INTRODUCTION

TO HEALTH
ASSESSMENT:
THE NURSING PROCESS
Lecturer: Jonnafe G. Gayatin, RMT, RN, MAN

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THE NURSING PROCESS
A systematic, rational method -Cyclical, follows a logical sequence
of planning and providing -Enables the nurse to respond to the
individualized nursing care. changing status of the client

-Identify client’s health status – actual or

potential health problems or needs
Purposes: -Establish plans to meet the identified needs
-Deliver specific nursing interventions to
meet those needs

-An individual
-Family
The client may be:
-Community
-Group
 CYCLIC AND DYNAMIC
• Data from each phase provide input to the next
phase

CLIENT CENTERED
• Plan of care is according to client’s
CHARACTERISTICS problems/needs
OF THE NURSING
FOCUS ON PROBLEM SOLVING AND
PROCESS DECISION MAKING
• Identifying possible solutions and choosing the
best one to implement
• Approaches include trial and error, intuition
and research
• Directed towards client’s responses to real or
potential disease/illness.
 INTERPERSONAL AND
COLLABORATIVE
• Communicating with clients, significant others
and support groups
• Collaborating with the health care team

UNIVERSAL APPLICABILITY
CHARACTERISTICS
OF THE NURSING • Nursing process is used as a framework for
PROCESS nursing care for all types of settings with clients
from all age groups

USE OF CRITICAL THINKING AND

CLINICAL REASONING
• Making clinical judgements based on
knowledge base in nursing and clinical
experience
 ATTITUDES THAT FOSTER CRITICAL THINKING
INTELLECTUAL
INSIGHT INTO INTELLECTUAL COURAGE TO
INDEPENDENCE FAIR-MINDEDNESS
EGOCENTRICITY HUMILITY CHALLENGE STATUS
QUO AND RITUALS
• Thinking for • Assessing all • Examining • Awareness of • Courage to
yourself and viewpoints one’s own the limits of recognize
making your and avoiding biases or one’s own that beliefs
own biases or customs; Self- knowledge are sometime
judgements prejudice awareness false or
misleading.
Courage to be
open to new
thinking.
ATTITUDES THAT FOSTER CRITICAL THINKING
INTEGRITY PERSEVERANCE CONFIDENCE CURIOSITY

• Being able to • Lifelong • Confidence in • Examining

readily admit determination the reasoning traditions and
and evaluate in finding process and exploring new
inconsistencies effective examining options
with and solutions to emotion laden-
between one’s client and arguments.
belief and nursing Anchored on
those of problems the belief that
another well-reasoned
thinking will
lead to
trustworthy
conclusions
 SETTING PRIORITIES

• Determining which is most relevant and most

important

DEVELOPING RATIONALES
COMPONENTS • Explanations of priority setting and nursing
OF CLINICAL interventions
• Acts as a check for potential errors, justifies
REASONING nursing actions and contributes to client safety

LEARNING HOW TO ACT

• Understanding relevant medical and nursing

information and translate knowledge into plan of
care
 CLINICAL REASONING IN TRANSITION

• Ability to recognize changes in client’s condition

over time

RESPONDING TO CHANGES IN THE

CLIENT’S CONDITION
COMPONENTS • Ability to detect changes, identify change in
OF CLINICAL priorities, adjust nursing care and alert primary
care provider when appropriate
REASONING
REFLECTION

• Identifying factors that improved client care and

those thar required changing or elimination
• Thinking back / Reviewing interventions
implemented and whether they were effective
OVERVIEW
OF THE
NURSING
PROCESS

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 COLLECTING, ORGANIZING, VALIDATING AND
DOCUMENTING CLIENT DATA

PURPOSE:
• To establish a database about the client’s response to
health concerns or illnesses and the ability to manage
healthcare needs

ACTIVITIES:

ASSESSING / • Establish a database

• Obtain nursing health history
ASSESSMENT • Conduct physical assessment
• Review client records
• Review nursing literature
• Consult support persons
• Consult health professionals
• Update data as needed
• Organize data
• Validate data
• Document / Communicate data
DIAGNOSING / DIAGNOSIS
• Purposes:
• To identify client’s strengths and health
Analyzing problems that can be prevented or resolved
by collaborative and independent nursing
and interventions
• To develop a list of nursing and
synthesizing collaborative problems
• Activities:
data • Interpret and analyze data
• Determine client’s strengths, risks and
problems
 Determining how to prevent, reduce or resolve the identified priority
client problems; how to support client strengths; and how to implement
nursing interventions in an organized, individualized and goal-directed
manner

PLANNING Purpose: To develop an individualized care plan that specifies client

goals/desired outcomes and related nursing interventions

Set priorities and ACTIVITIES: Communicate

goals/outcomes care plan to
in collaboration Select nursing Consult other Formulate a relevant heath
with the client strategies / health nursing care care providers
interventions professionals plan
 Carrying out (or Purpose: To assist Activities:
delegating) and the client to meet
-Reassess the client to
documenting the desired
update the database
planned nursing goals/outcomes;
-Determine the nurse’s
interventions promote wellness; need for assistance
IMPLEMENTING / prevent -Perform planned
illness/disease;
IMPLEMENTATION restore health;
nursing interventions
-Communicate nursing
facilitate coping actions implemented:
with altered Document care and
client response to care;
functioning
Give verbal reports as
necessary
 EVALUATING / EVALUATION

Measuring the degree to which Purpose: To determine whether

goals/outcomes have been achieved
Activities:
to continue, modify or terminate
and identifying factors that Collaborate with client and collect data related
plan of care to desired outcomes
positively or negatively influence
Judge whether goals/outcomes have been
goal achievement achieved
Relate nursing actions to client goals/outcomes
Make decision about problem status
Review and modify the care plan as indicated
or terminate nursing care
Document achievement of outcomes and
modification of the care plan
 In Review: PHASES OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE
• To establish a database about the client’s response to
• Collecting, organizing, validating and
ASSESSING health concerns or illnesses and the ability to manage
documenting client data
healthcare needs
• To identify client’s strengths and health problems that
can be prevented or resolved by collaborative and
DIAGNOSING • Analyzing and synthesizing data
independent nursing interventions
• To develop a list of nursing and collaborative problems
• Determining how to prevent, reduce or
resolve the identified priority client
• To develop an individualized care plan that specifies
problems; how to support client strengths;
PLANNING client goals/desired outcomes and related nursing
and how to implement nursing interventions
interventions
in an organized, individualized and goal-
directed manner
• Carrying out (or delegating) and • To assist the client to meet desired goals/outcomes;
IMPLEMENTING documenting the planned nursing promote wellness; prevent illness/disease; restore
interventions health; facilitate coping with altered functioning
• Measuring the degree to which
goals/outcomes have been achieved and • To determine whether to continue, modify or
EVALUATING
identifying factors that positively or terminate plan of care
negatively influence goal achievement
 Initial Assessment

TYPES OF Problem Focused Assessment

ASSESSMENT Emergency Assessment

Time Lapsed Assessment

TYPES OF ASSESSMENT
INITIAL
ASSESSMENT
Performed within a specified time
after admission to a health care
agency
Purpose: to establish a complete
database problem identification,
reference and future comparison
PROBLEM-FOCUSED
ASSESSMENT
Ongoing process integrated with
nursing care
Purpose: to determine the status
of a specific problem identified in
an earlier assessment
TYPES OF ASSESSMENT
EMERGENCY
ASSESSMENT
Done during any physiological or
psychological crisis of the client
Purpose: To identify life-
threatening problems / To
identify new or overlooked
problems
TIME-LAPSED
ASSESSMENT
Done several months after
initial assessment
Purpose: To compare the
client’s current status to
baseline data previously
obtained

The goal of medical
practice is to diagnose and
treat disease. The goal of
nursing is to diagnose and
treat human responses to
actual or potential health
problems.
Nurse’s Role in Health
Assessment
• obtaining the patient’s health history
• performing a physical assessment
• Nursing assessment focuses not only on
physiological and psychological responses to
actual or potential health problems but also on
the psychosocial, cultural, developmental and
spiritual dimensions.
• Compliment medical assessments to ensure
best possible care for patients
 COLLECTING DATA
Data collection is the
process of gathering
information about a client’s
health status
Database – contains all the
information about a client.
Includes nursing health history,
physical assessment, primary care Client data should include
provider’s history and physical past history as well as
examination, results of laboratory
and diagnostic tests and materials
current problems
contributed by other health
personnel
Types of Data
*Symptoms or covert data
*Can be described or verified only by that person
Subjective Data *E.g. sensations, feelings, values, beliefs, attitudes,
perceptions of personal health status and life
situation

*Signs or overt data

*Detectable by an observer or can be measured
Objective Data or tested against an accepted standard
*Obtained by observation or physical
examination
 CLIENT
• Best source of data
• Consideration: privacy and confidentiality
SUPPORT PEOPLE
• Family, friends, caregivers
• Consideration(e.g. in abuse): client wishes to remain anonymous. Client
authorizes gathering of data from support people / significant others

CLIENT RECORDS
Sources • Demographic profile
• Medical records

of Data • Laboratory records

• Records of therapies
HEALTH CARE PROFESSIONALS
• Nurses, social workers, primary care providers, physiotherapists
LITERATURE
• Provides additional and useful information regarding standards / norms;
cultural and social health practices; spiritual beliefs; assessment data for
specific client conditions; nursing interventions and evaluation criteria;
information on medical diagnosis, treatment and prognoses; current
methodologies and research findings
 Occurs whenever
the nurse is in
OBSERVING contact with the
client or support
persons

DATA Used mainly

COLLECTION INTERVIEWING when taking the
nursing health
history
METHODS
Major method
EXAMINING used in physical
assessment
 OBSERVING

To gather data using Two aspects:

the senses:
Patient / client (most important) Noticing the data
Environment Selecting, organizing, and
interpreting the data
 INTERVIEWING

Interview – a planned communication ; a conversation with a

purpose

Focused interview – the nurse This allows the nurse to collect

asks the client specific questions information that may have
previously been missed and yields
to collect information related to more in-depth information
the client’s problem. (D’Amico & Barbarito, 2013)
 DIRECTIVE INTERVIEW

• Highly structured and elicits specific information

• The nurse establishes the purpose of the
interview and controls the interview
• Client may have limited opportunity to ask
questions or discuss concerns
INTERVIEWING • Usually used when time is limited (e.g.
emergency situation)
APPROACHES
NON-DIRECTIVE INTERVIEW

• Also known as rapport-building interview

• Allows the client to control the purpose, subject
matter and pacing
• Rapport – an understanding between two or
more people
 TYPES OF INTERVIEW QUESTIONS:
Closed vs. Open-Ended Questions
CLOSED QUESTIONS
• Used in directive interview
• Restrictive and generally require “yes”
or “no” or short factual answers that
provide specific information
• What, When, Where, Who, Do, Did,
Does, Is, Are, Was, Were questions
• Often used when information is
needed quickly (e.g. emergency) or
when interviewing a highly stressed
person
OPEN-ENDED QUESTIONS
• Associated with non-directive
interview
• Invite clients to discover, explore,
elaborate, clarify or illustrate their
thoughts and feelings; invites answers
longer than 1 or 2 words
• What and How questions
• Gives clients freedom to divulge only
the information they are ready to
disclose
TYPES OF INTERVIEW QUESTIONS:
Neutral vs. Leading Question

NEUTRAL QUESTION LEADING QUESTION

Questions that client can answer Usually closed
without direction or pressure from Directs client’s answer
the nurse
Give client less opportunity to decide
Open-ended and used in non- whether the answer is true or not
directive interviews
May create problems if the client
gives inaccurate answers just to
please te nurse = inaccurate data
 • Avoid asking “Why” questions
• Can be perceived as interrogation by
the client (Kneisl and Trigoboff, 2013)
• Can put the client on the “defensive”
Point to
Remember… • Exception: In an emergency situation
the use of probing and direct
questioning may be appropriate to
gain a greater volume of data in a
shorter period of time (Kneisl and Trigoboff,
2013)
 Time
PLANNING
Place
THE
INTERVIEW Seating Arrangement
AND Distance / Proxemics
SETTING
Language
 OPENING
• Establish rapport
• Orientation: purpose and nature of the interview

BODY
STAGES OF • Client communicates what he/she thinks, feels, knows

AN and perceives in response to questions from the nurse

CLOSING
INTERVIEW • Offer to answer questions
• Conclude
• Provide a summary to verify accuracy and agreement
• Thank the client
• Express concern for the person’s welfare and future
• Plan for the next meeting
 EXAMINING
Physical Examination or Physical Assessment

Systematic data collection that uses observation (senses) to detect health

problems

INSPECTION
Techniques used to conduct the AUSCULTATION
examination: PALPATION
PERCUSSION
INTRODUCTION TO
HEALTH ASSESSMENT
(PART 2)
Jonnafe G. Gayatin, RMT, RN, MAN
ORGANIZING DATA
Also referred to as nursing health history, nursing assessment
or database form
ASSESSMENT FORMATS
Gordon’s Functional Health Patterns
Conceptual Models or Orem’s Self-Care Model
Frameworks Roy’s Adaptation Model

Includes factors and attitudes that

Wellness Models influence levels of wellness

Body Systems Model

Non-Nursing Models Maslow’s Hierarchy of Needs
Developmental Theories
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 Roy’s
Adaptation
Model

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Developmental Theories
VALIDATING DATA

The act of “double-checking” or verifying

data to confirm that it is complete,
factual and accurate.
 VALIDATING DATA

Ensure that Ensure that Obtain Differentiate Avoid jumping

assessment subjective and additional between cues into
information is objective data information and inferences conclusions and
complete agree that may have focusing in the
been Cues – subjective or wrong direction
objective data that can
overlooked be directly observed by
to identify
the nurse problems
Inferences – nurse’s
interpretation or
conclusions made
based on the cues
 The nurse validates data
when there are
Not all data requires
discrepancies between
validation. (e.g. height,
VALIDATING weight, lab studies)
data obtained in the
interview and physical
DATA assessment.

Nurses need to be aware

To build an accurate
Points to of their own biases,
values and beliefs and to
database, nurses must
validate assumptions
Remember… separate fact from
inference, interpretation
regarding client’s physical
or emotional behavior.
and assumptions.
 Compare subjective and objective data to verify the
client’s statements with your observations

Clarify any ambiguous or vague statements

GUIDELINES
IN Be sure your data consist of cues not inferences

VALIDATING
Double check data that are extremely abnormal
ASSESSMENT
DATA Determine the presence of factors that may interfere with
accurate measurement

Use references to explain phenomena

DOCUMENTING DATA Recording of client data
Documentation
Report – oral, written or computer-based communication intended to
convey information to others

Record – also called chart or client record; a formal legal document that
provides evidence of client’s care; can be written or computer based

The process of making an entry on a client record is called recording,

charting or documenting.

Nurse is accountable and should document according to organization

policies and universal standards
 Accurate documentation is essential
and should include all data collected
about the client’s health status.

Data are recorded in a factual manner

and not interpreted by the nurse.
Points to Avoid restating or paraphrasing client’s
subjective data (It should be
remember… documented verbatim in quotation
marks).

Avoid judgements or conclusions (e.g.

normal appetite)
 General Guidelines for Recording

Accepted
Date and Time Timing Legibility Permanence
terminology

Correct
Signature Accuracy Sequence Appropriateness
Spelling

Completeness Conciseness Legal prudence

 DATE AND TIME
• Document date and time for each recording.
• Time may be recorded in the conventional manner (12 hour; AM /
PM) or according to 24-hour (military) clock

TIMING
• Documenting should be done as soon as possible after an
DOCUMENTATION assessment or intervention. (Do not document before assessment
or intervention is done)
GUIDELINES LEGIBILITY (FOR WRITTEN DOCUMENTATION)
• Must be legible or easy to read. Hand-printing or easily understood
handwriting is permissible. (avoid script or shorthand)

PERMANENCE
• Written in “dark ink or permanent pen”
• For Electronic Records, changes are made in accordance with
software guidelines
 DOCUMENTATION
GUIDELINES
ACCEPTED TERMINOLOGY
• Use only commonly accepted
abbreviations, symbols and terms. Refer
to approved list given by the institution.
CORRECT SPELLING
• Incorrect spelling gives a negative
impression to the reader and decreases
the credibility of the nurse
SIGNATURE
• Includes name and title of the nurse
• For electronic records each nurse has his
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 DOCUMENTATION GUIDELINES
• ACCURACY
• Client’s name and identifying information should be stamped or written on each page of the
clinical record. Do not identify charts by room number. Special care is needed when caring for
clients with the same last name.
• Accurate notations consist of fact or observations not opinions or interpretations.
• Avoid general words (e.g. large, good, normal). Chart specific data (e.g. exact measurement)
• Write on every line, never between lines.
• If there is a blank space, draw a line through the blank space so that no additional information
can be recorded at any other time or by any other person. Then sign the notation
• When recording a mistake – draw a single line, indicate your name or initials above or near the
line (depending on agency policy). Avoid writing the word “error” when recording a mistake (it
may be interpreted as a “red flag” and lead to an assumption that a clinical error has caused
client injury). DO NOT ERASE, BLOT OR USE CORRECTION FLUID. Original entry must remain
visible. For computerized entry, follow agency protocol.
 SEQUENCE
• Document events in the order in which they occur.
DOCUMENTATION APPROPRIATENESS
• Record only information that pertains to client’s health problems and care.
Recording irrelevant information may be considered invasion of client’s
privacy and/or libelous.
COMPLETENESS
GUIDELINES

• Not all data that a nurse obtains about a client can be recorded. However,
the information that is recorded needs to be complete and helpful to the
client and the health care team.
• Record all assessments, dependent and independent nursing
interventions, client problems, client comments and responses to
interventions and tests, progress toward goals and communication with
other members of the health care team.
• Care that is omitted because of the client’s condition or refusal of
treatment must also be recorded. Document what was omitted, why it
was omitted and who was notified. (Remember, what is not documented is
NOT DONE.)
 CONCISENESS

• Recordings need to be brief as well as complete.

• Client’s name and the word “client” are omitted.
• End each thought with a period.

LEGAL PRUDENCE

DOCUMENTATION • Accurate and complete documentation should give legal

protection to the nurse, the health care team and the
GUIDELINES institution.
• Admissible in court as a legal document, the clinical
record provides proof of the quality of care given to the
client.
• Documentation is usually viewed as the best evidence of
what really happened to the client.
• Adhere to professional standards of nursing care but also
follow agency policies and procedures for intervention
and documentations in all situations.
ENSURING
CONFIDENTIALITY
AND SECURITY OF
COMPUTER
RECORDS
 • A personal password is required to enter and sign off
computer files. Do not share this password with
anyone, including other health team members.
• After logging on, never leave the terminal
unattended.
• Do not leave client information displayed on the
Tips and monitor where others may see it.
Suggestions: • Shred all unneeded computer-generated work sheets.
• Know the facility’s policy and procedure for correcting
an entry error.
• Follow agency procedures for documenting sensitive
material, such as diagnosis of AIDS.
• Information Technology (IT) personnel must install
firewall to protect server from unauthorized access.
Video #1
Data Collection (Basic Theory: Health History)

Data Collection
- the process of gathering information about a client’s health status
-must be both systematic and continuous in order to prevent omission of significant data.

Data base
-are information that are found about the patient and the history of the patient.
- contains all the information about a client includes:
• nursing health history
• physical assessment
• primary care provider’s history and physical examination
• result of laboratory and diagnostic tests
• material contributed by other health personnel

Kinds of Data
Constant Data – is the information that does not change over time. Ex. Race, blood type
Variable Data- can change quickly, frequently or rarely over time. Ex. us, age, level of pain.

Types of Data
Subjective – symptoms, covert data, only known to client, sensations, feelings, values, beliefs, attitudes
and perceptions.
Objective- signs, overt data (visible/can be seen or detected) detectable by observer or the nurse or can
be measured or tested, obtained by observation or physical examination. Include lab values (can be
seen, measured or tested and are not felt).

Sources of Data
Primary – client, best source of data
Secondary – all other (family, friends, other HCU and/or records)
The Client- can provide subjective data that no one else can offer
Support People – family members, friends and care givers
Client Records- include information documented by various healthcare professionals, include medical
records, records of therapies and laboratory records and must be taken in consideration of current
situation.
Health Care Professionals- verbal reports from other health care professionals serve as other potential
sources of information, promotes continuity of care
Literature- standards or norms against which to compare findings, cultural and social health practices,
spiritual beliefs, and assessment data needed for specific client conditions, nursing interventions and
evaluation criterial relevant to a client’s health problems.
CHADVASC – evaluation criteria for the use of anticoagulant, part of your assessment depending upon
the needs of the patients, information about medical diagnoses, treatment, prognoses, current
methodologies and research finding.

Data Collection Methods

Observing- to gather data using the senses
Two aspects:
 • Noticing the data
• Selecting, organizing and interpreting the data
Organizing observation:
• Signs of distress
• Threats to safety ( real or anticipated)
• Presence and functioning of equipment
• Immediate surrounding, including people
In order: life threatening>safety>equipment>surroundings
Interviewing- planned communication or a conversation with a purpose
Two approaches:
Direct Interview- structured, elicit specific information, nurse controlled and time constrained
Non-direct interview- rapport (building interview), client controlled

Types of Interview Questions

Closed questions- used in directive, usually yes/no questions, what, when, where and who
Open minded questions- used in nondirective interview, allows discovery, exploration, elaboration,
clarification and illustration, provides long answer, may start with what or how.
Neutral questions- closed, used in a directive interview, and directs the client’s answer
Leading questions- closed, used in a directive directs the client’s answer and avoid asking why

Planning the Interview and Settling

Time- client is physically comfortable and free of pain
-minimal interruptions by friends, family and other health professionals
Place - well- lit, well ventilated room, private
-relatively free of noise, movements and distractions
Seating arrangement- client in bed, nurse sit at a 45 degree angle to bed
Distance – proxemics is the study of use of space, 2-3 ft apart
Language- failure to communicate in language the client can’t understand is a form of discrimination
-use lay terms, use live interpreter when available.
Stages of an Interview
The Opening- established rapport (and orient the interviewer)
- Orientation
- The nurse will explain the purpose and nature of the interview ex. What information is needed,
how long the interview will take and what is expected of the client.
The Body – the client will communicate of what she/he thinks, feels, knows, perceives and response to
questions from the nurse.
- Includes questions that will elicit information that is needed for the assessment
The Closing- termination, techniques, summarize
• Offer to answer questions: “do you have any questions?”
• Conclude by saying “well that’s all I need to know for now”
• Thank the client
• Express concern for the client’s welfare and future: “I hope all goes well for you”.
• Plan for the next meeting
Summarize
- help terminate the interview
- reassure the client that the nurse has listed
- check the accuracy of the nurse’s perceptions of the things that were answered by the client
- clears the way for new ideas
- helps the client to note progress as well as a forward direction
Examining
- physical examination/ assessment
>is a systemic data collection method that uses observation
>uses hearing, smelling, sight, feeling to conduct the examination the nurse will use:
• Inspection, percussion, palpation, auscultation
• Head to toe or by body system

Video #2

Data Collection (Making a Comprehensive Health History)

Components of a Comprehensive Health History

• Date and time of history
• Identifying data aka biographic data
• Informant and reliability
• Chief complaint
• History of present illness
• Past history
• Family history
• Personal and social history
• Development level
• Psychological history

Date and Time of History- always important

- be sure to always document the time when you evaluate the patient, especially in cases of
urgent or hospital setting
- allows your assessment to be used by future providers
Biographic data- the identifying data
- includes client’s name address, age, sex, race marital status, occupation, religious, preference,
healthcare financing, and usual source of medical care
- usually closed questions that require specific answers because they are truth/facts.
Informant and Reliability
- source: patient, a family member or a friend, an officer, a consultant or the clinical record
- helps you to assess the quality of the referral information, questions you may need to address in
your assessment and written response
- reliability may not be precise in order to allow their healthcare workers to read your assessment
to understand that the information is not reliable.
Chief complaint – the reason that the client came to the hospital or to the clinic
- make every attempt to quote the patient’s own words
 - answer the question: “Describe the reason you came to the hospital or clinic today”
History of present times- complete, clear and chronological description of the problems prompting the
patient’s visit
- each symptoms will have its own paragraph
- attributes of a symptoms: OLDCARTS
• onset
• location
• duration
• character/quality
• associated symptoms
• aggravating factors
• relieving factors
• timing
• treatments
• setting
If the patient has 2 problems that are not related with each other, you have to have a different
paragraph for the second problem.
HISTORY OF PRESENT ILLNESS: OLDCARTS
Onset- when did it start, sudden or insidious
Location- specific location in the body, ex. RUQ, LUQ. LLQ, diffuse, generalized, left or right, etc.
Duration – how long a symptom is present ex. 5 min seizure, 5 min chest pain
- always important in diagnosis and determine the urgency of management and the kind of
management
Character/ quality- describes the type of the severity of the symptoms
For example:
Dyspnea- with moderate exertion at rest or minimal exertion
Abdominal pain- bloated, sharp, dull, gnawing, burning, pain as well as intermittent or continuous.
Pain also has an additional description which is the pain score ( identify how sever the pain is 1-10)
Associated symptom- what other symptoms are noted associated with the main problem ex. Abdominal
pain that is associated with vomiting and LBM or chest pain associated with dyspnea, headaches
associated with visual aura prior.
-are connected to each other

Aggravating factors- any situation or action that will worsen the symptoms ex. Headache that is
worse with bearing down or with bending down, dyspnea that is worse when a pt is in a
particular place (work)
Relieving factors- any situation or action that will make the symptom better
>opposite of the aggravating factors ex. Abdominal pain of appendicitis is better in a fetal
position or leg pain in PAD that is better when the leg is dangled.
Timing- when the symptoms occur
>associated with a specific event, time of the week, time of the day.
>doesn’t have to be a specific time ex. Some fevers only occur in the late afternoon or night as
in IB or some that only occurs after every meal in some types of ulcers.
Treatments- include any medication or herbal drugs or home remedies that were taken for the
problem whether received or not.
Setting- in what situations dues the symptoms occur.
 >happens only in certain situation

Constructing the History of Present Illness

Start with time- how long since you saw the patient did the symptoms start ex. 10 days prior to
consult admission
HPI- history of present illness
Sample:
Informant: Client
Reliability: 90%
Problem: DOB
- 3 days prior to admission, patient had sudden onset episodic DOB associated
with runny nose, not affecting ADLS worsened when walking through nearby
flower fields. No associated cough, fever, malaise vomiting, dizziness,
palpitations or tremors. Took salbutamol 1 tab TID and salmeterol+ fluticasone
propionate 250 mg 2 puffs with transient relief. Patient also had recent history
of URTI the preceding day. No consult done. Condition tolerated.
- 2 days prior to admission, symptoms worsened. DOB now associated with
wheezing, still not affecting ADL, nebulization with salbutamol 1 nebul done and
took 1 tab TID plus salmeterol + fluticasone propionate 250 puffs with transient
relief. No consult done. Condition tolerated.
- One hour prior to admission, patient was awakened by an episode of now
nebulization which prompted admission.

Video #3
Data Collection (Making a Comprehensive Health History)

Past history
Childhood Illness – include disease such as measles, rubella, mumps, whooping cough, chicken fox,
rheumatic fever, scarlet fever and polio
-Also includes all immunizations received tetanus, pertussis, diphtheria, polio, measles, rubella, mumps,
influenza, varicella, hepatitis B virus (HBV) human papilloma virus (HPV), memingococcal disease,
haemophilus in influenza type b, pneumoccocci and herpes zoster.

Adult Illness
Medical
Comorbids: diabetes, hypertension, hepatitis, asthma and HIV, allergies, other chronic illness
• Hospitalization
Ex. Date Institution Reason 10x Duration of the day
May 2020 Riverside Cholecystitis 5 days
Medication currently being taken
Ex. Generic Dose Tabs Timing
Apixaban 5 mg ½ tab BID
Surgical – all surgical procedures including dates what procedure and for what reason
Ex. Date Institution Procedure Reason
May 2020 Riverside Hemicolectomy Colon Cancer
Psychiatric – includes all psychiatric illness and time frame, diagnoses, hospitalizations and treatment.
OB/GYN: MIDAS CPCS, LMP, GP (TPAL)
• Menarche: age> of when the first menstruation occurred
 • Interval of Menstruation: regular or irregular or number of cycle days if regular
• Duration of menstruation
• Amount of bleeding during menstruation
• Symptoms associated

OB/GYN: MIDAS CPCS, LMP, GP (TPAL)

• Coitarche > is the age where the patient first had sexual intercourse
• Partners
• Contraceptive use (IUD) (condoms) (pills)
• Smear (PAP smear) > the date when the patient last had PAP smear
• LMP (last menstrual period) > the first day of the last menstrual period

OB/GYN: MIDAS CPCS, LMP, GP (TPAL)

• Gravida – number times become pregnant (even if miscarried)
• Para- number of times pt gave birth
• Term- number of pregnancies that lead to the birth of a full term baby
• Preterm- number of pregnancies that lead to the birth of a preterm baby
• Abortion- number of pregnancies that lead to an abortion/ miscarriage
• Live- number of living children
Answer: G6 P3 (T2 P1 A2 L3)

Family history – to ascertain risk factors for certain diseases, the ages of siblings, parent, and
grandparents and their current state of health or if they are deceased, the cause of death are
obtained.
- hypertension , coronary artery disease, elevated cholesterol level, stroke,
diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease,
headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, cancers as well as symptoms reported by patient.
Personal and social history – lifestyle and psychological history
- includes occupation; sources of stress, both recent and long-term, leisure
activities; religious affiliation and spiritual beliefs.
Baseline level of function
• Activities of daily living and instrumental activities of daily living
Activities of Daily Living (ADLs)
Bathing
Dressing
Toileting
Transferring
Continence
Feeding

• Instrumental activities of daily living (IADLs)

Using the telephone
Shopping
Preparing food
Housekeeping
Laundry
Transportation
Taking medicine
Managing money

Development level- usually best used in pediatric patients with regards to their developmental level

Video #4
Data Collection (Physical Assessment)
Types of Physical Examination
Comprehensive- complete
Focused- body system/ area
Functional- abilities

Comprehensive- an initial assessment that the patient has been admitted

-a total and complete assessment of all body systems which are normal and which of them has
significant changes.
Focused- usually used in cases when we need to examine a particular area based on the symptom or the
complaint of the patient.
Functional- examine one or more aspect of a client’s ability such as: ADLs> to determine the functional
ability of the client.

Physical Health Assessment

• to obtain baseline data about the client’s functional abilities
• to supplement, confirm, or refute data obtained in the nursing
• to obtain data that will help establish nursing diagnoses and plans of care
• to evaluate the physiologic outcomes of healthcare and thus the progress of a client’s health
problem.
• to make clinical judgements about a client’s health status
• to identify areas for health promotion and disease prevention
2 Aspects of Assessing the Client’s Health
1. The nursing health history
2. Physical assessment

HEAD – TO – TOE FRAMEWORK > most clinically used

Health assessment- conducted in a systematic and efficient manner that will result in the fewest
position change for the patient.

• General survey
• Vital signs
• Head
-hair, scalp, face
-eyes and vision
- nose
 - mouth and oropharynx
• Neck
-muscles
-lymph nodes
-trachea
-thyroid gland
-carotid arteries
-neck veins
• Upper extremities
-skin and nails
- muscle strength and tone
- joint range of motion
- brachial and radial pulses
-sensation
• Cheek and back
-skin
-thorax
-lungs
-heart
-spinal column
-breast and axillae
• Abdomen
-skin
-abdominal sounds
-femoral pulses
• External genitals
• Anus
• Lower extremities
-skin and toenails
-gait and balance
-joint range of motion
-popliteal, posterior tibial, and dorsalis pedis pulses
Shift assessment- in order to use as a baseline in order to compare the later data focused on the
immediate needs and problems
Observe
• level of consciousness
• skin color
• respiratory effort
• nutritional status
• body position
• speech
• hygiene and grooming
• Check vital signs including pain
• Auscultate lungs and apical pulse Can point to a life- threatening condition
• Check capillary refill and peripheral edema
• Auscultate bowel sounds
• Observe skin turgor and surfaces for lesions
• Observe mobility
• Examine drains, catheters, wound dressings, or tubes: location, patency, and description of
drainage, if any.

PREPARING THE CLIENT

• Explain the procedure
- What, when, where, why
• Reassure confidentiality
• Determine in advance any positions that are contraindicated
• Empty bladder
• Proper draping
• Children: least invasive to more invasive
• Adult: the head and neck, heart and lungs, and range of motion- ears, mouth, abdomen, and
genitals

PREPARING THE ENVIRONMENT

• Convenient time
• Well lighted
• Organized equipment
• Warm room for the patient to be comfortable
• Private
 PROPER POSITIONING

CLIENT POSITIONS AND BODY AREAS ASSESSED

POSITION DESCRIPTION AREAS ASSESSED CAUTIONS

Sitting A seated position, back Head, neck, and Other adults and weak
unsupported and legs posterior and anterior clients may require
hanging freely. thorax, lungs, breast, support.
axillae, heart, vital
signs, upper and lower
extremities, reflexes
Supine (horizontal Back-lying position Head, neck, axillae, Tolerated poorly by
recumbent) with legs extended; anterior thorax, lungs, clients with
with or without pillow breasts, heart, vital cardiovascular and
under the head. signs, abdomen, respiratory problems.
extremities, peripheral
pulses.
Semi- Fowler’s (30-45 Back lying with head of Jugular vein distension May be uncomfortable
degrees) the bed elevated unless the foot or knee
approximately 30-45 is elevated slightly.
degrees.
Sims’ Side lying position with Rectum, vagina Difficult for older
low ermost arm behind adults and people with
the body, uppermost limited joint
leg flex at hip and movement.
knee, upper arm flexed
at shoulder and elbow.
Dorsal recumbent Back lying position with Female genitals, May be
knees flexed and hips rectum and female contraindicated for
externally rotated; reproductive tract. clients with cardio
small pillow under the pulmonary problems.
head; soles of feet on
the surface.
 EQUIPMENT AND SUPPLES

EQUIPMNENT AND SUPPLIES USED FOR A HEALTH EXAMINATION

SUPPLIES PURPOSE
Flashlight or penlight To assist viewing of the pharynx or to determine
the reactions of the pupils of the eye.
Opthalmoscope anyway A lighted instrument to visualize the interior of
the eye.
Otoscope A lighted instrument to visualize the eardrum and
external auditory canal. (a nasal speculum may
be attached to the otoscope to inspect the nasal
cavities)
Percussion (reflex) hammer An instrument with a rubber head to test
reflexes.
Tuning Fork A two-pronged metal instrument used to test
hearing acuity and vibratory sense.
Gloves To protect the nurse.
Tongue blades (depressors) To depress the tongue during assessment of the
mouth and pharynx.

METHODS OF EXAMINING

• Inspection
• Palpation
• Percussion
• Auscultation

1. Inspection
- Through a visual examination which uses assessment using light, sense of light or eyes.
- Celiberate, purposeful and systematic.
- Moisture, color, and texture of body surfaces as well as shape position size, color and
symmetry.
- Sufficient lighting (natural or artificial lighting)
- Can be combined with other assessment techniques in order to perform the assessment
simultaneously in an efficient amount of time.
2. Palpation
- Examination of the body using the sense of touch.
- Texture, temperature, vibration, position, size, consistency and mobility of organs or
masses, distention, pulsation, tenderness or pain.
TWO TYPES:
Light
Deep
PALPATION: LIGHT

- Always precede deep palpation.

- The nurse will extend the dominant hands/ fingers parallel to the skin surface and gently
press while moving in a circular motion.
- Light Palpation, light depression of the skin.

PALPATION: DEEP

- Not done during routine examination and will require a significant skilled practitioner.
- Requires significant practitioner skill.
- Extreme caution: can cause damage.
- Not indicated in clients: can cause damage
- Not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
- Is done with 2 hands or can be one hand.

PALPATION: TEMPERATURE AND VIBRATION

TEMPERATURE: Use the dorsum (back) of the hand and fingers

VIBRATION: Palmer surface of the hand.

TACTILE FREMITUS VIBRATION OF

CHEST WALL ASSESSMENT

- vibration coming from the lungs Examiner feels for changes in

when the patient is vocalizing. intensity of Fremitus by palpating
chest wall.
- result of sound transmitting through
lung tissue.

CAUSES OF FREMITUS CAUSES OF FREMITUS

-excess air in lungs *LUNG CONSOLIDATION

-thickness of chestwall - air in healthy lung replace

something else (inflammatory
exudate, blood, pus, cells)

PALPATION: GENERAL GUIDELINES

* The nurse’s hands should be clean and warm and the fingernails short.

* Areas of tenderness should be palpated last

* Deep palpation should be done after superficial palpation

PALPATION

Assist a client to relax by:

1. Gowning and draping the client appropriately.

2. Positioning the client comfortably.
3. Ensuring that their own hands are warm before beginning.

3. PERCUSSION
- Act of striking the body surface to elicit sounds that can be heard or felt.
- Determine the size and shape of internal organs by establishing their borders
- Indicates: fluid filled, air filled, or solid
TYPES
- Direct
- Indirect

PERCUSSION: DIRECT

- Strikes the area with the pads of two, three, or four fingers or with the pad of the middle
finger.
- Movement is from the wrist.

PERCUSSION: INDIRECT

- Striking of an object held against the body area to be examined.

- PLEXIMETER- finger being hit
- PLEXOR- finger striking
- Strike distal interphalangeal joint.
- the angle should be 90 degrees
- the blows must be firm, rapid, and short to obtain a clear sound.

PERCUSSION: SOUNDS

-Describe according to its intensity, pitch, duration, and quality

PERCUSSION SOUNDS AND TONES
Sound intensity pitch duration quality example of
location
Flatness Soft High Short Extremely Muscle, bone
dull
Dullness Medium Medium Moderate Thud like Liver, heart
Resonance Loud Low Long Hollow Normal lung
Hyperresonance Very Very low Very long Booming Emphysematous
loud lung
Tympany Loud High Moderate Musical Stomach filles
(distinguished with gas air
mainly by
 musical
timber)

4. AUSCULTATION
- Process of listening the sounds produced within the body.
- describe according to their pitch, intensity, duration and quality
PITCH- frequency of the vibrations
INTENSITY (amplitude)- loudness or softness of a sound
DURATION OF A SOUND- length (long or short)
QUALITY OF SOUND- subjective description of a sound, for example, whistling, gurgling, or
snapping.

DIRECT AUSCULTATION

- using the unaided ear

- not using any materials for the hearing

INDIRECT AUSCULTATION

- using a stethoscope, which transmits sounds to the nurse’s ears.

- Using stethoscope

DATA COLLECTION
• OTHER SOURCES
• DIAGNOSTICS
• MEDICAL CHARTS

Diagnostics and Procedures- will yield important data for the diagnosis and management of the patient.

Intraop Record- can get a lot of information it could have a bearing with the care plan.

• Vital signs
• Blood or fluid loss
• Devices
• Procedure
• Final diagnosis

Intraop Technique

• What was done

• Intraoperative findings- can show that there were pus, absess, and infections once they open
the abdomen.
• Surgeon
• Nurses involved
• Final diagnosis
 MEDICAL CHARTS
COMPONENTS OF THE SOURCE-ORIENTED RECORD
FORM
Admission (Face) Sheet
Initial nursing assessment
Graphic record
Daily Care Record
Special Flow Sheets
Medication record
Nurse’s notes
Medical history and Physical Examination
Physician’s order form
Physician’s Progress Notes
Consultation records
Diagnostic reports
Consultation reports
Client discharge plan and referral summary
INFORMATION
legal name, birth date, age, gender, Social
Security number, address, marital status, closest
relatives or individual to notify in case of
emergency.
Date, time, and admitting diagnosis
Food or drug allergies
Name of admitting (attending primary care
provider)
Insurance information
Any assigned diagnosis related group (DRG)
Findings from the initial nursing history and
physical assessment.
body temperature, pulse rate, respiratory rate,
blood pressure, daily weight, and special
measurements such as fluid intake and output
and oxygen saturation
Activity, diet, bathing, and elimination records
Examples: fluid balance record, skin assessment
Name, dosage, route, time, date or regularly
administered medications
Name or initials of individuals administering the
medication.
Pertinent assessment of client
Specific nursing care including teaching and
client’s responses.
Client’s complaints and how the client is coping.
Past and family medical history, present medical
problems. Differential of current diagnoses,
findings of physical examination by the primary
care provider.
Medical orders for medication, treatments, and
so on.
Medical observations, treatments, client progress
and so on.
Reports by medical and clinical specialists.
Examples: laboratory reports, x-ray reports, CT
Scan reports.
Physical therapy, respiratory therapy
Started on admission and completed on
discharge: includes nursing problems, general
information, and referral data.
That's what we do with the data we have So what this organizing data it's also referred to as of course
processing of data in an organized fashion or in a systematic fashion OK so it's place already in a way
that they are clustered no according to a certain criteria so assessment formats a very from institution
to institution and we could make use of certain models or frameworks to organize the data that we have
collected the first model not our framework examples of this are your good dogs functional health
pattern yourself care model by Dorothy Oregon now and calista Roy's adaptation model are you still
familiar with this honestly

they are saying clear risks right so unsexual models or frameworks would help us get close to the top
that are related to each other OK so we can make use of this conceptual models or frameworks to
organize gate to cluster the data that are related to each other and will later on guide us to have a
clinical picture not of a certain aspect of our patient another assessment format is your Wellness model
it includes factors that influence levels of Wellness further examples of the Wellness models for example
one example of a Wellness model is the lifestyle OK what are the lifestyle collectivistic Sabha certain
patient press source a health risks another example would be the nutritional characteristics of the
patient so these fat words influence the Wellness of our patient along the continuum of health OK so we
can make use of these models full cluster and lifestyle practices what are the what is the common dying
of your patient what are the common stresses or health risks that your patient is presented do so these
are different factors and attitudes that influence the level of Wellness of our patient debug stress buying
lifestyle beliefs and practices not like for example they believe in organic king among a food or they
believe in nonmedical therapies Gaelic for example a few fresh or acupuncture so those are certain
models that we can use now to determine not the Wellness of our patient and of course last but not the
least are your non nursing models so not nursing models examples of these are but these systems model
your maslow's hierarchy of needs and the different developmental theories have you learned already
the developmental theories in your 100 yes or no

guys I'm not yet so I think you'll be learning it in your phone and of course part of your pediatric nursing
in your second year you will learn these different humans are developmental theories or theories of
development so again not as a summary so we make use of assessment for months such as conceptual
models or frameworks Wellness models and non nursing models to organize or cluster not related
information from the assessment that we have made not by collecting your subjective and objective
views so here is an example of organizing data affording to Gordon's functional health patterns OK so
the first column indicates the functional health pattern OK so let's take for example health perception
and management So what are now the different patterns now of health and well being and how is
health managed by the lion examples of the data that you put in here are compliance to medication red
chimneys is the client is the client what is Shane shoes thinking his or her maintenance medication is the
fly as does the fly and abide by the die yet or the exercise pattern or regular check up perception health
management so next is your nutritional and metabolic pattern so here we cluster no pattern of food and
fluid consumption related to the clients consumption so in relation to that so we check aside from the
diet patient we also check the condition of the steam thief here nails because my brains as well as the
height and weight so quickly pointed at my enclosed I mean if I was not BMI now of the patients end
nutritional metabolic our height and weight is a reflection of our nutrition
when it comes to physical activity guess activities of daily living because the activity and exercise of our
patient affects not our cardiovascular and respiratory status from The Walking Dead by these are Arabic
exercises that of course keep our heart and loves healthy so those are examples or another example is
the role relationship pattern of your patient and yellow mulation ships with a significant others and your
major roles and responsibilities as a mother as a father as students not as children OK so mega affect
applenet condition some patient remember the patient is not just a fishel logic being my psycho
emotional my spiritual my cultural my social aspect activation so we organize this data according to the
garden so mccluster similarly have another example Royce adaptation model so the roys adaptation
model our partner aspect now the fish ological functions the self concept the role function and the
interdependence of all these functions to each other low students

sorry we had a glitch so I had the glitch here with my Internet connection can you already hear me this
means OK thank you so let's proceed

Feedback exercise for example you took the blood pressure of your patient to which aspect
physiologique self concept role function or interdependence new chelis section app did you say become
blood pressure are very good so that's an example a self concept unbold should be for example like I am
a I am a mother of two kids visual logics of concept role function are interdependent I really function so
those are examples not of clustering data not according to this model let's proceed with your human by
the organ system so this this is an example already of your non nursing model see so let's take for
example the WBC count of your patient the initial look back among the different human body systems
there presented WBC count circulatory ZWB circulatory so then WBC is is responsible for what pretty
good immunity lymphatic system how about blood sugar not really very good in the crane system OK
exercise and activity pattern muscular means they're very good muscular let's give them an abnormal
body weakness you can give me actually two systems for body weakness they include well very good
nervous system and muscular system how about heart treat very good circulatory system how about
diarrhea diarrhea patient very good they just give system up skeem furger so very good menstrual cycle
email very good your female reproductive system chest X ray result of your patient very good yard
respiratory system actually played it line some heart so mobile and when I search as X ray couldn't
enlarged our heart so uh there and then additional national later on but basically just X ray would reflect
the condition of the lungs of your patient respiratory system OK so just a little tip from this woman
budget problems of your patient OK now meet the meet born no model not for organizing your data is
the body organ systems model we shall logic problem sufficiently how about can psychologic or psycho
emotional usually we make use of the Gordon's functional health patterns OK so I'm not sure guys
importance of organizing your data OK so let's proceed

this is another example of your non nursing models that different developmental series you will learn
more about this not as you go along and these for me have this is one of the very interesting topics not
when you are already in your SIM because you begin to understand no why you are thinking that way
why well your relationship with other people the ideology Sigmund Freud for psychosocial development
Erik erikson for psychosocial development Jean piaget for cognitive development and Lawrence
kohlberg for moral reasoning OK so now maybe check my Skype did you know many mention behind or
this is how you will cluster your data especially if you are assessing no the stages of growth and
development of your patient OK so for example your patient is a priest school child OK so I know
normally gay I initiative versus guilt OK so preschool age are afraid to be scolded no they are afraid of
punishment not so I'm not sure and of course for the phallic stage they are now becoming interested no
of there being male or female huh somebody sting wished I I'm a girl well I'm a boy OK how about
adolescence to adulthood or so so cognitive development changing this is how you will approach or you
will approach the lessons and adults for most thinking that so they could already explain things they can
already give rationale for their actions now so those are the different developmental theories that will
guide us on what are the normal OK behaviors of our patients as a search at a certain age so during
assessment normally I'm young last psychosocial development as psychosocial is normal OK so those are
the developmental series models that you can use to cluster data I normally and young thinking normal
reasoning OK or we keep development open in front or this is how they move this is how they interact
with equal gay so Nicola I don't trust versus mistrust not on backpack in the shop some other person I'm
gonna get there so yeah Bruce so I'm gonna get my trust there is still mistrust so I'm not sure adapter
mean that when we are assessing our patients with regards to what is normal and what is abnormal
following the different developmental OK so this is this model will help us organize not data that are
related to each other and these data will reflect a certain aspect of the client OK he didn't wanna class
my determann later on I'm normal abnormal during your analysis and sentences in the diagnostic page
or the nursing diagnosis face so that is why assessment is very very important as the first phase of the
nursing process OK so after you gather you organize your data OK because organizing your data will
make it easier for you to go on to the next phase which is diagnose now after organizing the data we
need to validate it what is the purpose of validation to verify data or to confirm data if it is complete if it
is factual and if it is accurate we don't just list right away because there are certain data subjective and
objective data that are fun flick Ting not malicious she feels warm she feels hot clear temperature
normal so I need to validate the feeling of the patient can develop on mug menopause I'm patient OK so
when you when the patient tells you I feel hot I feel warm it doesn't me right away that the patient has
fever OK that's because of the effect of the hormones gonna give time information OK so after
organizing your data you validate the data you double check you very fight to make sure that what we
the data that we have collected or gathered is complete factual and accurate OK So what are our
guidelines number one ensure that the assessment information is complete this is very very simple just
make sure that your history taking information sheet as well as your physical assessment data sheet is
complete OK my template number two we need to ensure that the subjective and objective data agree
with each other what do we mean by this inside OK for example patient tells you not gingka lot injury is
but upon your assessment you notice that it's not an insect bite it is a cigarette burn if we did and then
you could ask to verify now when did the when the when did the insect bite you OK then better mean if
the patient is really telling the truth by uh reviewing no this stages of the inflammatory process but we
need to ensure that the subjective and the objective data go inside another is full for example manner of
the fracture or manner of the dislocation does not go inside with the way the patient is you can find
notion who gay or not gay for example but yes so that pallab Bruce why is it not no so there are certain
things that we need to verify so we have further questions not like the manner of the injury next is we
need to obtain additional information that may have been overlooked so as we as you go along now as
studying the different assessment of our patient from head to toe now to be discussed in your midterms
and your finals you will be able to learn further no information that needs to be gathered for each part
of the body or for each system of the body OK next is we need to differentiate between cues and
inferences OK subjective or objective data that can be directly observed is known as your cues and
infrared is the interpretation of the nurse or conclusion based on the cues for example the patient has
LVM queue patient has sunken eyeballs that's a cute patient has sunken one panels that's a cute what is
an inference the patient may be dehydrated that's an inference because that's already the nurses in
interpretation or conclusion based on documents OK so that's the difference between a Q and an
infrared OK I know there example the patient is walking through and fro OK that's a cute the patient is
walking to and fro what's an inference the patient is agitated Speech OK that's an inference already so
we need to differentiate now our own interpretation from what is factual what is happening with
suppression OK and last minute they least avoid jumping into conclusion and focusing in the wrong
direction to identify problems I will not shop now we always look at the patient objectively and all
subjectively throughs are taken as is OK patient right so remember it now I'm critical thinking and bias
OK so that's part of critical thinking when you are gonna be playing so points to remember not all data
requires validation OK like laboratory studies OK when I'm with the result celebratory see that's what is
the reflection based on the machines not the termination of the for example the CBC the blood levels of
your patient I'm like wait maybe sharing tools and that height and weight is standardized already so
quote 555 no need to validate again I will tell you what type then what we have they're nice instruments
OK so just make sure that it is well calibrated and at weighing scale for the week OK next is the nurse
validates data when there are discrepancies between the data obtained in the interview and the
physical assessment similar to the example I said earlier I'm just need I got called West gay I was like the
temperature it's normal OK I feel feverish don't feel good are normal that's what I felt last week yes yes
last week booster feeling you need to validate now if there are discrepancies next is you need to be
aware of your own biases values and beliefs and separate facts from inference interpretation and
assumption gay So what we always make sure is what we are documenting and what we are stating in
the database of our patients are facts interpretation we do not say their patient is agitated no patient is
walking to and fro so move you are making inferences already if you are diagnosing you are patient but
not yet in assessment gay you don't put there in your assessment patient is anemic no what we put
there is RBC count I'm moving my 12 patient is fail there is fire there is sweetness we don't put their
patient is anemic that way they don't make inference or interpretation OK patient is paralyzed patient
and able to move extremities patient is paralyzed because it's already interpretation McGee who I'm
able to move right arm unable to move left leg so I'm looking at Next is to build an accurate database we
must validate our assumptions regarding clients cycle and emotional behavior OK must difficult to
validate can psycho emotional because it is body to given to you is subjective no no it's quite difficult to
validate it it is subjective data because subjective data is the clients own opinion of a certain condition
of himself or herself yeah so we take it patient we write it verbatim Lauer clear email check the
feedback temperature 36.9 degrees Celsius eight delete oil you will make use of this data to analyze and
this synthesize when you're already buying the client feels warm they don't normally when I meet young
temperature so you analyze one and yes unmixed face that's why I cannot learn accurate unpacked
document assessment feedback So what are the different guidelines that we need to follow and validity
OK first is to compare subjective and objective data not to verify client statements with observation
client feels warm check them clarify any ambiguous or vague statements for example client tells you I
feel sick I feel sick general OK so you need to clarify what are you feeling is there any pain do you have
any business comforts did you have any injury no Superman put on motion to clarify who are sick I know
probably take shot I feel sick some bolka I feel sick simply vicious psychologically sick or physically sick
be sure that your data consists of cues not inferences yeah it's working all and fro why can't yes Sir
patient is agitated because it's already an inference a patient is walking to and fro center not keep still
that's cute OK so that's how you takedown your notes huh assessment findings next double check the
data that are extremely abnormal example patient is sitting down very calm pillow on blood pressure
200 / 120 asking how are they laugh they check or request another nurse check you want abnormal
needed another example are great yeah pretty long what's the normal heart rate it's 60 to 130 heart
rate so when extremely abnormal very high or very low data OK so they didn't sign up the five owners
no would would exercise now how many extremely abnormal just to make sure I did laugh dating is
double checking extremely abnormal with it next is better in presence of factors that may interfere with
accurate measurement for example bug hi leans they have full health hey Helen I never spirit for you
read yeah of course if the factor that the patient has just arrived the patient walked no or ran on to say
we affect of course the accuracy of the respiratory care taking from your patient another would be
blood fresh word so of course 130 vital signs taking now but prior to taking the blood pressure patient
should be rested correct do you agree with me students guys are you still there can you give me some
some reactions there

signs not discussion they knew anything 101 our skills lab enter back in your vital signs I someone that
shut well so another example is italianissimo movies great well now it's a CG OK when taking the ECG
stop will appoint no Julie remove so gonna remove that cell phones or metals like coins and jewelry
from the patient because taking the ECG took my metal somebody will have an erratic result because of
the static cost by metals and magnetic magnetic media vices gay kiss on patient and come with update
I'm underside real some bad method no remove the heart attack the patient the interference accurate
measurement so that means proper positioning of the patient now and taking a CG as well as proper
placement of the program or of course removal of metals in the body OK so these are this is just an
example Thursday meeting for fear with after eight measurements OK and of course last look at the
least use references to explain phenomena go back to the books that is normal what is subnormal what
are the updated information that may help explain the condition of our patient examples I'm I'm go back
now to references so these are some of the guidelines that will help us validate our assessment the OK
check and compare check OK before you document your assessment data so we organize then we
validate our assessment feedback after organizing and validating we document documenting is the
recording taking down notes of all the assessment findings that we have gathered through interview
huh physical examination and of course our assessment So what is a report not a report is an oral
written or computer based communication intended to convey information to others so our report we
do it through our endorsement underreport is to an endorsement so we convey information to the next
 shipment runners we convey information to the physician when we are documenting all when we are
making reports right doctor patient has not eaten the whole morning since Aretha that's an oral report
also the chart or clients records is a formal legal document that provides evidence of client care it can be
written or for people take note here that they have underline formal document and I placed aye aye aye
made the evidence no word read one yes I want that the chart or the client report is a formal legal
document that's why we ask ourselves should be very careful and we should follow guidelines and
policies when documenting data even just for assessment they will just formal especially in assessment
and of course all client care activities the whole of the patients chart is considered as a legal document
and when legalities matter it can serve as evidence in court and that I needed next I see you reach
second year after your capping you will be already hopefully not having your exposure in the hospital
beside McGrath balance and temperature some patient OK it should be accurate it should be
documented correctly and accurately in the patient chart in chapter word 8 inch in temperature wipe it
high temperature low my shop temperature is very very important than the woman to support
unfamiliar it can serve as evidence so very very carefully when document so the process of making an
entry is but of course recording charting or documenting so Mama let's start with that and here please
take note the nurses accountable and should document according to organizational policies and
universal standards so the main basis for documentation organizational policies and universal standards
so even just know what our student nurse final, you're already part of the health care team if you are
there having your RLE exposures in the hospital so left align I also intake and output accurate take one
100CC again in Rome with that 1000CC where did the 900CC come from or be it will matter later on
especially if it will be used as evidence in court no someone left here next word with make short supply
ads hey it's remember accurate documentation is essential and should include all data collected about
the client's health status and still the same data are reported in a factual manner not based on the
interpretation of the nurse also avoid restating or fire freezing clients subjective feedback it should be
documented in verbatim in quotation marks with lab you are thought was a subjective data quotation
mark I feel sick I feel sick I feel like I'm going to harm it I feel like I'm going to vomit when patient is not
cheated interpretation but I feel no shame no I feel like I'm going to vomit not the interpretation that no
patient is no sheated analysis later on but what you will need to document is the patient said I feel like
I'm going to vomit OK because saying no patient saying I feel like I'm going to vomit doesn't necessarily
mean nanosheet patient expression or for example yeah interpretation so it should be documented in
pay fine Pena has many other interpretations aside from being machine that's why when we record top
one but end we don't have money patient subjective data listed the best chance not avoid judgment or
conclusions example normal appetite what is normal for you may not be normal for the patient how do
you document it properly ate half of the rice consume one glass of milk and one apple and one whole
egg OK so one apple half cup of rice one glass of milk you don't put their normal appetite so that's an
example now document what is factual what really happened what the patient is we don't document
the normal appetite heavy I'm gonna no you document what has been functional huh so clear that that's
how we document no when we are assessing our patients game able to walk four steps without
assistance nothing about I did not get any patient has is paralyzed or patient has a para pleasure a
patient has muscle pain before steps gay so I think it back make judgments or conclusions OK so that's
how we document the fact accurate and batch OK so there are 13 main guidelines for recording patients
data OK we'll discuss them one by one let's start with your date inside OK when you're documenting
 make sure that you have stated the date and time for each recording hey I'm the arrest Michigan
interview I know my date so not last charts on patient not name of the patient my baby not that time so
time can be documented in 12 hours now clock AM PM or it could be a 24 hour military flag on 24 hours
not signing OK so timing documenting should be done as soon as possible after an assessment or doctor
intervention do not document before you have done the assessment or intervention and the after hey
this way when you are in the clinical area you are required to have a small multiple alright you know
why some vital signs my notebook they pause are both substation igrafx patients chart you don't bring
and graft beside the patient so the last small notebook so last small notebook vital signs station
graphing hey so do not draft before assessment is done next legibility for written documentation so for
written documentation your penmanship should be legible and easy to read hand printing or easily
understood handwriting is permissible so use always now we avoid script or shorthand we might seem
what's not shorthand now so we don't make use of that one one word short long abbreviation gay boy
I'm because because we are very right now huh we are very adjusted that with text messaging my short
and I need uh online Bible way BTW I know but not usually now we avoid those things damn pause no
I'm big like an awkward messy so legibility should be very important now class we are different from
physicians OK so the documentation legible and he knows this notes Or success meant sheet so I can
match question next for recent documentation it should be written in ink or permanent pin one last
time add it's short boil pin not sentence now invent mega blocks stop Ben and usually client records in
the chart are double sided so bullpen no sign for electronic records changes are made in accordance
with software guidelines OK got under that device within some program that you cannot change the
information OK when you type something to change that are red shirt so you will learn more of those in
your nursing informatics such OK so again I'm finding a firmer right after and we do not document on
the next day OK so that part well once again access to the moment document do not have that habit
tomorrow so let me know right after that assessment so legibility practitioner proper handwriting for
those now maybe fakulty when it comes to 10 month ship it I'm gonna say remanent next would be
accepted terminology we make use of commonly accepted abbreviations symbols and curves you will be
fought with regards to the symbols and terms let me give you an example in the comments among us a
symbols I'm with Nathan is C with a bar on top and without ass with a bar on top so call 1 with those
without so uh those are just examples that I am sharing with you that why not you will be taught in your
fundamentals in nursing of the common abbreviations symbols and things you can also refer to the bold
examples of hey correct spelling please take notes in spelling gives a negative impression to the reader
and decreases the credibility of the nerves so make sure that when you are writing you are writing with
correct spelling signature it should include the mean and the title of the nurse so call me OK for example
when word art in yeah I still did 1S N CS that means student nurse got from CSD so for electronic records
of course you will have your own code or password not word my school my number or some boy for the
nurse that is unique to you for electronic records right so here based on the joint permission this is
established worldwide a here are the do not use list of symbols and units huh do not use you for unit
because it can be mistaken for zero or #4 or Sissy my balangir so word name where I used it can be
misinterpreted as intravenous or #10 the printer so right give international you me QD QD qod every
other day right get daily or every other day gay are you that but my zero open my zero or leaving 0
decimal point is mixed well who are Latin zero bye bye 10 milligrams study by 100 milligrams so one
whole number numb and long in the .0 gay solid 0 Norman leading zero popping decimal so when
decimal 0.25 ML beat song give after 70.25 ML bye see Abby Mila 25 MLK in Mesquite so when my when
does emotional fraction 0.25 and end so 0.25 one whole number misinterpret it is open yo hey
magnesium sulfate morphine sulfate magnesium sulfate it can be confused for one another so right my
long I'm more painful feet with magnesium sulfate OK so please take note of this multi very cool and
may the misinterpretation may affect not your care for your patience so please take note he shall not
lose my list OK so basically right now I've been talking to clamp row it could matter no.25 zero point
25ML it's way smaller than 25 10ML big difference man 110. Soldner document that accurately
especially on numbers terminology correct spelling and of course proper signature that's move on to the
next one you receive now we gonna see a curacy first reminder the clients name end identifying
information should be stamped or written on each beach of the client record every pitch so cut the
document my so let them mean supplier number date today time today special gear is needed when
clients have the same last name twins baby eight baby patient will BB8 baby be like the world is my you
wanna see you silly apellido Ruiz baby baby be similar OK my junior and senior in one syllable father and
son lucila my junior amazing you're my junior my daughter did forgive so special theory is needed
specially if not so clear we carefully must recheck give up you're holding the correct chart no not now it
could happen huh next would be I create locations consists of facts or above our observations not
opinions or interpretations again avoid your own interpretation I have given examples that earlier I
don't need elaborate on that now avoid general words like large board normal not because what is large
for you may not be large for others what is good for you may not be good for others like appetite
normal appetite normal weight measurement OK so short the clients ossific data the exact measure
when it comes to appetite when it comes to weight when it comes to height wrong when it comes to
size measure get 20 by 30 by 70 centimeters large it's not measurement shooting placement right on
every light never between lights so some idling yeah that's in between lines blocker no one and three for
each line on the chart again one and P for each line on the chart I know to building increases one entry
or one sentence well well we always remember that if there is a blank space draw a line through the
blank space so that no additional information can be recorded at any other time or by any other person
and then sign the notation what do I mean by this right remove make it 9 I swear so this is sample this is
one night my end vehicle blue for example of your writing I'm entry here Internet edge open end 39.
Hey so team So what do I do by Mary mean a blank space they didn't mention that yeah and then you
sign at the end I partner in Vietnam so and treat that is your protection asked the nurse now again
Wednesday night my line then they blank space add or draw a line on the blank space and then sign up
the end the game clear the bat so I the up went and tree I will put a line to complete that total to
complete the blank space and then I will sign and that is what is meant by this diagram that that will be
legally implicating on you good luck to you someone protection our entry in there is so next when we
draw a single line in the paper name and initials above or near the line depending on agency policy in
Chandler because it may be interpreted as a red flag not not follow my errors appear some patient no so
do not put the word error so the original entry must be visible so crash out one line laugh but I'm
intrigued playing the original entry should be visible for computerized entry follow the agency profile so
it depends you will learn it for your during your nursing informatics here I have also placed in all caps do
not erase do not block or do not news for action fluid for correction in our patients sharp mortal sin my
blood or my gamut correction loaded while lap hey goodnight again but highlight so here like increase
maybe for example so let me get intrigued what do I do please align insert that shot I will put my initials
here and then of course enter the entry I am sorry with the correct entity after how many inches my red
line and then my signature going up that means get delete for not sure I am the one in the Panama
shopper momo I am the one who deleted it and this is my correct entry and then in playing again delete
gay in in sign language not OK so that's how we make corrections if we have entered a mistake not are
my errors but as much as possible yeah writing and erroneous data on the patient chart I know love
much quote brass much as possible in Hawaii and madelung before check see patient is with me I can't
get my patience I'm gonna give me alright I'm gonna give me a call along about Ben sleeping my blow
my black and my red and she's depending on your ship mice scratch so let me check my email when
insert for now right Lena or Romeo notebook correctly section so I'm gonna eat that remove also left so
scratch rewrite rewrite miss transferring sharp or my hand hey so that is what happens OK OK so that's
clear accuracy can I have a thumbs up if clear on accuracy

OK very good connection manager Wi-Fi man OK so we're done with accuracy OK so very important give
me accurate and of course please take note that we should know how to properly correct the data that
we have encoded and we always make sure that what we have encoded in our patients chart is correct
A and accurate 5th minutes right deafness when your document and how animal dilone relax make sure
that you are confident that you are doing it correctly winning short scratch on my back on 3rd check
things before entering the bases once in break on what you are doing You mean that give me classmate
some more then I got charging then I got graphing students with my mother graphing charting

Yeah and each word time you said they serve Goodman in I'm miss or I serve as Sir 100 10/5 I'm missing
OK indeed make erase a indeed yeah but then that first year is action and they have a thumbs up on that
yeah in the there is always the proper way to correct on this OK and don't be afraid to say your CI Sir but
then long OK people all the more again it is it is move that game let him in jail indeed how we will be
there to guide you and supervise you on how to do it and upgrade again mine and what you are hey
when you're already in bed I know my job if you're doing it correctly and the confidence that UCI is there
guiding you and do it properly it can be smooth on your own have that motivation I will do this properly
I will concentrate I will write OK so I'm gonna show they are coming that to guide you and that to school
you has to dance I'm gonna have I need that make you help you learn how to do it properly so in human
in human responsibility is to do it correctly and confidence hey no OK let's move on to sequence the
document the events in order in the order in which they Porsche because when we document it should
be in 859 no pick a weird man listen to Asha this one gives the soil gain gain miss if I did look really long
but I know trouble look so weird OK so that part according to the timeline in which sequence so my
documentary mobile charting hey according to the events as they work and according to the
interventions as you did in oral care unbold remove minutes next is appropriateness record only
information that pertains to client health problems and air recording of irrelevant information may be
considered as invasion of clients privacy or you will be accused of libel libel hey it's a boy I'm glad that
patient hey so you are recording now or you are assessing now the local discharges of your patient I'm
up at the and and fuller I got serious steaks or your mom with my things abdomen because you're
accessing expression and war city diner you don't need to document it cannot expression G because
that's relevant information to your client care and lab charges they're giving birth OK later on from the
list emotional I'm sorry please now subjektive Don or sing diagnosis listening or I'm ciety chart because if
he can be considered a flight now or it is already an invasion express that so appropriate client
physiological response after giving birth hypogastric theme local discharges so that's just an example
that the nurse should also consider the appropriateness of the information that he or she is
documenting in the chart OK want to give me information but we also consider appropriateness when
we are document especially patient know sometimes they're psycho emotional normal I know you
expressed that's good one next is complete not only fast but the nurse some things about the client can
be recorded whoever they information that is recorded needs to be complete and helpful to the client
and the help So what we need as I've given the example earlier complete this charges amount
defendants and independent nursing interventions client problems client comments and responses to
interventions and tests progress towards voice and communication with other members of the health
care team condition or what does this mean for example the client refused super thanks yeah used to be
intubated so document what was on mitted why it was omitted and he was not ified so for example
client refused integration Paris informed hey refusal form refusal form or be an art form sign in sign
sufficiently I'm using cell form they may receive cell form so that's why the client has the right to self
determination client has the right to open refuse in our client here yes document it so have the client
side I'm I'm sorry or that do not receive one so Please remember what is not documented is not bad
play document refusal if you're the best scared beginner document when it comes to port remember
next is so they should be lion's why is playing simply refuse intubation so no need client refused
intubation refused intubation if you sounds form sign that means inside my client and end each spot
with a period so very concise but so this is where your training in grammar and English comes in maybe
English because it will be applied in your documentation my my appreciate you amigo making 6 it is
applied in our you don't need to be alive document but basic English and proper so now it's not easy
sweet we need to make it the horse left but not the least is legal prudence since the chart is a formal
legal document that serves as evidence in case of legal problems how are you guys so after it incomplete
documentation we'll give perfection to the nurse the health care team and the institution so when you
are properly documenting you are not just protecting yourself you're protecting the holy healthcare
theme and of course the institution it is admissible in court as a legal document so the clinical record
provides proof of the quality of care given to the patient so proof that some quality some gear and no
completeness and care what are the management's given to the patient completing the chart I'm not
leaving avoid taking on any shores and we properly correct our mistakes or errors in the documentation
next documentation is usually viewed as the best evidence of what really happened to the client upon a
time line complete correct huh and reminder I'd hear the professional standards of nursing care and
follow agency policies and procedures for intervention and documentation in all situation so when
you're working now I center see you are oriented why you are being given orientation on what did you
and of course it is your responsibility to study the patients chart thing in the book and in ending the
colors unbold pan right now with the advancement of technology we already make use of electronic
records so I know your generation is attacking generation you are what do you call this digital natives
come here come here digital immigrants from paper to elect to digital generation generation from
Electro or from paper to digital so not migrate immigrant when you were born I saw OK someone got
Jack funny things not more generation so it's easier for you to uh but the adapt to the electronic world
but legally again now we follow always agency protocol when documenting care for our patients when
documenting assessment findings no to follow that one OK especially now legal food dance is a similar
cases make sure that you do not own legal prudence especially in cases of abuse I assessment wise very
important not in cases of abuse so this is just an example unconscious patients forget that is very very
important so let's now proceed ensuring confidentiality and security of computer records since now we
are in a generation or we are in a time where in digital records is very common and usually used in the
hospital we have several tips and such as sessions to ensure protection insecurity of both the nurse as
well as the record itself the client record so number one remember that a personal password is required
to enter & off computer files so what's the main tip never share your password gay with anyone
including other health team members last protection when I email password when you had that mobus
word southwood mold entries gay or Miley patch on my leg number or in my password need to send in I
will let you out email password I'm sure password more with my sword Nelly password move into your
password in multiple data signatures fear in your data Next up sister veena or not some fashion thing in
that in outlook in password so that could happen in the So what is this do not share your password with
anyone can imagine this you know by sometimes uncontrollable circumstances that could lead to an
error and that error maybe that hey the number 2 hey attended hey I do not know the soap opera
others may see it I'm gonna shop and I bring the money for his face strategically in the station gay they
may he says or my instances sometimes nothing more than some significant others or some other
people know that they are the different example of my information birthdate and everything or
commitment in imposing patient possibly so simple birthday now leepa careful that is why versus you
thought you named it you don't get that now area hey Shred all I needed computer generated
worksheets yes we print something we print a we print we have print outs OK so all I needed is red now
is shredded I was thinking to her boy you've seen it in movies you've seen it in soap operas that Sam not
information in the used later on so we shred it huh hey Quinn next no the facilities policies and
procedures for correcting an entry error so you will be oriented on the agency's policy file no the agent
policy went correcting and entry error hey follow agency procedures for documenting sensitive
materials such as diagnosis of aids sample it's a very sensitive topic you may invade privacy and
confidentiality of information if you do not follow agency protocol OK so if I log it so policies and
procedures can also be termed as as not a lot first hey I thi personnel must is called a firewall to protect
server from unauthorized course not shop sports no protect the data especially if it is already digital
information and we not know very advantageous month if you are taking at the same time you are also
a nurse OK is sending a single class area to hospital management information system or ID office let me
add it that numbers OK so context cervical at the same time you're also good nurse you are you can also
be employed as part of the I team or the information technology team like when I T language class and
ID language information in the beginning includes new season so one month create forms and
documents no a nurse is needed because the nurse understands how things are how things go about in
the clinical area OK so we begin class in duty as stuff nurse did I see office forms to go even get checked
some some entries no so another quality control in three someday 80 office cerner's is the fermentation
it got to the check on complete an entry some data some assessment form now I think digitally encoded
not hopefully not yeah yeah I'm gonna career OK so with advancement technology additional jobs and
expertise can also be a career path for the nurse OK so now we know you're a nurse also an IP expert
clear I'm not mine carrier flash meant to act as if you are dead so organizing validating and documenting
client data is an important part of assessment so after gathering information collecting data no we of
course a organize the data using the different models we validate the data by double checking and
verifying information and we document data properly so that concludes the first phase of the nursing
process you proceed with the diagnosis and that concludes my topic with you word assessment not
introductory fool assessment
Which of the following methods of data collection

-all of the choices are correct*******

Which of the following is consider variable data

-ECG tracing

-birthday

-blood pressure

-age#

A kind of data does not changes over time

-variable data

-overt data

-neutral data

-constant data#

Contains all of the information about a client

-database #

-medical chart

-biographical data

-physical assessment

It is a planned communication or a conversation with a purpose

-all of the above#

-observe

-interview

-examine

This is to gather data by using the senses

-examine

-observe#

-All of the above

- interview

What is the best source of data

-roommates

-clients#

-family who lives with the pt.

-mother

Which of the following is the best categorized as a sign

-dyspnea

-Pain

-Cyanosis#

-bloating

Which of the following statements is best categorized as overt data

-bp 110/80#

- nurse in charge endorses pt. had bm

- doctor tells you pl. rales on pe

-records shows history of appendectomy

Blood pressure is what kind of data

-constant

-variable#

-covert

-neutral

Repetition of questions can breed mistrust and cause annoyance for the patient

-it may or may not be true depending on the patients

-false

-true#

It is highly structured interview and elicits specific information

-neutral

-directive#

-nondirective

-open-ended

Which of the following questions should be avoided

-how did you go to the park?

-where in the park did you go?

-why did you go to the park?#

-what happened to the park?

The following are the type of interview questions except

-neutral

-all the choices are correct#

-closed

-leading

Which of the following is a constant data

-age

-sex#

-height

-weight

It is a highly structured interview and elicits specific information

-directive#

-neutral

-nondirective

-open-ended

POST TEST 2

PATIENTS AGE IS CATEGORIZED INTO WHICH COMPONENT OF THE HEALTH ASSESSMENT

-history of present illness

-chief complaint

-past history

-biographic data#

WHICH OF THE FOLLOWING ARE ATTRIBUTE OF A SYMPTOM.

- All of the choices are correct******

ALSO KNOWN AS IDENTIFYING DATA

-biographic data
-date and time

-past history#

-chief complaints

THESE DESCRIBE ANY SITUATION OR ACTION THAT WILL MAKE THE SYMPTOM

-location

-timing

-setting

-relieving#

WHICH OF THE FOLLOWING CAN BE SOURCE OF DATA

-fellow nurses

-friend

-clinical record

-all of the choices are correct#

INCLUDED CLIENTS NAME,ADDRESS ,AGE,SEX,RACE, MARITAL STATUS,OCCUPATION,RELIGIOUS

PREFERENCE,HEALTHCARE FINANCING ,AND USUAL SOURCE OF MEDICAL CARE.

-present illness

-past history

-biographic data#

-chief complaints

ONE DAY PTA ,PATIENT EXPERIENCED SUDDEN ONSET, INTERMITTENT,STABBING EPIGASTRIC PAIN
RADIATING TO THE RLQ AND LLQ LASTING FOR 15MINS,PS 10/10,PARTIALLY RELIEVED BY KNEE CHEST
POSITION, WORSENED BY FOOD INTAKE ,WITH UNDOCUMENTED FEVER ,CHILL AND NAUSEA AND
VOMITING OF 5 TIMES ,APPROX.240ML PER EPISODE OF PREVIOUSLY TAKEN FOOD THAT IS PROJECTILE
AND COFFE COLORED. IN THIS HPI WHAT WERE THE ASSOCIATED SYMPTOM?

-all of the choices are correct#

-fever

-vomiting

-nausea

INCLUDE ALL MEDICATIONS, HERBAL DRUGS, HOME REMEDIES AND EVEN TOPICS THAT WERE TAKEN
FOR THE PROBLEM

-setting
-relieving

-onset

-treatments#

SPEAKS OF WHAT OTHER SYMPTOMS ARE NOTED ASSOCIATED WITH THE MAIN PROBLEM

-location

-setting

-associated symptoms#

-character

SPEAK ON HOW LONG A SYMPTOM IS PRESENT

-setting

-timing

-location

-duration#

WHICH OF THE FOLLOWING ARE ATTRIBUTES OF A SYMPTOM

-alleviating

-all of the choices are correct#

-setting

-aggravating

THIS IS THE REASON THE PATIENT CAME TO THE HOSPITAL

-history of present illness

-past illness

-chief complaint#

-biographic data

THIS ATTRIBUTE OF A SYMPTOM ANSWERS THE QUESTION CAN YOU POINT OUT WHERE IT HURTS?

-timing

-duration

-location#

-setting

ALSO KNOWN AS IDENTIFYING DATA

-past history

-biographic data#

-date and time

-chief complaints

POST TEST 3

Which of the following information is best categorized under OB/gyn history

- I have a 28 day cycle**********

THIS THE AGE OF FIRST MENSTRUATION

-menarche#

-coitarche

-lmp

-puberty

HOW DO YOU DEFINE LMP?

-when the last menstrual period ended

-day pt. conceived a baby

-first day of the menstrual period#

-when pt. last had sexual intercourse

SPEAKS OF THE NUMBER TIMES PT.`S PREGNANCY LEAD TO PRETERM BIRTH

-para

-preterm#

-live

-gravida

WHAT DATA MUST BE ELICITED OF REGARDING HISTORY OF HOSPITALIZATION

-all of the choices are correct#

-institution admitted

-reason of admission

-date of admission

THIS THE LAST AGE OF FORST SEXUAL INTERCOURSE

-menarche
-lmp

-puberty

-coitarche#

WHAT TYPE OF LEVEL OF FUNCTIONING IS BATHING

-none of the choices are correct

-instrumental activities of daily living

-activities of daily living#

- both adl and iadl

THIS IS ALSO KNOWN AS THE PERSONAL AND SOCIAHISTORY

-lifestyle history#

-past history

-functional history

-medical history

WHICH OF THE FOLLOWING STATEMENTS ARE CORRECT EXCEPT?

-none of the choices are correct

-it is the responsibility of the nurse to organize the patients story

-the patient story often unfolds in a similar sequence as the health history#

-it is the responsibility of the nurse to arrange patients information to fit the different components of
the health assessment

WHICH OF THE FOLLOWING INFORMATION IS THE BEST CATEGORIZED UNDER MEDICAL HISTORY

-I drink 1 bottle of beer everyday

-I walk 3miles a everyday

-I take amlodipine 5mg every morning#

-my mom has diabetes

WHAT IMPORTANT INFORMATION MUST BE WRITTEN DOWN IN THE HISTORY WITH REGARD TO
MEDICATIONS EXCEPT

-dose

-brand names#

-all of the choices are correct

-timing

SPEAKS OF THE NUMBER TIMES PT.S PREGNANCY LEAD TO PRETERM BIRTH

-preterm#

-grativa

-para

-live

WHEN ELICITING HISTORY OF CONTRACEPTIVE USE WHICH OF THE FOLLOWING QUESTIONS ARE
IMPORTANT TO ASK,EXCEPT?

-when was your IUD inserted?

-when did you have your intradermal implants inserted?

-how long have you been taking pills?

-do you carry condoms?#

THIS IS THE AGE OF FIRST SEXUAL INTERCOURSE

-coitarche#

-pubertt

-menarche

-LMP

LONG QUIZZ DOC HILLADO

These are usually closed questions with short specific answer. This allows identification of the owner
of the information

- Present illness
- Past history
- Biographic data*****
- Chief complaints

Which of the following statements is best categorized as primary data

- HR of 110bpm
- Crackles says he is sad all the time
- Report her son to be sad all the time
- Patient says he is sad all the time ******

Factors that may influence how comfortable the client will be and what special arrangements might
be needed.

- All of the choices are correct******

 - Gender
- Culture
- Age

Which of the following statements is best categorized as covert data

- Crackles noted on auscultation

- Patient grimace noted
- HR of 110bpm
- Patient says he is sad all the time*****

Which of the following chronic diseases are important to note in the past medical history

- Pneumonia ********** SALA

- UTI
- Hyperlipidemia
- Cellulitis*******

Describes in what situations does the symptom occur

- Timing
- Treatment
- Setting*******
- Onset

This sound is booming in quality

- Dullness
- Flatness
- Tympany
- Hyperresonance********

This is a type of auscultation used when assessing the heart

- Indirect*********
- Direct
- Light
- Deep

This sound is booming in quality

- Tympany*****SALA
- Flatness
- Dullness
- hyperresonance

What important information must be written down in the history with regard to surgical procedures,
except

- Institution admitted
- Date of admission
 - Reason for procedure
- All of the choices are correct******

In this HPI what the quality of the symptom? One day PTA, patient experienced sudden onset,
intermitted, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.. 240ml per and coffee colored.

- Stabbing ********
- Insidious
- Epigastric
- Sudden

The best framework for PE in all situations is the head-to-toe framework

- True
- False*******

Which of the following is an PE finding of palpation

- Circular rash
- Tympanitic
- Hyperactive bowel sounds
- Soft abdomen, non tender*****

Which of the following diseases are important in an interview fir family history, except

- Hypertension
- All of the choices are correct******
- Tb
- Thyroid disease

Which of the following is true of the purpose of taking a physical assessment

- Establishing nursing diagnosis

- All of the choices are correct ******
- For baseline data
- Evaluating outcomes

Give 1 vial Diazepam IV now which are of the medical chart does this belong to?

- Daily care record*******SALA

- Physicians order form *****
- Medical history ******** sala
- Nurses notes*** sala

Wala ang 16

The best position in performing digital rectal exam

- Sitting
 - Supine
- Sims ******
- Semi-fowlers

Source of the data will help determine which of the following, except

- Quality
- All of the choices are correct******
- Reliability
- Correctness

I feel hot and sweaty every afternoon is a sentence that speaks to which attribute of a symptom?

- Timing *******
- Setting
- Relieving
- Onset

My mom gave me Vicks vapor rub when I had a stuffy nose is a sentence that speaks to which
attribute of a symptom?

- Timing
- Setting
- Onset
- Treatment******

Which of the following is true of the time in an interview, except

- Should be when there are minimal interruption

- Must be decided but the nurse *******
- When pt. is free of pain
- When pt. is free of discomfort

Which of the following is an PE finding of inspection

- Cyanosis*****
- Nodular
- Fremitus
- Dullness

When preparing a client for PE this is an important way to maintain a client’s dignity and privacy

- Draping*****
- Isolation
- Confidentiality
- Single nurse

Which of the following are component of a comprehensive health exam, except

- Chief complaint
- All of the choices are correct*****
 - Biographic data
- Data and time

What type of level of functioning is showering

- None of the choices are correct

- Both ADL and IADL
- Instrumental activities of daily living
- Activities of daily living*************

Which of the following objective data validate a subjective data of dyspnea

- Wheezing of auscultation
- Increased JVP
- All of the choices are correct****
- Increased RR

This component of comprehensive health assessment is always important and allows your assessment
to be used by future providers

- Past history**** SALA

- Biographic data********SALA
- Date and time**********
- Chief complaints

On eliciting smoking history of a 60yo pt. states, I used to smoke 10yrs ago. I usually smokes half a
pack a day since I was 18 what would be his pack yrs?

- 25 *********
- 21******ARIII
- 30
- 16

Important things to prepare in the environment before PE, except

- Should be in a private room

- Make sure the room is warm enough for pt. to be comfortable
- Organize equipment prior to starting
- Use well lighted environment using natural light at all times*****

Nurse come assess lungs and heart of patient complaining of dyspnea. This describes which type of PE

- Functional
- Specific
- comprehensive
- focused******

In this HPI what was the character of the symptom? One day PTA, patient experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.,240ml per episode of previously taken food that is
projectile and coffee colored.

- Epigastric pain
- PS 10/10*********
- Gnawing
- Radiating

This component of a comprehensive health assessment is always important and allows your
assessment to be used by future providers

- Date and time*******

On eliciting smoking history of a 50yo pt. states I stated smoking when I 10yo, my uncle taught me
how. I could finish 30 sticks a day what would be his pack yrs.?

- 60*********

This sound is heard best when percussing the normal lung

- Tympany
- Dullness
- Flatness
- Resonance*****

When eliciting history of contraceptive use which of the following questions are important to ask?

- What type of pills are you taking?*****

- Do you keep your condoms in your wallet?
- Have you had a pap smear?
- Is your IUD still in place?

29yo female patient came into the ER due to dizziness and pallor. As the nurse in the ER you are
taking the health history. Which of the following components of the OB/GYN history may point to the
source of the problem

- Interval
- Menarche
- Symptom
- Amount ******

A distance that the most people are comfortable with during interview is

- 2-3m
- 2-4ft
- 2-4m
- 2-3ft*******

I noticed that I am having runny nose every morning is a sentence that speaks to which attribute of a
symptom?
 - Timing**********
- Setting
- Relieving
- Onset

The review of nursing and related literature can provide additional information for the database.
Which part of literature review is involved when you research for alternatives for blood transfusion?

- Cultural and social health practices

- Information about media diagnones, treatment, and prognoses######
- Standard or norms against which to compare findings*******
- Assessment data needed for specific client condition********** ari

During the initial interview the client makes this statement I don’t understand why I have to have
surgery I’m really not that sick or in pain right now what is the nurses best response?

- What kind of questions do you have about your surgery*******

- I think these are things you should be asking your doctor
- It’s ok to be worried. Surgery is a big step
- Have you had surgery before ******SALA

A patient came in to the ER and OB history revealed my first baby was born at 28wks and had to stay
in an incubator for long time …………..

- G2P1(1011)****** CORREK NI SA KAY KEITH PRO SA KAY YVON WRONG IDK

- G2P1(0111)******

Which of the following is true of treatments

- May show any drug interactions that may occur with medications given in the hospital
- All of the choices are correct ***********
- May show possible organ injury to watch out for
- Mat show possible increased risk of bleeding

Which of the following circumstances where open-ended questions would be best suited

- When there is an abundance of time*********

- Taking the past medical history****SALA
- All of the choices are correct******SALA
- Emergent situation

Describe the type of and the severity of the symptom

- Character*******

Speaks of any situation or action that will worsen the symptom

- Aggravating******
- Location
- Associated symptoms
- Character
Which of the following information is best categorized under past history

- All of the choices are correct*****

- I have a measles before
- I completed 6 months of TB treatment
- I got vaccinated for hepatitis B

Which element is best categorized as secondary subjective data?

- Client states severe pain when walking up stairs

- The nurse measures a weight loss of 10 pounds since the last clinic visit
- Spouse states the client has lost all appetite******
- The nurse palpates edema in lower extremities

Speaks of when the symptom occurs

- Relieving
- Location
- Setting
- Timing*******

This component of health assessment answers the question. Describe the reason you came to the
hospital or clinic today.

- Chief complaint *******

- Past illness
- History of present illness
- Biographic data

Which of the following information is best categorized under surgical history

- My father brought me for a check up for a swollen nodule when I was a child
- I had a cyst removed last year****
- None of the choices are correct
- I had leukemia when I was 10yo

A kind of data that change over time

- Variable data*****
- Constant data
- Neutral data
- Overt data

The finger that strikes the nondominat hand in contact with the body surface in order to produce a
sound

- Direct
- Indirect
- Pleximeter
- Plexor *******
Most important in determining data that can be taken from an intraoperative technique that speaks
of what was seen while doing the procedure

- Blood loss
- Devices intraoperative findings****
- Vital sign

Which statement would be true regarding use of observing method of data collection?

- When observing the nurse uses only the visual sense

- Observing is done only when no other nursing interventions ae being performed at the same
time
- Data should be gathered as they occur, rather than in any particular order
- Observed data should be interpreted in relation to other sources of collected data*******

On history taking pt. says the last day of her last menstrual period was on jan 10 and lasted only 5
days. What is her LMP?

- 6-jan*****
- 11-jan
- 10-jan
- 15-jan

I have vomiting and abdominal pain is a sentence that speaks to which attribute of a symptom?

- Associated symptoms********
- Setting
- Character
- Location

This sound is heard when percussing an emphysematous lung

- Dullness
- Tympany
- Flatness
- Hyperresonance*****

Which of the following is best categorized as a symptom

- Peripheral edema
- HR 76
- O2sat 98%
- Pain*******

Which of the following is the best categorized as a sign

- Bloating
- Dyspnea
- Cyanosis*******
- pain
A patient come in to the ER complaining of abdominal pain, upon pregnancy test it was positive. Upon
OB history patient is adamant that she has never has sexual partner prior to her boyfriend whom she
met 3months before. What would be her OB history?

- G1P1(0000)
- G1P1(0010)
- G1P0(0000)*****
- G0P0(0000)

Which of the following information would be best categorized in the past illness

- All of the choices are correct

- my father has cancer
- I used to have crippling sadness and was given medications for it********
- I smoke 2packs per day

My stomach hurts and feel awful is a sentence that speaks to which component of the health
assessment?

- Chief complaint *******

- Past illness
- History of present illness
- Biographic data

This best sound heard when percussing the liver

- Dullness *****
- Tympany
- Flatness
- Hyperresonance

In this HPI what was the duration of the symptom? One day PTA experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, aprrox 240ml per episode of previously taken food that is
projectile and coffee colored.

- Intermittent
- 15mins*****
- 5x
- None of the choices

Which of the following is considered a variable data, except

- Birthday******8

On history taking pt. says the last day of her menstrual period was on jan 3 and lasted only 3 days.
What is her LMP?

- 6-JAN
 - 1-jan********
- 3-jan
- 4-jan

When eliciting alcohol history which of the following information is important

- How pt. drinks

- How often pt. drinks*****
- Where pt. drinks
- All of the choices are correct

A conscious, deliberate skill that is developed through effort and with an organized approach

- Examining
- All of the choices are correct
- Observing*********
- Interviewing

Which of the following is the part of the history involving literature review for information about
medical diagnoses, treatment and prognoses

- Refusal of chemotherapy*******SAL
- Female circumcision ****SALA
- Refusal of blood transfusion and other blood product******
- Cardiac aneurysmal rupture for Kawasaki patient

Which of the following is true when choosing a place for interview

- Must be will lit*******

- Should be in a closed curtained area
- In clear view of the door
- Should be in a closed space

What type of level of functioning is taking tablets

- Both ADL and IADL******SALA

- Activities of daily living**********
- None of the choices are correct*****SALA
- Instrumental activities of daily living******SALA

Speaks of the number times pt pregnancy lead to birth

- Live
- Gravida
- Term
- Para********

What happened this question can best be categorized as

- Leading
- Open-ended******
 - Closed
- None of the choices are correct

The following are contents of the past medical history

- Immunization history*******
- Father dies of cancer
- Use of illicit drugs
- All of the choices are correct

The patient is vague when describing symptoms, and the details are confusing is a sentence that
speaks to which component of the health assessment?

- Reliability ********8
- Client
- Source
- Questions

Examination of the body using the sense of touch

- Inspection
- Auscultation
- Palpation********
- Percussion

My pain starts in the back and goes to the front is a sentence that speaks to which component of the
health assessment?

- Chief complaint
- Biographic data
- History of present illness******
- Past history

This attribute of a symptom is always important in diagnosis and therefore in determine urgency of
management and kind of management

- Duration******
- Timing
- Location
- Setting

Important things to prepare in the environment before PE, except

- Make sure the room is warm enough for pt. to be comfortable

- Nurse should set time that is convenient for the nurse ********
- Should be in private room
- Organize equipment prior to starting

Which of the following is the main reason for receiving verbal reports from other healthcare
professionals
 - Accurate medical records
- Sharing of information
- Completeness of record
- Continuity of care********

Each interview is influence by which of the following

- Time
- Language
- All of the choices are correct******
- Seating

Which of the following is true of history present illness

- All of the choices are correct******

- Complete
- Clear
- Chronologic

It is a complete, clear and chronologic description of the problems prompting the patients visit

- Biographic data
- Past history
- Chief complaint
- History of present illness******

What type of level of functioning is calling the doctor

- Both ADL and IADL

- None of the choices are correct
- Instrumental activities of daily living******
- Activities of daily living

Which of the following is the correct sequence of organizing observation

- Signs of distress> equipment> safety> surroundings

- Signs of distress> safety> surroundings> equipment
- Signs of distress> safety> equipment> surrounding******
- Safety> signs of distress> equipment> surroundings

Which of the following are sources of secondary data except

- Mother
- Chart
- All of the choices are correct*****
- Other healthcare workers

This is instrument is used in examining the external ear canal

- Tuning fork
- Percussion hammer
 - Otoscope******
- Ophthalmoscope

Which of the following information is important to record in the family history

- All of the choices are correct****

- Age at which family members die
- Cause of deaths
- Presence of chronic disease

Speaks of the number times pt pregnancy lead to full-term birth

- Live
- Para
- Term****
- Gravida

Post Test Topic 4 Data Collection Physical Assessment

1. 3 types of physical examination, except

-specific
2. parts of the medical PPE
-all of the choices are correct
3. a type of percussion best suited for examining adult sinuses
- direct
4. this is instrument is used in examining parts of the retina
-ophthalmoscope
5. a type of PE the examines a body system or a body area
- focused
6. a type of PE where all body system is assessed
-comprehensive
7. this sound is heard best when percussing the stomach
-tympany
8.. the two major components of nursing care
- health history and PE
9. what are the two type soft percussion
-direct and indirect
10. assessing by using the sense of sight
-inspection
11. this sound drum like in quality
-tympany
12. a type of PE that examines one or more aspects of the clients abilities
- functional
13. the following are the methods of examining
- all of the choices are correct
 NCM 101 Health
Assessment
Lectured by: Mr. Bornie Baguio RN, MAN
Topic Coverage this week:
Holistic Nursing Assessment
1.General status and vital signs
2.Mental status
• Children and adolescent
• Adult
3.Psychosocial, cognitive and moral development
4.Pain
5.Violence
6.Culture and ethnicity
7.Spiritual and religious practices
8.Nutritional status 2
General status
and vital signs
The General Survey
First encounter-
obvious physical
characteristics
It’s an introduction to
prepare for the
physical assessment
Gives an overall
impression
3
 Level of consciousness
✓ Vigilant – hyperalert, overly sensitive to environmental stimuli, startled very easily
✓ Alertness – awake, aware of self and environment. When spoken to in a normal
voice, patient looks at you and responds fully and appropriately to stimuli
✓ Lethargy – when spoken to in a loud voice, patient appears drowsy but opens
eyes and looks at you, responds to questions, then falls asleep
✓ Obtundation – when shaken gently, patient open eyes and looks at you but
responds slowly and is somewhat confused. Alertness and interest in environment
are decreased.
✓ Stupor – arouses from sleep only after painful stimuli. Verbal responses are slow
or absent. Lapses into unresponsiveness when stimulus stops. Has minimal
awareness of self or environment.
✓ Coma – despite repeated painful stimuli, patient remains unarousable with eyes
closed. No evident response to inner need or external stimuli is shown
4
 Temperature
Pulse

Respiration
Blood pressure 5
Vital signs- Definitions
Temperature, pulse, blood pressure, respiratory rate
Indicate the effectiveness of circulatory, respiratory, neural and endocrine body
functions.

• These measures referred to vital signs because of their importance as

indicators of body’s physiological status.
• Any difference between normal baseline measurement and present may
indicate the need for nursing and medical interventions
• Pain- considered to be the 5th vital sign
(Potter & perry,2010).

6
• Vital signs show an individual is alive.
They include heart beat, breathing rate,
temperature, and blood pressure. These
signs may be watched, measured, and
monitored to check an individual's level
of physical functioning. Normal vital
signs change with age, sex, weight,
exercise tolerance, and condition.

7
8
Guidelines in Taking Vital Signs:
1.The nurse caring for the client measures vital signs.
– Give important information about the client’s health status.
2.Equipment should be functional and appropriate.
– To ensure accurate findings.
3.Know the normal range of vital signs.
– Helps the nurse in detecting abnormalities.
4.Know the client’s normal range of vital signs.
– A nurse can detect a change in condition overtime.
9
5. Know the client’s medical history and any therapies or
medications prescribed.
6. Control or minimize any environmental factors that may affect
the vital signs.
– Temperature of the environment, physical activity and effects of illness
cause vital signs to change.
7. Use an organized, systematic approach when taking vital signs.
– Measure temperature first, and then check the pulse, respirations and
blood pressure.
8. Decide the frequency of vital sign assessment on the basis of
client’s condition.
9. Analyze the results of vital sign measurement.
10.Record or document the results of vital signs measured
10
 Frequency of Vital Signs
Nurses should take a patient’s vital signs:
• Upon admission to a facility
• Before and after any surgical procedure
• Before, during, and after administration of medications that
affect vital signs
• As per the institution’s policy or physician orders
• Any time the patient’s condition changes
• Before and after any procedure affecting vital signs
11
Mental status
• a structured assessment of client’s behavioural and cognitive
functioning—is a vital component of nursing care that assists
with evaluation of mental health conditions.
• The MSE is analogous to the physical examination and is
used to evaluate an individual’s current cogitative, affective
and behavioural functioning (Varcarolis, 2014).
• Specifically, the MSE assesses a client’s current state
including general appearance, mood and affect, speech,
thought process and content, perceptual disturbances,
impulse control, cognition, knowledge, judgment and insight
(Lasiuk, 2015). 12
MSE Elements
The acronym BEST PICK can assist with learning the main elements of
an MSE (Carniaux-Moran, 2008). A brief description of the elements that
are assessed includes:
• Behaviour and general appearance - age, sex, gender, cultural background,
posture, dress/ grooming, manner, alertness, as well as agitation,
hyperactivity, psychomotor retardation, unusual movements, catatonia, etc.
• Emotions: mood and state, emotional state and visible expression (state)
including description and variability.
• Speech—rate, amount, style and tone of speech.
• Thought content and processes—abnormalities, obsessions, delusions and
suicidal and homicidal thoughts and thought process as well as loose
associations, tangential thinking, word salad, and neologisms, circumstantial
thought, and concrete versus abstract thought. 13
MSE Elements
• Perceptual disturbances—illusions and hallucinations.
• Impulse control—ability to delay, modulate or inhibit
expressions or behaviours.
• Cognition—consciousness, orientation, concentration and
memory.
• Knowledge, insights and judgment—the capacity to identify
possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of
illness and maladaptive behaviours.
14
A. Children and adolescent
1. Focus on health promotion and illness prevention, particularly for care of well children with
competent parenting and no serious health problems (Hockenberry and Wilson, 2011). Focus on
growth and development, sensory screening, dental examination, and behavioral assessment.
2. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require
additional assessments because of unique health needs.
3. When obtaining histories of infants and children, gather all or part of the information from parents or
guardians.
4. Children who are chronically ill, disabled, in foster care, or adopted from a foreign country may
require additional assessment because of their unique health risks.
5. Parents may think that the examiner is testing or judging them. Offer support during examination
and do not pass judgment.
6. Call children by their preferred name and address parents as “Mr. and Mrs. Cruz” rather than by
first names.
7. Open-ended questions often allow parents to share more information and describe more of the
child’s problems.
8. Older children and adolescents respond best when treated as adults and individuals and often can
15
provide details about their health history and severity of symptoms.
Psychosocial, cognitive and moral development

16
17
18
19
20
21
• A personal & subjective experience w/ few or no
objective measurements.
• Nursing Definition (McCaffery) – “Whatever the
experiencing person says it is, and existing whenever
the person says it does.”
• Int. Assoc. for study of Pain (IASP)- “Unpleasant,
subjective sensory & emotional experience assoc. with
actual or potential tissue damage, or described in terms
of such damage.”
• Multidimensional phenomenon
• Viewed as an experience, not merely a symptom and not
a disease entity. 22
THEORIES:
1. Specific – Theory (Descartes-17th century) – specialized
pathways for pain transmission exist. Free nerve endings
existed in periphery as pain receptors. g transmitted through
the dorsal horn & substantia gelatinosa g thalamus g upper
level of the cortices.

2. Gate Control Theory – controlled by the dorsal horn of the

spinal cord
– Substantia gelatinosa in the dorasal horn of the SC acts as a
gate mechanism that can close or open.
– Most pain impulses are conducted over small-diameter nerve
fibers (A-delta) 23
PROCESS :
1. Pain transduction – stimulation of the nociceptors
2. Pain transmission – discharged impulse travels as
electric activity to spinal cord gbrain = pain
sensation.
– A-beta – larger and carry other sensory info. such
as touch
– A-delta – transmit pain fast.
- C fibers – transmit pain more slowly / no myelin
sheath.
3. Pain modulation – variation in the way clients 24

perceive similarly painful stimuli.

Pain reception
pathway :

25
Perception of pain :
• Pain Threshold – lowest perceivable intensity
of stimuli that is transmitted as pain.
• Pain Tolerance – amount of pain the client is
willing to endure.
• Past experiences of pain.

26
Physiological Responses to pain:
Sympathetic Stimulation :
1. dilation of bronchial tubes & hresp. rate.
2. hheart rate
3. peripheral vasoconstriction (pallor, hBP)
4. hblood glucose level
5. diaphoresis
6. hmuscle tension
7. dilation of pupils
8. iGI motility
27
Parasympathetic Stimulation :
1. pallor
2. muscle tension
3. iHR & BP
4. rapid, irregular breathing
5. nausea & vomiting
6. weakness or exhaustion

28
Behavioral Response:
• Phases of pain experience:
–Anticipation – allows a person to learn about
pain & its relief.
–Sensation – pain is felt. Gauging tolerance
level of pain.
–Aftermath – pain is reduced or stopped.

29
Behavioral Indicators of Effects of Pain
Vocalizations: moaning / crying / screaming / gasping /
grunting
Facial expressions : grimace / clenched teeth / wrinkled
forehead / tightly closed or widely opened eyes or mouth /
lip biting / tightened jaw
Body movement : Restlessness / immobilization / muscle
tension / hhand & finger movements / pacing activities /
rhythmic or rubbing motions / protective movement of body
parts.
Social Interaction : Avoidance of conversation / focus only on
activities for pain relief / avoidance of social contact /
reduced attention span.
30
Factors Influencing Pain :
a. Age f. Attention
b. Sex g. Anxiety
c. Culture h. Fatigue
d. Meaning of pain
e. Previous experience
f. Coping style
g. Family & social support
31
Assess for :
• Onset / time of occurrence
• Duration – chronic or acute
• Severity or intensity – scale 0 – 10
• Mode of transmission – normal pain pathway vs referred
pain
• Location / source
• Causation
• Causative forces / agent – spontaneous / self-inflicted

32
Pain Scale

33
Types of Pain :
o Acute Pain
o Chronic Pain
o Cutaneous or superficial pain
o Deep somatic pain
o Visceral pain
o Referred pain
o Malignant pain
o Pain of Psychological origin
▪ Pretended pain
▪ Psychogenic pain 34
Nursing Intervention :
Alleviating Anxiety Meditation
Autogenic Training Accupressure
Guided Imagery Rhythmic Breathing
Operant Conditioning Biofeedback
Touch Cutaneous Stimulation
Hypnosis Music
Progressive Relaxation Training

35
Pharmacology
Non-narcotic analgesics
‚ Acetaminophen (Tyenol, Datril)
‚ Acetylsalicylic acid (aspirin)
‚ Choline magnesium trisalicylate (Trilisate)

NSAIDS
‚ Ibuprofen (Motrin, Nuprin)
‚ Naproxen (Naprosyn)
‚ Naproxen sodium (Anaprox)
‚ Indomethacin (Indocin)
‚ Tolmetin (Tolectin)
‚ Piroxicam (Feldene) 36
Narcotic Analgesics
‚ Meperidine (Demerol)
‚ Methylmorphine (Codeine)
‚ Morphine sulfate (Morphine)
‚ Fentanyl (Sublimaze)
‚ Butorphanol (Stadol)
‚ Hydromorphone HCl (Dilaudid)
Adjuvants
‚ Amitriptyline (Elavil)
‚ Hydroxyzine (Vistaril)
‚ Caffeine
‚ Chlorpromazine (Thorazine)
‚ Diazepam (Valium)
37
Violence
• Family violence can be defined as “a situation in which
one family member causes physical or emotional harm
to another family member. At the center of this violence
is the abuser’s need to gain power and control over
the victim” (Violence wheel, 2009).

38
The cycle of violence.
(From Varcarolis, E.,
Carson, V., &
Shoemaker, N. [2010].
Foundations of
psychiatric mental
health nursing [6th ed.].
St. Louis: Saunders.)

39
Description:
1. Violence begins with threats or verbal or physical minor
assaults (tension building), and the victim attempts to comply
with the requests of the abuser.
2. The abuser loses control and becomes destructive and
harmful (acute battering), while the victim attempts to protect
himself or herself.
3. After the battering, the abuser becomes loving and attempts
to make peace (calmness and defusing of tension).
40
4. The abuser justifies that violence is normal and the
victim is responsible for the abuse.
5. Outsiders are usually unaware of what is happening
in the family.
6. Family members are isolated socially and lack
autonomy and trust among each other; caring and
intimacy in the family are absent.
7. Family members expect other members of the family
to meet their needs, but none are able to do so.
8. The abuser threatens to abandon the family.
41
Types of Violence
1. Physical Violence - Infliction of physical pain or
bodily harm
2. Sexual Violence - Any form of sexual contact
without consent
3. Emotional Violence - Infliction of mental anguish
4. Physical Neglect - Failure to provide health care to
prevent or treat physical or emotional illnesses
42
Types of Violence
6. Developmental Neglect - Failure to provide
physical and cognitive stimulation needed to
prevent developmental deficits
7. Educational Neglect - Depriving a child of education
8. Economic Exploitation - Illegal or improper exploitation
of money, funds, or other resources for one’s personal
gain

43
The vulnerable person
1. The vulnerable person is the one in the family unit
against whom violence is perpetrated.
2. The most vulnerable individuals are children and
older adults.
3. The perpetrator of violence and the person targeted
by the violence can be male or female.
4. Battering is a crime.
44
Characteristics of abusers
1. Impaired self-esteem
2. Strong dependency needs
3. Narcissistic and suspicious
4. History of abuse during childhood
5. Perceive victims as their property and believe
that they are entitled to abuse them
45
Characteristics of victims
1. Victims feel trapped, dependent, helpless, and
powerless.
2. Victims of abuse may become depressed as they are
trapped in the abusers’ power and control cycle
3. As victims’ self-esteem becomes diminished with
chronic abuse, they may blame themselves for the
violence and be unable to see a way out of the
situation.
46
Interventions
1. Report suspected or actual cases of child abuse or abuse of
an older adult to appropriate authorities (follow state and
agency guidelines).
2. Assess for evidence of physical injuries.
3. Ensure privacy and confidentiality during the assessment and
provide a nonjudgmental and empathetic approach to foster
trust; reassure the victim that he or she has not done anything
wrong.
4. Assist the victim to develop self-protective and other problem-
solving abilities. 47
Interventions
5. Even if the victim is not ready to leave the situation,
encourage the victim to develop a specific safety plan (a fast
escape if the violence returns) and where to obtain help
(hotlines, safe houses, and shelters); an abused person is
usually reluctant to call the police.
6. Assess suicidal potential of the victim.
7. Assess the potential for homicide.
8. Assess for the use of drugs and alcohol.
9. Determine family coping patterns and support systems. 48
Interventions
10. Provide support and assistance in coping with contacting
the legal system.
11. Assist in resolving family dysfunction with prescribed
therapies.
12. Encourage individual therapy for the victim that promotes
coping with the trauma and prevents further
psychological conflict.
13. Encourage individual therapy for the abuser that focuses
on preventing violent behavior and repairing
relationships. 49
Interventions
14. Encourage psychotherapy, counseling, group
therapy, and support groups to assist family members
to develop coping strategies.
15. Assist the family to identify an access to community
and personal resources.
16. Maintain accurate and thorough medical health
records.
50
Culture and ethnicity
• Culture - dynamic network of knowledge, beliefs,
patterns of behavior, ideas, attitudes, values, and
norms that are unique to a particular group of people.
• Ethnic group - people within a culture who share
characteristics based on race, religion, color, national
origin, or language.
• Ethnicity - an individual’s identification of self as part
of an ethnic group.
51
Personal Cultural Assessment
Five areas to be examined in assessing one’s
own culture and the influence it may have on
personal beliefs about health care are:
– Influences from own ethnic/racial background.
– Typical verbal and non-communication patterns.
– Cultural values and norms.
– Religious beliefs and practices.
– Health beliefs and practices.
52
Client Cultural Assessment
Six categories of information necessary for a
comprehensive cultural assessment of a client
are:
– Ethnic or racial background.
– Language and communication patterns.
– Cultural values and norms.
– Biocultural factors.
– Religious beliefs and practices.
– Health beliefs and practices. 53
Culturally Appropriate Care
• Respect clients for their different beliefs.
• Be sensitive to behaviors and practices different from your
own.
• Accommodate differences if they are not detrimental to
health.
• Listen for cues in the client’s conversation that relay a
unique ethnic belief about etiology, transmission,
prevention, etc.
• Teach positive health habits if client’s practices are
deleterious to good health.
54
Spiritual and religious practices
• A spiritual assessment assists the nurse in
planning holistic nursing care. Whether the
nurse is unclear about the patient's spiritual
belief or the patient has a spiritual belief
unfamiliar to the nurse, acronym models such
as FICA provide the basis for an organized,
open and non-biased assessment.
55
FICA model
One popular acronym tool is the FICA model. These are the areas of
assessment and possible questions that could be asked:
• F-Faith or beliefs: What are your spiritual beliefs? Do you consider yourself
spiritual? What things do you believe in that give meaning to life?
• I-Importance and influence: Is faith/spirituality important to you? How has
your illness and/or hospitalization affected your personal practices /beliefs?
• C-Community: Are you connected with a faith center in the community? Does
it provide support/comfort for you during times of stress? Is there a
person/group/leader who supports/assists you in your spirituality?
• A-Address: What can I do for you? What support/guidance can health care
provide to support your spiritual beliefs/practices?
56
Nutritional status

57
58
59
60
61
62
63
64
 References:
• Carniaux-Moran, C. (2008). The Psychiatric Nursing Assessement. In O’Brien, P.G., Kennedy, W.Z.,
Ballard, K.A. Psychiatric mental health nursing: an introduction to theory and practice.,Sudbury, MA: Jones &
Bartlett
• Weber, Janet R., Jane H. Kelley (2014); Health Assessment in Nursing; 5th Ed., Wolters Kluwer Health |
Lippincott Williams & Wilkins.
• Perry, A. G., (2014). Clinical Nursing Skills and Techniques. Mosby, Inc., an affiliate of Elsevier Inc., St.
Louis, Missouri 63043 ISBN 978-0-323-08383-6

65
Question 1
Pain is:
- A strongly unpleasant bodily sensation caused by actual or potential injury

Question 2
The stage that occurs between 5 – 13 years of age is concerned with:
- Industry vs. inferiority

Question 3
Who among the following proposed that personality development in childhood takes
place during five psychosexual stages, which are the oral, anal, phallic, latency, and
genital stages and that during each stage, sexual energy (libido) is expressed in
different ways and through different parts of the body?
- sigmund

Question 4
Facial expression, physiological changes and behavioral changes are a part of direct
observation for pain assessment.
- true

Question 5
Failure to provide health care to prevent or treat physical or emotional illnesses is a
form of which type of violence?
- Physical neglect

Question 6
The amount of force exerted against the walls of the artery by the blood is commonly
referred to as:
Blood pressure

Question 7
One of your friends tells you to steal some sweets. You are in Level 1, why do you NOT
steal?

- I might get caught and get in trouble

Question 8
Direct methods of nutritional assessment are summarized as:
 - abcd

Question 9
A technique that teaches your body to respond to your verbal commands. These
commands "tell" your body to relax and help control breathing, blood pressure ,
heartbeat, and body temperature to achieve deep relaxation and reduce stress is known
as:
- autogenic training

Question 10
The nurse is aware that the term bradycardia means:
- a heart rate of under 60 bpm

Question 11
At which phase of the cycle of violence does the abuser assumes a loving behavior,
contrite and makes promises to change?
- Honeymoon phase

Question 12
The capacity to identify possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of illness and maladaptive
behaviours are assessments to identify which element of the patient’s mental status
- Knowledge, insight and judgement

Question 13
Kohlberg was concerned with what type of development?
- moral

Question 14
Obsessions, delusions and suicidal and homicidal thoughts and thought process
alterations are categorized under which element of Mental Status Examination?
- Thought content and processes

Question 15
A situation in which one family member causes physical or emotional harm to another
family member is known as:
- Family violence

Question 16
______________________ is the amount of time something lasts or continues.
- Duration
Question 17
Which of the following vital sign will reveal information about pyrexia is:
- Temperature

Question 18
You are about to take the baseline vital signs. Before doing this you should ensure that:
- You inform the patient

Question 19
A person is considered obese with a BMI of:
- BMI of 30 or higher

Question 20
Pain management for acute pain involves pharmacological approaches only.
- false

Question 21
Which of the following assessment is a component of a patient assessment that
observes the entire patient as a whole and begins with the initial patient contact and
continue throughout the helping relationship?
- General survey

Question 22
What is the name of Erik Erickson's development theory?
- Psycho-social

Question 23
________________ is a pain that lasting for more than 6 months.
- Chronic pain

Question 24
Which of the following Non-Steroidal Anti-inflammatory drug (NSAIDS) is prescribed for
mild to moderate pain?
- Ibuprofen motrin

Question 25
Which pain scale is used for children?
- Wong-bake faces pain scale

Question 26
Which of the following is a specific nerve receptor for pain?
 - nociceptors

Question 27
BMI stands for:
- body mass index

Question 28
The height, weight, head circumference, body mass index (BMI), body circumferences
to assess for adiposity (waist, hip, and limbs), and skinfold thickness are the core
elements of:
- Antropometric assessment

Question 29
Which of the following refers to how much pain a person can reasonably endure?
- tolerance

Question 30
To assess for hypotension due to shock, the nurse would take which vital sign?
- Blood pressure

Question 31
Cindy understands her world primarily by grasping and sucking easily available objects.
Cindy is clearly in Piaget's ________ stage:
- Sensorimotor

Question 32
Pain that we experience it when our internal organs are damaged is related to:
- Visceral pain

Question 33
In which psychosexual stage of personality development does Oedipus and Electra
complexes become evident?
- Phallic

Question 34
Which of the following are the most vulnerable person for violence in the family unit?
- all

Question 35
An unresponsiveness from which a person arouses from sleep only after painful stimuli.
Verbal responses are slow or absent and lapses into unresponsiveness when stimulus
stops. Patient has minimal awareness of self or environment. This is known as:
 - stupor

Question 36
The categories of information necessary for a comprehensive cultural assessment of a
client includes all of the following, EXCEPT:
- political affiliation

Question 37
Failure to provide physical and cognitive stimulation needed to prevent developmental
deficits is a form of which type of violence?
- Developmental neglect

Question 38
Factors influencing pain would include which of the following?
- all

Question 39
Characteristics of abusers includes all of the following, EXCEPT:
- high self esteem

Question 40
The people within a culture who share characteristics based on race, religion, color,
national origin, or language is known as:
- ethnic group

Question 41
Mental Status assessment is a structured assessment of client’s behavioural and
cognitive functioning—is a vital component of nursing care that assists with evaluation
of:
- mental health conditions

Question 42
Intimacy vs. Isolation occurs at what stage?
- Young adulthood

Question 43
As victims’ self-esteem becomes diminished with chronic abuse, they may blame
themselves for the violence and be unable to see a way out of the situation.
- true

Question 44
Which of the following is also known as the 5th vital sign?
 - pain

Question 45
A description of pain is ______________________ when it is based on the individual’s
experience or perceptions.
- subjective

Question 46
Which assessment tool was developed to help health care professionals address
spiritual issues with patients?
- maslows

Question 47
What is Kohlberg's theory?
- People progress in their moral reasoning through stages

Question 48
Kohlberg was concerned with what type of development?
- moral

Question 49
To assess the effectiveness of cardiac compressions during adult cardiopulmonary
resuscitation (CPR), the nurse should palpate which pulse site?
- Carotid

Question 50
Nurses should take a patient’s vital signs during all of the following, EXCEPT:
- During any surgical procedure
PHYSICAL EXAMINATION OF THE
EARS, NOSE, SINUSES, MOUTH
AND THROAT
JOSHUA D. VARGAS, RN, MD
The Ear
• The Auricle. Inspect the auricle and surrounding tissue for
deformities, lumps, or skin lesions.
• If ear pain, discharge, or inflammation is present, move the auricle
up and down, press the tragus, and press firmly just behind the ear.
Ear Canal and Drum
• To see the ear canal and drum, use an
otoscope with the largest ear speculum
that the canal will accommodate and the
brightest light.
• Position the patient’s head so that you can
see comfortably through the instrument.
• To straighten the ear canal, grasp the
auricle firmly but gently and pull it upward,
backward, and slightly away from the head.
• Caution the patient to remain still.
Ear Canal and Drum
• Insert the speculum gently into the ear canal about a quarter inch,
directing it somewhat down and forward and through the hairs, if any,
toward the eardrum.
• Inspect the ear canal, noting any discharge, foreign bodies, redness of
the skin, or swelling. Cerumen, which varies in color and consistency
from yellow and flaky to brown and sticky or even to dark and hard,
may wholly or partly obscure your view.
• Inspect the eardrum, noting its color and contour. The cone of light—
usually easy to see—helps to orient you.
Ear Canal and Drum
• Identify the handle of
the malleus, noting its
position, and inspect
the short process of
the malleus.
Auditory Acuity
• To estimate hearing, test one ear at a time. Ask the patient to occlude
one ear with a finger, or better still, occlude it yourself.
• When auditory acuity on the two sides is different, move your finger
rapidly, but gently, in the occluded canal.
• Then, standing 1 or 2 feet away, exhale fully (so as to minimize the
intensity of your voice) and whisper softly toward the unoccluded ear
• To make sure the patient does not read your lips, stand behind the
patient, cover your mouth or obstruct the patient’s vision.
Air and Bone Conduction
• If hearing is diminished, try to distinguish conductive from
sensorineural hearing loss.
• You need quiet room and a tuning fork, preferably of 512 Hz or
possibly 1024 Hz.
Air and Bone Conduction
• Weber test
• Test for lateralization
• Place the base of the lightly vibrating
• tuning fork firmly on top of the
patient’s head or on the midforehead
• Ask where the patient hears it: on one
or both sides
• Normally the sound is heard in the
midline or equally in both ears.
Air and Bone Conduction
Rinne test
• Compare air conduction (AC) and bone
conduction (BC)
• Place the base of a lightly vibrating tuning
fork on the mastoid bone, behind the ear
and level with the canal.
• When the patient can no longer hear the
sound, quickly place the fork close to the
ear canal and ascertain whether the sound
can be heard again.
• Normally the sound is heard longer
through air than through bone (AC>BC).
The Nose
The Nose
• Inspect the anterior and inferior surfaces of the nose. Gentle pressure
on the tip of the nose with your thumb usually widens the nostrils
and, with the aid of a penlight or otoscope light, you can get a partial
view of each nasal vestibule. If the tip is tender, be particularly gentle
and manipulate the nose as little as possible.
• Note any asymmetry or deformity of the nose.
• Test for nasal obstruction, if indicated, by pressing on each ala nasi in
turn and asking the patient to breathe in.
The Nose
• Inspect the inside of the nose with an
otoscope and the largest ear speculum
available.
• Tilt the patient’s head back a bit and
insert the speculum gently into the
vestibule of each nostril, avoiding
contact with the sensitive nasal
septum.
• By directing the speculum posteriorly,
then upward in small steps, try to see
the inferior and middle turbinates, the
nasal septum, and the narrow nasal
passage between them. Some
asymmetry of the two sides is normal.
The Nose
• Observe the nasal mucosa, the nasal septum, and any abnormalities.
The nasal mucosa that covers the septum and turbinates.
• Note its color and any swelling, bleeding, or exudate. If exudate is present,
note its character: clear, mucopurulent, or purulent. The nasal mucosa is
normally somewhat redder than the oral mucosa
• The nasal septum
• Note any deviation, inflammation, or perforation of the septum. The lower
anterior portion of the septum (where the patient’s finger can reach) is a
common source of epistaxis (nosebleed).
• Any abnormalities such as ulcers or polyps.
The Nose
• Inspection of the nasal cavity through the anterior naris is usually
limited to the vestibule, the anterior portion of the septum, and the
lower and middle turbinates.
• Examination with a nasopharyngeal mirror is required for detection of
posterior abnormalities. This technique is used by
otorhinolaryngologists (ear, nose, and throat [ENT] specialists).
• Make it a habit to dispose of all nasal and ear specula after use.
The Sinuses
• Palpate for sinus tenderness.
Press up on the frontal sinuses
from under the bony brows,
avoiding pressure on the eyes.
Then press up on the maxillary
sinuses.
The Mouth and Throat
The Mouth and Throat
• Inspect the following:
• The Lips.
• Observe their color and moisture, and
note any lumps, ulcers, cracking, or
scaliness.
• The Oral Mucosa.
• Look into the patient’s mouth and, with
a good light and the help of a tongue
blade, inspect the oral mucosa for color,
ulcers, white patches, and nodules. The
wavy white line on this buccal mucosa
develops where the upper and lower
teeth meet.
• Irritation from sucking or chewing may
cause or intensify it.
The Mouth and Throat
• Inspect the following:
• The Gums and Teeth.
• Note the color of the gums, normally pink. Patchy brownness
may be present, especially but not exclusively in black people.
Inspect the gum margins and the interdental papillae for
swelling or ulceration.
• Inspect the teeth.
• Are any of them missing, discolored, misshapen, or abnormally
positioned? You can check for looseness with your gloved
thumb and index finger. Look for malocclusion of the teeth.
The Mouth and Throat
• Inspect the following:
• The Roof of the Mouth.
• Inspect the color and architecture of
the hard palate.
• The Tongue and the Floor of the
Mouth.
• Ask the patient to put out his or her
tongue. Inspect it for symmetry—a test
of the hypoglossal nerve (cranial nerve
XII).
• Note the color and texture of the
dorsum of the tongue.
The Mouth and Throat
• Inspect the following:
• Inspect the sides and undersurface of the
tongue and the floor of the mouth. These are
the areas where cancer most often develops.
• Note any white or reddened areas, nodules, or
ulcerations. Because cancer of the tongue is
more common in men older than 50 years,
especially in smokers and drinkers of alcohol,
palpation is indicated.
• Explain what you plan to do and put on gloves.
• Ask the patient to protrude his or her tongue.
• With your right hand, grasp the tip of the
tongue with a square of gauze and gently pull
it to the patient’s left.
• Inspect the side of the tongue, and then
palpate it with your gloved left hand, feeling
for any induration (hardness)
• Reverse the procedure for the other side.
The Pharynx
• Now, with the patient’s mouth open but the
tongue not protruded, ask the patient to say
“ah” or yawn. This action may let you see
the pharynx well. If not, press a tongue
blade firmly down upon the midpoint of the
arched tongue—far enough back to get
good visualization of the pharynx but not so
far that you cause gagging.
• Simultaneously, ask for an “ah” or a yawn.
Note the rise of the soft palate and the
uvula—a test of cranial nerve X (the vagal
nerve).
The Pharynx
• Inspect the soft palate, anterior
and posterior pillars, uvula,
tonsils, and pharynx.
• Note their color and symmetry and
look for exudate, swelling,
ulceration, or tonsillar enlargement.
Tonsils are graded based on size:
• 1: Tonsils are visible
• 2: Tonsils are between the tonsillar
pillars and the uvula.
• 3: Tonsils are touching the uvula.
• 4: Tonsils are touching each other.
PHYSICAL EXAMINATION OF
THE HEAD AND NECK
JOSHUA D. VARGAS, RN, MD
The Hair
• Note its quantity,
distribution,
texture, and
pattern of loss, if
any.
• You may see loose
flakes of dandruff.
The Scalp.

• Part the hair in

several places
and look for
scaliness, lumps,
nevi, or other
lesions.
The Skull.
• Observe the general size and
contour of the skull. Note any
deformities, depressions, lumps,
or tenderness.
• Learn to recognize the
irregularities in a normal skull,
such as those near the suture
lines between the parietal and
occipital bones.
The Face
• Note the patient’s
facial expression and
contours. Observe for
asymmetry, involuntary
movements, edema,
and masses.
The Skin.

•Observe the skin,

noting its color,
pigmentation,
texture, thickness,
hair distribution,
and any lesions.
The Neck.
• Observe the skin, noting its color,
pigmentation, texture, thickness,
hair distribution, and any lesions.
Inspect the neck, noting its
symmetry and any masses or scars.
• Look for enlargement of the
parotid or submandibular glands,
and note any visible lymph nodes.
The Lymph Nodes.
• Palpate the lymph nodes.
• Using the pads of your index and
middle fingers, move the skin over
the underlying tissues in each area in
a circular motion.
• The patient should be relaxed, with
neck flexed slightly forward and, if
needed, slightly toward the side
being examined. You can usually
examine both sides at once.
The Lymph Nodes.
Feel in sequence for the following nodes:
1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular- midway between the angle and the tip of the
mandible. These nodes are usually smaller and smoother than
the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of
the mandible
7. Superficial cervical—superficial to the sternomastoid
8. Posterior cervical—along the anterior edge of the trapezius
9. Deep cervical chain—deep to the sternomastoid and often
inaccessible to examination. Hook your thumb and fingers
around either side of the sternomastoid muscle to find them.
10.Supraclavicular—deep in the angle formed by the clavicle and
the sternomastoid
The Trachea and the Thyroid Gland.

• To orient yourself to the neck, identify

the thyroid and cricoid cartilages and
the trachea below them.
• Inspect the trachea for any
deviation from its usual midline
position. Then feel for any
deviation. Place your finger along
one side of the trachea and note
the space between it and the
sternomastoid. Compare it with
the other side. The spaces should
be symmetric.
The Trachea and the Thyroid Gland.
• Inspect the neck for the thyroid gland. Tip the patient’s head back a
bit. Using tangential lighting directed downward from the tip of the
patient’s chin, inspect the region below the cricoid cartilage for the
gland. The lower shadowed border of each thyroid gland shown here
is outlined by arrows.
The Carotid Arteries and Jugular Veins.
• Defer a detailed examination of
these vessels until the patient lies
down for the cardiovascular
examination.
• Jugular venous distention,
however, may be visible in the
sitting position and should not be
overlooked.
• You should also be alert to
unusually prominent arterial
pulsations.
Recording your findings
PHYSICAL EXAMINATION OF THE SKIN
Dermatological examination
• Before you can make a diagnosis of any skin lesion, it's important to
be able to accurately describe the skin lesion.
• A thorough examination of the whole skin is considered best
practice.
• First just look
• Note whether the patient looks ill or well. Note whether there any
clues as to systemic illness.
• Wipe off any creams, make-up or anything else that may obscure the
true nature of the lesions.
• Now focus on the lesion(s)
• Note the position of lesions:
• Consider whether the distribution is symmetrical or asymmetrical.
(Symmetrical distribution suggests an endogenous condition such as
psoriasis, while asymmetry is more typical of an exogenous condition such
as tinea.) Some rashes have a characteristic distribution such as with
shingles.
• Note whether flexor or extensor surfaces are involved.
• Establish whether there are areas of friction or pressure.
• Note whether sweaty regions are involved.
• Note whether exposed regions are involved.
• Consider whether sexual contact is a factor (consider genital lesions but also
the lower abdomen and upper thighs).
•Note the size of the lesion. Measure for accuracy.
•Establish whether it is single or multiple.
•If a rash exists, consider its morphology. Are individual lesions:
•Macular?
•Papular?
•Vesicular?
•Crusty?
•Urticarial?
•Note color, shape, regularity or irregularity.
•Note whether areas of inflammation around it exist.
•Consider whether the edge is clearly demarcated or poorly defined.
Now touch
• Tenderness. Warmth. Site within the skin. Thickness.
• Consistency (hard, soft, firm, fluctuant).
• Note whether firm pressure leads to blanching.
• Note whether it is friable and whether it bleeds easily.
• Scaling - disorders of the epidermis may produce scale, which may be
visible, or gentle scratching of the skin may make it apparent.
• If appropriate, look to see if there is any evidence of infestation - eg,
scabies' burrows.
• Note hair in the local skin and on the head.
• Look at the nails.
• Note whether mucous membranes are involved.
• Examine the genitals where appropriate.
• Note regional lymph nodes. This may be relevant for infectious or
malignant lesions.
Standard examination of the skin
without lesions
Setting up the examination
• Good lighting (daylight or its
equivalent)
• Good exposure (ask patient to
disrobe)
• Universal precaution
• Appropriate PPE
• No make up
Standard examination of the skin without
lesions
• Note basic demographics of the patient: age, sex, occupation,
nationality, country of origin.
• Past medical history.
• Family history.
• Personal and social history.
Standard examination of the skin without
lesions
• Focus on reviewing signs and symptoms related to the skin.
• Describe the skin:
• Color
• Moisture
• Temperature
• Texture
• Mobility and turgor
Describing color
Describing texture
Describing temperature
Describing moisture
Describing mobility and turgor
Sample Report
• No history of pigmentation changes, rashes, pruritus, brusing or
bleeding, changes in size and shape of moles, and previously
diagnosed skin disease.
• Dark brown skin appears smooth and supple, warm to touch, with
quick recoil after pinching. Nailbeds appear pinking and capillary refill
time is less than 2 secs. Moles appear with symmetric edges, regular
borders, no variation in color, all less than 0.5 cm. Tongue and
mucous membranes appear pinking and moist. Palpebral
conjunctivae appear pinkish. Hair is black and coarse, with no signs of
hair loss.
Patient with a skin complaint
Terminologies: Secondary Lesions
• Scale – flakes; accumulation of stratum corneum
• Crust – dried exudates
• Scar – fibrous tissue formed as part of wound healing
• Excoriation – erosion from scratching
• Lichenification – thickening, accentuated skin fold markings
• Depressed
• Atrophy (loss of substance, intract dermis)
• Erosion (epidermis)
• Fissure (linear)
• Ulcer (dermis)
Patient with a skin complaint
History:
• Evolution of lesions
a. Site of onset
b. Manner in which the eruption progressed or spread
c. Duration
d. Periods of resolution or improvement in chronic eruptions
Patient with a skin complaint
History:
• Symptoms associated with the eruption
a. Itching, burning, pain, numbness
b. What, if anything, has relieved symptoms
c. Time of day when symptoms are most severe
Patient with a skin complaint
History:
• Current or recent medications
• Associated systemic symptoms
• Ongoing or previous illnesses
• History of allergies
• Presence of photosensitivity
• Review of systems
• Family history
• Social, sexual, or travel history
Sample History
A 56-year-old diabetic man presented erythematous papules and
pustules on the neck and face who had developed since 3 months. He
had been treated with topical corticosteroids for the same time
period that resulted in progressive exacerbation. He additionally
showed patches of hair loss in the beard area, erythema and scaling
of the ears.
Sample History
A 32-year-old woman had developed moderate swelling, erythema and
papules of the central part of her face for 8 weeks. She started to
apply various topical cosmetic products sold for acne that did not
help. As one of her hobbies was outdoor biking she noticed that sun
exposure aggravated her skin condition, also resulting in burning and
stinging sensations. She consulted her general practitioner who
prescribed prednicarbat cream for topical application on the affected
regions. Whereas she observed a slight improvement of the skin
condition during the first week, she later on suddenly developed a
severe worsening with erythema, papules and many pustules.
Sample History
A 29-year old man presented to a dermatology department because of
inflammatory papules and nodules on both cheeks and the chin. The
forehead was not much affected. He had noticed severe seborrhea
and a progressive increase of large pores with continuous thickening
of the skin for several years. There were no comedones. Some small
erythematous lesions and papules were also found on the chest. He
had been treated for acne for several months without any significant
improvement.
Patient with a skin complaint
Physical Examination:
• the morphology of individual lesions
• the types of primary and secondary lesions
• the arrangement of the lesions.
• the distribution of the eruption
Examination of Hair
• Inspect hair quantity, texture and
distribution
Examination of Nails
•Inspect nail color, shape
and presence of lesions

1. Clubbing of fingers
2. Onycholysis
3. Paronychia
4. Terry’s nails
5. Beau’s lines

Psoriatic nails (“oil spots”,

pitting, onycholysis)
AIDS TO DERMATOLOGIC DIAGNOSIS
The examiner’s eye is the most important
instrument .
• Magnification
• Wood’s lamp
• Diascopy
• Patch testing
• Skin biopsy
Distribution
Distribution
Distribution
Distribution
PHYSICAL EXAMINATION OF
THE EYE
JOSHUA D. VARGAS, RN, MD
Preparation of the Patient
• Preparation of the patient and the environment is crucial to obtain
correct findings during the eye examination. If the Snellen chart is
located outside the exam room, then the patient should do this
portion of the examination prior to changing into a patient gown if a
complete examination is being performed.
• The area should be well lit and free of distractions.
• The remainder of the examination will be in a quiet, well-lit room
with all necessary equipment in the room.
The components of the eye examination
include:
1. Vision tests: distal, near, and peripheral
2. Inspection of the eye, eyebrows, lids, conjunctiva and sclera, cornea,
lens, iris, and pupils
3. Inspection and palpation of the lacrimal apparatus
4. Extraocular movements: assessment of cardinal fields, convergence,
corneal light test, cover–uncover test
5. Inspection of the fundi including the optic disc and cup, retina, and
retinal vessels
Vision Tests
• Visual Acuity (Distal).
• To test the acuity of central
vision, use a Snellen eye chart,
if possible, and light it well.
• Position the patient 20 feet
from the chart.
• Patients who use glasses or
contacts other than for reading
should wear them for the
examination
Vision Tests
• Visual Acuity (Distal).
• Coaxing to attempt the next line
may improve performance.
• A patient who cannot read the
largest letter should be positioned
closer to the chart; note the
intervening distance.
• Determine the smallest line of
print from which the patient can
identify more than half the letters
• Record the visual acuity
designated at the side of this line,
along with use of glasses or
contacts, if any.
Vision Tests
• Visual Acuity (Distal).
• Visual acuity is expressed as
two numbers (e.g.,20/30).
• The numerator indicates the
distance of the patient from the
chart and this number should
always be 20 unless the patient
moved closer to see, and the
denominator is the distance at
which a normal eye can read
the line of letters.
Vision Tests
• Visual Acuity (Near Vision).
• Rosenbaum chart
• Newspaper
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by Confrontation
• Screening starts in the temporal fields because most
defects involve these areas. Imagine the patient’s visual
fields projected onto a glass bowl that encircles the front
of the patient’s head.
1. Ask the patient to look with both eyes into your
eyes.
2. While you return the patient’s gaze, place your
hands about 2 feet apart, lateral to the patient’s
ears.
3. Instruct the patient to point to your fingers as
soon as they are seen.
4. Then slowly move the wiggling fingers of both
your hands along the imaginary bowl towards the
line of gaze until the patient points to them.
5. Repeat this pattern in the upper and lower
temporal quadrants. Usually a person sees both
sets of fingers at the same time. If so, fields are
usually normal.
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by
Confrontation
• FURTHER TESTING. If you find a defect,
try to establish its boundaries. Test one
eye at a time. If you suspect a temporal
defect in the left visual field, for example,
ask the patient to cover the right eye and,
with the left one, to look into your eye
directly opposite.
• Then slowly move your wiggling fingers
from the defective area toward the
better vision, noting where the patient
first responds.
• Repeat this at several levels to define the
border.
External Eye
• Position and Alignment of the Eyes.
• Stand in front of the patient and survey the eyes for position and alignment. If one or
both eyes seem to protrude, assess them from above.
• Eyebrows.
• Inspect the eyebrows, noting their quantity and distribution and any scaliness of the
underlying skin.
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower
• eyelids
External Eye
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower eyelids Edema
of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are
unusually prominent, when there is facial paralysis, or when the patient is unconscious.
External Eye
• Conjunctiva and Sclera.
• Ask the patient to look up as you
depress both lower lids with your
thumbs, exposing the sclera and
conjunctiva. Inspect the sclera and
palpebral conjunctiva for color, and
note the vascular pattern against the
white scleral background. Look for any
nodules or swelling.
External Eye
• Cornea and Lens.
• With oblique lighting, inspect the cornea
of each eye for opacities and note any
opacities in the lens that may be visible
through the pupil.
• Iris.
• At the same time, inspect each iris. The
markings should be clearly defined. With
your light shining directly from the
temporal side, look for a crescentic
shadow on the medial side of the iris.
Because the iris is normally fairly flat and
forms a relatively open angle with the
cornea, this lighting casts no shadow.
External Eye
• Pupils.
• Inspect the size, shape, and symmetry
of the pupils. If the pupils are large ( 5
mm), small ( 3 mm), or unequal,
measure them. A pupil guide with
black circles of varying sizes facilitates
measurement.
External Eye
• Test the pupillary reaction to light.
• Ask the patient to look into the distance, and shine a bright
light obliquely into each pupil in turn. (Both the distant gaze
and the oblique lighting help to prevent a near reaction.) Look
for:
• The direct reaction (pupillary constriction in the same eye)
• The consensual reaction (pupillary constriction in the opposite
eye)
• Always darken the room and use a bright light before
deciding that a light reaction is absent. If the reaction to
light is impaired or questionable, test the near reaction in
normal room light.
• Testing one eye at a time makes it easier to concentrate on
pupillary responses, without the distraction of extraocular
movement.
• Hold your finger or pencil about 10 cm from the patient’s
eye.
• Ask the patient to look alternately at it and into the
distance directly behind it.
• Watch for pupillary constriction with near effort.
Inspection and palpation of the lacrimal
apparatus
• Lacrimal Apparatus.
• Briefly inspect the regions of the lacrimal gland and lacrimal sac for swelling.
• Look for excessive tearing, dryness, or crusting of the eyes. Assessment of
dryness may require special testing by an ophthalmologist.
Extraocular movements
• Assess the extraocular movements, looking for:
• The normal conjugate movements of the eyes in each direction, or any
deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus
on extreme lateral gaze are normal. If you see it, bring your finger in to within
the field of binocular vision and look again.
• Lid lag as the eyes move from up to down.
Extraocular movements
• Cardinal fields.
• To test the six extraocular movements (EOMs), ask the
patient to follow your finger or pencil as you sweep
through the six cardinal directions of gaze. Making a wide
H in the air, lead the patient’s gaze:
• (1) to the patient’s extreme right
• (2) to the right and upward
• (3) down on the right
• (4) without pausing in the middle, to the extreme left
• (5) to the left and upward
• (6) down on the left.

• Pause during upward and lateral gaze to detect

nystagmus. Move your finger or pencil at 12”–18” from
the patient. Because middle-aged or older people may
have difficulty focusing on near objects, make this
distance greater for them than for young people. Some
patients move their heads to follow your finger. If
necessary, hold the head in the proper midline position.
Extraocular movements
• Convergence.
• Finally, test for convergence. Ask the
patient to follow your finger or pencil as
you move it in toward the bridge of the
nose. The converging eyes normally follow
the object to within 5 cm to 8 cm of the
nose.
• Corneal light reflex.
• From about 2 feet directly in front of the
patient, shine a light onto the patient’s eyes
and ask the patient to look at it. Inspect the
reflections in the cornea. They should be
visible slightly nasal to the center of the
pupils.
• A cover–uncover test may reveal a slight
or latent muscle imbalance not
otherwise seen
Ophthalmoscopic examination
• The nurse would examine the
patients eyes without dilating
the pupils. The view is
therefore limited to the
posterior structures of the
retina. To see more peripheral
structures, to evaluate the
macula well, or to investigate
unexplained visual loss,
ophthalmologists dilate the
pupils with mydriatic drops
unless this is contraindicated.
PHYSICAL EXAMINATION OF
THE THORAX AND LUNGS
JOSHUA D. VARGAS, RN, MD
INITIAL SURVEY OF
RESPIRATION AND
THE THORAX
• Observation and
documentation of the rate,
rhythm, depth, and effort
of breathing is the first step
of the respiratory
assessment.
General Survey
• Always inspect the patient for any signs of respiratory difficulty.
• Observe the patient’s facial expression—it should be relaxed and calm.
• Observe level of consciousness.
• Assess the patient’s color for cyanosis, especially the face, mucous membranes, and
nail beds. Recall any relevant findings from earlier parts of your examination, such as
the shape of the fingernails.
• Listen to the patient’s breathing.
• Are there any audible sounds (e.g.,wheezing or stridor)? If so, where do they fall in
the respiratory cycle?
• Inspect the neck.
• During inspiration, is there contraction of the accessory muscles, namely, the
sternomastoid and scalene muscles, or supraclavicular retraction? Is the trachea
midline?
General Survey
• Also observe the shape of the chest.
• The anteroposterior (AP) diameter may increase with aging, compared with
the lateral chest diameter.
• Usually there is a 2:1 ratio of transverse to anteroposterior diameters.
PHYSICAL EXAMINATION
POSTERIOR CHEST
Inspection
• From a midline position behind the patient, note the shape of the
chest and how the chest moves, including:
• Deformities or asymmetry
• Abnormal retraction of the intercostal spaces during inspiration.
• Retraction is most apparent in the lower intercostal spaces.
• Impaired respiratory movement on one or both sides or a unilateral
lag (or delay) in movement
Palpation
• Identify tender areas.
• Carefully palpate any area where pain
has been
• reported or where lesions or bruises are
evident.
• Assess any observed abnormalities
such as masses
• Test chest expansion.
• Feel for tactile fremitus.
Palpation
• Palpate and compare symmetric areas of
the lungs in the pattern shown in the
photograph. Identify and locate any
areas of increased, decreased, or absent
fremitus.

• Fremitus is typically more prominent in

the interscapular area than in the lower
lung fields and is often more prominent
on the right side than on the left. It
disappears below the diaphragm.
Percussion
AUSCULTATION
• Breath Sounds (Lung Sounds).
• Learn to identify patterns of breath sounds by their intensity, their pitch, and the
relative duration of their inspiratory and expiratory phases. Normal breath sounds
are:
• Vesicular, or soft and low pitched.
• They are heard through inspiration, continue without pause through expiration, and
then fade away about one third of the way through expiration.
• Bronchovesicular, with inspiratory and expiratory sounds about equal in
Length, at times separated by a silent interval.
• Detecting differences in pitch and intensity is often easier during expiration.
• Bronchial, or louder and higher in pitch, with a short silence between
inspiratory and expiratory sounds.
• Expiratory sounds last longer than inspiratory sounds.
AUSCULTATION
• Listen to the breath sounds with the diaphragm of a stethoscope
after instructing the patient to breathe deeply through an open
mouth.
• Use the pattern suggested for percussion, moving from one side to
the other and comparing symmetric areas of the lungs.
• If you hear or suspect abnormal sounds, auscultate adjacent areas so that you
can fully describe the extent of any abnormality.
• Listen to at least one full breath in each location.
• Be alert for patient discomfort resulting from hyperventilation (e.g.,
lightheadedness, faintness), and allow the patient to rest as needed
AUSCULTATION
• Note the intensity of the breath sounds.
• Breath sounds are usually louder in the lower posterior lung fields and
may also vary from area to area.
• If the breath sounds seem faint, ask the patient to breathe more deeply.
You may then hear them easily.
• When patients do not breathe deeply enough or have a thick chest wall, as
in obesity, breath sounds may remain diminished.
• Listen for the pitch, intensity, and duration of the expiratory and inspiratory
sounds. Are vesicular breath sounds distributed throughout the chest wall?
Or are there bronchovesicular or bronchial breath sounds in unexpected
places? If so, where are they?
AUSCULTATION
• Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
• Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
• Transmitted Voice Sounds.
• If you hear abnormally located bronchovesicular or bronchial
breath sounds or adventitious sounds, assess transmitted
voice sounds. With a stethoscope, listen in symmetric areas
over the chest wall as you:
• Ask the patient to say “ninety-nine.” Normally the sounds
transmitted through the chest wall are muffled and indistinct.
• Ask the patient to say “ee.” You will normally hear a muffled long E
sound.
• Ask the patient to whisper “ninety-nine” or “one-two-three.” The
whispered voice is normally heard faintly and indistinctly, if at all.
PHYSICAL EXAMINATION
ANTERIOR CHEST
Inspection
• Observe the shape of the patient’s chest and the movement
of the chest wall.
• Note:
• 1. Deformities or asymmetry
• 2. Work of breathing: abnormal retraction of the lower intercostal
spaces during
• inspiration. Supraclavicular or substernal retraction is often
present.
• 3. Local lag or impairment in respiratory movement
Palpation
1. Identification of tender areas
2. Assessment of observed
abnormalities
3. Further assessment of chest
expansion.
1. Place your thumbs along each costal
margin, your hands along the lateral
rib cage. As you position your hands,
slide them medially a bit to raise loose
skin folds between your thumbs. Ask
the patient to inhale deeply (as the
thorax expands
2. Observe how far your thumbs diverge
and feel for the extent and symmetry
of respiratory movement.
Palpation
Assessment of tactile fremitus.
Compare both sides of the
chest, using the ball or ulnar surface
of your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Palpation
Assessment of tactile fremitus.
Compare both sides of the
chest, using the ball or ulnar surface
of your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Percussion
• Percuss the anterior and
lateral chest, again comparing
both sides. The heart normally
produces an area of dullness
to the left of the sternum from
the 3rd to the 5th intercostal
spaces. Percuss the left lung
lateral to it.
Percussion
• In a woman, to enhance
percussion, gently displace the
breast with your left hand
while percussing with the right.
• Alternatively, you may ask the
patient to move her breast for
you.
• Identify and locate any area
with an abnormal percussion
note.
Percussion
• With your pleximeter finger above
and parallel to the expected upper
border of liver dullness, percuss in
progressive steps downward in the
right midclavicular line. Identify the
upper border of liver dullness. Later,
during the abdominal examination,
you will use this method to
estimate the size of the liver.
• As you percuss down the chest on
the left, the resonance of normal
lung usually changes to the
tympany of the gastric air bubble.
Auscultation
1. Listen to the breath sounds,
noting their intensity and
identifying any variations from
normal vesicular breathing.
Breath sounds are usually louder
in the upper anterior lung fields.
Bronchovesicular breath sounds
may be heard over the large
airways, especially on the right.
2. Identify any adventitious sounds,
time them in the respiratory cycle,
and locate them on the chest wall.
Do they clear with deep
breathing?
3. If indicated, listen for transmitted
voice sounds.
Vital Signs Taking
TEMPERATURE,
PULSE, RESPIRATION
AND BLOOD
PRESSURE

PREPARED BY:
JOBELLE GRACE H. MIRANDA, RN, MAN, USRN
TEMPERATURE, PULSE, RESPIRATION
AND BLOOD PRESSURE
DEFINITION:
Obtaining and recording of the vital signs (temperature, pulse,
and respiration) accurately and safely, recognizing deviation from
normal)

PURPOSES:
1. To determine the course of illness, this serves as a guide in
meeting the needs of the patient.
2. To afford an opportunity to observe the general condition of
the patient.
3. To aid the physician in making diagnosis and planning
patient’s care.
GENERAL CONSIDERATIONS:

- Make sure the patient has had

rested before taking vital signs.

- Remember that the frequency of

taking the TPR depends upon the
condition of the patient and the
policy of the agency.

- Inform the physician or head

nurse promptly for any significant
change in the vital signs.

- Explain the procedure to the

patient so that he/she feels at ease.
This Photo by Unknown Author is licensed under CC BY-SA-NC
A. TEMPERATURE
DEFINITION:
The balance between heat produced and heat loss.

SPECIAL CONSIDERATIONS:
- Stay with the patient while thermometer is in place.
- Provide individual thermometer for each patient.
- Use only rectal thermometer, for rectal temperature.
- When patient has diarrhea, do not take temperature by rectum.
- Using the axillary method, see to it that the axilla is dry, and the bulb of the thermometer is
within the hollow of the axilla.
- Remember that rectal temperature is taken to check the anal passage/opening of the newborn
baby.
A.1 USING
DIGITAL
THERMOMETER

EQUIPMENT:
• Digital Axillary Thermometer
• Cotton balls
• Paper tissue or wipes
• Soap solution/Petroleum Jelly
 A.1.1 AXILLARY METHOD

STEPS RATIONALE
1. Rinse, dry, turn on, and read the digital
thermometer
2. Dry it with a cotton ball or a soft paper A cotton ball with the aid of friction helps in drying
tissue from the bulb toward the fingers the thermometer.
with a firm twisting motion.

3. Wipe the axilla in order to dry it without Friction may produce heat thereby resulting to
using friction (gently pat it). inaccuracy of recording of the body temperature.

4. Place the digital thermometer into the
axilla with the bulb directed toward the
patient’s head, bring the patient’s arm
down close to his body and place his
forearm over his chests.
When the bulb rests against the superficial blood
vessels in the axilla and the skin surfaces are
brought together to reduce the amount of air
surrounding the bulb a reasonable reliable
measurement of body temperature can be
obtained.
5. Leave the digital thermometer in
place until it beeps. (Approximately
1-3 minutes)
 
6. Remove the digital thermometer
and wipe from the fingertips to the
bulb in a firm twisting motion.
 
7. Read the thermometer and then,
wash it with soap and water for
waterproof digital thermometer or
else wipe it with alcohol swab.
8. Dispose the tissue used in wiping
the thermometer in a receptacle
used for soiled items.
9. Return the clean digital
thermometer to its container.
Allowing sufficient time for the axillary tissue
to reach its maximum temperature results in
a reasonable accurate measurement of
the body temperature.
Cleansing from an area where there are
few organisms to an area where there are
numerous organisms minimizes the spread
of organisms to cleaner areas. Friction helps
to loosen matter from a surface.
Washing/alcohol swabs remove organisms.
Confining contaminated articles helps
prevents the spread of pathogens.
 
Ensure safety of the digital thermometer
 A.1.2 RECTAL METHOD
STEPS
1. Place a small amount of petroleum jelly or Vaseline
cream on a piece of tissue paper.
2. Rinse, dry, turn on, and read the digital
thermometer
3. Lubricate the digital thermometer about 1 inch from
the bulb.
 
4. Place the patient in a side lying position and separate the
buttocks so that the anal sphincter is seen. Insert the digital
thermometer for 1 ½ inches into the rectum. Permit buttocks
to fall in place.
5. Leave the digital thermometer in place for 1-3
minutes or until it beep. Hold it in place if the patient is
irrational or a restless child.
6. Remove, wipe and read the thermometer and
proceed with its after care as indicated in the axilla
temperature taking.
RATIONALE
In preparation for lubricating the rectal
thermometer.
 
Lubrication reduces friction and thereby facilitates
insertion of the thermometer; this minimizes irritation
of the mucous membrane of the anal canal.
If not placed directly into the anal opening,
the bulb of the thermometer may injure the
sphincter.
Allowing sufficient time for thermometer to
register results in a more accurate
measurement of body temperature.
Same principles as in oral method.
 • A.2.1 TEMPORAL (FOREHEAD) METHOD - measuring the temperature of something without
having to touch it or even be near it.

• EQUIPMENT:
• Infrared Temporal Thermometer

The advantages of using a thermometer gun include:

• Ability to monitor the temperature without touching a contagious person/patients
• Can be used for various applications
• Lightweight, compact and easy to use
• Fast scanning of large crowds
• An important resource for many places like airports, hospitals, schools, etc.
• Great for taking temperatures of uncooperative patients– such as infants, small children, etc.
• Infrared thermometer on a baby saves time and relieves stress
The disadvantages of using a thermometer gun include:
• Inaccurate readings caused by operator error
• Unnoticed environmental conditions that skew readings
• Likelihood of causing false readings that can greatly inconvenienced people
• Possible quarantining of people who aren’t sick
 STEPS RATIONALE
1. Set the Reading to Fahrenheit or To set the gun for proper scanning
Celsius
You can move the toggle switch
easily to change your measurement
to Fahrenheit or Celsius.
2. Set the Measurement Unit  
Choose what kind of reading you’re
doing – food, body temperature, etc.
3. Aim the Gun Blocking the target can give inaccurate
Aim the gun towards the object or reading
person. Make sure there is nothing
blocking the gun and target/patient.
4. Get Close Far distance can alter the result of scan.
Get close to the object or person –
between one and two feet.
5. Pull the Trigger To assess the body temperature.
Pulling the trigger gives an instant
infrared reading on the gun’s display.
A.2.2 TYMPANIC (EAR) METHOD
- Taking temperature in the ear.

probe
CONSIDERATION:
• Always take the temperature in the
same ear, as the reading in the
right ear may differ from that in the
left ear. This is a physiological
difference which occurs naturally
and is important to keep this in
mind when taking a reading.
• Consider external factors.

EQUIPMENT:
• Infrared Ear Thermometer
• Cap or Probe
Ear temperature can be affected by things other than true body temperature, for
example when the person has been:
•
• 1. Wearing something over their ears
• 2. Lying on one ear or the other
• 3. Exposed to very hot or very cold temperatures
• 4. Recently swimming or bathing

• In these cases, remove the external factors and wait 30 minutes prior to taking a
temperature.

When not to use an ear thermometer

 TYMPANIC (EAR) METHOD

STEPS RATIONALE

1. Make sure a new, clean Hygiene Ensure accurate measurement

cap is in place before each
measurement.

2. Place the ear probe snugly in ear  

canal and direct towards opposite
temple.

3. Keep the thermometer steady in Inaccurate reading may result & health
the ear canal assessment will be incorrect

4. Take a measurement by pressing Assess accurate body temperature.

the "Measurement" button and wait
until you achieve the correct body
temperature

5. Dispose of the used hygiene cap Prevents cross contamination

properly
B. OBTAINING THE PULSE (RADIAL ARTERY)

DEFINITION:
• The expansion of the arterial walls occurring with each ventricular contraction.

PURPOSES:
• 1. To count the number of times that the heart beats per minute.
• 2. To obtain information regarding condition of the heart action and patient’s
general condition.

SPECIAL CONSIDERATIONS:
• Remember that one pulse or one complete rise and fall of the arterial wall is
considered as one beat or count.
• Take the pulse at a convenient site for the patient and the nurse.
• When taking the pulse, note the rate, rhythm, the volume and quality of the
arterial wall.
• Do not take pulse when the patient is restless or when a child is crying.
• If peripheral pulse is difficult to obtain, take the apical or cardiac rate.

EQUIPMENT:
• Watch with a second hand and stethoscope if needed (apical pulse).
 OBTAINING THE PULSE (RADIAL ARTERY)
STEPS RATIONALE
1. Have the patient rest his arm alongside of This position places the radial artery on the inner aspect
his body with the wrist extended and the palm of the patient’s wrist. The nurse’s fingers rest
of the hand facing downward. conveniently on the artery with the thumb in a position
  on the outer aspect of the patient’s wrist.

2. Place the 1st, 2nd, 3rd fingers along the radial The fingerprints, sensitive to touch, will feel the
artery and press it gently against the radius; pulsation of the patient’s radial artery.
rest the thumb on the back of patient’s wrist. If the thumb is used for palpitating the patient’s pulse
the nurse may feel her own pulse.

3. Apply only enough pressure so that you, can Moderate pressure allows the nurse to feel the superficial
feel the patient’s pulsating artery directly. radial artery expand and contract with each heartbeat;
  too much pressure will obliterate the pulse. If too little
pressure is applied, the pulse will be imperceptible.

4. Using a watch with a second hand, count the Sufficient time is necessary to detect irregularities or
number of pulsation felt on the patient’s artery other defects.
for one full minute.

5. If the pulse rate is abnormal, repeat the Repeating the count is necessary to allow regular timing
counting in order to determine accurately the between beats.
rate, the quality and rhythm of the pulse.
C. OBTAINING THE RESPIRATORY RATE

DEFINITION:
• The process by which oxygen and carbon dioxide
are interchanged.

PURPOSES:
• 1. To obtain the respiratory rate per minute.
• 2. To obtain an information of the patient’s
respiratory status and condition.

SPECIAL CONSIDERATIONS:
- Note the rate depth and character of
respiration.
- Note the color of the patient and his act of
breathing while taking his respiration.
- The patient should not be made aware that his
respiration is being taken.

EQUIPMENT: Watch with second hand.

 OBTAINING THE RESPIRATORY RATE

STEPS
1. While the fingertips are still in place
after counting the pulse rate, observe
the patient’s respiration.
 
RATIONALE
Counting the respiration while presumably still
counting the pulse keeps the patient from
becoming conscious of his breathing and
possibly altering his usual rate.

2. Note the rise and fall of patient’s A complete cycle of inspiration and expiration
chest with each inspiration and constitutes one act of respiration.
expiration. You can make observation  
without disturbing the patient’s clothes
and bed.
3. Using a watch with a second hand, Sufficient time is necessary to observe rate,
count the number of respiration for one depth and other character of respiration.
full minute.
4. If respiration is abnormal repeat the Repeating the count is allowed.
count in order to determine accurately
the rate and characteristics of
breathing.
 D. TAKING BLOOD PRESSURE
DEFINITION:
• To take systolic, diastolic and pulse pressure.
• To determine certain physiologic changes that may occur.
• To determine the pumping action of the heart.
• To aid in diagnosis.
• To evaluate the general condition of the patient.

SPECIAL CONSIDERATIONS:
• Keep patient physically and emotionally rested before taking the blood pressure.
• For required repeated reading take blood pressure in the same arm, in the same position and time.
• Take blood pressure reading as quickly as possible to prevent venous congestion.
• Allow 20-30 seconds for venous circulation to return to normal if repeated reading is necessary.
• Report promptly to the physician or head nurse any significant change in blood pressure.
• Size of cuff should be appropriate to the size of the patient’s arm.

EQUIPMENT:
• Sphygmomanometer
• Appropriately sized blood pressure cuff
• Stethoscope
 TAKING BLOOD PRESSURE
STEPS
1. Place patient in a comfortable position with
the arm supported and palm upward.
2. Roll patient’s gown above the elbows;
Choose the proper BP cuff size: place the cuff so
that the inflatable bag is centered over the
brachial artery. The lower edge of cuff is 2cm.
Above the antecubital fossa.
3. Wrap the cuff smoothly around the arm and
tuck end of cuff securely under preceding
wrapping.
4. Place yourself so that aneroid gauge can be
read at eye level, and no more than 3 feet
away.
5. Use the fingertips to feel for a strong pulsation
in the antecubital, space.
RATIONALE
This position places the brachial artery so that the
stethoscope can rest on it conveniently in the
antecubital area.
Most measurement errors occur by not taking the time to
choose the proper cuff size.
Proper placement of the cuff pressure applied directly
over the artery will yield most accurate reading.
A twisted cuff and wrapping could produce unequal
pressure and an inaccurate reading.
If the eye level is above or below aneroid gauge,
parallax will give an inaccurate reading.
Accurate blood pressure readings are possible when the
stethoscope is directly over the artery.
6. Place the bell of the stethoscope on the
brachial artery in the antecubital space where
the pulse was noted without causing too much
pressure.
7. Pump the bulb of manometer until the
mercury rises to approximately 20 to 30 mmHg.
Above the anticipated systolic pressure.
8. Using the valve on the bulb, release 2 to 3 mm
per heart-beat and note on the manometer the
point at which the first sound is heard, record this
figure as the systolic pressure.
9. Continue to release the air in the cuff evenly
and gradually. Sounds may become a bit
“muffled”.
10. Note the reading on the manometer when
the last distinct loud sound is heard. Record this
figure as the diastolic pressure.
 
11. Allow the remaining air to escape quickly,
remove the cuff and cleanse the equipment.
Sound transmission can be distorted when source
and reception are misaligned.
 
Pressure in the cuff prevents blood from flowing
through the brachial artery.
 
Systolic pressure is that point at which the blood in
the brachial artery is first able to force its way
through, against the pressure exerted on the vessel
by the cuff of the manometer.
The artery is open, but still partly occluded.
 
Diastolic pressure is that point when blood flows
freely in the brachial artery and is equivalent to the
amount of pressure normally exerted on the walls
of the arteries when the heart is at rest.
Parallax is the apparent change of position of an
object when seen from two different points.
Sample of Temperature, Pulse and Respiratory Graphing
Sheet
Behavior and general appearance
- congruent to the patient look like
- dress properly
- alertness
- stress/restless
- Catatonia – extreme restlessness or fixity sometimes awkward position for a long
time
- Reflective of a psychiatric problem

Emotions
- looks stress in
Volatile – any time burst into anger
- visible expression – smiling, angry, in fear

Speech
- spontaneous or logic
- connected to each other
- logical make sense
- stutter interference
- tone (monotonous only one tone of the voice)
- rise and a fall

Thought content and processes

- logical flow content conversation. Straight to the point. Wander away from the
conversation that maybe underlaying a mental condition
Hints of abnormalities or hints or perversion
- obsession – repetitive thought of someone. Intrusive thought of patient most
thinking of the time. Keeps talking, going back.
- delusions - is false representation of reality. Fixed false belief. Cannot be change
Delusion of divinity – he believe that e is god
Delusion of granger – rich or powerful
- illusions – is a stimulus but the person is misinterpreting the stimulus. The eye
glass looks like a snake or scorpion
- hallucination – there is no stimulus, but the person says something that wish may
be real. Example is there is no eyeglasses the but he see snake or scorpion
Suicidal - thought can be settle. Contemplating thought
Homicidal thoughts – killing somebody or causing harm
Loose associations – words are not connected to the next phrase. The flow of
thought is loose
Tangential thinking – gaps of memories things forget.
Word salad – one word to another
Neologisms – creation of new words. It is not found in the dictionary
Circumstantial thought – concrete verses abstract talk. Intellectual state of
conversation

Perceptual disturbances – illusions and hallucinations (visual hallucination and

auditory hallucination - somebody is whispering to them. Tactile hallucination –
there is inspect crawling in their skin)

Impulse control
- ability to delay or modulate expression or behaviors

Cognition
– orientation to person ability of patient to imply oriented to place
- concentration they may tell the weather
- Memory listen attentively or analyze

Knowledge, insights and judgement

- response how this person resolve day to day problem. Probable consequences to
their action

Children and adolescent

- use dolls to communicate with the children
- comfortable for the parent. Not to judge the parent
open ended questions - expansion of the thought. Elaboration
close ended questions - brief response / yes or no
Sigmund freud’s stages of psychosexual development
Psychosocial predominant
Each stage has a psychosocial task

Oral – 0-1.5 years - Communication comes from the mouth

id – primitive to satisfy oneself

Anal - 1.5-3 years – control being in anal or toilet training. Control bladder

Phallic - 3-6 years – genital region. Explorative in sexuality. Contradicting.

Superego emerges from interactions with parents. Oedipal (for males) and electra
(for females) complexes appear
Ego – is the no or conscience. Once in between to give in in id or superego
- Preschool stage
Temporary feelings that can be developed into constructive feelings

Latency - 6-11 years – school age. Abeyance of sexual urges as the child develops
more intellectual and social skills, hobbies, sports for developing friendship with
members the same sex. The superego continues to develop. Defense mechanisms
appear.
- denial. This does not happen
- blaming
- Substitute their conflict into solutions

Genital – adolescence – puberty allows impulses to reappear. Resolved and if no

major fixation have occurred, the individual will develop heterosexual attachments
outside of the family. Romantic love can lead to a successful marriage and
parenting
- regression. Example is crying
Erik Erikson stages Focuses in the psychosocial development
Each development of the child has a task to resolve. To grow up responsible

Infancy - trust satisfy with their oral needs and mistrust. Hard time strusting

Toddlerhood – autonomy

Adolescence – identity and role confusion ( develop identify crisis) . You know
who you are. According to your age

Young adulthood – intimacy (whom to commit yourself and intimate relationship

with) and isolation (live alone. Could not trust people. jealous). Testing roles and
then integrating them to form single identity, or they become confused

Middle adulthood – generativity ( ability to generate knowledge and experience

that could left behind to the next generation) and stagnation. People discover a
sense of contributing to the world, usually trough family and work, or they may
feel a lack of purpose.

Piaget’s stages of cognitive development

Sensorimotor – object permanence
Preoperational – grammar to express concepts, symbolic thinking. Imagination
and intuition are strong, but complex abstract thoughts are still difficult.
Conservation is developed.
Concrete operational – concepts attached to concrete situations. Time, space, and
quantity are understood and can be applied, but not as independent concepts
Formal operational – theoretical, hypothetical, and counterfactual thinking.
Abstact logic and reasoning. Strategy and planning become possible. Concepts
learned in one context can be applied to another

Kohlberg’s theory of moral development

Moral – is concept of what’s good and bad. What is acceptable and unacceptable
Level one preconventional
Step one – punishment and obedience orientation. Obey rules to avoid punishment
Step two - naïve hedonism. Conforms to get rewards and to have favors returned

Level two conventional

Step three – good boy/ good girl morality. Conforms to avoid disapproval or
dislike by others
Step four – conforms to avoid censure by authorities. Know the enforcement of the
law.

Level three postconventional

Step five – conforms to maintain communities. Emphasis on individual rights.
Step six – individual principles consciences. Guilty. Anchored in family

Pain – existing
- unpleasant
- personal subjective experience can test
- stimulated actual tissue damage
- anticipated damage
- state of inflammation. There maybe damage. Potential tissue damage
- multidimensional phenomenon - psychological pain,
- fifth vital signs

Theories
1. specific
Nausea ceptors – detect pain from stimuli
2. gate control theory
- close or open

2. pain transmission Afferent to the gate of control

A-beta and A-delta transmit pain very fast within a fraction of second
Myelin covering of the nerves. Fatty composition

Pain threshold –
Pain tolerance – how long can you endure the pain
Past experiences of pain - Interpretation of the pain

According to Hansel ye Fight and flight responses – is the primitive responses for
survival. Need action or flee from the conflict

Parasympathetic stimulation - Maintain balance. Opposite of sympathetic

stimulation
- the purpose is contradicted of sympathetic to back to normal

Anticipation –

Aftermath – you learned. No longer the same before

Vocalizations
Sometimes Pain is made up

Body Movement
Immobilization – cannot move
Muscle tension – contraction of the muscle

Factors influencing pain

Culture - stoic in pain
Quality of pain – knife or stabbing pain
Ideal relief – rest, sleeping, eating
Duration – few seconds, hours, or days
Chronic pain in less than six months

Ethnic group - Share common culture and tradition

Abuse occurs because the victim allows the Abuser to abuse them
Personality - values upbringing as a child
Narcissistic - person who inlove in themselves
Pain modulation – how we experience pain. Is it dull, sharp, low intensity or high
intensity

Pain threshold – intensity of pain how we experience pain

Pain tolerance – how long can you endure the pain. Dysmenorrhea

Past experiences of pain - Interpretation of the pain

Sympathetic stimulation
- is the activation of your hormone that elevate respiration and blood pressure.
- The purpose is increase blood distribution to the muscle for action. Fight or flight
response
- all vital signs are up
- Gastrointestinal tract and urinary tract will decrease function. All blood is
diverted to muscle
- prolonged

According to Hansel ye Fight and flight responses – is the primitive responses for
survival. Need action or flee from the conflict or to confront your stressor

Parasympathetic stimulation
- Maintain balance. Opposite of sympathetic stimulation
- the purpose is contradicted of sympathetic to back to normal to main homeostasis
imbalance

Phases of pain experience

Anticipation – to learn about pain and its relief. Expected pain

Sensation – feeling the pain, density

Aftermath – you learned. You’ll able to study the pain what’s it impact to you. No
longer the as same before
Behavioral indicators of effects of pain - Sometimes Pain is made up
Vocalizations –
Facial expression -
Body Movement –
Social interaction –
Immobilization – cannot move
Muscle tension – contraction of the muscle
Stress came the word istresse which means contraction. Tightening the muscle. An
involuntary

Factors influencing pain

Age – the younger you are the better to adopt your stress. Regression
Sex – male has higher threshold but women can tolerate pain longer than men
Culture - stoic in pain (different) example, tattoos, noble suicide, very dramatic to
pain
Meaning of pain – if you experience it before you were able to adopt the future
pain
Previous experience - if you experience it before you were able to adopt the future
pain
Coping style – warm compress, cold compress, distracting self, family support.
Attention, anxiety and fatigue

Assess for:
L – LOCATION. Ask question
I – intensity: how can you measure. Use a tool, pain scale. Pain cannot measure
can be only priximated
Q – quality of pain: make the patient describe the experience of pain. Knife like
pain or stabbing pain
U – usual chronology: pattern of occurrence of pain. In morning, night, afternoon,
after lifting object
I – ideal relief: what does the patient do to reduce pain. Relieve by Rest (decreases
the demand for oxygenated blood to the heart) “coronary heart disease”, sleeping,
eating
Example: if the patient exert effort the demand for oxygenated increases in the
blood but if it’s not enough blood pump to the coronary artery the heart of the
patient may suffer from hypoxia (acid creates irritation)
D – duration: how long is the pain. few seconds, hours, or days
- acute pain occurs in less than six months
Chronic pain in less than six months

PQRST – predisposing precipitating factor, quality, relief , severity, time

Cold spa – as a umonic. To identify symptoms and pain

Phases pain scale – use for children who cannot qualify and quantify the pain. We
uses the faces

Types of pain
Acute pain – high intensity but short duration pain. Wound

Chronic pain – gradual and progressive pain (small to bigger) last more than 6
months. Cancer

Cutaneous or superficial pain – emanating from the skin such lavation, liberation

Deep somatic pain – arising from muscles and bones. Actual or potential pain

Visceral pain – emanating from viscera (compartment contains organ, example:

the brain has viscera, the brain is a tissue have no nociceptors we don’t directly
feel pain from the brain tissues. Chest is another viscera that contains heart and
lungs. The abdomen serve as your GI tract, hips or reproductive system

Referred pain – arising from the periphery. The pain is on the hand but you detect
the pain from the heart

Radiating pain - from the source to the radiation. No pain from the source

Malignant pain – malignancy of cancer

Pain of psychological origin – pretended pain. The make up pain. To avoid

accountability

Psychogenic pain – is real to the patient but when they go to the doctor there is
nothing found link to their pain. It’s just a thought. Hallucination or delusion
NURSING INTERVENTION:
Alleviating anxiety – elevate anxiety
Autogenic training – control pain
Guided imagery – using image to distract the patient from the source of pain
Operant conditioning – telling yourself that the pain is not real, pain is temporary
Touch – establish a good relationship with them. The patient should trust you first
Hypnosis – putting patient into deep sleep. In a positive perspective
Progressive relaxation training – using muscle control and breathing exercitation
Meditation – is an introspection (looking into oneself)
Acupressure – using the finger pressure rather than needle. Form of relaxation
Rhythmic breathing – using breathing exercise using a metronome (pyramid needle)
to guide the rhythm
Biofeedback – use of gadget. An electrical device. Help you to control pain so that
the alarm goes off
Cutaneous stimulation – massage.
Music – is a good form pain relieving measures

Pharmacology
Non-narcotic analgesics – mild to moderate pain

Piroxicam – indicated for patient who have arthritis

Narcotic analgesics - Moderate to severe pain

- develop tolerance

Morphine sulfate – consideration check the respiratory rate

- causes respiratory rate depression

Adjuvants – support therapy to pain

- Physiciatric drugs

Violence - Form of aggression

Ethnic group - Share common culture and tradition

Abuse occurs because the victim allows the Abuser to abuse them
Personality - values upbringing as a child
Narcissistic - person who inlove in themselves

Sexual violence – perversion

Emotional violence - Threating to abandon or abandoning. Defaming family in

public

Physical neglect –

Developmental neglect – did not give opportunity for child to decide, choose

Educational neglect – education

Economic exploitation – did not give enough resources to develop normally or

progress normally

Vulnerable person – women and child, older people

Characteristics of abusers

1. impaired self-esteem - less

2. strong dependency needs – dependent to their family

3. narcissistic and suspicious – by aggression

4.

Interventions

Empathy – put yourself in a situation of the patient

They did not do wrong

Culture and ethnicity

Culture – exist because there is commonality between members

Ethnic group – share characteristics. Boundary

Ethnicity – share common tradition and culture and pass-through generation

Individuals practice their own belief

CLIENT CULTURAL ASSESSMENT

Ethnic or racial background – where the patient belong. Aeta

Language and communication patterns – own unique or dialect

Cultural values and norms – familiar rituals, the elder who makes the patients
decision

Biocultural factors – medical sciences, anthropological considerations. Living in

high how they perform rituals. Adaptive capability

Religious beliefs and practices – decision making process

Health beliefs and practices – traditional doctors (quack doctor)

Spiritual –

Nutritional status - To determine the health status of the patient. Quality and
quantity of food

External environmental factors like: Capacity to purchase food

Underfeeding and overfeeding considered malnourish

DIRECT METHODS OF NUTRITIONAL ASSESSMENT

These are summarized as ABCD

Anthropometric methods - From head to toe

Clinical methods -

Dietary evaluation methods – how many meals in a day

Biochemical, laboratory methods –

I. Anthropometric assessment
- BMI – body mass index
- mid upper and calf circumstances
- weight loss during the past 3

II. Global evaluation

- accommodation type
- ently or nnursing home
- taking more than 3 prescription
- psychological stress or acute disease in the past 3 months
- mobility
- neuropsychological problems
- pressure sores or skin ulcers
III. Dietetic assessment
- quantity and quality of eating meals
- loss of appetite
- digestive problems, chewing or swallowing difficulties causing decline in patient
food intake
- beverages consumed per day
- mode of feeding

IV. Subjective assessment

- does patient consider having any nutritional problems
- how would the patient consider his health status in comparison with other people
of the same age?

INDIRECT METHODS OF NUTRITIONAL ASSESSMENT

- ecological variables including agricultural crops production
- economic factors e.g. household income, per capita income, population density,
food availability and prices
- cultural and social habits
- vital health statistics: morbidity, mortality and other health indicaotrs e.g., infants
and under-fives mortality, utilization of maternal and child health care services,
fertility indices and sanitary conditions

Scarcity might result to malnutrition

Metric
BMI = kg/m2

Imperial
BMI = 703 x lbs/in2
Underweight - Below 18.5
Normal – 18.5 - 24.9
Overweight – 25.0 – 29.9
Obese – 30.0 and above
Question 1
Pain is:
- A strongly unpleasant bodily sensation caused by actual or potential injury

Question 2
The stage that occurs between 5 – 13 years of age is concerned with:
- Industry vs. inferiority

Question 3
Who among the following proposed that personality development in childhood takes
place during five psychosexual stages, which are the oral, anal, phallic, latency, and
genital stages and that during each stage, sexual energy (libido) is expressed in
different ways and through different parts of the body?
- sigmund

Question 4
Facial expression, physiological changes and behavioral changes are a part of direct
observation for pain assessment.
- true

Question 5
Failure to provide health care to prevent or treat physical or emotional illnesses is a
form of which type of violence?
- Physical neglect

Question 6
The amount of force exerted against the walls of the artery by the blood is commonly
referred to as:
Blood pressure

Question 7
One of your friends tells you to steal some sweets. You are in Level 1, why do you NOT
steal?

- I might get caught and get in trouble

Question 8
Direct methods of nutritional assessment are summarized as:
 - abcd

Question 9
A technique that teaches your body to respond to your verbal commands. These
commands "tell" your body to relax and help control breathing, blood pressure ,
heartbeat, and body temperature to achieve deep relaxation and reduce stress is known
as:
- autogenic training

Question 10
The nurse is aware that the term bradycardia means:
- a heart rate of under 60 bpm

Question 11
At which phase of the cycle of violence does the abuser assumes a loving behavior,
contrite and makes promises to change?
- Honeymoon phase

Question 12
The capacity to identify possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of illness and maladaptive
behaviours are assessments to identify which element of the patient’s mental status
- Knowledge, insight and judgement

Question 13
Kohlberg was concerned with what type of development?
- moral

Question 14
Obsessions, delusions and suicidal and homicidal thoughts and thought process
alterations are categorized under which element of Mental Status Examination?
- Thought content and processes

Question 15
A situation in which one family member causes physical or emotional harm to another
family member is known as:
- Family violence

Question 16
______________________ is the amount of time something lasts or continues.
- Duration
Question 17
Which of the following vital sign will reveal information about pyrexia is:
- Temperature

Question 18
You are about to take the baseline vital signs. Before doing this you should ensure that:
- You inform the patient

Question 19
A person is considered obese with a BMI of:
- BMI of 30 or higher

Question 20
Pain management for acute pain involves pharmacological approaches only.
- false

Question 21
Which of the following assessment is a component of a patient assessment that
observes the entire patient as a whole and begins with the initial patient contact and
continue throughout the helping relationship?
- General survey

Question 22
What is the name of Erik Erickson's development theory?
- Psycho-social

Question 23
________________ is a pain that lasting for more than 6 months.
- Chronic pain

Question 24
Which of the following Non-Steroidal Anti-inflammatory drug (NSAIDS) is prescribed for
mild to moderate pain?
- Ibuprofen motrin

Question 25
Which pain scale is used for children?
- Wong-bake faces pain scale

Question 26
Which of the following is a specific nerve receptor for pain?
 - nociceptors

Question 27
BMI stands for:
- body mass index

Question 28
The height, weight, head circumference, body mass index (BMI), body circumferences
to assess for adiposity (waist, hip, and limbs), and skinfold thickness are the core
elements of:
- Antropometric assessment

Question 29
Which of the following refers to how much pain a person can reasonably endure?
- tolerance

Question 30
To assess for hypotension due to shock, the nurse would take which vital sign?
- Blood pressure

Question 31
Cindy understands her world primarily by grasping and sucking easily available objects.
Cindy is clearly in Piaget's ________ stage:
- Sensorimotor

Question 32
Pain that we experience it when our internal organs are damaged is related to:
- Visceral pain

Question 33
In which psychosexual stage of personality development does Oedipus and Electra
complexes become evident?
- Phallic

Question 34
Which of the following are the most vulnerable person for violence in the family unit?
- all

Question 35
An unresponsiveness from which a person arouses from sleep only after painful stimuli.
Verbal responses are slow or absent and lapses into unresponsiveness when stimulus
stops. Patient has minimal awareness of self or environment. This is known as:
 - stupor

Question 36
The categories of information necessary for a comprehensive cultural assessment of a
client includes all of the following, EXCEPT:
- political affiliation

Question 37
Failure to provide physical and cognitive stimulation needed to prevent developmental
deficits is a form of which type of violence?
- Developmental neglect

Question 38
Factors influencing pain would include which of the following?
- all

Question 39
Characteristics of abusers includes all of the following, EXCEPT:
- high self esteem

Question 40
The people within a culture who share characteristics based on race, religion, color,
national origin, or language is known as:
- ethnic group

Question 41
Mental Status assessment is a structured assessment of client’s behavioural and
cognitive functioning—is a vital component of nursing care that assists with evaluation
of:
- mental health conditions

Question 42
Intimacy vs. Isolation occurs at what stage?
- Young adulthood

Question 43
As victims’ self-esteem becomes diminished with chronic abuse, they may blame
themselves for the violence and be unable to see a way out of the situation.
- true

Question 44
Which of the following is also known as the 5th vital sign?
 - pain

Question 45
A description of pain is ______________________ when it is based on the individual’s
experience or perceptions.
- subjective

Question 46
Which assessment tool was developed to help health care professionals address
spiritual issues with patients?
- maslows

Question 47
What is Kohlberg's theory?
- People progress in their moral reasoning through stages

Question 48
Kohlberg was concerned with what type of development?
- moral

Question 49
To assess the effectiveness of cardiac compressions during adult cardiopulmonary
resuscitation (CPR), the nurse should palpate which pulse site?
- Carotid

Question 50
Nurses should take a patient’s vital signs during all of the following, EXCEPT:
- During any surgical procedure
Question 1
All are components of eye examination includes the following except:

Response: Test for lateralization

Correct answer: Test for lateralization

Score: 1 out of 1 Yes

Question 2
The following statements are true except:
I

Response: Anisocoria of 0.5mm is present in virtually all individuals

Correct answer: Anisocoria of 0.5mm is present in virtually all individuals

Score: 1 out of 1 Yes

Question 3
The chief muscle for breathing is innervated by:Supraclavicular nerve

Response: Phrenic nerve

Correct answer: Phrenic nerve

Score: 1 out of 1 Yes

Question 4
You are a nurse assigned in the OPD, a person from Kenya came in with a
chief complain of abdominal pain and fever and initial assessment was acute
cholecystitis vs hepatitis. in the case presented, how will you assess jaundice?

Response: Use a bright and examine the buccal mucosa for yellowish
discoloration of mucosa

Correct answer: Use a bright and examine the buccal mucosa for yellowish
discoloration of mucosa
Score: 1 out of 1 Yes

Question 5
How to straighten the ear canal:

Response: Grab the pinna firmly but gently and pull it upward and
backward and slightly away from the head.

Correct answer: Grab the pinna firmly but gently and pull it upward and
backward and slightly away from the head.

Score: 1 out of 1 Yes

Question 6
In testing the hearing, in order to minimize distractions by preventing lip
ready the examiner can do the one of the following measures:

Response: Use mask when speaking

Correct answer: Use mask when speaking

Score: 1 out of 1 Yes

Question 7
Dryness of the skin can be associated in the following conditions except:

Response: None of the above

Correct answer: None of the above

Score: 1 out of 1 Yes

Question 8
You’re the nurse assigned in the neuro ward and you are taking care of
patients who are suffering from stroke. You are assessing the cardinal
movements of the extraocular muscles and you know very well that they
are lateral rectus muscle is innervated by what cranial nerves?

Response: Abducens nerve

Correct answer: Abducens nerve

Score: 1 out of 1 Yes

Question 9
A finding that may indicate CN XII damage:

Response: Deviation of the tongue

Correct answer: Deviation of the tongue

Score: 1 out of 1 Yes

Question 10
Adventitious breath sound that may indicate upper respiratory tract
obstruction:

Response: Stridor

Correct answer: Stridor

Score: 1 out of 1 Yes

Question 11
Correct order of physical examination of the chest and thorax:

Response: Inspection, palpation, percussion, auscultation

Correct answer: Inspection, palpation, percussion, auscultation

Score: 1 out of 1 Yes

Question 12
Dullness during percussion may indicate the following except:

Response: COPD

Correct answer: COPD

Score: 1 out of 1 Yes

Question 13
General term for enlarged thyroid gland

Response: Goiter

Correct answer: Goiter

Score: 1 out of 1 Yes

Question 14
Hard and fixed lymph nodes suggest:

Response: Inflammation

Correct answer: Inflammation

Score: 1 out of 1 Yes

Question 15
The following is true about the examination of the head and neck except:

Response: None of the above

Correct answer: None of the above

Score: 1 out of 1 Yes

Question 16
In examining patient with a skin complain the following must be noted
except:

Response: the interruption of the eruption

Correct answer: the interruption of the eruption

Score: 1 out of 1 Yes

Question 17
In disease conditions that causes narrowing of airways, what adventitious
breath sound you may expect to hear during auscultation?

Response: Wheezing
Correct answer: Wheezing

Score: 1 out of 1 Yes

Question 18
The following are types of secondary skin lesions except

Response: Papule

Correct answer: Papule

Score: 1 out of 1 Yes

Question 19
Correct pairing of tonsil grading:

Response: Grade 2 – tonsils are between pillars and uvula

Correct answer: Grade 2 – tonsils are between pillars and uvula

Score: 1 out of 1 Yes

Question 20
True of Webers test, except:

Response: Sound normally lateralize

Correct answer: Sound normally lateralize

Score: 1 out of 1 Yes

Question 21
The nerve that innervates all the intrinsic tongue muscles

Response: Hypoglossal nerve

Correct answer: Hypoglossal nerve

Score: 1 out of 1 Yes

Question 22
The following are symptoms of pulmonary tuberculosis, except:
Response: Bulimia

Correct answer: Bulimia

Score: 1 out of 1 Yes

Question 23
A patient in the community approached you and told you that she has
been suffering from a vesicular skin lesion in her back on a which is very
painful and upon inspection you suspected that she might be suffering from
shingles. What is the distribution of the abovementioned lesion?

Response: Dermatomal

Correct answer: Dermatomal

Score: 1 out of 1 Yes

Question 24
You noted a septal perforation upon examining a 32-year old male patient
in the ORL OPD. The causes of this finding are the following except:

Response: Intranasal influenza vaccine

Correct answer: Intranasal influenza vaccine

Score: 1 out of 1 Yes

Question 25
One of the two common techniques in holding the otoscope:

Response: Pencil grip

Correct answer: Pencil grip

Score: 1 out of 1 Yes

Question 26
A patient diagnosed with neurofibromatosis 1 came in your primary care
clinic and noted several café au lait spots in his skin. The above-mentioned
lesion is an example of:

Response: Patch

Correct answer: Patch

Score: 1 out of 1 Yes

Question 27
In assessing the skin, the following are described except:

Response: Thermometer

Correct answer: Thermometer

Score: 1 out of 1 Yes

Question 28
Functions of the nose, except

Response: Aesthetic functions

Correct answer: Aesthetic functions

Score: 1 out of 1 Yes

Question 29
During otoscopy, what landmark you need you look for to orient yourself
on the structures you need to examine:

Response: Cone of light

Correct answer: Cone of light

Score: 1 out of 1 Yes

Question 30
A simple test to check the acute inflammation of the external ear.
Response: Tug test

Correct answer: Tug test

Score: 1 out of 1 Yes

Question 31
Contact lenses and eyeglasses must be removed when testing the distal
visual acuity.

Response: False

Correct answer: False

Score: 1 out of 1 Yes

Question 32
Asymmetric chest expansion can be in one of the following conditions:

Response: Flail chest

Correct answer: Flail chest

Score: 1 out of 1 Yes

Question 33
The skin’s ability to return to its place when pinched or lifted up:

Response: Turgor

Correct answer: Turgor

Score: 1 out of 1 Yes

Question 34
The following are risk factors for melanoma except:

Response: Younger age group

Correct answer: Younger age group

Score: 1 out of 1 Yes

Question 35
A primary lesion that is usually seen in patient with acne;

Response: Nodule

Correct answer: Pustule

Score: 0 out of 1 No

Question 36
You are a nurse assigned in the ENT OPD and you are assessing a senile
client. You are suspecting hearing loss what should you do next?

Response: Do tonoscopy

Correct answer: Distinguish between conductive and sensorineural hearing loss

using air and bone conduction test

Score: 0 out of 1 No

Question 37
All are true except:

Response: Adventitious breath sounds are seen in almost all normal

individuals

Correct answer: Adventitious breath sounds are seen in almost all normal
individuals

Score: 1 out of 1 Yes

Question 38
The anterior-posterior chest diameter may increase with aging:

Response: True

Correct answer: True

Score: 1 out of 1 Yes

Question 39
Arrange the sequence in examining the cervical lymph nodes:
i.Supraclavicular
ii.Posterior cervical
iii.Tonsillar
iv.Preauricular
v.Occipital
vi.Submental
vii.Posterior auricular
viii.Deep cervical chain
ix.Submandibular
x.Superficial cervical

Response: iv, vii, v, iii, ix, vi, x, ii, viii, i

Correct answer: iv, vii, v, iii, ix, vi, x, ii, viii, i

Score: 1 out of 1 Yes

Question 40
What disease condition that has small and large plaque with silvery scales?

Response: Psoriasis

Correct answer: Psoriasis

Score: 1 out of 1 Yes

Question 41
Landmark of the thyroid ithmus:

Response: 3rd and 4th tracheal rings

Correct answer: 3rd and 4th tracheal rings

Score: 1 out of 1 Yes

Question 42
Functions of the skin except:
Response: Synthesize calcium

Correct answer: Synthesize calcium

Score: 1 out of 1 Yes

Question 43
The following are needed in setting up the following are needed except:

Response: Make up

Correct answer: Make up

Score: 1 out of 1 Yes

Question 44
Normal diaphragmatic excursion

Response: 3-7 cm

Correct answer: 3-7 cm

Score: 1 out of 1 Yes

Question 45
Accurate description of the skin lesion is very important in making a
dermatologic

Response: True

Correct answer: True

Score: 1 out of 1 Yes

Question 46
In cranial nerve X paralysis, what finding you may expect see when
assessing the pharynx?

Response: Soft palate fail rise

Correct answer: Soft palate fail rise

Score: 1 out of 1 Yes

Question 47
Direct and consensual reaction are done to test__________.

Response: Pupillary reaction

Correct answer: Pupillary reaction

Score: 1 out of 1 Yes

Question 48
Inspiratory and expiratory sounds that are equal in length

Response: Bronchovesicular

Correct answer: Bronchovesicular

Score: 1 out of 1 Yes

Question 49
Test for lateralization:

Response: Weber test

Correct answer: Weber test

Score: 1 out of 1 Yes

Question 50
Considered the best practice in examining the skin:

Response: Thorough observation

Correct answer: Thorough observation

Score: 1 out of 1
Question 1
It is a basic nursing tool in which the nurse ensures that the interaction
focuses on the patient and the patient’s concerns and can gather complete
information that can help improve the health of patients.

Response: Therapeutic Communication Skills

Correct answer: Therapeutic Communication Skills

Score: 1 out of 1 Yes

Question 2
It allows patients time to gather their thoughts and provide accurate
answers. Silence can be therapeutic, communicating nonverbal concerns.

Response: Purposeful silence

Correct answer: Purposeful silence

Score: 1 out of 1 Yes

Question 3
Which therapeutic communication technique is being used in this nurse-
client interaction?
Client: “My father spanked me often.”
Nurse: “Your father spanked you often, he was a disciplinarian.”

Response: A. Restatement

Correct answer: A. Restatement

Score: 1 out of 1 Yes

Question 4
These are sensitive, personal, and privileged information of patients:

Response: Social security I.D.

Correct answer: Social security I.D.

Score: 1 out of 1 Yes

Question 5
Students are permitted to perform controlled acts authorized to nursing if
they meet all three criteria:

Response: Have been taught by their faculty, preceptor or Nurse Educator.

Response: Have the knowledge, skill and judgment to perform them as

determined by their preceptor or faculty member.

Response: Are supervised by a member of the nursing staff at hospitals or

the faculty member.

Correct answer: Have been taught by their faculty, preceptor or Nurse

Educator. , Have the knowledge, skill and judgment to perform them as
determined by their preceptor or faculty member. , Are supervised by a
member of the nursing staff at hospitals or the faculty member.

Score: 3 out of 3 Yes

Question 6
Under the Philippine Nursing Act of 2002 R.A. 9178, nursing students do
not perform professional nursing duties. They are to be supervised by their
clinical instructors.

Response: False

Correct answer: False

Score: 1 out of 1 Yes

Question 7
It relates to the content of the communication. The nurse makes a simple
statement, usually using the same words as patients.

Response: Restatement

Correct answer: Restatement

Score: 1 out of 1 Yes

Question 8
When a patient goes to the laboratory and offers his or her arm for blood
extraction is an example of an Express onsent.

Response: False

Correct answer: False

Score: 1 out of 1 Yes

Question 9
The nurse changes the topic when a situation is uncomfortable because of
personal experiences or coping mechanisms.

Response: Changing the subject

Correct answer: Changing the subject

Score: 1 out of 1 Yes

Question 10
A student nurse is learning about the appropriate use of touch when
communicating with clients during the health assessment. Which statement
by the instructor best provides information about this aspect of therapeutic
communication?

Response: A. "Touch carries a different meaning for different individuals."

Always ask permission.

Correct answer: A. "Touch carries a different meaning for different

individuals." Always ask permission.

Score: 1 out of 1 Yes

Question 11
These are the inherent factors of effective nursing care:
Response: All of the above

Correct answer: All of the above

Score: 1 out of 1 Yes

Question 12
It is a special agreement to allow something to happen such as a surgery
based on full disclosure of risks, benefits, alternatives, and consequences of
refusal.

Response: Informed consent

Correct answer: Informed consent

Score: 1 out of 1 Yes

Question 13
In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive
and strict privacy legislation “to protect the fundamental human right of
privacy, of communication while ensuring free flow of information to
promote innovation and growth.” .” (Republic Act. No. 10273, Ch. 1, Sec.
2).

Response: False

Correct answer: False

Score: 1 out of 1 Yes

Question 14
During the interview, when patients are angry, the nurse listens for
associated themes and avoids becoming defensive or personalizing the
situation.

Response: True

Correct answer: True

Score: 1 out of 1 Yes

Question 15
“Don’t worry everything will be alright”, is an example of_____________.

Response: False reassurance

Correct answer: False reassurance

Score: 1 out of 1 Yes

Question 16
Obtaining valid nursing history and gathering information on the
physiologic, psychological, socio-cultural, and spiritual status. The nursing
role focuses on promoting health, screening for problems, and intervening to
restore or improve health or function as optimally as possible.

Response: Interview

Correct answer: Interview

Score: 1 out of 1 Yes

Question 17
These are ethical considerations in conducting health assessments except for:

Response: Supervision

Correct answer: Supervision

Score: 1 out of 1 Yes

Question 18
The goal is to elicit as much data about health status including biographical
data, reasons for seeking care, and history of present concern.

Response: Working phase

Correct answer: Working phase

Score: 1 out of 1 Yes

Question 19
Avoid being at different levels from the patient like standing in front of
her/him. It makes the patient feels inferior, he/she may not share critical
information and may feel you are disinterested.

Response: True

Correct answer: True

Score: 1 out of 1 Yes

Question 20
Is an agreement to a client to accept a course of treatment or procedure
after being provided complete information, including the benefits and risks
of treatment, alternatives to the treatment, and prognosis if not treated by
a health care provider.

Response: Informed consent

Correct answer: Informed consent

Score: 1 out of 1 Yes

Question 21
The closing phase is where the nurse ends the interview by summarizing
and stating what the two to three most important patterns or problems
might be and asking patients if they would like to mention or need
anything else.

Response: True

Correct answer: True

Score: 1 out of 1 Yes

Question 22
All is true about non- verbal therapeutic communication except for:
Response: d. Posture: Nurse is standing in open posture, while the client is
sitting in a chair.

Correct answer: d. Posture: Nurse is standing in open posture, while the client
is sitting in a chair.

Score: 1 out of 1 Yes

Question 23
It was mandated by Article III, Section 9 of R. A. 9173, promulgated by
the Philippine Regulatory Board of Nursing which serves as the ethical -and
legal basis in the practice of the nursing profession in the Philippines.

Response: Philippine Nursing Code of Ethics

Correct answer: Philippine Nursing Code of Ethics

Score: 1 out of 1 Yes

Question 24
It is the ability to focus on patients and their perspectives. Talking to
patients with eye contact.

Response: Active listening

Correct answer: Active listening

Score: 1 out of 1 Yes

Question 25
It helps to minimize uncomfortable feelings but may mislead a patient into
minimizing a health concern or neglecting to perform a needed health-
promoting activity.

Response: False reassurance

Correct answer: False reassurance

Score: 1 out of 1 Yes

Question 26
The following behaviors are expected of nursing students, except:

Response: Perform controlled acts without close supervision of a clinical

instructor.

Correct answer: Perform controlled acts without close supervision of a clinical

instructor.

Score: 1 out of 1 Yes

Question 27
Choose the three guidelines to avoid mistakes for nursing students:

Response: Nursing students should always be under the supervision of their

clinical instructors.

Response: They should be given assignments that are at their level of

training , experience, and competency.

Correct answer: Nursing students should always be under the supervision of

their clinical instructors. , They should be given assignments that are at
their level of training , experience, and competency.

Score: 2 out of 2 Yes

Question 28
Students are not permitted to:

Response: Act as a witness under any circumstances or for any purpose.

Response: Give phone advice for discharged families.

Response: Take verbal or telephone orders.

Response: Transport patients alone when the presence of an RN is required.

Correct answer: Act as a witness under any circumstances or for any

purpose. , Give phone advice for discharged families. , Take verbal or
telephone orders. , Transport patients alone when the presence of an RN is
required.

Score: 4 out of 4 Yes

Question 29
When the community health nurse visits a patient at home, the patient
states, “I haven’t slept the last couple of nights.” Which response by the
nurse illustrates a therapeutic communication response to this patient?

Response: . "You're having difficulty sleeping?"

Correct answer: . "You're having difficulty sleeping?"

Score: 1 out of 1 Yes

Question 30
It is the ability to perceive, reason, and communicate an understanding of
another person’s feelings without criticism.

Response: Empathy

Correct answer: Empathy

Score: 1 out of 1 Yes

Question 31
A nurse states to a client, “Things will look better tomorrow after a good
night’s sleep.” This is an example of which communication technique?

Response: D. The nontherapeutic technique of "giving false reassurance"

Correct answer: D. The nontherapeutic technique of "giving false reassurance"

Score: 1 out of 1 Yes

Question 32
In verbal Communication, all is correct except for:

Response: Tell your patient that everything will be alright after the surgery.
Correct answer: Tell your patient that everything will be alright after the
surgery.

Score: 1 out of 1 Yes

Question 33
It is a phase where the nurse establishes rapport by introducing herself/
himself and explaining the purpose of the interview.

Response: Beginning phase

Correct answer: Beginning phase

Score: 1 out of 1 Yes

Question 34
It is the ability to connect with the patient and demonstrate compassion,
sensitivity, and patient-centered care.

Response: Caring

Correct answer: Caring

Score: 1 out of 1
LONG QUIZ 1
Question 1
It is a basic nursing tool in which the nurse ensures that the interaction focuses on the
patient and the patient’s concerns and can gather complete information that can help
improve the health of patients.
Response: Therapeutic Communication Skills
Correct answer: Therapeutic Communication Skills
Score: 1 out of 1 Yes

Question 2
It allows patients time to gather their thoughts and provide accurate answers. Silence
can be therapeutic, communicating nonverbal concerns.
Response: Purposeful silence
Correct answer: Purposeful silence
Score: 1 out of 1 Yes

Question 3
Which therapeutic communication technique is being used in this nurse-client
interaction?
Client: “My father spanked me often.”
Nurse: “Your father spanked you often, he was a disciplinarian.”
Response: A. Restatement
Correct answer: A. Restatement
Score: 1 out of 1 Yes

Question 4
These are sensitive, personal, and privileged information of patients:
Response: Social security I.D.
Correct answer: Social security I.D.
Score: 1 out of 1 Yes

Question 5
Students are permitted to perform controlled acts authorized to nursing if they
meet all three criteria:
Response: Have been taught by their faculty, preceptor or Nurse Educator.
Response: Have the knowledge, skill and judgment to perform them as determined by
their preceptor or faculty member.
Response: Are supervised by a member of the nursing staff at hospitals or the faculty
member.
Correct answer: Have been taught by their faculty, preceptor or Nurse Educator. ,
Have the knowledge, skill and judgment to perform them as determined by their
preceptor or faculty member. , Are supervised by a member of the nursing staff at
hospitals or the faculty member.
Score: 3 out of 3 Yes

Question 6
Under the Philippine Nursing Act of 2002 R.A. 9178, nursing students do not perform
professional nursing duties. They are to be supervised by their clinical instructors.
Response: False
Correct answer: False
Score: 1 out of 1 Yes

Question 7
It relates to the content of the communication. The nurse makes a simple statement,
usually using the same words as patients.
Response: Restatement
Correct answer: Restatement
Score: 1 out of 1 Yes

Question 8
When a patient goes to the laboratory and offers his or her arm for blood extraction
is an example of an Express onsent.
Response: False
Correct answer: False
Score: 1 out of 1 Yes

Question 9
The nurse changes the topic when a situation is uncomfortable because of personal
experiences or coping mechanisms.
Response: Changing the subject
Correct answer: Changing the subject
Score: 1 out of 1 Yes
Question 10
A student nurse is learning about the appropriate use of touch when communicating
with clients during the health assessment. Which statement by the instructor best
provides information about this aspect of therapeutic communication?
Response: A. "Touch carries a different meaning for different individuals." Always ask
permission.
Correct answer: A. "Touch carries a different meaning for different individuals."
Always ask permission.
Score: 1 out of 1 Yes

Question 11
These are the inherent factors of effective nursing care:
Response: All of the above
Correct answer: All of the above
Score: 1 out of 1 Yes

Question 12
It is a special agreement to allow something to happen such as a surgery based on full
disclosure of risks, benefits, alternatives, and consequences of refusal.
Response: Informed consent
Correct answer: Informed consent
Score: 1 out of 1 Yes

Question 13
In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive and strict
privacy legislation “to protect the fundamental human right of privacy, of
communication while ensuring free flow of information to promote innovation and
growth.” .” (Republic Act. No. 10273, Ch. 1, Sec. 2).
Response: False
Correct answer: False
Score: 1 out of 1 Yes

Question 14
During the interview, when patients are angry, the nurse listens for associated
themes and avoids becoming defensive or personalizing the situation.
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 15
“Don’t worry everything will be alright”, is an example of_____________.
Response: False reassurance
Correct answer: False reassurance
Score: 1 out of 1 Yes

Question 16
Obtaining valid nursing history and gathering information on the physiologic,
psychological, socio-cultural, and spiritual status. The nursing role focuses on
promoting health, screening for problems, and intervening to restore or improve
health or function as optimally as possible.
Response: Interview
Correct answer: Interview
Score: 1 out of 1 Yes

Question 17
These are ethical considerations in conducting health assessments except for:
Response: Supervision
Correct answer: Supervision
Score: 1 out of 1 Yes

Question 18
The goal is to elicit as much data about health status including biographical data,
reasons for seeking care, and history of present concern.
Response: Working phase
Correct answer: Working phase
Score: 1 out of 1 Yes

Question 19
Avoid being at different levels from the patient like standing in front of her/him. It
makes the patient feels inferior, he/she may not share critical information and may
feel you are disinterested.
Response: True
Correct answer: True
Score: 1 out of 1 Yes

Question 20
Is an agreement to a client to accept a course of treatment or procedure after being
provided complete information, including the benefits and risks of treatment,
alternatives to the treatment, and prognosis if not treated by a health care provider.
Response: Informed consent
Correct answer: Informed consent
Score: 1 out of 1 Yes

Question 21
The closing phase is where the nurse ends the interview by summarizing and stating
what the two to three most important patterns or problems might be and asking
patients if they would like to mention or need anything else.
Response: True
Correct answer: True
Score: 1 out of 1 Yes

Question 22
All is true about non- verbal therapeutic communication except for:
Response: d. Posture: Nurse is standing in open posture, while the client is sitting in a
chair.
Correct answer: d. Posture: Nurse is standing in open posture, while the client is
sitting in a chair.
Score: 1 out of 1 Yes

Question 23
It was mandated by Article III, Section 9 of R. A. 9173, promulgated by the Philippine
Regulatory Board of Nursing which serves as the ethical -and legal basis in the
practice of the nursing profession in the Philippines.
Response: Philippine Nursing Code of Ethics
Correct answer: Philippine Nursing Code of Ethics
Score: 1 out of 1 Yes

Question 24
It is the ability to focus on patients and their perspectives. Talking to patients with
eye contact.
Response: Active listening
Correct answer: Active listening
Score: 1 out of 1 Yes
Question 25
It helps to minimize uncomfortable feelings but may mislead a patient into
minimizing a health concern or neglecting to perform a needed health-promoting
activity.
Response: False reassurance
Correct answer: False reassurance
Score: 1 out of 1 Yes

Question 26
The following behaviors are expected of nursing students, except:
Response: Perform controlled acts without close supervision of a clinical instructor.
Correct answer: Perform controlled acts without close supervision of a clinical
instructor.
Score: 1 out of 1 Yes

Question 27
Choose the three guidelines to avoid mistakes for nursing students:
Response: Nursing students should always be under the supervision of their clinical
instructors.
Response: They should be given assignments that are at their level of training ,
experience, and competency.
Correct answer: Nursing students should always be under the supervision of their
clinical instructors. , They should be given assignments that are at their level of
training , experience, and competency.
Score: 2 out of 2 Yes

Question 28
Students are not permitted to:
Response: Act as a witness under any circumstances or for any purpose.
Response: Give phone advice for discharged families.
Response: Take verbal or telephone orders.
Response: Transport patients alone when the presence of an RN is required.
Correct answer: Act as a witness under any circumstances or for any purpose. , Give
phone advice for discharged families. , Take verbal or telephone orders. , Transport
patients alone when the presence of an RN is required.
Score: 4 out of 4 Yes
Question 29
When the community health nurse visits a patient at home, the patient states, “I
haven’t slept the last couple of nights.” Which response by the nurse illustrates a
therapeutic communication response to this patient?
Response: . "You're having difficulty sleeping?"
Correct answer: . "You're having difficulty sleeping?"
Score: 1 out of 1 Yes

Question 30
It is the ability to perceive, reason, and communicate an understanding of another
person’s feelings without criticism.
Response: Empathy
Correct answer: Empathy
Score: 1 out of 1 Yes

Question 31
A nurse states to a client, “Things will look better tomorrow after a good night’s
sleep.” This is an example of which communication technique?
Response: D. The nontherapeutic technique of "giving false reassurance"
Correct answer: D. The nontherapeutic technique of "giving false reassurance"
Score: 1 out of 1 Yes

Question 32
In verbal Communication, all is correct except for:
Response: Tell your patient that everything will be alright after the surgery.
Correct answer: Tell your patient that everything will be alright after the surgery.
Score: 1 out of 1 Yes

Question 33
It is a phase where the nurse establishes rapport by introducing herself/ himself and
explaining the purpose of the interview.
Response: Beginning phase
Correct answer: Beginning phase
Score: 1 out of 1 Yes

Question 34
It is the ability to connect with the patient and demonstrate compassion, sensitivity,
and patient-centered care.
Response: Caring
Correct answer: Caring
Score: 1 out of 1
Interviewing
-Need to obtain a valid nursing health history

- Establish rapport, trusting relationship

- Gather info on physiologic, psychological,

sociocultural, and spiritual status

Phases of the interview

Pre-interaction phase
Beginning phase
Working
Closing

• Pre‐interaction phase: Review health record

• Beginning phase- Introduce self, Explaining the purpose of the interview

• Assuring the client that confidential info will

remain confidential (HIPAA)

• Making sure that the client is comfortable and

has privacy

• Develop trust & rapport using verbal and

nonverbal skills
Working phase • Goal is to elicit as much data about health status

• Biographical data

• Reasons for seeking care

• History of present health concern

• Past health history and family history

• Review of body systems for current health

problems

• Lifestyle and health practices and developmental

level

• Listening, observing cues, and using critical thinking skills to interpret and validate information
received from the client.

• Collaborating with the client to identify the client's problems and goals.
Summary and Closing Phase Should end gracefully, not abruptly
• Summarizing information obtained during the working phase

• Validating problems and goals with the client

• Identifying and discussing possible plans to resolve the problem with the client.

• Asking about any other concerns or further questions ("Is there anything else you would like to
mention?"

Nonverbal Communication
- Appearance: professional, uniform/ID
- Dress code re: hair, nails, jewelry (minimal)
• Demeanor: Warm, professional
• Facial expression: Neutral, friendly
• Silence: Allows you and client to reflect
• Listening: ACTIVE listening
• Posture: At same level as client, open posture
• Attitude: Nonjudgmental, accepting
Nonverbal Communication to Avoid • Excessive or insufficient eye contact
• Distraction and distance

- Don't be "mentally distant"

- Physical distance: for the interview avoid physical distance exceeding 2‐3 feet during the
interview. Greater distance conveys a non‐caring attitude or a desire to avoid close contact

• Standing: Avoid being at different levels from the

patient. Makes them feel inferior, may not share critical information; may feel you are
disinterested.

Verbal Communication
• Open‐ended questions or statements
- "How?" or "What?" or "Tell me .....". Use these type questions first

• Closed‐ended questions: "When?"; "Did?"

- Useful in keeping the interview on course
- Used to clarify information from open ended Qs

• Laundry list: Provide a list of words to choose

from ("Is the pain sharp, dull, mild, stabbing?")

• Rephrasing: Helps clarify information the client said; allows reflection

Well‐placed phrases - "Yes", "Go on", "I agree"
- Encourages the client to continue
Inferring- May elicit more data or verify existing data
- Be careful not to lead the client to untrue answers
Providing information- Give the client information as questions and concerns arise

Verbal Communication to Avoid

 Biased or leading
questions

• Rushing through the

interview

• Reading the questions

• False reassurance
• Unwanted advice

• Using authority

• Using professional/ medical

jargon

• Talking too much

• Interrupting

• Using "why" questions

Functional Status Functional status is the person's ability to
carry out the Basic self‐care activities of daily living (ADLs)
Instrumental activities of daily living (IADLs)- Activities necessary for function in society

- Household chores, cooking, cleaning, laundry,

shopping, transportation, money management,
using the telephone, making decisions, safety
decisions and social needs

Cultural variations - May be reluctant to share personal information.

- Variation with language, verbal/nonverbal

- Variation in disease or illness perception

- Variation in time orientation (past, present,

future)

- Family role
COLDSPA for symptom analysis
  Character (description - what does it feel like)

• Onset (When did it start)

• Location (Where is it, does it radiate)

• Duration (How long does it last? Recur? Constant v. intermittent?)

• Severity (intensity, how much it bothers you, 0‐10

scale).

• Pattern (what makes better or worse)

• Associated Factors (other symptoms) AND

• Affects the client (how does it affect you)
During the interview process, the nurse uses both open-ended and closed-ended questions.
During what phase of the interview process does the nurse use these specific types of questions?
A: working

During the working phase, the nurse collects data by asking specific questions. Two types of
questions are closed-ended and open-ended questions. Each type has a purpose; the nurse
chooses which type will help solicit the appropriate information. Pre-interaction, beginning, and
closing are all phases in the interview process. The pre-interaction phase is prior to meeting the
client, when the nurse collects data from the medical record. The information gathered from the
medical record is used to conduct the client interview. The beginning phase is when
introductions are exchanged, privacy is ensured, and actions are made by the nurse to relax the
client. The closing phase is when a review of the interview is conducting, summarizing areas of
concerns or importance, allowing the client to ask any closing questions.
A clinic nurse is caring for a newborn and the newborn's parents. Observing parental behavior is
an important nursing function during this child's well-baby visit. What would the nurse expect
during observation? A: Parents encouraging the baby's happy behaviors

The nurse observes the parents as they speak to their infant for encouragement of happy
behaviors and comfort for crying. Parental behavior should be appropriate for the situation; a
detached or irritable parent is cause for concern.
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client
did not want to wait. The nurse has heard about this client many times from colleagues and is
aware that she is very talkative. Which of the following is a helpful technique to improve the
quality of the interview for both provider and client? A: Briefly summarize what the client
says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

The nurse can also say, "I want to make sure I take good care of this problem because it is very
important. We may need to talk about the others at the next appointment. Is that OK with you?"
This is a helpful technique that can help the nurse to change the subject, but at the same time,
validate the client's concerns; this can provide more structure to the interview.
Which of the following questions is most useful in the assessment of a client's diabetes
management? "What is your routine for checking your blood sugar these days?"

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where
exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen
similar cases in other clients and recognizes that is likely from prolonged work at a computer,
particularly using a mouse. Which of the following is the most effective use of inferring that the
nurse might implement in this situation? Do you perform any sustained or continually
repetitive motions with that arm?"

Inferring information from what the client tells you and what you observe in the client's behavior
may elicit more data or verify existing data. Be careful not to lead the client to answers that are
not true. The question, "Do you perform any sustained or continually repetitive motions with that
arm?" is open enough to not lead the client to an expected answer but narrow enough for the
nurse to help elicit more information from the client about probable causes of his pain.
Recommending that the client change his posture while working at the computer is premature, as
the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a
computer a lot, don't you?" is a leading question, as it encourages the client to answer in the
affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more
information from the client but is not an example of inferring.

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?"
This type of response to the patient is used for what purpose? To clarify
Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions
prompt patients to identify other symptoms or give more information so that you can better
understand the situation.

The nurse is preparing to conduct an interview with a hospitalized patient. What nursing
intervention can best ensure a confidential and comfortable environment for the patient? Asking
permission to draw the client's privacy curtain.

In order to support effective communication, the client must feel that the environment is
comfortable and the conversation will be confidential. Drawing the privacy curtain is an effective
way to project privacy and thus improve the comfort on the environment where the interview
will take place.
Which type of question is asked first by the nurse in order to attain a full description of the
client's symptoms and to generate and test diagnostic hypotheses? open-ended questions to
encourage the client to tell his or her story.

Using the visualization of "the cone," the process begins with open-ended questions to hear "the
story of the symptom," ideally in the client's own words. Specific questions are then used to get
the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and
negatives, are used to retrieve information from the review of systems assessment.
A client is asked to describe "something that brings the most hope." Which functional health
pattern is the nurse assessing?A: value-belief

The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or
decisions. The self-perception-self-concept pattern describes body image, feeling state, self-
esteem, personal identity, and social identity. The role-relationship pattern describes patterns of
role interactions and relationships including family functioning and problems, and work and
neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern
and its effectiveness in terms of stress tolerance. A client's spouse answers the interview
questions and will not leave the examination room. What should the nurse suspect be occurring
with the client? A: physical abuse

Physical abuse should be considered if the partner tries to dominate the interview and will not
leave the room. Nonverbal communication is a very important aspect in nurse-client
relationships. What can the nurse do to help gain trust in clients? Select all that apply. Do not use
facial expressions such as rolling the eyes or looking bored or disgusted. Use gestures
intentionally to illustrate points, especially for clients who cannot communicate verbally.

Make sure that dress and appearance are professional

The physical appearance of the nurse sends a message to the client. Thus, it is important for
nurses to ensure that their dress and appearance are professional. Facial expressions should be
relaxed, caring, and interested. Facial expressions common in social situations (eg, rolling the
eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate
points, especially for clients who cannot communicate verbally. The nurse may point with a
finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are
purposeful rather than distracting from the communication.

During the client interview, the nurse asks specific questions such as "What were you doing
when the pain started?" or "Was the pain relieved when you rested?" In what phase of the
interview is the nurse involved? working

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying
and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand.
What type of communication is this? Active listening

Active listening is the ability to focus on the client and their perspectives. It requires the nurse to
constantly decode messages including thoughts, words, opinions, and emotions. For example, if
a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial
expression of compassion.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory
problems caused by excessive smoking? Suggest methods and provide resources to assist
with smoking cessation

The client will know that the nurse understands that it is hard to quit smoking if the nurse
suggests methods available to help kick the smoking habit. The nurse should keep a neutral and
friendly expression, and avoid any display of surprise or shock at the situation. A neutral,
friendly expression will help the client to open up and explain to the nurse his efforts at breaking
free from the habit. The nurse need not tell the client that excessive smoking could cause cancer,
as the client will be well aware of the dangers of smoking.
Tell me about your pain" is an example of an open-ended question. True

If the patient has not mentioned his or her perspective on illness during the open-ended portion
of the interview, explore this perspective prior to the directive. Probe the personal context of the
illness by asking, "How has this affected you

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work
and stress levels. The nurse recognizes this as what type of information? Lifestyle and health
practices profile

By assessing the client with regards to nutritional habits, use of substances, education, and work
and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine
the history of present health concerns, the nurse should ask questions relating to the onset,
duration, and treatments, if any have been conducted on the client, for the present health concern.
The questions related to personal health history assist the nurse in identifying risk factors that
stem from previous health problems. Family health history helps the nurse to identify potential
risk factors for the client.

A nurse is discussing with a client the client's personal health history. Which of the following
would be an appropriate question to ask at this time? "What diseases did you have as a
child?"

Information covered in the personal health history section includes questions about birth, growth,
development, childhood diseases, immunizations, allergies, medication use, previous health
problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain
experiences, and emotional or psychiatric problems.

The nurse is beginning a health history interview with an adult client who expresses anger at the
nurse. The best approach for dealing with an angry client is for the nurse to allow the client to
verbalize his or her feelings.

When interacting with an angry client approach this client in a calm, reassuring, in-control
manner. Allow him to ventilate feelings.

The nurse is planning to interview a client who is being treated for depression. When the nurse
enters the examination room, the client is sitting on the table with shoulders slumped. The nurse
should plan to approach this client by A: expressing interest in a neutral manner.

When interacting with a depressed client, express interest in and understanding of the client and
respond in a neutral manner.
Working with an Interpreter Prepare ahead of time
• Nurse must be present
• Be patient; takes time
• Speak slowly/clearly
• Pause to allow interpreter
to translate
• Timing: about 20‐30
minutes at a time

• Avoid side conversations

• Express the information
in 2‐3 different ways if
needed to account for
dialects
• Use an interpreter to
ensure family can read
and understand materials
• Use trained interpreter
• NO children (HIPAA
violation)
Interacting with an anxious client Provide the client with simple, organized
information in a structured format.

• Explain who you are and your role and

purpose.
• Ask simple, concise questions.
• Avoid becoming anxious like the client.
• Do not hurry.
• Decrease any external stimuli.
Interacting with an angry client Approach the client in a calm, reassuring, in‐
control manner.
• Allow the client to vent feelings.
• Avoid any arguments with or touching the
client.
• Obtain help from other health care
professionals as needed.
• Facilitate personal space so that the client
does not feel threatened or cornered.
Interacting with a depressed client Express interest in and understanding of the
client and respond in a neutral manner.
• Take care not to communicate in an upbeat,
encouraging manner.
Interacting with a manipulative client, Provide structure and set limits.
• Differentiate between manipulation and areasonable request.
• Obtain an objective opinion from othernursing colleagues.
Discussing sensitive issues,Be aware of your own thoughts and feelings
regarding dying, spirituality, and sexuality.

• Ask simple questions in a nonjudgmental manner.

• Allow time for ventilation of client's feelings as needed.

• If you do not feel comfortable or competent discussing personal, sensitive topics, you may
make referrals as appropriate.
Interacting with a seductive client, Set firm limits on overt sexual client behavior and avoid
responding to subtle seductive behaviors.
• Encourage client to use more appropriate methods of coping in relating to others.
Review of Systems. Each body system is addressed to find out current health problems or
problems from the pat that may still affect them or recur.

• This is ONLY SUBJECTIVE INFORMATION

• Document description of health status as well as DENIAL of signs, symptoms, diseases or
problems.
• Use lay terminology; words they understand
Reason for seeking health car "What is your major health problem or concerns at this time?"
• "How do you feel about having to seek health care"
• Patient state in his/her own words vs. reciting their medical diagnosis.
History of Present Health Concern Encourage the client to explain the health problem in detail,
give details.
• Symptom analysis
Family Health HistoryIncludes genetic conditions and others
• Include as many genetic relatives as client can recall
- Maternal and paternal grandparents, aunts and
uncles on both sides, parents, siblings and client's children.

• Draw a genogram to organize the info

- Use standard symbols for gender and relationships
- Summarize the types of health problems present, Personal Health History (Past History)
Beginning with childhood to present
- Childhood illnesses
- Chronic illnesses; Illnesses or allergies
- Medications recent past or current
- Pregnancy
- Hospitalization or surgery
- Accidents or injuries
- History of any pain
- Emotional or mental problems
Lifestyle and Health Practices • Description of typical day
• Nutrition and weight management
• Activity level and exercise
• Sleep and rest
• Medication, tobacco, alcohol & substance use
• Self‐concept and self‐care responsibilities
• Coping and stress management
A nurse collects data about a client's family health history. Which family member's health
problems should the nurse include when documenting this information in the database? As
many maternal and paternal relatives as the client can recall.

Both maternal and paternal relatives are included in the family health history. Problems can arise
in families that are not genetically based but are manifest by virtue of exposure to lifestyle
practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the
relative is deceased, the cause and age of the relative is recorded. A client scheduled for surgery
tells the nurse that he is very anxious about the surgery. What is an appropriate action by the
nurse when interacting with this client? Provide simple and organized information.

The nurse should provide simple and organized information to reassure the client about the
procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in
an in-control manner. The nurse refers the dying client or client with spiritual concerns to a
spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as
it would make the client more anxious.

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he,
are being interviewed by the nurse to update the client's health history. The nurse also has the
client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken
with the client's primary care physician, who had relayed some concerns to the nurse regarding
the progression of the client's disease. Which source of biographic information should the nurse
view as primary? The client

Biographic data usually include information that identifies the client, such as name, address,
phone number, gender, and who provided the information—the client or significant others. The
client is considered the primary source and all others (including the client's medical record) are
secondary sources. In some cases, the client's immediate family or caregiver may be a more
accurate source of information than the client. An example would be an older adult client's wife
who has kept the client's medical records for years or the legal guardian of a mentally
compromised client. In any event, validation of the information by a secondary source may be
helpful.

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling
on her left side. Which of the following questions would be best for eliciting information related
to associated factors? "What other symptoms occurred during the spell?"

Examples of questions related to associated factors include the following: "What other symptoms
occur with it? How does it affect you? What do you think caused it to start? Do you have any
other problems that seem related to it? How does it affect your life and daily activities?" The
question, "How bad was the tingling and numbness?" relates to severity. The question, "How
long did the spell last?" relates to duration. The question, "Where did the numbness and tingling
occur?" relates to location.
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular
accident. The nurse is unable to completely understand the client. What is the nurse's best action
Ask the client to repeat the statement or question.

The nurse should ask clients to repeat questions or statements if the nurse is unable to understand
what the client said. The nurse can also paraphrase client responses to verify understanding.
Learning about the effects of the illness does what for the nurse and the patient? Gives them
the opportunity to create a complete and congruent picture of the problem.

A student nurse is conducting her first patient interview. The student suddenly draws a blank on
what to ask the patient next. What is a useful interview technique for the student to use at this
point? Summarization

Summarization can be used at different points in the interview to structure the visit, especially at
times of transition. This technique also allows the nurse to organize his or her clinical reasoning
and to convey it to the patient, making the relationship more collaborative. It is also a useful
technique for learners when they draw a blank on what to ask the patient next.
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal
illness or sexuality, the nurse should have knowledge of his or her own thoughts and feelings
about these issues.

Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then
recognize that these factors may affect the client's health and may need to be discussed with
someone.

During the interview of an adult client, the nurse should provide the client with information
as questions arise.

Another important thing to do throughout the interview is to provide the client with information
as questions and concerns arise. Make sure that you answer every question as thoroughly as you
can. If you do not know the answer, explain that you will find out for the client. The more clients
know about their own health, the more likely they are to become equal participants in caring for
their health.

The nurse is beginning the review of systems with a client. Which approach would ensure that all
major body systems are included in this assessment? head to toe
Name: XXX

Date January 20, 2021

SOAP

SUBJECTIVE:

ID: K.B, DOB 9/08/1990, age 30. Male comes to clinic alone. Appears to be a reliable historian.

CC: “I am here for my yearly exam.” “

HISTORY OF PRESENT ILLNESS (HPI):

A 29-year-old male came for his well visit. He states he his last physical was a year ago and everything
was good. Feels well otherwise. No other complaints.

PAST MEDICAL HISTORY

• High cholesterol. Diagnosed 4 years ago. Took Lipitor but stopped about 6 months ago due to
stomach issues and was not prescribed any other cholesterol medications.

• Gastritis. Diagnosed 4 years ago. Has flare ups. Last flare up a year ago. Takes a medication
(does not know the name) to treat it. States it comes when he is stressed.

• Denies any other medical conditions including any other heart disease, diabetes, or asthma.

• Denies any psych history or hospitalizations.

• Denies any exposure to TB or any other infectious diseases.

PAST MEDICAL PROCEDURES

• Hernia (January 2005) treated with surgery, no complications since.

• Denies any other surgeries

MEDICATIONS-

Denies any current prescription, over the counter, or herbal medications.

ALLERGIES-

Denies any allergies to medication, food, or any environmental allergies.

LMP (as applies)-

N/A
FAMILY HISTORY

• All grandparents are currently living except MGF who passed away at 78 years of age from
Covid-19. MGF also had pacemaker and diverticulitis. MGM has irregular heartbeat. FGM & FGF have no
medical history.

• Patients mother has no significant medical conditions. Father had 2 heart stents put in around 5
years ago and has seasonal allergies. No other complications. Siblings-has a brother with early-stage
diabetes and obesity, and a sister who had a kidney transplant 12 years ago. No other complications.
Children- has 3 girls all with no medical conditions.

• Patient also denies any other heart, kidney, diabetes, asthma problems. Patient denies any
cancer, obesity (other than brother), muscle problems, bleeding disorders, psych problems, genetic
disorders, or allergies in the family (other than father’s seasonal allergies).

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE HISTORY-Sexually active. One partner. Denies any STD/STI

TOBACCO USE: Denies any tobacco use.

-ALCOHOL USE: Denies any alcohol.

-DRUG USE: Has one joint of pot on weekends. Denies any other drug use

-MARITAL HISTORY: Married with three kids. Lives in a home. Feels safe to go home. Reports no violence
or abuse at home.

-OCCUPATION: Director of purchasing for regional management office in NJ

-EXERCISE/DIET: Has cereal & milk for breakfast and has chicken/meat for lunch & dinner. Eats a lot of
candy. Denies drinking caffeine.

-STRESS/SLEEP: Stresses a lot from job, no coping strategy. Bikes for hobby. Wears helmet. Volunteers in
free time for EMS.

IMMUNIZATIONS:

Immunizations up to date except flu vaccine which is he is scheduled to take.

SPIRITUAL AFFILIATION

Jewish

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills, weight loss/gain, or fatigue

EYES: Denies seeing floaters in vision, blurred vision. Last eye exam 3 month ago.

EARS, NOSE, MOUTH/THROAT: Denies any difficulty hearing, hearing loss, ringing, or buzzing in ear.
Denies any earaches. Denies any runny nose, congestion, sinuses, or difficulty smelling. Denies any
difficulty chewing, swallowing, sore throat, ulcer/blisters in mouth. Last dental exam 8 months ago.

CARDIOVASCULAR: States he gets sudden onset chest pain every week from stress. States chest pain
feels like tightening in middle of chest. Denies any abnormal heartbeat.

RESPIRATORY: Denies SOB or hard time breathing. Denies cough.

GASTROINTESTINAL: Has daily bowel movements. Gets occasionally-every month or so- constipation
related to stress, and it goes away itself. Denies any blood or black colored stool.

GENITOURINARY: Denies any hematuria, dysuria, or difficulty urinating. Denies any discharge.

MUSCULOSKELETAL: Complaints of sore back from bad bed occasionally, go away by sleeping flat.

Denies any joint or muscle pain, swelling, or redness.

INTEGUMENTARY/BREAST: Denies dryness, rash, hyperpigmented areas, lesions or moles.

NEURO: Denies any LOC, imbalance, head injuries, or unsteadiness.

PSYCH: Denies depression, suicide, bipolar, schizophrenia, or sleeping problems.

ENDOCRINE: Denies heat or cold intolerance, hair lost, weight gain or loss.

HEMATOLOGIC/LYMPHATIC: Denies any bleeding disorders, abnormal bleeding, or nosebleeds.

ALLERGY/IMMUNOLOGY: Denies any food, drug, or environmental allergies.

PLAN OF CARE:

Educate patient on DASH diet and healthier food choices such as no more than 6 oz a day of lean meats.

Educate patient on incorporating exercise into his daily life.

Educate patient on lowering his stress levels.

Educate patient on health risks of smoking marijuana.

Send patient home with leaflet on healthy lifestyle habits and food choices printed in his language.

Schedule a follow up with patient to get cholesterol levels tested.

RISK ASSESSMENT:

A. Patient is at risk for heart diseases due the fact that he does not take medications for his high
cholesterol, gets chest pain from stress, eats meats two times a day, does not exercise regularly, and has
a family history of heart disease (Centers for Disease Control and Prevention, 2019).

B. Patient is at risk for gastrointestinal problems due to chronic stress from work and due to
history of recurrent gastritis (Mayo Clinic, 2019).

C. Patient is at risk for obesity due to stress, family history, and eating fatty and high sugar foods
(World Health Organization, 2020).

REFERENCES:

Centers for Disease Control and Prevention. (2019). Know your risk for heart disease.
https://www.cdc.gov/heartdisease/risk_factors.htm

Mayo Clinic. (2019). Chronic stress puts your health at risk. https://www.mayoclinic.org/healthy-
lifestyle/stress-management/in-depth/stress/art-20046037

World Health Organization. (2020). Obesity and overweight. https://www.who.int/news-room/fact-

sheets/detail/obesity-and-overweight
 GUIDELINES FOR EFFECTIVE
INTERVIEW AND
THERAPEUTIC COMMUNICATION
HEALTH ASSESSMENT ( NCM 101)

BETHANY C. TERUEL, RN, MN

INTERVIEW AND HEALTH HISTORY
• THE NURSING ROLE FOCUSES ON PROMOTING HEALTH, SCREENING FOR PROBLEMS,
AND INTERVENING TO RESTORE OR IMPROVE HEALTH OR FUNCTION AS OPTIMALLY
AS POSSIBLE.

• THE HEALTH HISTORY FORMS THE FOUNDATION FOR CARE AS PATTERNS EMERGE
AND PROBLEMS ARE IDENTIFIED.

• IT PROVIDES CONTEXT FOR THE CURRENT SITUATION AND COMPLETE PICTURE OF

HOW ISSUES ARE RELATED.
THERAPEUTIC COMMUNICATION

• IS A BASIC NURSING TOOL IN WHICH THE NURSE ENSURES THAT THE INTERACTION
FOCUSES ON THE PATIENT AND THE PATIENT’S CONCERNS.

KEY ELEMENTS: CARING AND EMPATHY

• CARING IS THE ABILITY TO CONNECT WITH THE PATIENT AND DEMONSTRATE

COMPASSION, SENSITIVITY, AND PATIENT-CENTERED CARE.
• EMPATHY MEANS THE ABILITY TO PERCEIVE, REASON, AND COMMUNICATE
UNDERSTANDING OF ANOTHER PERSON’S FEELINGS WITHOUT CRITICISM
NONVERBAL COMMUNICATION SKILLS

• THE NURSE’S PHYSICAL APPEARANCE, FACIAL EXPRESSION, POSTURE

AND POSITIONING IN RELATION TO THE PATIENT, GESTURES, EYE
CONTACT, VOICE, AND USE OF TOUCH ARE ALL IMPORTANT
COMPONENTS.

• THE NURSE SHOULD NOT ASSUME THAT TOUCH IS CULTURALLY

ACCEPTABLE.

• PERMISSION TO TOUCH THE PATIENT IS A COURTESY.

TECHNIQUES FOR AN EFFECTIVE
INTERVIEW

•ACTIVE LISTENING
•ADAPTIVE QUESTIONING
•NONVERBAL COMMUNICATION
•EMPATHY, VALIDATION, AND REASSURANCE
•PARTNERING AND SUMMARIZATION
•TRANSITIONS AND EMPOWERMENT
 VERBAL COMMUNICATION SKILLS
• ACTIVE LISTENING IS THE ABILITY TO FOCUS ON PATIENTS AND THEIR
PERSPECTIVES.
• RESTATEMENT RELATES TO THE CONTENT OF COMMUNICATION. THE
NURSE MAKES A SIMPLE STATEMENT, USUALLY USING THE SAME WORDS
OF PATIENTS.
• REFLECTION IS SIMILAR TO RESTATEMENT; HOWEVER, INSTEAD OF
SIMPLY ECHOING THE PATIENT’S COMMENTS, THE NURSE SUMMARIZES
THE MAIN THEMES.
• ENCOURAGING ELABORATION (FACILITATION) ASSISTS PATIENTS TO
MORE COMPLETELY DESCRIBE PROBLEMS.
• PURPOSEFUL SILENCE ALLOWS PATIENTS TIME TO GATHER THEIR
THOUGHTS AND PROVIDE ACCURATE ANSWERS. SILENCE CAN BE
THERAPEUTIC, COMMUNICATING NONVERBAL CONCERN•
• FOCUSING HELPS WHEN PATIENTS STRAY FROM TOPIC AND NEED
REDIRECTION. IT ALLOWS THE NURSE TO ADDRESS AREAS OF
CONCERN RELATED TO CURRENT PROBLEMS.
• CLARIFICATION IS IMPORTANT WHEN THE PATIENT’S WORD CHOICE
OR IDEAS ARE UNCLEAR.
• SUMMARIZING HAPPENS AT THE END OF THE INTERVIEW, WHEN THE
NURSE REVIEWS AND CONDENSES IMPORTANT INFORMATION INTO
TWO OR THREE OF THE MOST IMPORTANT FINDINGS.
NONTHERAPEUTIC RESPONSES
• • FALSE REASSURANCE HELPS TO MINIMIZE UNCOMFORTABLE FEELINGS BUT MAY MISLEAD A
PATIENT INTO MINIMIZING A HEALTH CONCERN OR NEGLECTING TO PERFORM A NEEDED HEALTH-
PROMOTING ACTIVITY.
• • SYMPATHY IS FEELING WHAT A PATIENT FEELS FROM THE VIEWPOINT OF THE NURSE, NOT OF THE
PATIENT.
• • UNWANTED ADVICE, ALTHOUGH COMMON IN SOCIAL SITUATIONS, IS NON- THERAPEUTIC,
BECAUSE IT USUALLY IS FROM THE NURSE’S PERSPECTIVE, NOT THE PATIENT.
• • BIASED (LEADING) QUESTIONS IMPOSE JUDGMENT AND LEAD PATIENTS TO RESPOND IN THE WAY
THEY THINK THE NURSE WANTS.
• • CHANGING THE SUBJECT MAY HAPPEN WHEN A SITUATION IS UNCOMFORTABLE FOR A NURSE
BECAUSE OF PERSONAL EXPERIENCES OR COPING MECHANISMS.
• • ENVIRONMENTAL DISTRACTIONS CONTRIBUTE TO NONTHERAPEUTIC COMMUNICATION.
• • TOO MANY TECHNICAL TERMS OR TOO MUCH INFORMATION CAN OVERWHELM PATIENTS. AS SHE
OR HE DEVELOPS MEDICAL VOCABULARY AND KNOWLEDGE, THE BEGINNING NURSE MUST
PRACTICE TRANSLATING FROM MEDICAL TERMINOLOGY TO LAY LANGUAGE.
• • TALKING TOO MUCH AND INTERRUPTING ARE NONTHERAPEUTIC. THE PROFESSIONAL NURSE
LISTENS MORE THAN TALKS.
 PHASES OF THE INTERVIEW PROCESS

PRE-INTERACTION PHASE
BEFORE MEETING WITH THE PATIENT, THE NURSE COLLECTS DATA FROM THE MEDICAL
RECORD AND REVIEWS THE PATIENT’S HISTORY OF MEDICAL ILLNESSES OR SURGERIES,
CURRENT MEDICATION LIST, AND PROBLEM LIST.

BEGINNING PHASE
THE NURSE INITIALLY INTRODUCES HERSELF OR HIMSELF BY NAME, STATES THE PURPOSE
OF THE INTERVIEW, AND ASKS THE PATIENT HIS OR HER PREFERRED NAME
WORKING PHASE
THE NURSE ASKS SPECIFIC QUESTIONS, TWO TYPES OF WHICH ARE
CLOSED ENDED AND OPEN ENDED.

• CLOSED-ENDED (DIRECT) QUESTIONS YIELD “YES” OR “NO” ANSWERS. AN

EXAMPLE IS “DO YOU HAVE A FAMILY HISTORY OF HEART DISEASE?” THEY
ARE IMPORTANT IN EMERGENCIES OR WHEN A NURSE NEEDS TO
ESTABLISH BASIC FACTS.

• OPEN-ENDED QUESTIONS REQUIRE PATIENTS TO ELABORATE. THEY ARE

BROAD AND PROVIDE RESPONSES IN THE PATIENT’S OWN WORDS. THEY
ARE KEY TO UNDERSTANDING SYMPTOMS, HEALTH PRACTICES, AND AREAS
REQUIRING INTERVENTION.
• CLOSING PHASE
• THE NURSE ENDS THE INTERVIEW BY SUMMARIZING AND STATING
WHAT THE TWO TO THREE MOST IMPORTANT PATTERNS OR
PROBLEMS MIGHT BE, AS WELL AS ASKING PATIENTS IF THEY
WOULD LIKE TO MENTION OR NEED ANYTHING ELSE.
• THE NURSE ALSO THANKS PATIENTS AND FAMILY MEMBERS FOR
TAKING THE TIME TO PROVIDE INFORMATION.
AREAS REQUIRING EMPHASIS:
• INTERCULTURAL COMMUNICATION, THE SENDER OF AN INTENDED
MESSAGE BELONGS TO ONE CULTURE, WHILE THE RECEIVER IS FROM
ANOTHER.
• PATIENTS WITH LIMITED ENGLISH OFTEN IDENTIFY FRUSTRATING
LANGUAGE BARRIERS WHEN NAVIGATING THE HEALTH CARE SYSTEM.
• GENDER AND SEXUAL ORIENTATION ISSUES COMMUNICATION STYLES
VARY BETWEEN AND WITHIN EACH GENDER GROUP. MEN MAY PREFER
MORE INFORMATION AND FACTS, WHEREAS WOMEN MIGHT
APPRECIATE MORE SOCIAL AND EMOTIONAL INTERACTIONS.
 SPECIAL SITUATIONS
• A. FEARS ABOUT ILLNESS, RESULTS FROM TESTS, INTERACTIONS WITH HEALTH CARE
PROFESSIONALS, AND OTHER FACTORS MAY CAUSE PATIENTS TO HAVE EMOTIONAL
RESPONSES, SUCH AS CRYING, ANXIETY, OR ANGER.
• B. HEARING IMPAIRMENT (SIGNING, WRITING, LIP READING, FACIAL EXPRESSION)
• C. LOW LEVEL OF CONSCIOUSNESS ( RELY ON FAMILY MEMBERS)
• D. COGNITIVE IMPAIRMENT (SUBSTITUTE SOUND ALIKE WORDS)
• E. MENTAL HEALTH ISSUES
1. ANXIETY- ANXIETY IS AN EXPECTED RESPONSE TO A THREAT TO WELL-BEING.
2. CRYING- HEALTH ISSUES ARE SENSITIVE AND SOMETIMES POSE SAD SITUATIONS FOR
BOTH PATIENTS AND THE NURSE.
3. ANGER- WHEN PATIENTS ARE ANGRY, THE NURSE LISTENS FOR ASSOCIATED THEMES
AND AVOIDS BECOMING DEFENSIVE OR PERSONALIZING THE SITUATION.
4. ALCOHOL OR DRUG USE- PATIENTS WITH CHEMICAL IMPAIRMENT HAVE DIFFICULTY
ANSWERING COMPLEX QUESTIONS, SO THE NURSE USES DIRECT AND SIMPLE
QUESTIONS INSTEAD.
D. PERSONAL QUESTIONS

-WHEN INTERVIEWING PATIENTS, THE NURSE ASKS

QUESTIONS WITHIN THE NURSING ROLE.
E. SEXUAL AGGRESSION
- SEXUAL AGGRESSION INCLUDES INAPPROPRIATE JOKES,
FLIRTATIOUS COMMENTS, SEXUAL SUGGESTIONS, OR SEXUAL
ADVANCES.
“a process in which the nurse
consciously influences the
patient or helps them in better
understanding through verbal
and nonverbal communication,
while encouraging patients to
express their feelings and
ideas, which is an important
prerequisite for the
realization of relation of
mutual acceptance and
respect.” 
SciFed Nursing & Healthcare
 “the quality of
communication in
interactions between nurses
and patients has a major
influence on patient
outcomes.”

Maureen Nokuthula Sibiya

titled
Effective Communication in
Nursing
•  better assessments of
patients and their health

• stronger problem-solving
a b i l i t i e s w h e n
determining what may be
impacting a patient.
• helps to alleviate
anxiety or other negative
emotions in patients,
such as fear or
loneliness, more
effectively than standard
forms of communication.
ROLE PLAYING VIDEO ON
THERAPEUTIC AND NON
THERAPEUTIC COMMUNICATION
THANK YOU
Question 1
In disease conditions that causes narrowing of airways, what adventitious breath sound
you may expect to hear during auscultation?
Response: Wheezing
Correct answer: Wheezing
Score: 1 out of 1 Yes

Question 2
A part of health promotion and disease prevention activities in patient with skin
complaints, the following must be included in the self skin examination health teaching
except;
Response: Advise patient use emollient
Correct answer: Advise patient use emollient
Score: 1 out of 1 Yes

Question 3
A patient came in to the ER with central cyanosis, the following conditions you will
consider except:
Response: Beta Thalassemia
Correct answer: IDA
Score: 0 out of 1 No

Question 4
In assessing pallor and cyanosis, fingernails and lips are the areas you need to
examine because:
Response: They consist of thick layers of mucous membrane that changes in blood flow
can be easily seen
Correct answer: The layer is thin enough to cause less scatter of light
Score: 0 out of 1 No

Question 5
The following statements are true except:
Response: Pupillary constriction is a parasympathetic response
Correct answer: Visual cortex is part of the parietal lobe of the brain
Score: 0 out of 1 No

Question 6
You noted a septal perforation upon examining a 32-year old male patient in the ORL
OPD. The causes of this finding are the following except:
Response: Intranasal influenza vaccine
Correct answer: Intranasal influenza vaccine
Score: 1 out of 1 Yes

Question 7
In examining patient with a skin complain the following must be noted except:
Response: the interruption of the eruption
Correct answer: the interruption of the eruption
Score: 1 out of 1 Yes

Question 8
The following are types of secondary skin lesions except
Response: Papule
Correct answer: Papule
Score: 1 out of 1 Yes

Question 9
You are a nurse assigned in the OPD, a person from Kenya came in with a chief
complain of abdominal pain and fever and initial assessment was acute cholecystitis vs
hepatitis. in the case presented, how will you assess jaundice?
Response: Use a bright and examine the buccal mucosa for yellowish discoloration of
mucosa
Correct answer: Use a bright and examine the buccal mucosa for yellowish
discoloration of mucosa
Score: 1 out of 1 Yes

Question 10
Which statement is true about cyanosis
Response: Central cyanosis occurs when there is low venous oxygen level in the blood
Correct answer: Peripheral cyanosis occurs when cutaneous blood flow is decreased
Score: 0 out of 1 No

Question 11
The skin’s ability to return to its place when pinched or lifted up:
Response: Turgor
Correct answer: Turgor
Score: 1 out of 1 Yes

Question 12
The following are functions of the skin except:
Response: Excretion of waste
Correct answer: Wound regression
Score: 0 out of 1 No

Question 13
You are a dialysis nurse and you are taking of patient with pitting edema. Which of the
following is true of pitting edema:
Response: It’s a depression left when pressure is applied in the non-dependent area of
the body
Correct answer: A depression left for 16 seconds when pressed
Score: 0 out of 1 No

Question 14
Swollen and tender lymph nodes suggest:
Response: Infection
Correct answer: Infection
Score: 1 out of 1 Yes

Question 15
Asymmetric chest expansion can be in one of the following conditions:
Response: Flail chest
Correct answer: Flail chest
Score: 1 out of 1 Yes

Question 16
A patient diagnosed with neurofibromatosis 1 came in your primary care clinic and
noted several café au lait spots in his skin. The above-mentioned lesion is an example
of:
Response: Patch
Correct answer: Patch
Score: 1 out of 1 Yes
Question 17
A patient in the community approached you and told you that she has been suffering
from a vesicular skin lesion in her back on a which is very painful and upon inspection
you suspected that she might be suffering from shingles. What is the distribution of the
abovementioned lesion?
Response: Dermatomal
Correct answer: Dermatomal
Score: 1 out of 1 Yes

Question 18
How to straighten the ear canal:
Response: Grab the pinna firmly but gently and pull it upward and backward and slightly
away from the head.
Correct answer: Grab the pinna firmly but gently and pull it upward and backward and
slightly away from the head.
Score: 1 out of 1 Yes

Question 19
A finding that may indicate CN XII damage:
Response: Deviation of the tongue
Correct answer: Deviation of the tongue
Score: 1 out of 1 Yes

Question 20
You’re the nurse assigned in the neuro ward and you are taking care of patients who
are suffering from stroke. You are assessing the cardinal movements of the extraocular
muscles and you know very well that the superior oblique muscle is innervated by what
cranial nerve?
Response: Abducens nerve
Correct answer: Trochlear nerve
Score: 0 out of 1 No

Question 21
True of Rinne’s test, except:
Response: Conductive hearing loss sound is heard through bone as long as or longer
than is through the air
Correct answer: None of the above
Score: 0 out of 1 No
Question 22
The following is true about the examination of the head and neck except:
Borders of the anterior triangle of the neck, except
Response: SCM
Correct answer: Hyoid bone
Score: 0 out of 1 No

Question 23
Dryness of the skin can be associated in the following conditions except:
Response: None of the above
Correct answer: None of the above
Score: 1 out of 1 Yes

Question 24
In cranial nerve X paralysis, what finding you may expect see when assessing the
pharynx?
Response: Soft palate fail rise
Correct answer: Soft palate fail rise
Score: 1 out of 1 Yes

Question 25
The anterior-posterior chest diameter may increase with aging:
Response: True
Correct answer: True
Score: 1 out of 1 Yes

Question 26
Accurate description of the skin lesion is very important in making a dermatologic
Response: True
Correct answer: True
Score: 1 out of 1 Yes

Question 27
Inspiratory and expiratory sounds that are equal in length
Response: Bronchovesicular
Correct answer: Bronchovesicular
Score: 1 out of 1 Yes

Question 28
Dullness during percussion may indicate the following except:
Response: COPD
Correct answer: COPD
Score: 1 out of 1 Yes

Question 29
Functions of the nose, except
Response: Aesthetic functions
Correct answer: Aesthetic functions
Score: 1 out of 1 Yes

Question 30
Correct order of physical examination of the chest and thorax:
Response: Inspection, palpation, percussion, auscultation
Correct answer: Inspection, palpation, percussion, auscultation
Score: 1 out of 1 Yes

Question 31
A patient diagnosed with acne came in your primary care clinic and noted several
lesions on here back and face. The above-mentioned lesion is an example of:
Response: Papule
Correct answer: Pustule
Score: 0 out of 1 No

Question 32
Test for lateralization:
Response: Weber test
Correct answer: Weber test
Score: 1 out of 1 Yes

Question 33
All are true except:
Response: Adventitious breath sounds are seen in almost all normal individuals
Correct answer: Adventitious breath sounds are seen in almost all normal individuals
Score: 1 out of 1 Yes

Question 34
Normal diaphragmatic excursion
Response: 3-7 cm
Correct answer: 3-7 cm
Score: 1 out of 1 Yes

Question 35
Gradual loss of ability of the eye to focus due to aging:
Response: Presbyopia
Correct answer: Presbyopia
Score: 1 out of 1 Yes

Question 36
Landmark of the thyroid ithmus:
Response: A and B
Correct answer: 2nd, 3rd and 4th tracheal rings
Score: 0 out of 1 No

Question 37
The chief muscle for breathing is innervated by:Supraclavicular nerve
Response: Phrenic nerve
Correct answer: Phrenic nerve
Score: 1 out of 1 Yes

Question 38
Contact lenses and eyeglasses must be removed when testing the distal visual acuity.
Response: False
Correct answer: False
Score: 1 out of 1 Yes

Question 39
A finding that may indicate CN XII damage:
Response: Deviation of the tongue
Correct answer: Deviation of the tongue
Score: 1 out of 1 Yes

Question 40
Arrange the sequence in examining the cervical lymph nodes:
i.Supraclavicular
ii.Posterior cervical
iii.Tonsillar
iv.Preauricular
v.Occipital
vi.Submental
vii.Posterior auricular
viii.Deep cervical chain
ix.Submandibular
x.Superficial cervical
Response: iv, vii, v, iii, ix, vi, x, ii, viii, i
Correct answer: iv, vii, v, iii, ix, vi, x, ii, viii, i
Score: 1 out of 1 Yes

Question 41
The following are symptoms of pulmonary tuberculosis, except:
Response: Bulimia
Correct answer: Bulimia
Score: 1 out of 1 Yes

Question 42
A simple test to check the acute inflammation of the external ear.
Response: Tug test
Correct answer: Tug test
Score: 1 out of 1 Yes

Question 43
The anterior-posterior chest diameter may increase with aging:
Response: True
Correct answer: True
Score: 1 out of 1 Yes

Question 44
You are assigned as nurse to care for a patient with dermatologic problem. Which of
the following is coonsidered the best practice in examining the skin:
Response: Thorough observation
Correct answer: Thorough observation
Score: 1 out of 1 Yes

Question 45
The nerve that innervates all the extrinsic tongue muscles
Response: Hypoglossal nerve
Correct answer: Hypoglossal nerve
Score: 1 out of 1 Yes

Question 46
During otoscopy, what landmark you need you look for to orient yourself on the
structures you need to examine:
Response: Cone of light
Correct answer: Cone of light
Score: 1 out of 1 Yes

Question 47
You are a nurse assigned in the ENT OPD and you are assessing a senile client. You
are suspecting hearing loss what should you do next?
Response: Distinguish between conductive and sensorineural hearing loss using air and
bone conduction test
Correct answer: Distinguish between conductive and sensorineural hearing loss using
air and bone conduction test
Score: 1 out of 1 Yes

Question 48
The following are risk factors for melanoma except:
Response: Dark eyed individuals
Correct answer: Dark eyed individuals
Score: 1 out of 1 Yes

Question 49
General term for enlarged thyroid gland
Response: Goiter
Correct answer: Goiter
Score: 1 out of 1 Yes
Question 50
Adventitious breath sound that may indicate upper respiratory tract obstruction:
Response: Stridor
Correct answer: Stridor
Score: 1 out of 1
THE HEALTH CARE TEAM
IN HEALTH ASSESSMENT

 BETHANY C. TERUEL, RN,MN

• The health care team consists of
a group of people who
coordinate their particular skills
in order too assist a patient or
his family.

• The personnel, who comprise a

particular team will depend
upon the needs of a patient.
• They also help with doing physical
examinations and ordering drugs and
treatments when people have more
common or routine medical or surgical
problems.
Team-based health care is the provision
of health services to individuals, families, and/or their
communities by at least two health providers who work
collaboratively with patients and their caregivers—to the
extent preferred by each patient – to accomplish shared
goals within and across settings to achieve.

The whole-team approach, also called the team-based

approach, is a style of project management in which
everyone on the project team is held equally responsible
for the quality and success of the project. ... In agile
development, this means that everyone on the
development team is equally responsible for quality.
THE HEALTH CARE TEAM
AUXILLARY PHYSICIANS
PERSONNEL

VILLAGE HEALTH HEALTH NURSES

GUIDES TEAM

SOCIAL WORKERS
TRAINED DAIS

HEALTH
ASSISTANTS
THE PHYSICIAN

• In hospital setting, the physician is

responsible for the medical
diagnosis & for determining the
therapy required by a person who is
ill or injured.
• A physician is a person who is
legally authorized to practice
medicine in particular
jurisdiction.
 NURSE
• A number of nursing personnel
may be involved in the health
team & may have their own
nursing team. A nursing team is
comprised of personnel who
provide nursing service to a
patient or his family.
• The team leader “Head Nurse” is
responsible for delegation of
duties to members of her team
& care given to the patients.
• The role of the nurse in health assessment
includes obtaining the patient’s health history
and performing a physical assessment.
• This role can be carried out in a variety of
settings, including the acute care setting, clinic
or outpatient office, school, long-term care
facility, and the home.
• A growing list of nursing diagnoses is used by
nurses to identify and categorize patient
problems that nurses have the knowledge,
skills, and responsibility to treat in-dependently.
 THE DIETITIAN
• When dietary & nutritional
services are required a dietitian
may also the member of the
health team. Dietitians supervise
the preparation of meals
according to the doctor’s
prescription.
• The nutritionist in a community
setting recommends health diets
for people & is frequently
involves in board advisory
services in regard to purchase &
preparation of food.
 THE PHYSIOTHERAPIST
• The physiotherapist provides
assistance to a patient who
has problem related to his
musculoskeletal system.
• Their functions include;
assessing mobility & strength,
providing therapeutic measures,
& teaching patients news skills &
measures.
MEDICAL SOCIAL
WORKER
 THE SOCIAL WORKER
• The patient & his/her family
member are assisted by social
worker with such problems such
as finances, rest home
accommodation, counseling or
marital problems, adoption of
children.
THE OCCUPATIONAL
THERAPIST
• The occupational therapist
assists patients with some
impairment of function to gain
skills as they are related to
Activities of Daily Living (ADL) &
help with a skill that is
therapeutic.
THE PARAMEDICAL
TECHNOLOGIST
• It includes laboratory
technologies, radio-logic
technologists.
• The Laboratory technologists
examine & study specimens
such as urine, faeces, blood &
discharges from wound.
RADIOLOGIST
• The radiologic technologist assist
with wide variety of x-ray procedures,
from simple chest radiograph to more
complex fluroscopy.

Through radio active materials,

nuclear medicine technologist can
provide diagnostic information about
functioning of a patient’s liver etc.
 THE PHARMACIST
• The pharmacist prepares &
dispenses pharmaceuticals in
hospitals & community settings.

• The role of pharmacist in

monitoring & evaluating the actions
of medications on patients is
becoming increasingly prominent
THE INHALATION THERAPIST
The inhalation therapist or
respiratory technologist is skilled
in therapeutic measures used in
care of patients with respiratory
problems.
• These therapist are
knowledgeable about oxygen
therapy, devices, intermittent
positive pressure breathing
respirators, artificial mechanical
ventilators, accessory devices
used for inhalation.
PSYCHOLOGIST
• The clinical psychologist
constitutes an important
member in the health care team.

• The psychological dimension of a

person is looked into and the
health care services are
accordingly planned.
CLERGY
• The spiritual dimension of a
patient comes into play more
during a person’s illness.

• Patients who draw their spiritual

strength from God are the ones
who successfully cope with
illness. The role of a clergy is
therefore very important.
THANK YOU!
Guidelines for
Effective Interview
and
Therapeutic
Communication
HEALTH ASSESSMENT ( NCM 101)

BETHANY C. TERUEL, RN, MN

Interview and Health History
 The nursing role focuses on promoting health, screening for
problems, and intervening to restore or improve health or
function as optimally as possible.

 The health history forms the foundation for care as patterns

emerge and problems are identified.

 It provides context for the current situation and complete

picture of how issues are related.
TECHNIQUES FOR AN EFFECTIVE
INTERVIEW
 Active listening
 Adaptive questioning
 Nonverbal communication
 Empathy, validation, and reassurance
 Partnering and summarization
 Transitions and empowerment
THERAPEUTIC COMMUNICATION

 is a basic nursing tool in which the nurse ensures that the

interaction focuses on the patient and the patient’s concerns.

Key elements: Caring and Empathy

 Caring is the ability to connect with the patient and

demonstrate compassion, sensitivity, and patient-centered
care.
 Empathy means the ability to perceive, reason, and
communicate understanding of another person’s feelings
without criticism
Nonverbal Communication Skills

 The nurse’s physical appearance, facial expression,

posture and positioning in relation to the patient,
gestures, eye contact, voice, and use of touch are all
important components.

 The nurse should not assume that touch is culturally

acceptable.

 Permission to touch the patient is a courtesy.

 Verbal Communication Skills
• Active listening is the ability to focus on patients and
their perspectives.
• Restatement relates to the content of communication.
The nurse makes a simple statement, usually using the
same words of patients.
• Reflection is similar to restatement; however, instead of
simply echoing the patient’s comments, the nurse
summarizes the main themes.
• Encouraging elaboration (facilitation) assists patients to
more completely describe problems.
 Purposeful silence allows patients time to gather
their thoughts and provide accurate answers.
Silence can be therapeutic, communicating
nonverbal concern•
 Focusing helps when patients stray from topic and
need redirection. It allows the nurse to address
areas of concern related to current problems.
 Clarification is important when the patient’s word
choice or ideas are unclear.
 Summarizing happens at the end of the interview,
when the nurse reviews and condenses important
information into two or three of the most important
findings.
Nontherapeutic Responses
 • False reassurance helps to minimize uncomfortable feelings but may
mislead a patient into minimizing a health concern or neglecting to
perform a needed health-promoting activity.
 • Sympathy is feeling what a patient feels from the viewpoint of the nurse,
not of the patient.
 • Unwanted advice, although common in social situations, is non-
therapeutic, because it usually is from the nurse’s perspective, not the
patient.
 • Biased (leading) questions impose judgment and lead patients to
respond in the way they think the nurse wants.
 • Changing the subject may happen when a situation is uncomfortable
for a nurse because of personal experiences or coping mechanisms.
 • Environmental distractions contribute to nontherapeutic
communication.
 • Too many technical terms or too much information can overwhelm
patients. As she or he develops medical vocabulary and knowledge, the
beginning nurse must practice translating from medical terminology to lay
language.
 • Talking too much and interrupting are nontherapeutic. The professional
nurse listens more than talks.
 Phases of the Interview Process
Pre-interaction Phase
Before meeting with the patient, the nurse collects data from the
medical record and reviews the patient’s history of medical illnesses or
surgeries, current medication list, and problem list.

Beginning Phase
The nurse initially introduces herself or himself by name, states the
purpose of the interview, and asks the patient his or her preferred
name
Working Phase
The nurse asks specific questions, two types of which are
closed ended and open ended.

• Closed-ended (direct) questions yield “yes” or “no”

answers. An example is “Do you have a family history of
heart disease?” They are important in emergencies or
when a nurse needs to establish basic facts.

• Open-ended questions require patients to elaborate.

They are broad and provide responses in the patient’s
own words. They are key to understanding symptoms,
health practices, and areas requiring intervention.
 Closing Phase
 The nurse ends the interview by summarizing and
stating what the two to three most important
patterns or problems might be, as well as asking
patients if they would like to mention or need
anything else.
 The nurse also thanks patients and family
members for taking the time to provide
information.
Areas requiring emphasis:
 Intercultural Communication, the sender of an
intended message belongs to one culture, while the
receiver is from another.
 Patients with limited English often identify frustrating
language barriers when navigating the health care
system.
 Gender and Sexual Orientation Issues
Communication styles vary between and within
each gender group. Men may prefer more
information and facts, whereas women might
appreciate more social and emotional interactions.
 Special Situations
 A. Fears about illness, results from tests, interactions with health care
professionals, and other factors may cause patients to have
emotional responses, such as crying, anxiety, or anger.
 B. Hearing Impairment (signing, writing, lip reading, facial
expression)
 C. Low Level of Consciousness ( rely on family members)
 D. Cognitive Impairment (substitute sound alike words)
 E. Mental Health Issues
1. Anxiety- Anxiety is an expected response to a threat to well-being.
2. Crying- Health issues are sensitive and sometimes pose sad
situations for both patients and the nurse.
3. Anger- When patients are angry, the nurse listens for associated
themes and avoids becoming defensive or personalizing the
situation.
4. Alcohol or Drug Use- Patients with chemical impairment have
difficulty answering complex questions, so the nurse uses direct
and simple questions instead.
D. Personal Questions
-When interviewing patients, the nurse asks
questions within the nursing role.
E. Sexual Aggression
- Sexual aggression includes inappropriate
jokes, flirtatious comments, sexual suggestions,
or sexual advances.
Competencies
• Therapeutic Communication
“a process in which the nurse
consciously influences the patient
or helps them in better
understanding through verbal and
nonverbal communication, while
encouraging patients to express
their feelings and ideas, which is
an important prerequisite for the
realization of relation of mutual
acceptance and respect.”
SciFed Nursing & Healthcare
Journal
Competencies
• BENEFITS
“the quality of communication
in interactions between nurses
and patients has a major
influence on patient
outcomes.”

Maureen Nokuthula Sibiya

titled
Effective Communication in
Nursing
Competencies
• BENEFITS
• better assessments of
patients and their health

• stronger problem-solving
abilities when determining
what may be impacting a
patient.
• helps to alleviate anxiety or
other negative emotions in
patients, such as fear or
loneliness, more effectively
than standard forms of
communication.
THANK YOU
Health Assessment NCM 101

Bethany C. Teruel, RN, MN

 patient  " the process of influencing patient
behavior, producing changes in

education: knowledge, attitudes, and skill

required to maintain and improve
health.”
 The process may begin with the
imparting of information, but also
includes interpretation and
integration of the information in
such a manner as to bring about
attitudinal or behavioral changes
 It considers the patient-holistically, with
all his needs and concerns, and sets
goals with the patient for desired
outcomes.
Definition of patient
teaching:

Patient teaching refers to only one component

of the patient education process the actual
imparting of information to the patient.

The transfer of knowledge that takes place with

patient teaching does not ensure behavioral
change.
  Adapt to illness/disability:
Patient education helps
chronic people to develop
ways of coping with their
Goals of impairments and live life to the
maximum potential.
patient  Cooperate with the
prescribed therapy: Patient
education: education will assist patients
who needs dialysis to learn
ways to be cooperative
and still maintain their sense
of self
3. Learn to solve problems when
confronted with new situations:

Patient education teaches patients

the skill of problem solving so that
they can figure out solutions when
they are alone and at home.

e.g: takes sweet if they feel

symptoms of hypoglycemia
4.Prevent hospitalization or re-
hospitalization:
The ultimate goal of patient
education is to help the patient
to be as fully functioning a
person
as possible in his/her home
and community and it reduce
re-hospitalized.
 1. The Patient Education Process has
four steps: Assessment,
Relationship Planning, Implementation
and Evaluation. The Nursing
between the Process has five steps:
Assessment, Nursing
Patient Diagnosis, Planning,
Education Implementation and
Evaluation.
Process and 2. The Patient Education Process
should not be thought of as
the Nursing something entirely separate
from the Nursing Process.
Process Providing education to patients is
a nursing intervention
 Other differences
3.
Education process parallel with nursing
process.
Home Teaching
The Nurse & Health
Teaching

Competencies
• Therapeutic Communication
• Health Plan
• Health Teaching
Plan

• Increase Health
Literacy
• Promote Healthy
Practices
• Address Health
problems
• Health Teaching Plan

• LEARNING OBJECTIVES/
OUTCOMES
• OUTLINE
• METHODS OF INSTRUCTION
• TIMEFRAME
• INSTRUCTIONAL MATERIAL
• EVALUATION
 Understanding
varied groups
In the conduct of
the Health
Teaching
 POINTS IN
PREPARING FOR
EFFECTIVE
TEACHING WITH
VARIED LEARNING
GROUPS
WHAT IS YOUR TOPIC?

WHO ARE YOUR

AUDIENCE?

WHERE IS YOUR
TEACHING TAKING
PLACE?
WHAT IS YOUR TOPIC?

Do you know your topic

very well?

Do you have a Health

Teaching Plan?
 WHO ARE YOUR
AUDIENCE?
Do you know your audience
well?

Are you ready to teach

them in their own
learning context?
 WHERE IS YOUR TEACHING
TAKING PLACE?

Can you conduct your Plan effectively

in your given location?
Are you able to communicate your
lesson given external factors?
ELEMENTS THAT MAKES AN
EFFECTIVE HEALTH TEACHING

• CLARITY OF TOPIC
• EFFECTIVITY IN THE DELIVERY
• EFFICIENT USE OF THERAPEUTIC
COMMUNICATION
• USE OF APPROPRIATE MATERIALS
Health Teaching Plan
 Health
•PATIENT Teaching Plan
SCENARIOS

Teaching objectives Learning objectives

1. Assess knowledge level /
awareness on current health
status
2. Draw out significant data of
client’s health practices & health
behaviors
1. Engage actively in Nurse client
interaction
2. Express willingness and openness
in client interview
3. Identify current health needs with
Student Nurse
4. Benefit from the knowledge
shared by the Student nurse
 Health
•ALFORA, Teaching Plan
ABELLA-
42 YRS OLD MULTI GRAVIDA, 2mos pregnant on
8th child

Learning objectives Outline

To know what is Family Planning Discuss Family Planning
To understand properly the Family Planning Contraceptives and its uses
To know the use of Contraceptives Discuss the advantages and
correctly disadvantages of
To properly understand the Contraceptive contraceptives
Methods. Discuss the common vaccine
To evaluate the uses of Contraceptives and given to mothers in the 1st
the Family Planning trimester
To identify the advantages and
disadvantages of Contraceptives.
Assess for the complete immunization for
the mother in her 1st trimester and onwards.
23 year old primigravida for
1st prenatal check up
Brgy Officials assembly
Teachers in the Elementary
School
36 year old primigravida
Mother
@ the Health Center
Bgry hall
@ the elementary
school
Pediatric Ward @
Riverside Hospital

Mothers in the Daycare @ Brgy Day CAre

Center
OPD of Corazon Locsin @ CLMMRH
MMRH
AKSYUN Radyu Bacolod @Radio station
Video Blog Online
FB Posting Online
Kindergarten pupils @ classroom of a
kindergarten school
• Health Teaching Plan

• LEARNING OBJECTIVES – 3
• OUTLINE (1 major topic, 1 minor)
• METHODS OF INSTRUCTION- case to case
• TIMEFRAME- 15 min presentation
• INSTRUCTIONAL MATERIAL- 1-2 appropriate
for audience
• EVALUATION-
RELEVANT ETHICO-LEGAL GUIDELINES IN
CONDUCTING HEALTH ASSESSMENT

V. HEALTH ASSESSMENT
Ethics – declarations of what is right and wrong.
• The purpose of ethics is to govern conduct to protect
an individual’s rights.

CODE OF ETHICS – a written list of professional values

and standards of conduct
PHILIPPINE NURSING CODE OF ETHICS

• Promulgated by the Philippine Regulatory Board of

Nursing
• Philippine Nurses Association and Association of Nursing
Service Administrators of the Philippines
• mandated by the article III, Section 9, of republic 9173
• Serves as ethico -legal basis in the practice of the nursing
profession in the Philippines.
AMENDED CODE OF ETHICS FOR NURSES

ARTICLE I Preamble

Sec.1 Health is a fundamental right of every individual. The Filipino registered nurse
believing in the worth and dignity of each human being, recognizes the primary
responsibility to preserve health at all cost. This responsibility encompasses the promotion
of health, prevention of illness, alleviation of suffering, and restoration of health. However,
when the foregoing are not possible, assistance towards a peaceful death shall be his/her
obligation.
Sec.2 To assume this responsibility, registered nurses
have to gain knowledge and understanding of man’s
cultural, social, spiritual, psychological, and ecological
aspects of illness, utilizing the therapeutic process.
Cultural diversity and political and socio-economic status
are inherent factors to effective nursing care.
ARTICLE 1 PREAMBLE

Sec.3 The desire for the respect and confidence of

clientele, colleagues, co-workers, and the members of
the community provides the incentive to attain and
maintain the highest possible degree of ethical conduct.
NURSING STUDENT ROLES AND
RESPONSIBILITIES
THE FOLLOWING BEHAVIORS ARE EXPECTED OF
NURSING STUDENTS:

• Respects the safety and well-being of patients

• Recognizes limits of knowledge, skills, and judgement
• Understands and clarifies own role in the provision of care
• Is accountable for the quality of care provided within the established objectives
• Uses clear, accurate and effective communication
• Identifies need for and obtains appropriate supervision
• Notifies educator if not achieving objectives
• Follows policies, procedures and principles
STUDENTS ARE PERMITTED TO:

• Perform controlled acts authorized to nursing if they meet all three criteria:

• Have been taught by their faculty, preceptor or Nurse Educator

• Have the knowledge, skill and judgment to perform them as determined by their
preceptor or faculty member
• Are supervised by a member of the nursing staff at Hospitals or the faculty member.
 STUDENTS ARE NOT PERMITTED TO:

• Perform delegated medical acts

• Act as a witness under any circumstances or for any purpose
• Provide second signature/check for controlled drugs, blood products, breast milk, and
medications listed as requiring independent double checking, double signing and
documentation
• Provide telephone advice for discharged families
• Take verbal or telephone orders
• Be left in sole charge of any patient
• Transport patients alone when the presence of an RN is required
• Perform controlled acts without close supervision by an RN
GUIDELINES TO AVOID MISTAKES OF NURSING
STUDENTS
1. Nursing students should always be under the supervision
of their clinical instructors
2. They should be given assignments that are at their level
of training , experience, and competency
3. They should be advised to seek guidance especially if
they are performing procedure for the first time
4. They should be oriented to the policies of the nursing
unit where they are assigned
5. Their performance should be assessed frequently to
determine their strengths and weaknesses
6. Frequent conferences with the students will reveal their
problems which they may want to bring to the attention
of their instructors or vice-versa. Discussion of these
problems will iron out doubts and possible solutions may
be provided.
LIABILITY FOR THE WORK OF NURSING
STUDENTS
◼ Under the Philippine Nursing Act of 2002
R.A. 9173, nursing students do not perform
professional nursing duties. They are to be
supervised by their clinical instructors.
 DATA PRIVACY ACT OF 2012

• In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive and strict privacy legislation
“to protect the fundamental human right of privacy, of communication while ensuring free flow of
information to promote innovation and growth.” (Republic Act. No. 10173, Ch. 1, Sec. 2).
SCOPE AND APPLICATION

• The Data Privacy Act is broadly applicable to individuals and legal entities that process
personal information, with some exceptions.
• Approach
• The Philippines law takes the approach that “The processing of personal data shall be
allowed subject to adherence to the principles of transparency, legitimate purpose, and
proportionality.”
COLLECTION, PROCESSING, AND CONSENT

• The act states that the collection of personal data “must be a declared, specified, and
legitimate purpose” and further provides that consent is required prior to the collection
of all personal data.
• It requires that when obtaining consent, the data subject be informed about the extent
and purpose of processing, and it specifically mentions the “automated processing of his
or her personal data for profiling, or processing for direct marketing, and data sharing.”
• Consent is further required for sharing information with affiliates or even mother
companies.
• Consent must be “freely given, specific, informed,” and the definition further requires that consent to
collection and processing be evidenced by recorded means. However, processing does not always require
consent.
• Consent is not required for processing where the data subject is party to a contractual agreement, for
purposes of fulfilling that contract. The exceptions of compliance with a legal obligation upon the data
controller, protection of the vital interests of the data subject, and response to a national emergency are
also available.
• An exception to consent is allowed where processing is necessary to pursue the legitimate interests of the
data controller, except where overridden by the fundamental rights and freedoms of the data subject.
• Required agreements
• The law requires that when sharing data, the sharing be covered by an agreement that provides adequate
safeguards for the rights of data subjects, and that these agreements are subject to review by the National
Privacy Commission.
 SENSITIVE PERSONAL AND PRIVILEGED INFORMATION
• The law defines sensitive personal information as being:
About an individual’s race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations;
• About an individual’s health, education, genetic or sexual life of a person, or to any proceeding or any offense committed or
alleged to have committed;
• Issued by government agencies “peculiar” (unique) to an individual, such as social security number;
• Marked as classified by executive order or act of Congress.
• All processing of sensitive and personal information is prohibited except in certain circumstances. The exceptions are:
• Consent of the data subject;
• Pursuant to law that does not require consent;
• Necessity to protect life and health of a person;
• Necessity for medical treatment;
• Necessity to protect the lawful rights of data subjects in court proceedings, legal proceedings, or regulation.
INFORMED CONSENT

• Is an agreement to a client to accept a course of treatment or procedure after being

provided complete information, including the benefits and risks of treatment, alternatives
to the treatment and prognosis if not treated by a health care provider.
• Before a surgery, the informed consent process is the practical application of shared
decision making between a surgeon and a patient.

• Usually the client signs a form provided by the agency. It is the record of the
informed consent.
TWO TYPES OF CONSENT
• 1. Express- may take the form of either an oral or written agreement. ( needed for invasive
procedure)
• 2. Implied- exists when the individual’s nonverbal behavior indicates agreement ( ex. Patients
who position their bodies for an injection procedure or in a medical emergency where the
individual cannot provide or express consent)
• Primary care provider- is the one responsible to obtain an informed consent
• A nurse practitioner, nurse anesthetist, nurse midwife who will perform procedure in their
advance practice
GENERAL GUIDELINES FOR THE INFORMATION GIVEN
TO PATIENT
The diagnosis or condition that requires treatment
The purposes of treatment
What the client can expect to feel or experience
The intended benefits of treatment
Possible risks or negative outcomes of treatment
Advantages and disadvantages of possible alternatives to the treatment( including no treatment)
THREE MAJOR ELEMENTS OF INFORMED CONSENT

• 1. The consent must be given voluntarily.

• 2. The consent must be given by a client or individual with the capacity and competence
to understand.
• 3. The client or individual must be given enough information to be the ultimate decision
maker.
THREE GROUPS OF PEOPLE WHO CANT PROVIDE
CONSENT:
• 1. Minor
• 2. Unconscious or injured
• 3. People with mental illness who have been judged by professionals to be incompetent.
• Nurse’s Role-
-not to explain the procedure but to witness the client’s signature on the form
1. The client gave consent voluntarily
2. The signature is authentic
3. The client appears competent to give consent
PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
• ~ The patient has the right to considerate and respectful care.
• ~ The patient has the right to obtain from his physician complete and current information concerning his diagnosis, treatment, and
prognosis in terms the patient can reasonably expect to understand.
• ~ The patient has the right to receive from the physician information necessary to give informed consent prior to the start of any
procedure and/or treatment.
• ~ The patient has the right to refuse treatment and to be informed of the medical consequences of his action.
• ~ The patient has the right to every consideration of his privacy concerning his own medical care program.
• ~ The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential.
• ~ The patient has the right to expect within its capacity, a hospital must take reasonable response to the request of a patient for service.
• ~ The patient has the right to obtain information as to any relationships his hospital has to other health care and educational institutions
insofar as his care is concerned.
• ~ The patient has the right to be advised if the hospital propose to engage in or perform human experimentation affecting his care or
treatment.
• ~ The patient has the right to expect reasonable continuity of care.
• ~ The patient has the right to examine and receive an explanation of his bill.
• ~ The patient has the right to know what hospital rules and regulations apply to his conduct as a patient.
• Dorothy Joy V. Villaraza =>
CORE VALUES OF
NURSING IN
CONDUCTING
HEALTH ASSESSMENT
NCM 101

BEHANY C. TERUEL, RN,MN

1. Love of God
 service to God tgrough others; Gos as the center of your life in words, thoughts and deeds
 aring as the core of nursing
 knowing, alternating rhythms, patients, honesty, humility, trust, hope; center of all attributes
2. Caring as the Core of Nursing
 a. compassion
 b. competence
 c. confidence
 d. conscience
 e. commitment
 _culture of excellence
 _ discipline
 _ integrity
 _professionalism

a. Compassion
 equated to caring; the humane quality of understanding the suffering w/c others wanting to
do something about it; deep awareness of sympathy for another’s suffering.
b. Competence
 adequate and well qualified to perform a specific role->encompasses a combination of knowledge,
skills and attitude utilize

c. Confidence
 to improve performance, a feeling of self assurance; ability to perform or accomplish task and trust;
 feeling of self awareness arising from appreciation of one's own abilities

d. Conscience
 sense of right or wrong

e. Commitment to
 _culture of excellence
 performing to aim for perfection; update knowledge
 _discipline
 self control and obeying rules
 _integrity
 associated with honesty; moral soundness; steadfast adherence to a strict moral or ethical code
 _professionalism
 specialized knowledge of a subject to a field
3. Love of People
 volunteerism; comply to the feeling of caring care to other
unconditionally

4.Love of Country
 _patriotism- make sacrifices to your own country
 _preservation and enrichment of rhe environment and culture heritage
 Values of a Student Nurse
 CDUCN (pneumonics)
 C- compassion/courtesy( good manners)
 D- dedication/ discipline(sense of responsibility and accountability)
 U- uprightness ( being honorable with ur actions;righteousness; personal
and professional integrity)
 C- competence and commitment (to god through man)
 N- neatness(in person & in work)
CORE PROFESSIONAL VALUES

 Nursing is a caring profession. Caring encompasses

empathy for and connection with people. Teaching
and role-modeling caring is a nursing curriculum
challenge.
 Caring is best demonstrated by a nurse's ability to
embody the five core values of professional nursing.
 Core nursing values essential to baccalaureate
education include human dignity, integrity,
autonomy, altruism, and social justice.
CORE VALUES OF NURSING IN HEALTH
ASSESSMENT

1. Empathy and Caring

2. Communication
3. Teaching
4. Critical Thinking
5. Psychomotor Skills
6. Applied Therapeutics
7. Ethical and Legal Considerations
8. Professionalism
 Empathy and Caring
A nursing school should teach its students the true value of empathy and
compassionate care. Empathy is a nurse’s ability to understand, be aware of, be
sensitive to, and vicariously experience the feelings, thoughts, and experiences of the
patient and their family.
 Communication
The exchange of thoughts, messages, or information is of vital importance to the
nursing process. A nurse uses communication skills, speech, signals, writing, and
behavior during patient assessment, as well as the planning, implementing, and
evaluating of nursing care.
 Teaching
We believe one of the most important roles of a nurse is to assist patients and their
families with receiving information necessary for maintaining a patient’s optimal health.
A nurse provides patients and families with information that is based on their assessed
learning needs, their abilities, their learning preference, and their readiness to learn.
 Critical Thinking

Nurses are constantly involved with making accurate and appropriate

clinical decisions. We believe nurses must be able to think critically and
make decisions when patients present problems for which there may not
be clear, textbook solutions.
 Psychomotor Skills
We believe that fundamental to nursing is the “laying on of hands” to provide
comfort, and the use of specific skills to accomplish client assessment and to
provide and evaluate nursing care. Nursing skills are utilized in a manner that
maximizes client comfort and dignity, optimizes the client’s ability to respond
positively, provides the highest level of accuracy of information, and provides for
the most favorable patient outcomes.
 Applied Therapeutics
A nurse applies medically-ordered therapeutic modalities, like pharmacological
and nutritional interventions, etc. A nurse’s application of these modalities is based
on a knowledge base regarding their therapeutic uses, as well as skills in patient
assessment and evaluation.
 Ethical and Legal Considerations
A nurse plans, provides, and evaluates nursing care guided by specific ethical
and legal boundaries. We believe the Code of Ethics for Nurses provides the
ideal framework for safe and correct practices and behavior. Ethical behavior
also involves accountability, responsibility, confidentiality, truthfulness, fidelity,
and justice. Nurses who clarify their values are enhanced in their ability to
practice ethically.

 Professionalism

Professionalism involves the characteristics of a nurse that reflects his or her professional status. These
characteristics involve behaviors with regards to self, patients, others, and the public as they reflect the values of
the nursing profession.
Core Values of Nursing
BREAST AND LYMPHATIC SYSTEM

LYMPHATIC INVASION/MUSCULAR INVASION

- Difficulty in breading
- Body mechanics will be very poor

6TH

- Marker for inframammary line/bra line

AREOLA COMPLEX

- darker portion around your nipples

- is the one compassing both the nipple and the areola

MONTGOMERY TUBERCLES

- prominent among the pregnant and lactating mothers

- pores
- prominent during pregnancy and lactating mothers
- provides oil, lubrication to the breast

EXTRAL OBLIQUE MUSCLE

- involve respiration

BREAST USUALLY RECTANGULAR RATHER THAN ROUND

5TH AREA IS THE TAIL OF THE SPENCE OR THE AXILLARY BREAST TISSUE

AFTER MENOPAUSE THE GLANDULAR STRACTURE WILL ANTROPHY, THERE WILL BE NOTABLE DECREASE
NUMBER OF OBULES BECAUSE OF THE REGRESSION OR DECREASE DEPLETED ESTROGEN SUPPLY.

SLIDE 7

1. MATURE, BUT INACTIVE

- There is no reproductive cycle the patient wont not be pregnant
2. EARLY PREGNANCY
- Further branching of your ducts and lobules
3. MIDPREGNANCY
- The body is already program that the …….. coming out anytime soon it must produce of ducts
and lobules
4. Lactating
- Witch’s milk/colostrum
5. REGRESSION AFTER WEANING
- Regression of your ducts and lobules
- Decline in the milk production
THE SURFACE OF THE AREOLAR AS SMALL JROUNDED ELEVATION FORM BY SEBACEOUS GLAND SWEAT
GLANDS AND ACCESSORY AREOL GLANDS.

SLIDE 9

SUPERNUMERARY NIPPLE

- One or more nipple is being observe in few people

- Pigmentation/ga-itom2
- Prominent during lactation

SLIDE 11

GYNECOMASTIA

- Cause overly express estrogen among the male

- Broad, firm
- Male breast enlargement

PSEUDOGYNECOMASTIA

- Attributed to obesity alone

MOST OF THE LYMPHATIC SYSTEM OF THE BREAST USUALLY DRAIN IN AXILLARY LYMPH NODES THEY
MAY EMERGED IN TAIL OF SPENCE.

Slides 12

CENTRAL NODES

- Located at the center of the axilla

- Lies alone the chest wall

SUBSCAPULAR NODES

LATERAL NODES

- Follow the course of the numerous

- It drains the arm

Slide 13

SBE

- Self-breast examination
- What you do personally on your own

CBE

- Clinical breast exam

- Done by medical profession
S1- papilla elevation

S2- breast budding

S3- conical breast

S4- secondary mound

GALACTORRHEA

- Drainage of milky substance without any relation to pregnancy and lactation

- Cause by hyperthyroidism and tumor in pituitary gland

PROLACTINE

- Responsible for milk production

Slide 37

- Fungating mass

Slide 43

- Erythematous

Slide 44

- Serosanguinous of the nipples

Slide 45

Magnified Montgomery tubercles Hyperkeratosis

Slide 46

- Peau d’orange

CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

LEFT VENRTICLE

- This the most hard working chamber of the heart

- Found behind the right ventricle into left

APICAL IMPULSE

- The highest the loudest and the most recognizable heartbeat upon auscultation

PMI
 - Locate in left boarder of the heart normally in the intercostal space. Just medial to mid clavicular
line. 4th to 5th
- Not usually palpable

Slide 4

CYSTUS INVERSUS

- A heart normally found in the side of the chest

DESTROCARDIA

- Malposition of the heart of the left right side of the chest

Slide 5

Left ventricular hypertrophy Right ventricular hypertrophy

Slide 6

RIGHT ATRIUM

- Were the catheter inserted

Slide 9

SYSTOLE PUMING

- Heart contract
- Aortic bulb is open
- Mitral bulb closes and pulmonic valve are open and tricuspid bulb closes

DIASTOLE FILLING

- Aortic bulb is close

- Mitral bulb is open
- Pressure In the heart
- Left atrium down to left ventricle

Slide 12

Aortic stenosis

Typical rheumatic heart disease

S3

- Pathologic or red flag a failing heart

Slide 14

A2

- First sound
 - Signify closure of aortic valve

P2

- Closure of pulmonic valve

INSPIRATION

- The feeling time is increase

Slide 15

BELL

- Mumur,S3,S4, LOW PITCH

-extra of pathologic sounds

DIAPHRAGM

- Use for relatively high intensity of high pitch sound cause by S1, S2

SA NODES (SIANOATRIAL)

- Facilitate electrical conduction system

- Located in the junction in vena cava
- Power full/legal wife

STROKE VOLUME

- The volume of blood injected when heart beat

AFTERLOAD

- Refers to the degree of vascular resistance to ventricular contraction

PRESSUREOVERLOAD

- Problem with your afterload

- Disease or pathology of the afterload

VOLUME OVERLOAD

- Is a disease of pathology of preload

AUTOMATICTY

- Or the capacity to generate electrical impulses for a circumvented around the heart for the
heart to contract.

CHEST PAIN

- Cardinal manifestation of heart disease particularly scenic in nature

- Is one of the most serious of all patient complain, cardio vascular complain
- Cause by 1% most likely chest pain or heart attack
- Most common symptom of coronary disease
FAINTING (syncope)

- There is poor blood delivery to your brain

LEVEL C TO D/CATEGORY 3 TO 4

- At rest, impaired activity

ONSET

- Sano nag sugod

CHARACTERISTIC

- Daw gina lihap, daw gina kumos

DURATION

- Halin kagina, asta subong ara japon

LOCATION

- Diin nga area sa doghan

RADIATION

ASSOCIATION

- Masakit lng and doghan kong mag hakwat ko, kong ga kotoy tyan ko, kong mahigda

ALLEVIATING FACTORS

- Ano ginahi mo sa patient pra ma dula ang sakit sa doghan

INTERMETENT CLUADICATION

- Indicative of vinus insufficiency, arterial insufficiency

- Nag sakit ang tiil mop ag jogging mo pero pagpahuway mo nadula

ATRIAL FIBRIATION

- Irregular heart beat

DYSPNEA

- Shortness of breath/difficulty of breathing

ORTHOPEA

- Occurs when the patient is a supine/ tas gulpi lng nag tindog tas ng hapo kna

PND (PAROXYSMAL NOCTURNAL DYSPNEA)

Paroxysmal – abot2
Nocturnal – sa gabeh lng

Dyspnea – hapo

SWELLING OR EDEMA

- Palng habok2

FAINTING

- Cardinal manifestation of your ……..

- Period of aura

Slide 25

Ascites Bipedal edema Periorbital edema

- Due to cirrhotic change - Endocrine problem
of the liver

INSPECTION

- Use your eye in order to detect any abnormality

Slide 55

Chronic arterial insufficiency Chronic venous insufficiency

Hypertension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint is a
deformation as.

- Boutonniere deformity

The most predominant quadrant of the female breast where 33% of breast cancer cases according to
National Cancer Database is?

- Upper outer quadrant

Which structure is used to demarcate the point of origin where the female breast is further divided into
4 quadrant?

- Sternum

Which event is true regarding systole?

- Aortic valve opening

Mother showed a toy to her child during examination the hid it under the blanket. The child then
searched for the toy under the blanket thereafter. It is assumed that the child should be at least what
age?

- 6 months old

Which structure is used to demarcate the point of origin where female breast is further divided into 4
quadrants?

- Nipple

The following are normal age-related findings among the elderly.

- A and B

Patient J, a female recently sought consult due to difficulty sleeping she claims to have episodes of
dyspnea awakening her from sleep usually 1-2 hours after going to bed urging her to sit up a nearby
window for some air. This symptom is medically known as?

- Paroxysmal nocturnal dyspnea

Babinski reflex (extensor plantar response) in elderly patients is abnormal and indicates.

- Spinal cord compression

Women typically have a 13% risk of developing breast cancer over their lifetime. Angela Jolie on the
other hand had an estimated 87% risk of developing the disease and a 50% risk of ovarian cancer due to
heredofamilial tendencies discovered via gene testing. She underwent double mastectomy and later had
her ovaries and fallopian tubes removed significantly reducing risk of developing cancer. What specific
gene mutation conferred Angelina Jolie her risk for breast and ovarian cancer?

- BRCA1

Among edentulous patients, the tongue may enlarge due to the following.

- A. amyloidosis

The most predominant quadrant of the male breast where 17% of the breast cancer cases are detected
according to the national cancer database is?

- Upper outer quadrant

The following heart sounds can be best heard using the diaphragm of the stethoscope

- Closure of the aortic

Patrick, a 14 years old adolescent, has been hooked to alcoholic beverages and habitual smoking of
cigarettes which caught his parent’s attention. He was brought to the clinic for behavioral modification
and counseling which of the following approaches will best benefit Patrick?

- Interview Patrick separately from parents to provide safe space for discussion of personal or
sensitive concerns that need to be voiced out
Patient HY, a 33YO female patient, sought consult at the OPD due to singular breast mass described as
soft, elastic, well delineated, mobile. Which of the following lesions most probable based on the
patient’s profile and description?

- Firboadenoma

The statement jane, 34yo, mother of baby boy KY- 90% reliability as informant, tita, 45YO female
caremaker at home of baby boy KY – 50% reliability as informant should be included in the pediatric
history under which category of information?

- History of present illness

Breast cancer among men occurs in approximately 1% of the population. A nurse knowledgeable of this
incidence will put emphasis on palpation of which territory to detect the lesion?

- Axillary tail of spence

Enuresis, thumb sucking, and temper tantrums are to be documented under

- Developmental history

The most widely used tool for the assessment of the risk of developing pressure ulcer is?

- Barden scale

Black splinter hemorrhages in the middle or distal third of the fingernail are more likely to be due.

- Trauma

Patient KL, a 13yo female, was accompanied by the mother to purchase her first pair of brassieres. Her
breasts still has no distinct contour separation of the nipple-areola complex. Grossly her breast has now
assumed a rounded contour with tissues configuring a small cone. This can be documented by nurses as
Tanner stage

- Stage 4

Which statement is true regarding the condition system of the heart?

- A and B

Patient JK, a 60yo female sought consult due to difficulty sleeping. She claims to have episodes of
dyspnea awakening her from sleep usually 1-2 hours after going to bed urging her to sit up or to rush to
a nearly window for some air. This symptoms medically known as?

- Paroxysmal nocturnal dyspnea

The most widely used method of screening for valvular heart disease according to American college of
cardiology and the American heart association is/

- 2-dimensional echocardiography

The following are areas which differentiate the pediatric fromadult history taking and assessment except.

- Parental and birth history

Babinski reflex extensor plantar response in elderly patients is abnormal and indicates.

- Spinal cord compression

The following are normal age-related findings among the elderly

- None of the above

The following statement about nipple discharges is/are true.

- Spontaneous unilateral bloody discharge from one or two ducts may indicate carcinoma

Which event is false during diastole

- A and b

Patient GD, a 25yo

- Inform the patient of the unreliability

The following statements about nipple discharges is/are true

- A and B

The following views/maneuvers are employed in the inspection of the breast except.

- Breast compressed at midline