is felt.
2. Alternately, use the sharp and dull end of the sterile
pin or needle to lightly prick designated anatomic areas
at random. The face is not tested in this manner.
3. Allows at least two seconds between each test.
Position or Kinesthetic Sensation
1. Commonly, the middle fingers and the large toes are
tested for the kinesthetic sensation.
2. To test the fingers, support the patient’s arm with one
hand and hold the patient’s palm in the other.
3. To test the toes, place the patient’s heels on the
examining table.
Asks the patient to close his/her eyes.
4. Grasps a middle finger or a big toe firmly between your
thumb and index finger and exert the same pressure on
both sides of the finger or toe while moving it.
5. Use a series of brisk up-and-down movements before
bringing the finger or toe suddenly to rest in one of the
three positions.
6. Moves the finger of toe until it is up, down, or straight
out, and asks the patient to identify the position.
Tactile Sensation
For the entire test, the patient’s eyes need to be closed.
One-and-Two Point Discrimination
Alternately stimulates the skin with two pins first
simultaneously and then with one pin after. Asks whether
the patient feels one or two pin first.
Stereognosis
Places familiar objects such as key, paper clip, or coin in
the patient’s hand, and asks the patient to identify them.
If the patient has a motor impairment of the hands and is
unable to manipulate an object, write a number or letter
on the patient’s palm, using a blunt instrument, and ask
the patient to identify it.
Extinction Phenomenon
Simultaneously stimulates two symmetric areas of the
body, such as the thighs, the cheeks, or the hands.
VITAL SIGNS
TEMPERATURE
- it is the difference between heat produced and heat lost
by the body and is measured through the use of a
thermometer
METHODS IN TAKING BODY TEMPERATURE
ORAL METHOD
Contraindications
1. Infants
2. Unconscious and irrational patients
3. Patients who breaths through their mouths
4. Those with disease of the oral cavity or surgery of
the nose of mouth
5. Patients who have just taken hot or cold foods or
fluids.
AXILLARY METHOD
- many hospitals in the Philippines obtain patient’s
temperature by the axillary method if the axilla has just
been washed, obtaining temperature should be delayed

RECTAL METHOD
Contraindications
1. with rectal surgery
2. With diarrhea
3. With disease of the rectum
4. With cardio vascular alteration because the presence
of the thermometer in the rectum may stimulate the
vagus nerve causing bradycardia or rhythm disorder
5. With leukemia which may traumatize the rectal
mucosa causing bleeding
TYPES OF THERMOMETER
1. Electronic digital thermometer. Used for oral, rectal,
axillary temperature measurements
2. Tympanic thermometer. For taking temperature via
ear.
3. Temporal artery thermometer. Measures arterial
temperature through infrared scanning of the temporal
artery
4. Disposable paper strips with temperature sensitive
dots. Used for skin/surface temperature measurement.
5. Infrared temperature.
PULSE RATE
- It is the rhythmical throbbing that result from a wave of
blood passing through an artery as the heart contracts.
stem with alcohol swab.
6. Pats the axillary dry using washcloth or tissue paper
7. Turns the thermometer on
8. Places the thermometer in axilla directed upward.
Position the patient’s arm across the chest.
9. Leaves thermometer in place for 2 - 60 seconds or until
a sound (beep is heard)
10. Removes and wipes the thermometer dry using tissue
paper.
(refers handouts)
DOCUMENTATION
CONTENTS
- Documented on graphic charts, which allow you to
monitor or plot the patterns of the vital signs
NORMAL BODY TEMPERATURE
Oral Temperature: 36.1-37.2C or 97-99F (Ave: 37C)
Rectal Temperature: 36.7-37.8C or 98-100F (Ave: 37.5C
Axillary Temperature: 35.6-36.7 or 97-99F (Ave: 36.7C)
Tympanic Temperature: 37.5C or 99.5F
NORMAL PULSE RATE

POSSIBLE SITES FOR TAKING THE PULSE:

1. Apical NORMAL RESPIRATION RATE
2. Popliteal artery
3. Radial artery
4. Carotid artery
5. Temporal artery
6. Brachial artery
7. Dosalis pedis
8. Posterior tibialic
9. Femoral artery

RESPIRATION RATE WHERE TO RECORD VITAL SIGNS

- It is the exchange of oxygen and carbon dioxide
between the atmosphere and body cells and is initiated Vital Signs Master List
by the act of breathing - it is usually seen in the station for documentation of
vital signs in all patients in the ward/area without
PROCEDURE needing to see the chart
1. Reads the chart
2. Washes hands
3. Prepare the equipment and brings to the bedside
4. Identifies the pt and explain the procedure
5. Wipes the thermometer from the bulb towards the
TPR SHEET
- also seen usually in the station, that aside from writing
on the vital signs taken, the frequency of urination and
defecation can be seen readily in the sheet
CONSIDERATIONS
- Make necessary reassessment of abnormal results
before recording
- Follow agencies protocol regarding the use of
appropriates pen colors
- Ask permission before using patient’s chart
- A mistaken entry in the chart is not allowed
- No tampering of entries

PATIENTS CHART

GRAPHIC CHART
- we also term this as the TPR graphic chart. In this sheet,
the progress of the vital signs recorded can be seen right
away through the plotting done in it. It is usually seen
attached in the patient’s chart.

VITAL SIGNS SHEET

-vital signs documentation in tabulated form and is ually
found in the patient’s chart.

NURSES NOTES
- documentation of vital signs in a narrative form along
with the nurse’s notes
COMPLETING THE PATIENT’S INFORMATION SECTION
- For thus section of the graphic chart, make sure that
patient’s name, attending physician, room number and
hospital number are filled out. Always use BLACK pen
when filling out this part.

THE VERTICAL LINES AND SPACES OF TIME

FILLING OUT OF DATE. HOSPITAL DAY, POST

OPERATUVE AND POSTPARTUM SECTION

PLOTTING THE PULSE AND TEMPERATURE

 FED, URINE AND STOOLS

PLOTTING THE PULSE AND TEMPERATURE

PLOTTING RESPIRATION, WEIGHT, ACTIVITY, DIET, PT. NURSING CARE PLAN


A-ASSESSMENT
1. Perform a thorough head-to-toe assessment
2. Document all assessment findings
3. Verify, validate and double check data
4. Record subjective data in client’s own words
Note: Data from significant other and other professionals
may also be subjective if they consist of opinion and
perception rather than fact.
5. Cluster the data by writing the objective and subjective
cues under its corresponding functional health pattern
(based on Gordon’s) in a separate sheet.
6. Establish priority using Maslow’s Hierarchy of needs.
Identify whether the problem or need if high, medium, or
low priority.
7. Identify the need of the client based on Gordons
Functional Health Pattern
- helps identify nursing priorities and help direct nursing
interventions based on identified priorities.
- Helps the formulation of expected outcomes for quality
assurance requirements of third-party prayers.
- Nursing diagnoses help identify how a client or group
responds to actual or potential health and life processes
and knowing their available resources of strengths that
can be drawn upon to prevent or resolve problems.
- Provide a common language and forms a bases for
communication and understanding between nursing
professionals and the healthcare team
- Provides a basis of evaluation to determine if nursing
care was beneficial to the client and cost-effective
- For nursing students, nursing diagnoses are an effective
teaching tool to help sharpen their problem-solving and
critical thinking skills.

HIGH PRIORITY
- Life threatening situation (example: difficulty breathing,
hemorrhage)
- Something that needs immediate attention ( example:
preparation for a test, discharge from the facility that will
occur shortly
- Something that is very important to the patient.
( example: pain, anxiety)
- High Priority - potentially life threatening and require
NANDA INTERNATIONAL (NANDA-1)
immediate actions.
- NANDA - INTERNATIONAL earlier known as the North
American Nursing Diagnosis Association
MEDIUM PRIORITY
- (NANDA) is the principal organization for defining,
- involve problems that could result in unhealthy
distribution and integration of standardized nursing
consequences such as physical and emotional
diagnoses worldwide.
impairment but not likely to threaten life.
CLASSIFICATION OF NURSING DIAGNOSES (TOXONOMY
LOW PRIORITY
II)
- low priority - problem will be easily resolved
- health maintenance

D-DIAGNOSIS
1. After identifying the need of the client, refer to the
classification of diagnosis according NANDA-1
2. Identify what type of nursing diagnosis you are going
to write.

Clinical judgment concerning a human response to health

condition/life processes or vulnerability for that
response, by an individual, family or community.
“Human responses are the criteria concern of the nursing
care” NANDA 1, 2013

PURPOSE TYPE OF NURSING DIAGNOSIS

1. PROBLEM-FOCUSED DIAGNOSIS
- a clinical judgment concerning an undesirable human
response to health condition/life process that exists in an
individual, family or community.
Nursing diagnosis + related factors + defining
characteristics
2. RISK DIAGNOSIS
- A clinical judgment concerning the susceptibility of an
individual, family or community for developing an
undesirable human response to health condition/life
processes
Risk diagnostic label + risk factors
3. HEALTH PROMOTION DIAGNOSIS
- Clinical judgment concerning motivation and desire to
increase well-being and to actualize health potential.
- These responses are expressed by a readiness to
enhance specific health behavior, and can be used in any
health state.
- Note: In case where an individual are unable to express
their own readiness, the nurse may determine that a
condition for health promotion exist and then act on
client’s behalf.
Diagnostic label or one-part-statement
4. SYNDROME DIAGNOSIS
- a syndrome diagnosis is a clinical judgment concerning
with a cluster of problem or risk nursing diagnoses that
are predicted to present because of a certain situation or
event.
- they too, are written as one-part statement requiring
only the diagnostic label.
POSSIBLE NURSING DIAGNOSIS
- A possible nursing diagnosis is not a type of diagnosis as
are actual, risk, health promotion and syndrome. Possible
nursing diagnoses are statements describing a suspected
problem for which additional data are needed to confirm
or rule out the suspected problem. It provides the nurse
with the ability to communicate with other nurses that a
diagnosis may be present but additional data collection is
indicated to rule out or confirm the diagnosis.
Risk:hindi pa actual na na feel sa pt, probable pa
AEB: signs and symptoms
HOW TO WRITE A NURSING DIAGNOSIS
(Parts of a nursing diagnostic label)
1. Descriptor or modifier
2. Focus of the diagnosis of the key concept of the
diagnosis.
COMPONENT OF A NURSING DIAGNOSIS
- A nursing diagnosis has typically three component: the
problem and its definition, the etiology, the defining
characteristics.
Etiology - what causes the pain
PROBLEM AND DEFINITION
- The problem statement or the diagnostic label describes
the client’s health problem or response for which nursing
therapy is given as concisely as possible.
- A diagnostic label usually has two parts: qualifier and
focos of the diagnosis
- QUALIFIER (modifiers) - are words that have been added
to some diagnostic labels to give additional meaning,
limit or specify the diagnostic statements
- Exempted in this rule are one-word nursing diagnoses
(e.g Anxiety, fatigue, nausea) where their are qualifier
and focus are inherent in the one term
ETIOLOGY
- The etiology or related factors and risk factors,
component of a nursing diagnosis label identifies one or
more probable causes of the health problem, are the
conditions involved in the development of the problem,
gives direction to the required nursing therapy, and
enables the nurse to individualize the client’s care.
- Nursing interventions should be aimed at etiological
factors in order to remove the underlying cause of the
nursing diagnosis. Etiology is linked with the problem
statement with the phrase “related to”
DEFINING CHARACTERISTICS
- Defining characteristics are the clusters of signs and
symptom that indicate the presence of a particular
diagnostic label.
- In actual nursing diagnoses, the defining characteristics
are the identified signs and symptoms of the client
- For risk nursing diagnosis, no signs and symptoms are
present therefore the factors that cause the client to be
more susceptible to the problme form the etiology of a
risk nursing diagnosis.
- Defining characteristics are written following the phrase
“as evidenced by” or “as manifested by” in the diagnostic
statement.
PARTS OF THE DIAGNOSTIC LABEL
Ineffective (modifier) breathing pattern (focus of the
diagnosis)
NOTE: 1. Each nursing diagnosis has a label and a clear
definition
2. It is critical to know the definition of the diagnoses
3. Nurses must need to know the diagnostic indicators.
DIAGNOSTIC INDICATORS
The information that is used to diagnose and
differentiate one diagnosis from another
Include:
1. Defining characteristics
- observable cues/inferences that cluster as
manifestations of a diagnosis (e.g. signs and symptoms)
- an assessment that identifies the presence of a number
of defining characteristics lends support to the accuracy
of the nursing diagnosis
2. Related factors
- an integral component of all problem focused diagnoses
- Etiologies, circumstances, facts or influences that have
the some type of relationship with the nursing diagnosis
- Example: cause, contributed facts
3. Risk factors
HOW TO WRITE A NURSING DIAGNOSIS:
PROBLEM FOCUSED:
Diagnostic label + related factors + defining
characteristics
RISK DIAGNOSIS
Diagnostic label + risk factors
HEALTH PROMOTIONS
Diagnostic label
Diagnostic label + defining characteristics
DIAGNOSTIC PROCESS: HOW TO DIAGNOSE
There are three phases during the diagnostic process:
1. data analysis
- analysis of data involves comparing pt. Data against
standards
2. Identification of the client’s health problems,
health risk and strengths
- In this decision-making step after data analysis the
nurse together with the client identify problems that
support tentative actual, risk and possible diagnoses.
- It involves determining whether a problem is a
nursing diagnosis, medical diagnosis, or a collaborative
problem
- Also at this stage is wherein the nurse and the
client identify that client’s strengths, resources and
abilities to cope.
3. Formulation of diagnostic statements
- Formulation of diagnostic statement is the last step
of the diagnostic process wherein the nurse creates
diagnostic statements.
ONE-PART NURSING DIAGNOSIS STATEMENT
- Health promotion diagnoses are really written as one-
part statements because related factors are always the
same: motivated to achieve a higher level of wellness
through related factors may be used to improve the of
the chosen diagnosis. Syndrome diagnoses also have no
related factors. Examples of one-part nursing diagnosis
statement include:
- Readiness for Enhance Breastfeeding
- Readiness for enhances coping
- Rape trauma syndrome
TWO-PART NURSING DIAGNOSIS STATEMENT
- Risk and possible nursing diagnoses have two-part
statements: the first part is the diagnostic label and the
second is the validation for a risk nursing diagnosis or the
presence of the risk factors. It is not possible to have the
a third part for risk or possible diagnosis because signs
and symptoms do not exist. Examples of two-part
nursing diagnosis statements include:
- Risk for infection related to compromised host defenses
- Risk for injury related to abnormal blood profile
- Possible social isolation related to unknown etiology.
THREE-PART NURSING DIAGNOSIS STATEMENT
- An actual or problem-focused nursing diagnosis have
the three-part statements: diagnostic label, cintirbution
factor (related to) and signs and symptoms (as evidenced
by). Three part nursing diagnosis statement is also called
the PES format which includes the Problem etiology and
signs and symptoms. Examples of three-part nursing
diagnosis statement include:
- Impaired physical mobility related to decreased muscle
control as evidence by inability to control lower
extremities
- Acute pain related to tissue ischemia as evidenced by
statement of “I feel severe pan on my chest”
VARIATIONS ON BASIC STATEMENT FORMATS
- Using “secondary to” to divide the etiology into two
parts to make the diagnostic statement more descriptive
and useful. Following the “secondary to” is often a
pathophysiologic or diseae process or a medical
diagnosis. For example, Risk for Decreased Cardiac
Output related to reduced preload secondary to
myocardial infarction
- Using “complex factors” when there are too many
etiologic factors or when they are too complex state in a
brief phrase. For example, Chronic Low Self-Esteem
related to complex factors.
- Using “unknown etiology” when the defining
characteristics are present but the nurse does not know
the cause or contributing factors. For example,
Ineffective coping related to unknown etiology.
- Specifying a second part to the general response or
NANDA label to make it more precise. For example:
Impaired skin integrity (Right anterior chest) related to
disruption of skin surface secondary to burn injury.
O-OUTCOME IDENTIFICATION
- The formulation of goals and measurable outcomes that
provides the basis for evaluating nursing diagnoses.(ANA,
2014)
“Outcomes need to be identified before nursing
interventions are determined”
1. ESTABLISH PATIENT OUTCOMES AND OUTCOME
CRITERIA
Patient Outcome - an educated guess, made as a broad
statement about what that patient’s state will be after
the nursing interventions is completed.
- It directly addresses the problem statement in the
nursing diagnosis.
- Must be behavioral
- Written to indicate a desired state
- Contain an action verb and a qualifier that indicate level
of performance that need to be achieved.
(Qualifier - a description of the parameter for thr
outcome)
2. DETERMINE WHETHER:
Short term outcome: can be met in a relatively short
period (within days or less than a 1 week)
Lon-term outcome: requires more time (perhaps several
week or months). Usually describe expected benefits or
results that are seen after the pan of care has been
implemented.
“The nurse needs to revise the outcomes if the patient’s
situation or medical condition changes”
How to write?
- Specific, measurable, realistic statements of goal
attainment.
- Present information that will guide the evaluation phase
of the nursing process
- Answers the questions who, what actions, under what
circumstances, how well and when
ALFARO-LEFEVERE (2014) AN OUTCOME CRITERIA
REQUIRES THE FOLLOWING:
SUBJECT: Who is the person expected to achieve the
goals?
Verb: What actions must that person do to achieve the
goal?
Condition: Under what circumstances is the person to
perform the action?
Criteria; How well is the person to perform the action?
Specific Time: When is the person expected to perform
the action?
P-PLANNING
Activities of the plannig phase:
1. Planning Nursing Intervnetions
- determine appropriate nursing interventions for specific
pt
- Are any treatment based upon the clinical judgment and
knowledge that a nurse performs to enhance
patient/client outcome. (Bulecheck et. Al 2013)

2. Writing a Patient plan of care
- It documents the problem solving process
- It is a critical element in focusing nursing activities
- It serves as the evaluation criteria
- It must reflect the standard of care
IMPORTANT CONCEPTS IN WRITING A PLAN OF CARE
1. Patient centered
2. Step by step process as evidence by the following:
A. Sufficient data are collected to substantiate
nursing diagnosis
B. At least one goal must be sated to each nursing
diagnosis
C. Outcome criteria must be identified for each goal.
D. Nursing interventions must be specifically
designed to meet the identified goal
E. Each nursing interventions must be supported by
scientific rationale
F. Evaluation must address whether each goal was
completely met, partially met of completely unmet
I-IMPLEMENTATION
A. Action phase
B. Actual initiation of the plna
C. Activities
Reassessment
Setting priorities
Perform nursing interventions
Recording of nursing actions
IMPLEMENTATION SKILLS NEEDED
1. Intellectual skills
2. Interpersonal skills
3. Technical skills
E-EVALUATION
The sixth phase
The judgment of the effectiveness of nursing care to
meed patient goals based on patient’s responses
On going all throughout the nursing process
The plan of care is the foundation of evaluation
ACTIVITIES
1. Review patient goals and outcome criteria
A. Observing pt behavior
B. Using documentation of patient’s responses
C. Receiving feedback (pt. Family, other members of
the health team)
2. Collect Data
Objective and subjective data
Example:
Goals: The pt will state that pain is relived within
10minutes after positioning
The subjective statement of the pt would
be needed to judge whether this goals has been
achieved.
3. Measure Goal/Outcome Achievement
Making judgment about the goal attainment by
comparing the pt’s actual behavioral responses to the
predicted responses and predetermined outcome criteria
developed in the planning phase.
JUDGMENTS THAT MAY BE MADE ARE AS FOLLOWS:
ALFARO-LEFEVRE, 2014)
- The goal was completely met
- The goal was partially met
- The goal was completely unmet
4. Record judgment or measurements of goal attainment
- Write subjective and objective data
- Document the judgment made aout the goal
attainment.
- Avoid ambiguous terminology (inadequate, good,
extremely well, normal)
5. Revise or modify the plan of care
Reassessment
If there is a new diagnosis, write a new plan of care.
ENDORSEMENT
It is the communication process that occurs between
two shifts of nurses whereby the specific purpose is to
communicate information about patients under the care
of nurses for continuity of care.
It is also referred as Bedside Handover
PROCESS
- Endorsement start when the receiving Charge Nurse (1)
and Medicating/Bedside Nurse (1) is already present.
- The number of staff nurses who will receive the
endorsement depend from one ward to another. Some
may have 2 Charge nurses, 1 Bedside and 1 Medicating
nurse.
- Usually, 15-30mins before start of shift, the
endorsement may begin.
ENDORSEMENT
- During morning shifts (7am-3pm) the Head Nurse may
or mat not be present during endorsement
- The outgoing charge nurse prepares the
endorsement table with the Kardex; Charge nurse’s
endorsement logbook; and medicating nurse’s
endorsement sheet.
- Outgoing Nurse
- nurses who will endorse/hand-over the patient to
the next shift
- Incoming/Receiving nurse
- nurses who will receive the endorsement
- The endorsement starts with a prayer which varies
from ward to ward practice
- Special announcements or reminders are endorsed
first.
- e.g CT scan out of order; Medical residents and
consultants general meeting; scheduled monthly ward
meetings, etc.
- The outgoing Charge nurse begins with the summary of
the total census within their shift from last total census,
admissions, discharge , trans-out, trans-in and deaths.
KARDEX
The Charge nurse endorses the
patient’s nursing care plan in a form of
a kardex and starts from the 1 st to the
last room (vacant rooms are also
endorsed if it is out of order, reserved,
or with incoming admission
SAMPLE KARDEX (NSG/MEDICAL CARE PLAN)
A kardex is a desktop file that has slots for mutiple
pages. Thick cardstock pages (Nursing care plan sheets)
are inserted into the slots, one for each pt. The pages are
written in with a pen and is updated every shift.
In each Nursing Care Plan Sheet is a brief overview of
what transpire during the course of the pt’s admission.
Vital information are written on it for easy access of the
nurses.
Tickets for special procedures, IV solutions and
medicines with very specific dates are also included in
the Kardex.
THE OUTGOING NURSE ENDORSES THE NURSING CARE
PLAN AS FOLLOWES:
The pt’s room number, pt’s complete name, age and
sex and religion.
The AP on board and with their respective co-
managements if any are endorsed. Nurses should also
take note if any of the on board physician are OOT
inclusive of the dates. If so, the physician in lieu should
be endorsed termed as “to see-pt”
Nurse should also specify if the pt belongs to a house
case or privates case
House case - means the pt did not choose his.her
attending physician but rather assigned automatically
who in deck for the admission day.
Private Case - means that the pt has chosen the AP
himself (AP should be affiliated with the hospital)
CC upon admission as well as impression/tentative
diagnosis are stated. For newly admitted pts, a brief
history of the pt’s illness are read directly from the chart,
or any vital information in connection with pt’s current
condition.
Patient’s special diet,
Full diet, liquid diet, soft diet.
If on diabetic diet, calculations should be noted
including breakdown of protein, fats, carbs (calculated by
AP upon admission or referred to the hospital dietician)
Modified diets should be endorsed per Religion. E.g.
Islam diet (no pork), SDA diet, (no pork no seafoods)
Food allergies should also be noted.
Any special attachments should be made known, for
example: pts hooked to mechanical ventilations. ET yube
size, depth, set of the mechanism should be stated
clearly patents with nasogastric tube - French size,
indication of NGT if for feeding or draining purposes.
If for feeding, the osteorized feeding (OF) schedule is
endorsed including how many ml per feeding, frequency
and cycle per 24H
If for draining purposes, it should be noted if open to
drain via bottle clamped
Chest tubes - the placement of tube (left or right)
and the current level of liquid (output per shift is strictly
noted)
Placement of AV shunts; post operative sites; opsite
dressing etc.
Vital signs frequency and if pt are on strict I & O
monitoring.
It with neurovital signs, previous and latest GCS and
RLS score are endorsed.
For VS, abnormal results such as increase in
temperature and any abnormalities in blood pressure are
endorsed. If any interventions are made for such
recordings and if the resident physician are made aware.
Example: Temperature of 38.6C, TSB rendered and PRN
paracetamol tab given PO, latest temp 37.8 C - Dr. Abella
aware.
For intake and output monitoring, endorse if ot has
minimal or zero output within the shift and what
interventions are made.
SPECIAL PRECAUTIONS NOTED BY THE DOCTOR IS
ENDORSED
EXAMPLE. Watch out for any unsualities such as nausea,
vomiting >3x, watery stools >3x
Nurses should endorse if such unsualities occured
within the shift.
SPECIAL PROCEDURES IF ANY SUCH AS SRUGERY
CHEMOTHERAPY (BONE MARROW ASPIRATION,
INTRATHECAL CHEMO) BLOOD TRANSFUSIONS ETC.
SURGERY: Nurses endorse the procedurem date and
time, consents signed, accounting clearance, staff
personnel in diff. Dept. Aware of the said procedure. Pre-
opeative checklist are also endorsed if accomplished
CHEMOTHERAPY: Nurses endorse the procedurem date
and time and consents signed, special
equipment/medicines needed.
BLOOD TRANSFUSION: Nurse endorse the specific
medical order made by the AP. How many units are to be
transfused, what blood product to be used, blood type,
duration of transfusion, rest periods. If with any pre-post
BT assessment by resident physician, pre-post BT
medication
NURSES ENDORSE IF PT IS SEEN BY THE AP IN CHARGE
OR DUTY - AP in charge should see the pt immediately
once on floor if not, it should be endorsed,
NURSES ENDORSE IF PT IS SEEN BY THE RESIDENT
PHYSICIAN IN CHARFE OR ON DUTY - AP should see the
pt within 24hrs upon admission, if not resident physician
in charge should be made aware.
LABORATORY STUDIES SUCH AS BLOOD EXTRACTIONS
AND SPECIMENS TO BE ENDORSEF IF TAKEN BY MT OR
IF WITH PENDING RESULTS. SIGNIFICANT FINDINGS
SHOULD BE ENDORED PROPERLY - Blood extractions
such as CBC serum electrolytes FBS etc.
- If with CBC monitoring, frequency and specific
timing should be endorsed to the nurse.
- If for BLOOD C/5, blood should be extrected before
starting antibiotics (medicating nurse should be made
aware)
Specimen such as stool and urine exam, sputum AFB
etc.
If for stool exam x3 takes inform the nurse if stool
exam number 1 has results before sending specimen.
DIAGNOSTIC STUDIES SUCH AS CHEST XRAY,
ULTRASOUNDS, CT SCANS ARE ENDORSED
Ultrasounds - some ultrasounds need fasting such as
ultrasound of the abdomen. Nurse should take notes of
time of procedure as to set what time pt has to start
fasting
CT SCAN - nurses should endorse if with consent and
accounting clearance. Also, take not of those need bowel
preparations such as CT of whole abdomen, and on what
procedures needs a contrast medium or dye. Nurse
should endorse the radiologist AP
XRAYS - nurses should endorse significant results.
SPECIAL NURSING PROCEUDRES, IF ANY ARE ENDORSED
TO INCOMING SHIFT
Example: IVF to start once on NPO, CBB, hot sitz bath,
new born care, change of dressing
SPECIAL MEDICATIONS WITH SPECIFIC TIMING ARE
ENDORSED TO MEDICATING NURSES
EXAMPLE: Eprex 4000 IU SC once a day 3x a week (MWF)
HGT monitoring every 6hours with regular insulin 6 units
for results >180mg/dl
PRN MEDICATIONS ARE ENDORSED THRU MEDICINE
TICKETS. NOTE IF GIVEN WITHIN THE SHIFT.
Oxycontin 10mg/tab 1/2 tab every 2hrs to be given
in cases of VAS score >6/10
Paracetamol 500mg/tab 1 tab PRN for temperature
>37.8C
 - Use ME
INTRAVENOUS FLUIDS ARE ENDORED TOGETHER WITH - Post0Op charting: new sheet after the PACU notes
SIDE DRIPS (if any) - Chary usage
Nurses should properly endorse IV solution, how
many ml, how many hours to run, drop rate, due time DO NOT INCLUDE
expected to consume and current level. IVF to follow - Routine doctor’s orders
should also be endorsed to incoming shifts - Endorsed to NOD
Sidedrips are endorsed with the IV solution - Diet, unless for a certain procedure
incorporation, how many ml, how many hours to run, - Include in health teachings
drop rate, if on cycle (on what current cycle), due time
expected to consume, current level and if hooked to an NARRATIVE CHARTING
infusion pump. - Method of nsg interventions and the impact of these
interventions on client outcomes are recorded in
SAME PROCESS OF ENDORSEMENT WILL BE DONE IN chronological order covering a specific time frame
EACH PT UNTIL ALL ROOMS ARE COVERED. - Data is recorded in the progress notes, often without an
Questions or clarifications may be asked organizing frameworks
- Record the time and date of the entry
End the endorsement of formally saying “END OF - Assessment
ENDORSEMENT” to notify all participants that the - Record only facts, leave out personal opinions and
endorsement has come to a conclusion and the judgments
responsibility is handed over to the incoming nurses. - Interventions
- Care provided
NOTE: Incoming nurse should count all the endorsed pt if - Pt response to care
it coincides with the total census previously stated by the
outgoing nurse at the beginning of endorsements

An exact number if census is critical in making sure all

incoming and outgoing pts are being accounted for. Any
discrepancy in total census is a direct responsibility of the
charge nurse

ALSO PERFORM ASSESSMENYT

ROUNDS - INTRODUCE YOUR SELF AND YOUR SHIFT
ASK QUESTIONS

DOCUMENTATION

CHARTING
- never send the chart home with the pt.
- fill in the headings
- never write on medical order sheet
FOCUS DATA ACTION RESPONSE (FDAR)
- check for new orders; include orders for new lab tests in
charting
FOCUS CHARTING
- PA, Nsg. Interventions r/t current situation
- Record relevant details - describes the patient’s perspcetive and focuses on
documenting the pt’s current status, progress towards
- Signing nurse’s notes
- Avoid erasures, superimpositions goals and response to interventions
PURPOSE THE DON’T ON FDAR
- To easily identify critical patient issues/ concerns in the - DON’T begin charting until you check the name and
progress notes identifying number on the pt’s chart on each page
- To facilitate communication among all disciplines - Chart procedure or cares in advance
- To improve time efficiency with documentation - Clutter notes with repetitive or frequency changing data
- To provide concise entries that would not duplicate pt notes with repetitive or frequently changeing data
information already provided on flow sheet/checklist already charted on the flowsheet
- Make or sign an entry for someone else
WHEN IS FDAR NECESSARY - Change and entry because someone tells you
- To describe a pt problem/focus/ concern from the care - Label a pt or show basis.
plan - Try to cover up a mistake or incident inaccuracy or
- To document an activity or treatment that was carried mission
out - White out or erase an error. Don’t throw away notes
- To document a new findings with an error on them
- To document an acute change in pt’s condition - Squeeze in a missed entry or “leve spce” for someone
- To identify the descipline making the entry as well as else who forgot to chart. Don’t write in the margin
the topic of the note. - Use meaningless words and phrases. Such as good day
- To describe all specifics regarding pt/family teaching and no complaints
- To document a significant event or unsual peisode in pt - Use notebook or pencils
care. Example:
- Admission GENERAL GUIDELINES
- Pre and Post (specify assessment - Focus charting must be evident at least once every shift
- Pre-transfer assessment - Focus charting must be patient oriented not nursing
- Discharge planning task-oriented
- Discharge status - Indicate the date and time of entry in the first column
- Transfusion RBS - Separate the topic words for the body of notes:
- Begin thrombolytic therapy A. Focus note written on the the second column.
-PRN medication required. B. Data, action and response on the third column
- To identify an exemption to the expected outcome - sig name for every time entry
- To document an activity or treatment was not carred - Document only pt’s concern and/or plan of care e.g
out health teachings per shift, Hence, GENERAL NOTES ARE
- To best describe pt’s condition in relation to medical NOT ALLOWED
diagnosis. - Document pts’s status on admission, for every transfer
to/form another unit, or discharge
FDAR - Follow the DO’s of documentation
- Do time and date all entries - USE BLUE or BLACK for AM and PM. RED for night
- Use flowsheet/checklist. Keep information on FDAR
flowsheet/checklist current Focus Charting Parts
- Do chart as you observe - The columns are usually use din focus chartin for
- Write your observations and sign your own name. Sign documentation
and initial every entry - Date and Hour
- Do describe pt’s behavior and use direct pt quotes when - Focus
appropriate - Progress notes
- Record exactly what happens to pt and care given. Be
factual and compelte
- Draw a single line thru an error. Make this entry as
a”error and sign your name”
- Use only approved abbreviations
- Use next available line to chart
- Document patient’s current status and response to
medical care and treatments.
- Write legibly. Use ink. Accepted abbreviations
F-FOCUS
- Identifies the content or purpose of the narrative entry
and is separated from the body of the notes in order to
promote easy data retrieval and communication

This is the subject/purpose for the note.

The focus can be:

- Nursing diagnosis EX. Ineffective airway clearance

- Event (admission, transfer, discharge, teaching etc.)
EX. Transfer post procedure; Medication Education
- Pt event or concern (code blue, vomiting, coughing)
EXAMPLE
- Health Teachings - be specific
- Abnormal laboratory./diagnostic results
EX: Decreased platelet count
- Avoid using “continuity of care”

D-DATA
- The data category is like assessment phase of the
nursing process. It is in this category that you would be
writing your assessment cues lie: vs, behaviors, and other
observations noticed from the pt. Both subjective and
objective data are recorded in the data category
- This is the written in the narrative and contains only
subject (what pt says and the things that you are
measurable) and objective data (what you
assess/findings, vs and things that are measurable.)
- This lays the supporting evidence for why you are
writing the note.

A-ACTION
- The action category reflect the planning and
implementation phase of the nursing process and
includes immediate and future nursing actions. It may
also include any changes to the plan of care
- This is the verb area
- Write here what you did about the findings you found in
the data part of the notes
- This includes medication, calling the doctors,
repositioning etc.

R-RESPONSE Growth & Development

- The response category reflect the evaluation phase of
the nursing process and describes the client’s response to Growth
any nursing and medical care -physical change and increase in size
- This is where you write the pt responded to you action. -includes height, weight, dentition, and bone age

Development
an increase in the complexity of function
an increase in skill or the ability to function or a
qualitative change
Maturation
An increase in competence and adaptability PRINCIPLES OF GROWTH & DEVELOPMENT
To function at a higher level
- G&D are continuous processes from conception until
Psychosexual development death
Developing instinct or sensual pleasure (sexual drive) - G&D proceed in an orderly manner
Freudian theory - Diff. children pass through the predictable stages at diff.
Rates
- All body systems do not develop at the same rate
- Dev’t is cephalocaudal
- Dev’t proceeds from proximal to distal body parts
- Dev’t proceeds from gross to refined skills
- There is an optimum time for initiation of experiences
or learning
- Neonatal reflexes must be lost before development
- A great deal of skill & behavior is learned by practice

FACTORS AFFECTING GROWTH & DEVELOPMENT

1. GENETICS
- Family history of diseases may be inherited
- Chromosomes carry genes that determine physical
characteristics, intellectual potential, and personality.
- Sex, race, and nationality
Psychosocial development
Erikson’s stages of personality development Gender – girls are born lighter & shorter than boys
Health – a child who inherits genetically transmitted
disease may not grow as rapidly or develop as fully as a
healthy child
Intelligence – children with high intelligence do not
generally grow faster physically than other children

2. NUTRITION
- The greatest influence on physical and intellectual
development.
- poor maternal nutrition may limit growth &
intelligence potential

3. ENVIRONMENT
- Harmful Pre-Natal Env’t
a. Nutritional deficiencies
b. Mechanical problems
Moral Development c. Metabolic endocrine disturbances
-ability to know right from wrong and to apply these to d. Medical treatment
real-life situations e. Infectious diseases/illness during pregnancy
f. Faulty placental implantation/malfunction
Cognitive Development g. Smoking/alcoholism/use of certain drugs
-ability to: - Natal Env’t
-learn or understand from experience - immediate factors that the child is
-acquire and retain knowledge exposed during birth
-respond to a new 1. Anesthesia
situation 2. Method of delivery
-solve problems 3. Immediate care
 - Post-Natal Env’t
A. Internal
- Intelligence
- Hormonal Imbalance
- Emotions
B. External
- Socioeconomic status of the family
- Nutrition
- Illness and injury
- Parent-Child Relationship
- Ordinal position in the family
4. TEMPERAMENT
-the way individuals respond to their internal and
external environment
- inborn characteristic set at birth
- not developed by stages

- REACTION PATTERNS
-Activity Level – level of activity among children -significant characteristic
differs widely -nursing implications
-Rhythmicity – it manifests a regular rhythm in -state examples or situations
physiologic function
-Approach – a child’s response on initial contact METHODS OF STUDYING CHILDREN
with a new stimulus
-Intensity of Reaction – some react to situations with
their whole being, others rarely demonstrate
-Distractibility – children who are easily
distracted are easy to care for
-Attention Span & Persistence – ability to
remain interested
-Threshold of Response – intensity level of
stimulation
-Mood Quality – a happy child has a positive
mood quality - studying the same group of participants over a
-Adaptability - the ability to change one’s particular time period.
reaction to stimuli over time - studying groups of participants in different age groups
at the same point in time
5. CULTURE
- habits, beliefs, language, values and attitudes
of cultural groups influence the child’s G & D

6. HEALTH
– illness, injury or other congenital conditions
can affect G&D

7. FAMILY
-the purpose of the family is to provide support PATTERNS OF GROWTH & DEVELOPMENT
and safety for the child
- Parental Attitudes Directional Studies
- Child-rearing Philosophies -Cephalocaudal
-head to tail
STAGES OF HUMAN DEVELOPMENT -Proximodistal
 -near to far
-Differentiation MOTOR DEVELOPMENT
-from simple to more complex operations and - process wherein children learn to control and
functions integrate their muscles in purposeful movements

Each child displays definite predictable pattern Motor behavior skills:

* These patterns are universal and basic to all human - Reflexive or rudimentary -
beings General fundamental skills
- balancing
Sequential Studies - Specific skills
- Orderly sequence - Specialized skills
- Each stage is affected by the preceding stage
Developmental Pace THEORIES OF DEVELOPMENT
- Does not progress at the same time or pace
- Periods of accelerated growth and periods of THEORY
decelerated growth - A systematic statement of principles that provides a
Sensitive Periods framework for explaining some phenomenon
- Positive or negative stimuli enhance or defer the
achievement of a skill or function DEVELOPMENTAL TASK
Individual Differences - a skill or a growth responsibility arsing at a particular
- Rates of growth vary time in an individual’s life

BIOLOGIC GROWTH & PHYSICAL DEVELOPMENT THEORIES OF DEVELOPMENT

Biophysical
Linear growth or height Personality
- occurs as a result of skeletal growth Psychosocial
Weight Psychosexual
- Birthweight is a reflection of intrauterine env’t Temperamend
- In general, Attachment
-it doubles by 4-7 mos. Cognitive
-triples by the end of the 1st yr Behaviorist
-by 2-2.5yrs birthweight quadruples Social Learning
Bone Age Ecologic systems
-determined by comparing the mineralization of Moral Development
ossification centers Spiritual Development
Dentition
-Major stages:
1. Growth BIOPHYSICAL THEORY
2. Calcification
3. Eruption
4. Attrition

DEVELOPMENT OF ORGAN SYSTEMS

Respiratory, digestive, renal & musculoskeletal

- Growth proceeds fairly in childhood
Neurologic tissues
- Grow rapidly in the 1st 2 yrs.
- Brain reaches mature proportions by 2-5 yrs.
1. ARNOLD GESELL (1880 - 1961)
Lymphoid tissues
- Describe the development of the physical body
- Grow rapidly during infancy and childhood
- Theory stated that development is directed by
Skeletal growth & maturation
genetics
- Provides the best estimate of biological age
 - Obtains images of a child’s developmental - personality develops in five overlapping stages
milestones from birth to adulthood
- 10 stages of developmental were identified - THE LIBIDO CHANGES ITS LOCATION OF EMPHASIS;
-identified as the “father of child development” in FIXATION-INABILITY TO PROCEED TO THE NEXT STAGE
the US BEC. OF ANXIETY-DOES NOT ACHIEVE SATISFACTORY
-asserted that child devt is a process of maturation PROGRESSION AT 1 STAGE
or differentioan and refining of abilities & skills based on
an inborn “timetable” FREUD’S 5 STAGES OF DEVELOPMENT
-each stage was assigned a percentage freq. for
which the devtal milestone occured ORAL (BIRTH - 1 1/2 years)
- pleasure is accomplished by exploring the
month and by sucking
PSYCHOSOCIAL THEORIES - striving for immediate gratification of needs
- ego begins to emerge
- BEGINS TO SEE SELF AS SEPARATE FR. THE
MOTHER; IMMEDIATE GRATIFICATION
ANAL ( 1 1/2 - 3 years)
- pleasure is accomplished by exploring the
organs of elimination
- conflict is between those demands of society
and the parents
- RETENTION OF FECES ORDEFECATION
PHYCHOSOCIAL DEVELOPMENT LEARNS TO DELAY IMMEDIATE GRATFIC FOR
- refers to the development of personality FUTURE GOALS
Personality PHALLIC (4 - 6 years)
- can be considered as the outward expression of the - pleasure is accomplished by exploring the
inner self genitals
IT ENCOMPASSES A PERSONS TEMPERAMENT. - child is attracted to the parent of the opposite
FEELINGS, CHARACTER TRAITS, INDEPENDENCE, SELF- sex
ESTEEM, SELF-CONCEPT, BEHAVIOR, ABILITY TO LATENCY (6 years - puberty)
INTERACT WITH OTHERS, AND ABILITY TO ADAPT TO LIFE - pleasure is directed by focusing on relationship
CHANGES with same-sex peers and the parents of the same-
sex
1. SIGMUND FREUD (1856-1939) - ability to care and related to others
- an Austrian neurologist founder of psychoanalysis GENITALS (Puberty and after)
- pleasure is directed in the development of
sexual relationships
- plans life goals and grains strong sense of
PSYCHOANALYTIC/ PSYCHOSEXUAL THEORY identity
- introduced number of concepts about
development that are still in used today: 2. ERIK ERIKSON (1902-1994)
- concepts of unconscious minds THEORY OF PSYCHOSOCIAL DEVELOPMENT
- defend mechanism - described 8 stages of dev’t
- id, ego, and superego
- UNCONSCIOUS =PART OF THE MENTAL LIFE INFANCY
THAT THE PERSON IS UNAWARE OF - birth to 18 mos,
- ID-PLEASURE,UNCONSCIOUS - trust vs mistrust
- EGO-REALISTIC PERSON; BALANCES ID - attachment to the mother
- DEF.MECH METHODS USE TO FULFILL THE ID - soft sound and touch; visual stimulation
IN SOCIALLY ACCEPTABLE MANNER -VISUAL STIMULATION FOR ACTIVE CHILD
SUPEREGO=SOCIETY’S “DON’T’S” INVOLVEMENT
- proposed that the underlying motivation to human
dev’t is a dynamic, psychic energy, which he called libido TODDLER
 - 18 mos to 3 years MIDDLE ADULTHOOD
- autonomy vs shame and doubt - 35 TO 65 yrs
- gaining some basic control over self and env’t - generativity vs stagnation
- opportunities for decision making; praise for - fulfilling life goals that involve family, career and
the ability to make decisions society
-EARLY CHILDHOOD
LATE ADULTHOOD
PRE-SCHOOL - 65 yrs to death
- 3 to 6 years - integrity vs despair
- initiative vs guilt - looking back at one’s life
- preschool age (3-5 years old)
- using initiative in planning or carrying out 3. ROBERT HAVIGHURST (1900-1991)
plans
- initiative has discovered that learning new Theory
things is fun - learning is basic to life & that people continue
- or develop a sense of regarding parents to learn throughout life
limits or being criticized of activities done - describe G & D as occurring during 6 stages,
- becoming purposeful and directive each assoc. with 6 to 10 tasks to be learned
- explore new activities; allow to play
-LATE CHILDHOOD Havighurst’s age period
- Infancy & Early Childhood
SCHOOL AGE - Middle Childhood
- 6 - 12 YRS - Adolescence
- industry vs inferiority - Early Adulthood
- developing social, physical and learning skills - Middle Age
- allowing to assemble and complete short - Later Maturity
projects
- also known as latency 4. ROBERT PECK
- basic strengths
- during this time the brain is furthering its Theory
development and as a result, we are capable of learning, - believes that although physical capabilities &
creating and accomplishing numerous new skills and function decrease with old age, mental & social
knowledge, therefore developing a sense of industry capacities tend to increase in the latter part of life
- this is also a very social stage of development. If
one experiences feelings of inadequacy and inferiority 3 developmental task during old age
among his/her peers, one could have a serious problems 1. Ego differentiation vs. work-role preoccupation
in terms of competence and self-esteem in the future 2. Body transcendence vs. body preoccupation
- as the world expands a bit, the most significant 3. Ego transcendence vs. ego preoccupation
relationship is shifting from parents to the school and
neighbourhood 5. ROGER GOULD
- transformation is a central theme during
ADOLESCENCE adulthood
- 12 - 20 YRS - 20’s, time when a person assumes new role
- identity vs role confusion - 30’s, role confusion often occurs
- developing sense of identity - 40’s, person becomes aware of the time
- opportunities to discuss feelings, offer support and limitation
praise for decision making - 50’s, acceptance of each stage as a natural
progression of life marks the path to adult maturity
EARLY ADULTHOOD
- 20 -35 years 7 stages of adult development
- intimacy vs isolation
- establishing intimate bond of love and friendship
 - a retrun to the attachment figure when threatened
of for comfort
- the use of the attachment figure as a security base
from which the child can explore the surrounding
env’t
- expression of anxiety (separation anxiety) when the
attachment figure is absent
- INFANT-CAREGIVER RELP IS THE 1ST OF SUCH
ATTACHMENT

COGNITIVE THEORY
TEMPERAMENT THEORIES
Cognitive development
1. STELLA CHESS & ALEXANDER THOMAS - manner in which people learn to think, reason, and
- is multidimensional leading to the dev’t of a child’s use language & other symbols
personality traits - involves a person’s intelligence, perceptual ability,
- has a role in the dev’t of anxiety, depression, & ability to process information
attention deficit disorder, and other types of
behavior 1. JEAN PIAGET (1896-1980)

READ: Theory of cognitive devlopment

- examples of behavior style in each of the reaction - an orderly, sequential process in which a
patterns of temperament variety of new experiences (stimuli) must exist before
intellectual abilities can develop

5 phases of cognitive development

SENSORIMOTOR (birth to 2 yrs)

Stage 1 Use of reflexes (birth-1 mo.)
Stage 2 Primary circular reaction (1-4 mos.)
- sucking habits are developed
Stage 3 Secondary circular reaction (4-8mos.)
- begins to discover the external env’t
Stage 4 Coordination of secondary schemata (8-
12mos.)
- 1st intellectual behavior patterns emerge
Stage 5 Tertiary circular reaction
- discovers new ways of solving problems by
experimentation
Stage 6 Inventions of new means (18-24mos.)
- possesses mental images of the env’t & utilizes
ATTACHMENT THEORY cognitive skills to solve problems

1. JOHN BOWLBY (1907-1990) PRECONCEPTUAL PHASE (2-4 yrs.)

-Early childhood experiences have strong influence - Egocentric approach to accommodate the demands
on the child’s dev’t and later behavior of the env’t
- Humans have an essential need for attachment - Everything relates to “me”
- SHARES COMMON BELIEF WITH FREUD’S; WORKED - Language dev’t is rapid
WITH CHILDREN DURING WARTIME; LONG LASTING
STRONG EMOTIONAL BONDS WITH OTHERS INTUITIVE THOUGHT PHASE (4-7 yrs)
- Egocentric thinking diminishes
Attachment theory - Thinks of one idea at a time
- the desire to be near to the attachment figure - Includes others in the env’t
 - Words express thoughts 2. LEV VYGOTSKY (1896-1934)
- “Social Constructivist”
CONCRETE OPERATIONS PHASE (7-11 yrs) - Adults guide children to learn
- Solves concrete problems - dev’t depends on the use of language, play, &
- Cognizant of viewpoint social interaction
- Explored the concept of cognitive devt within a
social, historical, and cultural context
FORMAL OPERATIONS PHASE (11-15 yrs)
- Uses rational thinking ECOLOGIC SYSTEMS THEORY
- Reasoning is deductive & futuristic
1. URIE BRONFENBRENNER (1917-2005)
CENTERING 5 levels or systems
– look at an object and see only one characteristic of that - Microsystem - close relationships on a daily basis
object HOME,SCHOOL,FRIENDS ; EXO-PARENT’S JOB, LOCAL
CONSERVATION SCHOOL BOARD
– change in form does not change the size or amount of - Mesosystem – relationship of microsystems with
content one another
REVERSIBILITY - Exosystem – settings that may influence the child
– ability to retrieve steps but the child may not have daily contact
ASSIMILATION - Macrosystem – attitudes & beliefs of the child’s
– changing a situation on one’s perception if it fits his culture & society
thoughts - Chronosystem – time period in which the child is
ACCOMODATION growing up
– Adapt thoughts perceived to fit what is perceived
THEORIES OF MORAL DEVELOPMENT
BEHAVIORIST THEORY
- Learning takes place when an individual’s response MORAL DEVELOPMENT
to a stimulus is either positively or negatively reinforced - Learning what ought to be & what not to be done
- Moral – “relating to right and wrong”
1. B.F. SKINNER (1904-1990) - Morality – reqt’s necessary for people to live
- Organisms learn as they respond to or “operate” together in society
on their environment
- Operant conditioning, rewarded or reinforced 1. LAWRENCE KOHLBERG
behavior will be repeated - Focused on the reasons an ind’l makes a
- Behavior that is punished will be suppressed decision
- Moral dev’t progresses through 3 levels & 6
SOCIAL LEARNING THEORIES stages
Individuals learn by observing & thinking about the
behavior of the self & others 3 levels of moral dev’t
- BASED ON THE PRINCIPLE THAT; spanning
behaviorist and cognitive theories PREMORAL or PRECONVENTIONAL LEVEL
- Egocentric focus
1. ALBERT BANDURA - Birth to 7 yrs
- Learning occurs through imitation
- Practice requires more awareness, self-motivation, CONVENTIONAL LEVEL
self-regulation of the individual - Societal focus
- The ind’l actively interacts with the env’t to learn - 7 to 12 yrs.
new skills & behavior
- BELIEVES THAT; social learning theorists contend POSTCONVENTINAL, AUTONOMOUS, or PRINCIPAL
that this process may not always lead to change in beh. In LEVELREMORAL or PRECONVENTIONAL LEVEL
contrast to beh. Theory that says theres a permananet - Universal focus
change in beh. - older than 12 yrs
6 stages of moral dev’t
- punsihment & obedience
- ind’l instrumental purpose & exchange
- mutual interpersonal expectations, relationships &
conformity
- Social system & conscience maintenance
- Prior rights & social contract
- Universal ethical principle

2. CAROL GILLIGAN (1936-present)

- Most frameworks for research in moral dev’t do
not include the concepts of caring & responsibility
- Moral dev’t proceeds through 3 levels & 2
transitions

3 levels of moral dev’t

Stage 1: caring for oneself
Stage 2 : caring for others
Stage 3: caring for self & others

THEORIES OF SPIRITUAL DEVELOPMENT

SPIRITUAL DEVELOPMENT THEORY

- An individuals understanding of their relationship
with the universe & their perceptions about the direction
and meaning of life

1. JAMES FOWLER
- Dev’t of faith as a force that gives meaning to a
person’s life
- Faith – form of knowing, a way of being in relation
to an “ultimate environment”
Theory of spiritual dev’t
Pre-Stage: Undifferentiated faith (infant)
Stage 1: Intuitive-Projective faith (toddler-
preschool)
Stage 2: Mythical-literal faith (school age)
Stage 3: Synthetic-conventional faith
(adolescent)
Stage 4: Individuative-reflective faith (late
adolescent-young adult)
Stage 5: Conjunctive faith (adult)
Stage 6: Universalizing faith (adult)

2. WESTERHOFF
- Describes faith as a way of being &infancy &
childhood behaving that evolves from an experienced
faith guided by parents & others during