HEALTH ASSESSMENT

SKILLS LAB
ESTABLISHING THE NURSE-PATIENT RELATIONSHIP

States that “ human relationship between

an individual who is sick or in need of
health services, and a nurse especially
educated to recognize and to respond to
the need for help
HOW TO ESTABLISH NURSE-
PATIENT RELATIONSHIP
 ASSESSMENT
1. Address patient by name; introduced self and role; use clear, specific
communication.
2. Assess patient’s needs, coping strategies, defenses, and adaptation
styles.
3. Determine patient’s need to communicate.
4. Assess reason patient needs health care
5. Assess factors about self and patient that normally influence
communication.
6. Assess persona barriers to communicating with patients.
7. Assess patient’s language and ability to speak.
8. Assess patient’s literacy level.
9. Assess patient’s ability to hear, ensure hearing aid is functional if
worn, ensure patient hears and understand words.
10. Observe patient’s patterns of communication and verbal or
nonverbal behavior.
11. Assess resources available in selecting communication
methods.
12. Assess patient’s readiness to work toward goal attainment.
13. Consider when patient is due to be discharged or transferred.
 PLANNING

1. Identify expected outcomes

2. Plan orientation phase.
3. Plan working phase.
4. Plan termination phase.
 IMPLEMENTATION
1. Establish nurse-patient relationship during orientation phase.
● Create a climate of warmth and acceptance, was aware of nonverbal
cues, provided comfort and support.
● Use appropriate nonverbal behaviors.
● Observe patient’s nonverbal behaviors, sought clarifications if
necessary.
● Explain purpose of interaction when information was being shared.
● Use active listening.
● Identify patient’s expectations in seeking health care.
● Interview patient about health status, lifestyle, support systems,
patterns of health and illness and strengths and limitations.
● Encourage patients to ask for clarification at any time.
● Use therapeutic communication techniques when interacting with
patients.
2. Set mutual goals during the working phase.
● Use therapeutic communication skills.
● Discuss and prioritize problem areas.
● Provide information to patient, helped patient express needs and feelings.
● Use questions carefully and appropriately, asked one question at a time,
used direct questions, and used open-ended statements as much as
possible.
● Avoid communication barriers.
3. Communicate with patient during termination phase
● Use therapeutic communication skills to discuss discharge or
termination issues, guided discussion to patient changes in
thoughts and behaviors.
 EVALUATION
1. Observe patient’s verbal and nonverbal responses to communication, note
patient’s willingness to share information and concerns.
2. Note your response to patient and patient’s response to you, reflect on
effectiveness of techniques.
3. Evaluate patient’s ability to work toward identifiable goals re-evaluate and identify
barriers if patient goals are not met.
4. Summarize and restate goals, reinforce patient strengths, outlineissues requiring
work, and develop an action plan.
5. Identify unexpected outcomes.
 RECORDING AND REPORTING

1. Recorded pertinent communication, responses to illness or

therapies, and responses that demonstrate understanding
or lack thereof.
2. Reported relevant information to team members.
ESTABLISHING
COMMUNICATION WITH AN
ANXIOUS PATIENT
 ASSESSMENT
1. Introduced self appropriately, explained purpose of
interaction.
2. Assessed for cues indicating patient is anxious.
3. Assessed for possible factors causing patient anxiety.
4. Assessed factors influencing communication with patient.
5. Discussed with family possible causes of patient’s anxiety.
 PLANNING

1. Identify expected outcomes

2. Prepare for communication by considering patient goals,
time allocation and resources.
3. Recognize personal level of anxiety, tried to remain calm
4. Prepare quiet, calm area, allow ample personal space.
 IMPLEMENTATION

1. Use appropriate nonverbal behavior and active listening skills.

2. Use appropriate verbal techniques that are clear and concise
in response, acknowledged patient’s feelings, and provided
direction to patient.
3. Help patient acquire alternative coping strategies,
4. Provide necessary comfort measures.
 EVALUATION

1. Observe for continuing presence of signs and behaviors

reflecting anxiety.
2. Have patient discuss way to cope with anxiety and make
decisions about own care.
3. Evaluate patient’s ability to discuss factors causing anxiety.
4. Identify unexpected outcomes.
 RECORDING

1. Record cause of patient’s anxiety and any

exhibited signs.
2. Report methods used to relieve anxiety and
patient’s response.
VITAL SIGNS TAKING
 BODY TEMPERATURE
● the balance between the heat produced by the body and the heat lost from
the body.
● Normal body temperature: Axillary: 36.5-37.5 degrees celcius in all age
groups.

Types of Body Temperature:

● Core temperature – the temperature of the deep tissues of the body. Measured by
taking oral and rectal temperature.
● Surface temperature – the temperature of the skin, subcutaneous tissue and fat.
Measured by taking axillary temperature.
Factors affecting the body’s heat production
● Basal Metabolic Rate(BMR) – the younger the person, the higher the
BMR; the older the person, the lower the BMR. Therefore, the older
persons, have lower body temperature than the younger persons.
● Muscle Activity – exercise increases body heat production.
● Thyroxine Output – increases cellular metabolic rate. Hyperthyroidism
is characterized by increased body temperature.
● Epinephrine, norepinephrine, and sympathetic stimulation – increase
the rate of cellular metabolism. These in turn increase body
temperature.
● Fever – increases the rate of cellular metabolism.
Processes Involved in Heat Loss
● Radiation-transfer of heat from the surface of one object to
surface of another without contact between two objects.
● Conduction-transfer of heat from one molecule to a molecule
of lower temperature.
● Convection- dispersion of heat by air currents.
● Evaporation- continuous vaporization of moisture from the
respiratory tract and from the mucosa of the mouth and from
the skin.
Factors affecting Body Temperature
1. Age – infant’s body temperature is greatly affected by the temperature of the environment.
Elder people are at risk of hypothermia due to decreased thermoregulatory controls, decrease
subcutaneous fat, inadequate diet, and sedentary activity.

2. Diurnal Variations(Circadian Rhythms) – highest temperature is usually reached between

8PM-12MN; and the lowest temperature is reached between 4-6 AM.

3. Exercise – strenuous increases BMR thus, the body temperature.

4. Hormones – e.g. progesterone, thyroxine, epinephrine and norepinephrine increase body

temperature; estrogen decreases body temperature.

5. Stress – sympathetic nervous system stimulation increases the production of epinephrine

and norepinephrine, thereby increasing the metabolic rate and heat production.
Alterations in Body Temperature

● Pyrexia/hyperthermia/fever – temperature above normal

range.
● Hyperpyrexia – very high fever, 41 degrees celcius (105.8 deg.
Fahrenheit) and above.
● Hypothermia – subnormal core body temperature. This may
be caused by excessive heat loss, inadequate heat production
or impaired hypothalamic function.
Types of Fever

1. Intermittent Fever-the body temperature alternates at regular intervals between

periods of fever and periods of normal or subnormal temperatures.
2. Remittent Fever-a wide range of temperature fluctuations (more than 2C) occurs
over the 24-hour period, all of which are above normal.
3. Relapsing Fever-short febrile periods of a few days are interspersed with periods of
1 or 2 days of normal temperature.
4. Constant Fever-the body temperature fluctuates minimally but always remains
above normal.
Clinical Signs of Fever

1. Onset
Increased heart rate
Increased respiratory rate and depth
Shivering
Pallor, cold skin
Complaints of feeling cold
Cyanotic nail beds
“gooseflesh” appearance of the skin
Cessation of sweating
2. Course
Absence of Chills
Glassy-eyed appearance
Increased pulse and respiratory rate
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness, delirium or convulsions
Herpetic lesions of the mouth
Loss of appetite
Malaise, weakness and aching muscles
3. Defervescence(fever abatement)
Skin that appears flushed and feels warm
Sweating
Decreased shivering
Possible dehydration
Interventions for Clients with Fever
1. Monitor vital signs.
2. Assess skin color and temperature.
3. Monitor WBC, hematocrit value, and other pertinent laboratory reports
4. Remove excess blankets when the client feels warm, but provide extra warmth when
the clients feels chilled.
5. Provide adequate nutrition and fluids
6. Measure I and O
7. Reduce physical activity
8. Provide oral hygiene
9. Provide a tepid sponge bath
10. Provide dry clothing and bed linens.
11. Administer antipyretics
Methods of Temperature Taking

ORAL- most accessible and convenient method.

Procedure:
1. Allow 15 minutes to elapse between a client’s intake of hot or cold food or smoking and the
measurement of oral temperature.
2. Place thermometer under the tongue, directed towards the side.
3. Wash the thermometer before use, from bulb to the stem, after use, from the stem to the
bulb. This practice ensures medical asepsis.

Contraindications:
Oral lesion or surgery
Cough
Nausea and vomiting
Very young children
Restless, disoriented
Seizure prone
Rectal – the most accurate method/reliable
Procedure:
1. Provide privacy.
2. Position - Sim’s
3. Apply disposable gloves.
4. Squeeze liberal portion of lubricant.
5. With non-dominant hand, separate client’s buttocks to expose the anus.
6. Ask client to breathe slowly and relax.
7. Gently insert thermometer into anus.
8. If resistance is felt during insertion, withdraw
9. thermometer immediately.
10. Once positioned, leave thermometer in place
11. Remove thermometer from anus.
12. Wipe with antiseptic solution.
13. Return thermometer to storage
14. Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue
15. Remove gloves and dispose.
 Contraindications:
● Anal or rectal conditions or surgeries [hemorrhoids,
hemorrhoidectomy]
● Diarrhea
Axillary – safest and most non-invasive method of temperature
taking.
Procedure:
1. Pat dry the axilla
2. Place the thermometer on the client’s axilla
3. Place the arm tightly across the chest to keep the
thermometer in place.
Temporal Artery
● safe and non-invasive; very fast
● requires electronic equipment that may be expensive or unavailable.
 PULSE
● Wave of blood created by contraction of the left ventricle of the heart.

Pulse sites

1. Temporal - over the temporal bone of the head ; superior and lateral to the eye

1. Carotid - at the lateral aspect of the neck

3. Apical - at the left midclavicular line 5th intercostal space

4. Brachial - at the inner aspect of the upper arm (biceps muscles) or medially

at the antecubital space

5. Radial - on the thumb side of the inner aspect of the wrist.

6. Femoral - along side of the inguinal ligament

7. Posterior tibial- at the middle aspect of the ankle, behind the medial malleolus.
8. Pedal(dorsalis pedis)- at the dorsum of the foot

.
9. Popliteal- at the back of the knee
Assessment of Pulse
Procedure:
1. Perform hand hygiene
2. Assess
3. Position
4. Place tips of first two fingers of hand over groove along radial or thumb side of
client’s inner wrist
5. Lightly compress
6. Determine strength of pulse .
7. After pulse can be palpated regularly, look at the watch’s second hand and begin
to count
Rate- The normal PR per min are as follows:
● Newborn to 1 mo.: 120-160 beats/min
● 1yr: 80- 140 bpm
● 2yrs: 80-130 bpm
● 6yrs: 75-120 bpm
● 10 yrs: 50-90 bpm
● Adult: 60-100 bpm
● Tachycardia – Pulse rate above 100 beats per minute (adult)
● Bradycardia – Pulse rate below 60 beats per minute (adult)
● Rhythm – pattern and intervals of beats
○ DYSRHYTHMIA – irregular rhythm
● Volume (amplitude) – strength of pulse
○ Normal – moderate pressure
○ Full or bounding pulse – can be obliterated only by great pressure
○ Thready pulse (weak, feeble)– it can easily be obliterated
Factors Affecting Pulse Rate
Age – younger persons have higher pulse rate than older persons.
Sex/gender – after puberty, female have higher PR than the males.
Exercise – increases BMR, thereby increasing the pulse rate.
Fever – increases BMR, therefor the PR increases.
Medications – digitalis, beta blockers, decrease PR; epinephrine atropine
sulfate increase pulse rate.
Hemorrhage – increases pulse rate as compensatory mechanism for blood loss.
Stress – sympathetic nervous stimulation increases the activity of the heart.
Position changes – In sitting or standing position, there is decrease venous
return to the heart , decrease BP, therefore, increase in the heart rate.
 RESPIRATION
● Refers to the act of breathing
3 Processes
❖ Ventilation - movement of gases in and out of the lung
❖ Diffusion - exchange of gases from an area of higher
pressure to an area of lower pressure
❖ Perfusion - the availability and movement of blood for
transport of gases, nutrients and metabolic waste products.
 Two Types Of Breathing:
❖ Costal (thoracic) – involves movement of the chest.
❖ Diaphragmatic (Abdominal) – involves movement

Respiratory Centers:
❖ Medulla Oblongata – primary center
❖ Pneumotaxic center – responsible for the rhythmic quality of breathing.
❖ Apneustic Center – responsible for deep, prolonged inspiration
Assessing respiration
Procedure:
1. Position client.
2. Place client’s arm in relaxed position across abdomen or
lower chest, or place hand directly over client’s upper
abdomen
3. Observe complete respiratory cycle.
4. After cycle is observed, look at watch’s hand and begin to
count
● Rate – normal:16-20 cycles/min (adult); 30-60 cycles per min (newborn)
If BP is elevated – the RR becomes slow
If BP is decreased – RR becomes rapid
● Depth – observe the movement of the chest
may be normal, deep or shallow
● Rhythm – observe for regularity of exhalations and inhalations
● Quality or character – refers to respiratory effort and sound of breathing
 Major Factors Affecting RR:
● Exercise – increases RR
● Stress – increases RR
● Environment
* Increased temp. – decreases RR
*decreased temperature – increases RR
*increased altitude – increases RR
● Eupnea- normal respiration that is quiet, rhythmic, effortless
● Tachypnea- rapid respiration marked by quick, shallow breaths.
● Bradypnea -slow breathing
● Hyperventilation- prolonged and deep breaths . carbon dioxide is excessively
exhaled.
● Hypoventilation- slow shallow respiration.
● Dyspnea- difficult and labored breathing.
● Orthopnea- ability to breath only in upright position.
 BLOOD PRESSURE

● is a measure of the pressure exerted by the blood as it pulsates through

the arteries.
Systolic pressure – pressure of blood as a result of contraction of the
ventricles
Diastolic pressure- the pressure when the ventricles are at rest (60-90
mmHg)
Pulse pressure – the difference between systolic and diastolic pressure
(normal: 30-40 mmHg)
Factors affecting BP

● Age – older people have higher BP due to decreased

elasticity of blood vessels.
● Exercise – increases cardiac output, hence the BP.
● Stress – Sympathetic nervous system
● Race – hypertension is one of the 10 leading causes of
death among Filipinos.
● Obesity – BP is generally elevated among overweight and
obese people.
● Sex/Gender
● Medications – some medications can increase or decrease BP
● Diurnal variations – BP is lowest in the morning and highest in
the late afternoon or early evening
● Disease Process – DM, renal failure, hyperthyroidism cause
increase in BP.
Assessing BP
Procedure:
1. Ensure the client is rested
2. Allow 30 minutes to pass if the client had smoked or ingested caffeine before taking the
BP
3. Use appropriate size of BP cuff
4. Position the patient in sitting or supine position
5. Apply BP cuff snugly, 1 inch (2.5 cm) above the antecubital space
6. Use the bell shaped diaphragm of the stethoscope since the BP is a low-frequency sound
7. Inflate deflate the cuff slowly, 2-3 mmHg at a time
8. Wait 1-2 mins before making further determinations
9. Document readings.
Classification of blood pressure for adults

Blood Pressure SBP DBP

Classification mmHg mmHg

Hypotension <90 <60

Normal 90- 120 Less than 80

Elevated 120–129 Less than 80

Stage 1 130-139 80-89

Hypertension

Stage 2 ≥140 ≥90

Hypertension

Hypertensive Crisis >180 >120