Health Assessment | NCMA 121 First Year | Second Sem

Nursing Assessment  To identify the status of a specific

problem identified in an earlier

NURSING ASSESSMENT
assessment

 According to Carpenito: Assessment is

INITIAL ASSESSMENT
the deliberate and systematic
 Also known as “TRIAGE” – usually done
collection of data to determine a
in an emergency room
client’s current and past health status
 checking and assessing which patient
and functional status and to determine
needs an assistance first
the client’s present and coping
 Performed within a specified time
patterns.
after admission to a healthcare agency
 According to Atkinson and Murray (1991):
 To establish a complete database and
Assessment is a part of each activity
reference
the nurse does for and with the patient.
TIME – LAPSED ASSESSMENT

 Systematic and continuous collection,  Conducted to ensure that the patient

organization and documentation of data. is recovering from his disease and his

 A continuous process carried out during condition has stabilized

all phases of the nursing process.  May span the length of one or two hours

 Data collected should be relevant to a or a couple of months

particular problem.  The current status of the patient is

compared to the previous baseline

COMPLETE HEALTH HISTORY 4 DIFFERENT TYPES
during and prior to treatment
OF NURSING ASSESSMENT

EMERGENCY ASSESSMENT
1. FOCUSED (PROBLEM)
 During physiologic or psychologic
2. INITIAL
crisis of the client
3. LAPSED (TIME)
 To identify life threatening problems
4. EMERGENCY
 Yes or no questions for the mean time
FOCUSED ASSESSMENT
(close-ended)
 Problem is exposed and treated

 Ongoing process is integrated with

Nursing Assessment
nursing care
Types of Data
 Part of the goal is to diagnose and
1.Subjective Data
treat the patient in order to stabilize
1.1 symptoms or covert data
the patient’s condition
1.2 apparent only to the person affected

1.3 anything that a patient verbalizes

2.Objective Data
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Health Assessment | NCMA 121 First Year | Second Sem

2.1 signs or overt data III. History of Present Illness

2.2 detectable by an observer iii.i Past History

2.3 can be measured, tested > Childhood illness

> Childhood immunizations

* Chief Complaint - CC
> Allergies
C - Character
> Hospitalizations
O - Onset
> Medications
L - Location
iii.ii. Lifestyle
S - Severity
> Personal habits
P - Pattern
> Diet
A - Associated Factors
> Sleep and rest patterns

I. Obtaining Health History > Activities of daily living

- Health history provides information on iii.iii. Social Data

the patient's: > Family relationships and

> Health status friendships

> Know the social, emotional, physical, > Ethnic affiliation

cultural, and spiritual identity. > Educational history

> Requires 30-60 mins > Occupational history

> Patient may complete health history forms > Economic status

before interview > Home and neighborhood conditions

> some information may be obtained from

IV. Developmental Impairments
medical records and updated during
> Developmental Impairments
interview
> Intimacy vs Isolation

II. Family Health History > Generativity vs Stagnation

> Document information in a genogram and > Ego integrity vs Despair

in a list of familial diseases. > Erik Erikson Psychosocial Theory

> Nurses must be familiar with the field Sources of Data

of genomics. A. Client

- Best source of data, subjective data

B. Support people

- Family members, friends and caregivers

- Important source of data if the client

is young and unconscious or confused

C. Client records

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Health Assessment | NCMA 121 First Year | Second Sem

- Information documented by other > Clarify

healthcare professionals.
2.2 Types of Interview

D. Health care professionals a. Non-Directive Interview

- verbal reports - Rapport - Building interview

- Controlled by the client

E. Literature

- journals, reference texts, published b. Information Gathering Interview

studies - Combination of non-directive and

Data Collection Methods directive interview

1. Observing
c. Directive Interview
2. Interview
- Highly Structured

1. Observing - Controlled by the Nurse

= To gather data using the senses - Elicits specific information

= A conscious, deliberate skill - Nurse use directive questions

= 2 aspects
2.3 Types of Interview Questions
- Noticing the data
 Open-ended
- Selecting, organizing and interpreting
> used in non-directive interview
the data
> lets the client to explore, elaborate,

2. Interview clarify thoughts or feelings

= Planned communication or conversation > used in eliciting attitudes and mental

with a purpose status

= To get or give information > Often begin with what and how

= Identify problems of mutual concern  Closed- ended

= Evaluate change, teach, provide support > Used in directive interview

= Provide counselling or therapy > answerable by yes or no

> where, who, what, do, is

2.1 Phases of the Interview
> for patients who are highly stressed
 Pre-Introductory
and has difficulty communicating
 Introductory
 Neutral
> Purpose of the interview
> a question asked to a particular
> Confidentiality
during data collection. A question asked
 Working Phase
that's not directly biased.
> Longest phase
 Leading
> Verbal/nonverbal
> a biased question, assuming question
 Summary and Closing
that elicits a specific type of answer.
> Summarize/restate

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 Health Assessment | NCMA 121 First Year | Second Sem

> Help the patient answer a question > Offering false reassurance

with leading only when the he/she is > Asking persistent or probing questions

confused or can no longer answer open > Changing the subject

ended questions. > Taking things literally

> Closed, directive, persuasive > Giving Advice

> Jumping to conclusions

Factors to Consider During the Interview

1.Time Examining

- when the client is physically ~ Physical Examination

comfortable and free of pain - Carried out systematically

- Cephalocaudal or head to toe approach

2. Place ~ Screening Examination

- Well-lighted, well-ventilated room, - Also called review of systems

free of noise and distractions. Comfortable - A brief review of essential functioning

for both the nurse and patient. or various body parts or systems

3. Seating Arrangement Review of Systems

- Ideal seating arrangement: the nurse and ~ Thorax and Lungs - DOB, etc

patient sit in two chairs placed at right ~ Breast / regional lymphatics - lumps,

angles to a desk or a table or a few feet etc.

apart with no table ~ Heart / neck vessels - BP, chest pain

4. Distance etc.

- Maintain a 2 to 3 feet distance during ~ Peripheral vascular - edema, etc.

interview ~ Abdomen - constipation, etc.

5. Language ~ Male genitalia - urination, erection,

- Avoid medical jargon etc.

- - Translators, interpreters
Activities of Daily Living (ADL)

Things to avoid during an interview > Hygiene

> Leading the patient - bathing, grooming, shaving and oral

> Biasing yourself care

> Letting family members answer for patient > Continence

> Asking more than on question at a time > Dressing

> Not allowing enough response time > Eating

> Using medical jargon - the ability to feed oneself

> Assuming rather than clarifying and > Toileting

validating - the ability to use a restroom

> Taking the patient's personally > Transferring

> Feeling personally uncomfortable

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 Health Assessment | NCMA 121 First Year | Second Sem

- actions such as going from a seated to > Document any parts of the assessment

standing position and getting in and out that are omitted or refused by patient

of bed > Avoid using language

Assessment Specific Documentation

Instrumental Activities of Daily Living
Guidelines
(IADL)
> Record pertinent positive and negative
> Finding and utilizing resources
assessment data
- looking up phone numbers, using a
> Document any parts of the assessment
telephone, making and keeping doctor’s
that are omitted or refuted by patient
appointments
> Avoid using judgmental language
> Driving or arranging travel
> Avoid evaluative statements; cute
- either by public transportation, such as
specific statements or action you observe
Paratransit or private car
> State time intervals precisely
> Preparing meals
> Use specific measurements
- opening containers, using kitchen
> Draw pictures when appropriate
equipment
> Refer to findings using anatomic
Documentation Guidelines
landmarks
> Sign each entry with full legal name and
> Use the face of a clock to describe
professional credentials
finding that are circular pattern
> Do not leave a space between entries
> Document any change in patient's
> Use a single line to cross out an error,
condition during a visit or from previous
then date, time, and sign correction
visits
> Never correct another person's entry
> Describe what you observed, not what you
> Use quotes to indicate direct patient
did
response

> Document in chronological order

Physical Assessment
> Write legibly

> Use permanent ink (black preferred) WHAT IS PHYSICAL ASSESSSMENT?

> Document in complete but concise manner,  A systematic way of collecting objective

using phrases and abbreviations as data from a client using the four

appropriate. examination techniques

> Document telephone calls that relate to USE??

patient's case  to assess or identify current health

> If it is not documented, it was not done status

> Record pertinent positive and negative

PURPOSE OF PHYSICAL ASSESSSMENT
assessment data
1. Obtain physical data about the client’s

functional abilities
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Health Assessment | NCMA 121 First Year | Second Sem

2. Supplement, confirm, or refute data  Tongue depressor

obtained in the client’s health history  4x4 Gauze

3. Obtain data that will help the nurse  Tuning Fork

data establish diagnoses and plan the  Stethoscope

client’s care
 Wrist Watch
4. Evaluate the physiologic outcomes of
 Tape Measure
health care and thus the progress of a
 Marker/Pencil
patient’s health problem
 Record Sheet
5. To make clinical judgments about a
 Waste Receptacle
client’s health status

6. To identify areas for health promotion Positioning your Patient

and disease prevention Standing

For: Assessment of posture, gait and

PREPARATORY PHASE
balance.
1. Introduce self to the client. Verify his
Contraindication (CI): Patients who are
identity. Explain the purpose why such
weak, disabled, or paralyzed may need
procedure is necessary and how he could
assistance or may not be able to assume
cooperate (i.e., positioning).
this position.

2. Help him put on a clean gown and offer a

Sitting
bedpan or a urinal to empty his bladder.
> seated position, back unsupported and
3. Ensure privacy by closing the doors or
legs hanging freely
pulling the curtains around him.
For: Head, neck, posterior and anterior
4. Invite a relative or a significant other
thorax, breast, axillae, heart, vital
to stay with the client, as necessary
signs, upper extremities, lower
5. Provide adequate lighting.
extremities and reflexes.

6. Gather the Materials or Equipment. CI: Elderly and weak clients that may

7. Ensure the examination table is at a require support.

comfortable working height. Perform hand

Dorsal Recumbent
hygiene.
> Back lying position with knees flexed and
Materials:
hips externally rotated; small pillow under
 Height Chart
the head; soles of the feet on the surface
 Weighing Scale
For: Head and neck, axillae, anterior
 Snellen’s Chart
thorax, lungs, breasts, heart,
 Penlight
extremities, peripheral pulses, vital
 Card board
signs and vagina
 Sterile gloves
CI: clients with cardio pulmonary problems
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Health Assessment | NCMA 121 First Year | Second Sem

: Not used for abdominal testing because > The client is lying on the back with the

of the increased tension in abdominal hips and knees flexed at right angles and

muscles feet in stirrups.

: If patient has abdominal pain, flexing FOR: assessment of female rectum and

knees is usually more comfortable. vagina. (for a brief period only)

CI: May be uncomfortable and tiring for

Supine elderly people. Often embarrassing

> The client is lying on the back. The head  Make sure that the only area exposed is

and shoulders are usually elevated with a the one that needs assessing.

small pillow. The arms and legs are Knee Chest

extended and the legs are slightly abducted > Assessment of rectal area

For: head neck axillae, anterior thorax,

Techniques in Physical Assessment
lungs, abdomen, extremities, peripheral
Order of examination areas
pulses
1. Adult: cephalocaudal
: best position to palpate the abdomen
> From Head to Toe
CI: Tolerated poorly by clients with
2. Pedia: Least invasive to more invasive
cardiovascular and respiratory problems
areas

Sim’s > start with extremities, head, skin.

> The client is lying on the side with the

Assessment Techniques
body turned at 45 degrees. The lower leg
1. Inspection (I)
is extended, with the upper leg flexed at
2. Palpation (P)
the hip and knee to a 45-to-90-degree
3. Percussion (P)
angle.
4. Auscultation (A)
For: Assessment of rectum and vagina

CI: Difficult for elderly and people with Abdominal Area

limited joint movement > sequence used for abdominal area

(I) Inspection
Prone
(A) Auscultation
> The client is lying on the abdomen with
(P) Percussion
head turned to the side.
(P) Palpation
For: Posterior thorax, hip joint movement
* DO NOT PALPATE the abdomen if the patient
CI: Often not tolerated by the elderly and
is suspected to have abdominal aortic
people with cardiovascular and respiratory
aneurism (AAA)
problem
> the aneurism may be ruptured.

Lithotomy

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Health Assessment | NCMA 121 First Year | Second Sem

> if there is a tumor and it is soft or 2.Indirect Percussion - two hands. Only the

liquidly, DO NOT PALPATE for it may be middle finger is touching the body surface

ruptured. while the other middle finger will do the

tap action
Inspection
3. Blunt Percussion - whole hand will be
 Visual examination of the patient done
placed in the body surface and the other
in a methodical, deliberate,
hand in a fist position and strike in the
purposeful, and systematic manner.
placed hand.
 Careful observation
> used in assessing the lower back
 Proper tangential lighting is necessary
(kidney).
 Begins with the initial contact and

continues all throughout the assessment

Types of sounds heard
 Moisture, color and texture of the body
1.Flat - soft (thigh) (over tissue as
surfaces, as well as shape, position,
muscle and bone)
size, color, and symmetry of the body.
2.Dull - medium (right upper abdomen)

(filled with
Percussion
3.Resonance - loud (intercostal)
 Striking of the body surface with short,
4.Hyper Resonance - very loud (intercostal)
sharp strokes
5.Tympany - loud (popped cheek) (filled
 palpable vibrations and characteristic
with air)
sound.

 location, size, shape Palpation

 density of underlying structures • sense of touch.

 to detect the presence of air or fluid • The use of hand to touch and feel the

in a body space patient’s skin, organs, mass, and other

 elicit tenderness delineated structures in the body

• The pads of the fingers are used

Types of Percussion
• Assess temperature; turgor; texture;
1. Direct Percussion - using sharp rapid
moisture; vibrations; position, size,
movements from the wrist, strike the body
shape, consistency and mobility of organ
surface to be percussed with the pads of
or masses; distention; pulsation; and the
two, three, or four fingers or middle
presence pain upon pressure
finger alone Primarily used to assess
> Pain: even w/o touching or any other
sinuses in the adult.
contact with the area.
 Using one hand to strike the surface of
> Tenderness: pain upon pressure/ pain upon
the body
palpation

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Health Assessment | NCMA 121 First Year | Second Sem

> Finger Pads: used to assess fine texture *Hold the bell LIGHTLY against the body

(pulse, cyst, tumor) being auscultated.

> Palmar: sensitive to vibration, texture Diaphragm

and presence of fluid and consistency of *used to detect HIGH-PITCHED SOUNDS

the mass *Heartbeat, breath sounds, bowel movements

> Dorsum: used to assess surface *should be 1.5 inches wide

temperature *hold the diaphragm FIRMLY against the body

1. Light Palpation: moving the hand in part

circle

: depth - half inch or 1 cm > Bruit - sound produced/turbulent blood

: tenderness and muscle tone flow

2. Deep Palpation: 1 inch - 2 cm - a condition that requires an attention.

: abdominal organs and abdominal masses. A stenosis or blockage in cardiovascular

: one hand on the top of the other. area.

: the hand at the top applies the pressure Pregnancy Assessment

while the lower hand remains relaxed to
Obstetrical Data
perceive the tactile sensation.
> OB Scores / OB History
- pressure can damage internal organs.

3. Bimanually: check the liver or spleen, 1. Gravida / Gravidity

also the breasts especially if it is large > Number of pregnancies regardless of

in size done with two hands. duration as long as the mother becomes

: done with two hands. pregnant even abnormal.

Auscultation 2.Para / Parity

> listening to sounds produced within the > Number of VIABLE pregnancy or the total

body. number of pregnancies in which the fetus

> uses stethoscope has reached the age of viability and

Characteristics of sound heard during subsequently delivered whether dead or

auscultation alive at birth.

1. Pitch – ranging from high to low

2.1 Viability
2. Loudness – soft to loud
> ability of the fetus to live outside the
3. Quality – gurgling or swishing
uterus at the earliest possible gestational
4. Duration – short, medium or long
age.
Bell
> ability of the fetus to live outside the
*Use the bell of the stethoscope to detect
uterus
LOW-PITCHED SOUNDS
Age of Viability: 20-24 weeks
*The bell should be at least 1 inch wide.
*US Standard: 20 weeks of gestation
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Health Assessment | NCMA 121 First Year | Second Sem

> Multiple pregnancies do not increase

3.Primigravida
the parity.
> woman who is pregnant for the first time
> twins, triplets will only equate to 1

4.Primipara delivery = 1 parity

> woman who has given birth to one child

2.Abortion is not included in parity count.
past age of viability; woman who has
> if the baby is delivered less than 20
completed one pregnancy to age of viability
AOG = abortion
and subsequently delivered the fetus,
3.Live birth or still birth is counted in
whether alive or dead at birth.
parity count.

5.Multigravida > Still birth - baby is already dead

> woman who has been pregnant previously; inside the uterus

2 or more pregnancy.
Three Trimester

6. GRANDMULTIGRAVIDA 1st trimester = Week 1 - Week 12

> Woman who has had 6 or more pregnancies 2nd Trimester = Week 13 - Week 26 AOG

3rd Trimester = Week 27 - end of pregnancy

7. MULTIPARA

> Woman who has carried two or more Full Term = 37 weeks AOG - 40 weeks AOG

pregnancies to viability; woman who has * <37 weeks = Pre-term pregnancy

carried two or more pregnancies of stage * >40 weeks = Post-term pregnancy

of viability and subsequently born alive

TPALM
or dead.
T - Term - full term infants born 37 weeks

8. NULLIGRAVIDA P - Pre-term - preterm infants born from

> Woman who has never been and is not 30 - 36 weeks

currently pregnant A - Abortion - <20 weeks

L - Living children - number of living

9. NULLIPARA
children
> Woman who has not carried a pregnancy
M - Multiple - number of pregnancy where
beyond 20 weeks
the mother carried multiple fetus.

10. GRANDMULTIPARA LMP – Last Menstrual Period

> Woman who has had 6 or more viable > FIRST DAY (day when you see blood in

deliveries, whether, the fetuses were alive your underwear) of your last

or dead. menstruation/menstrual period

Principles in Identifying Parity

EDD/EDC: Expected Date of Delivery /
1.Number of pregnancies is counted and not
Expected Date of Confinement
the number of fetuses.
> Due date

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Health Assessment | NCMA 121 First Year | Second Sem

> estimated at 40 weeks AOG decrease the accuracy of fundal height

EDC: <2 weeks before EDC or a week after measurements.

the EDC/EDD  Typically, the distance from the uterine

fundus to the symphysis pubis in

AOG: Age of Gestation
centimeters is equal to the week of
> how far the pregnancy is
gestation between the 20th and 31st
> age of the fetus in the uterus
weeks of pregnancy.
Naegele’s Rule
 McDonald’s rule becomes inaccurate
> Use to determine expected date of
during the third trimester of pregnancy
delivery (EDD) or expected date of birth
because the fetus is growing more in
(EDB)
weight than in height during this time.
= add this to the Last Menstrual
Formula:
Period/Date
AOG in weeks = Fundic Height (measurement
If Jan-March = +9 in months + 7 in days
in CM) x 8/7
If Apr-Dec
AOG in months = Fundic Height x 2/7
= -3 in months + 7 in days + 1 in year
LIMITATIONS

Age of Gestation • Inaccurate in obesity, polyhydramnios

1.Mcdonald's Rule and uterine fibroids (lumps).

2.Manual Computation • Measurements beyond 4 cm of gestational

3.Bartholomew's Rule age need to be further evaluated.

1.Mcdonald's Rule • Measurements greater than the expected

> used to determine age of gestation in may indicate a multiple gestation,

weeks by measuring from the fundus (obtain polyhydramnios, fetal anomalies (such as

the fundal height) to the symphysis pubis macrosomia).

Procedure: • Measurements smaller than expected may

1.Empty bladder (full bladder displaces the indicate uterine growth retardation

uterus) and dorsal recumbent.

2.Measure (in CM) the distance abdominally 2.Manual Computation

from the top of symphysis pubis over the > Most used way of computing age of

curve of the abdomen to the top of the gestation

uterine fundus.
Jan - 31 days July - 31 days
 Fundic Height in cm correlates well with
Feb - 28/29 days August - 31 days
weeks of gestation between 20-31 weeks.
March - 31 days September -30 days
(may vary upon 31st week)
April - 30 days October - 31 days
 In later pregnancies, as in the third
May - 31 days November - 30 days
trimester, variations in fetal weight
June – 30 days December - 31 days

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Health Assessment | NCMA 121 First Year | Second Sem

Ex.

May 26, 2020 = LMP

May: 31-26 = 5 days (subtract the date of Fundic Height based on Home-based maternal

LMP to the total dates in the same month.) birth record by DOH

June= 30 July=31 Aug=31 (no of days passed 5th month: 20 cm

before the patient came for check-up) 6th month: 21-24 cm

Sep= 13 (date when the patient came in for 7th month: 25-28 cm

check-up) 8th month: 29-30 cm

(Add the days accumulated and divide) 9th month: 30-34 cm

Total: 110 /7 = 15. 7

15 7/7 AOG = 16 weeks of AOG Leopold Maneuvers

> using Leopold maneuvers, palpate the

3.Bartholomew's Rule
: fundus -above : lower pelvic area - baba
> use to determine age of gestation by
: lateral aspects of the abdomen - side of
proper location of fundus at abdominal
the abdomen
cavity

Assist in determining the:

> Estimates the AOG relative to the height

of the fundus of the uterus above the : Fetal lie - where the fetus is lying in

symphysis pubis relation to the mother's back

: Size - may be estimated by measuring

< 12 weeks = not palpable/pelvic cavity
fundal height and by palpation
3 months = above symphysis

5 months = level of umbilicus : Presentation - the presenting part of the

7 months = between umbilicus and xyphoid fetus into the maternal pelvis

9 months = touching/below xyphoid - the presentation may be cephalic,

10 months = level of 9 months due to breech, or shoulder

lightening; about 4 cm : Position - the fetal presentation in

> fetal head settles into the pelvis to relation to the maternal pelvis

prepare for birth, and the uterus returns - include right occiput anterior (ROA),
to the height it was at 36 weeks.
left occiput posterior (LOP), left sacrum

anterior (LSA), etc...

> At about 12 to 14 weeks of pregnancy, the
1st Maneuver
uterus becomes palpable as a firm globular
 Face the client’s head. Place your hands
sphere over the symphysis pubis
on the fundal area and palpate around

the fundus.

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Health Assessment | NCMA 121 First Year | Second Sem

 Expecting to palpate a soft, irregular Determine the location of the fetal back /

mass in the upper quadrant of the to hear fetal heart sound

maternal abdomen  On one side of the abdomen, you will

palpate round nodules

 FISTS AND FEET OF THE FETUS

 Kicking and movement are expected to

be felt

 The other side of the abdomen, feels

smooth

Determine which part of the fetus is in the  FETAL BACK

fundus
3rd Maneuver
 If palpated a soft mass, irregular shape
 Move your hands down to the pelvic area.
and difficult to move
Palpate the area just above the
 FETAL BUTTOCKS
symphysis pubis.
 If palpated round and hard, movable
 Grasp the presenting part with the thumb
 FETAL HEAD
and third finger
 NORMAL FINDINGS – soft mass (fetal

buttocks), round and hard (fetal head)

 Oblique or transverse lie needs to be

noted. If vaginal delivery is expected,

external version can be performed to

rotate the fetus to the longitudinal

lie. Breech or shoulder presentation can

Determine the presenting part /confirms
complicate delivery if it is expected to
fetal position
be vaginal.
 Round, firm and ballotable on palpation
2nd Maneuver
 UNENGAGED FETAL HEAD
 Move your hands to the lateral sides of
 Soft and irregular on palpation
the abdomen, applying firm, even
 FETAL BUTTOCKS
pressure
 Soft, presenting part at the
 You will palpate round nodules on one
symphysis pubis indicates BREECH
side, and feel smooth on the other side
presentation

 BALLOTABLE / BALLOTEMENT –

rebounding of the fetus against

the examiner’s fingers on

palpation

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Health Assessment | NCMA 121 First Year | Second Sem

 Soft, presenting part at the  Breech or shoulder presentations can

symphysis pubis indicates BREECH complicate delivery if it is expected to

presentation be vaginal

4th Maneuver Fetal Positions

 Face the client’s feet. Place your hands

on the abdomen. Point your fingers

toward the mother’s feet.

 Then try to move your hands toward each

other while applying downward pressure

Systemic Changes

I. Circulatory / Cardiovascular

1. Pedal Edema

a. Cause > Gravid uterus that impedes

Used in the late stage of pregnancy to
venous return
determine how far the fetus has descended
b. Nursing Care
into the pelvic inlet
 Elevate legs above hip level (30mins)
 If the hands move together easily
 Side-lying
 FETAL HEAD HAS NOT DESCENDED INTO THE
 Good circulation and increases
PELVIC INLET
glomerular filtration rate (GFR)
 If the hands do not move together and

stop to resistance met 2.Increase Cardiac Output

 FETAL HEAD IS ENGAGED INTO THE PELVIC a. Pseudo anemia > physiologic anemia

INLET caused by pregnancy.

 Increased blood volume (CO), plasma

ABNORMAL FINDINGS
increases and total RBC increases
 Oblique or transverse lie needs to be
 Plasma increase exceeds the increase of
noted
RBC
 If vaginal delivery is expected,
 Plasma increases 40 – 50%, RBC increaes18
external version can be performed to
– 30%
rotate the fetus to the longitudinal lie
 Occurs by 30 – 34 weeks on AOG and peaks
 FETAL SPINE AXIS IS PARALLEL TO THE
at approximately 32 – 34 weeks AOG
MATERNAL SPINE AXIS
 Prepregnancy values return in the 3rd

trimester

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Health Assessment | NCMA 121 First Year | Second Sem

b. Client Concerns  Pressure of the uterus

 Dizziness, light headedness, easy  Displacement of stomach and small

fatigability intestine

c. Nursing Care  Decrease gastric motility, decrease

 Sit or lie down and lower your head gastric tone, decrease emptying of the

 Take deep breaths stomach

 Provide safe environment in case of falls b. Nursing Care

 Eat foods rich in iron  Drink fluids

 High in fiber foods

3. Varicosities
 Exercise regularly
a. Usually occur in the 2nd and 3rd
 Go if you have to go
trimester

b. Weakening of walls of the veins or valves 3. Heartburn

and venous congestion a. Cause

c. Lower extremities and vulva  May also be related to decreased GI

d. Nursing Care motility and displacement of stomach

 Wear support hose, avoid  Reflux of stomach acid into the

constricting clothing esophagus

 Elevate feet when sitting b. Nursing Care

 Lying with feet and hips elevated  Small meals

 Avoid long periods of standing or  Avoid spicy, greasy and fatty foods

sitting  Never bicarbonate – EDEMA!

II. Gastrointestinal
4. Hemorrhoids
1. Morning Sickness
a. Cause
a. Cause
 May occur as a result of increased
 Body’s reaction to pregnancy hormone
venous pressure
Human Chorionic Gonadotropin (HCG)
 Pressure of enlarge uterus in the
b. 1st trimester, subsides 3rd month
intestine
c. Hyperemesis Gravidarum
b. Nursing Care
d. Nursing Care
 High in fiber foods
 Soda crackers
 Drink plenty of fluids
 Eat small meals often
 Warm sitz bath
 Drink small amounts of fluids during
 Walking
the day to avoid DHN
 Apply suppositories, ointments or

2. Constipation / Flatulence compresses as ordered

a. Cause

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Health Assessment | NCMA 121 First Year | Second Sem

5. Ptyalism V. Musculoskeletal

 Excessive salivation 1. Lordosis – “Pride of Pregnancy”

 Uterine growth pulls the pelvis forward

6. Pica
– causes the spine to move forward –
 A craving or ingestion of non-
gradual lordosis
nutritional substances
 Enlarging breasts cause the shoulders to
 Can be a major concern if the craving
droop forward
interferes with proper nutrition in
 Progesterone and relaxin production
pregnancy
 Waddling gait

7. Carbohydrate metabolism is also altered  Backaches are common

– MATERNAL HYPOGLYCEMIA b.Nursing Care > Low heeled shoes

III. RESPIRATORY
2. Leg Cramps
1. Shortness of Breaths
a. Increase pressure of gravid uterus on the
a. Enlarging uterus pushes up on the
lower extremities
diaphragm
b. Low calcium level intake
b. Respiratory pattern changes from
c. Fatigue and muscle weakness
ABDOMINAL to COSTAL
d. 2nd and 3rd trimester
c. Common complaint during the last
e. Nursing Care
trimester
 Getting regular exercises, especially
d. Oxygen requirements increase because of
walking
the additional cellular growth of the body
 Dorsiflexing the foot of the affected leg
and the fetus
 Increasing calcium intake
e. Changes are normal and are to be expected

during the last trimester

VI. TEMPERATURE
f. Nursing Care – adequate rest
 Increase in Basal Body Temperature due
IV. URINARY
to increase progesterone
1. Frequency of urination occurs in the 1st
VII. ENDOCRINE
and 3rd trimester
a. Thyroid gland enlargement
 1st trimester due to increase blood
 Due to estrogen and HCG that may cause
supply in the kidneys
thyroid levels to rise
 3rd trimester due to enlarged uterus
 Untreated thyroid diseases during
2. Decreased bladder tone may occur caused
pregnancy may lead to premature birth,
by hormonal changes
preeclampsia, miscarriage and low birth
3. Renal threshold for glucose may be
weight
reduced due to increase glucocorticoids

– lactose and dextrose spill into urine

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Health Assessment | NCMA 121 First Year | Second Sem

 Management – discuss with AP especially  Talking to a friend

those clients who has an existing

VIII. Weight
thyroid disease
a. Minimum Weight Gain: 20 – 25 lbs

VII. EMOTIONAL b. Maximum Weight Gain: 25 – 35 lbs

a. 1st trimester c. Normal: 24 – 30 lbs

 REJECTION

 feeling upset about an unplanned

pregnancy

 ambivalence

b. 2nd trimester

 FANTASIZE

 looking visibly pregnant and feeling the

baby move, can make you feel any number

of emotions LOCAL CHANGES

 may daydream to prepare for motherhood I. PRESUMPTIVE SIGNS

and think about the maternal qualities 1. Amenorrhea

she would like to possess 2. N & V

c. 3rd trimester 3. Increase size and increased feeling

of fullness in breasts
 RESPONSIBILITIES
4. Pronounced nipples
 it is common to feel more anxious about
5. Urinary frequency
the childbirth and how a new baby will
6. Quickening – the first perception of
change your life
fetal movement (14th – 16th week)
 the woman’s readiness for the experience
7. Fatigue
and her identification with the
8. Discoloration of the vaginal mucosa
motherhood role

 accepts the growing fetus as distinct

II. PROBABLE SIGNS
from herself and a person to nurture
1. Uterine enlargement
 Prepares realistically for the birth and
2. Hegar’s sign
parenting of the child
3. Goodell’s sign
d. Nursing Care / Some points to consider
4. Chadwick’s sign
to avoid emotional stress during pregnancy:
5. Ballottement

 Talking to your spouse 6. Braxton Hick’s contractions

 Counselling 7. Positive pregnancy test measuring

 Taking extra rest for HCG

 Taking a walk
III. POSITIVE SIGNS
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Health Assessment | NCMA 121 First Year | Second Sem

1. Fetal heart rate detected by  probable signs of pregnancy

electronic device (Doppler transducer)

b. Leukorrhea
at 10 – 12 weeks and by non – electronic
 whitish gray, non – foul vaginal
device (fetoscope) at 20 weeks gestation
discharge (acidic mucus)
2. Active fetal movements palpable by
 caused by elevated levels of estrogen
examiner
 stimulate increased activity of
3. Outline of fetus via radiography or
cervical glands
ultrasound
 the mucus collects in the cervix to

I. UTERUS form a mucus plug

a. Hegar’s sign  seals the endocervical canal and

 softening and thinning of the lower prevents bacteria from ascending

uterine segment (isthmus softening)  into the uterus

 occurs about week 6

III. OVARIES
 probable signs of pregnancy
a. the maturation of new follicles

b. Goodell’s sign (follicle stimulating hormone – FSH) is

 softening of the cervix (cervix and blocked

vagina softening)  released by the pituitary gland

 occurs at the beginning of the 2nd  stimulates the growth of ovarian

month follicles – necessary in ovulation

 probable signs of pregnancy b. cease ovum production

c. Braxton Hick’s contractions

IV. ABDOMINAL WALL
 painless, irregular contractions of
a. Striae Gravidarum
the uterus
 reddish purple stretch marks
 may occur sporadically in the 3rd
 may occur in the abdomen, breasts,
trimester
thighs, and upper arms
 normal as long as no cervical change
 due to enlarging uterus
is noted
 destruction of subcutaneous tissues
 probable signs of pregnancy
b. Umbilicus pushed out

 Due to enlarging uterus

II. VAGINA

a. Chadwick’s sign V. BREAST

 bluish coloration of the mucus a. Increase estrogen

membranes of cervix, vagina and vulva  preparation for lactation

 increased vascularization b. Nipples erect

 occurs about week 6 c. Production of colostrum and estrogen

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Health Assessment | NCMA 121 First Year | Second Sem

VI. SKIN 1. Initial Comprehensive assessment

a. Linea Nigra >> Collection of subjective data about the

client's perception of his/her health of

 brown line from umbilicus to symphysis
all body systems. As well as objective
pubis
gathered during step-by-step physical
 typically shows up 20th week of gestation examination.

>> done for baseline information. Will ask

 related to changing hormones and
all the important information.
developing fetus
>> needed when client first enters the

health care facility to provide baseline

b. Chloasma
data for future health concerns.
 “mask of pregnancy”

 blotchy brownish hyperpigmentation of 2. Ongoing or partial assessment

>> consists of data collection that occurs

the cheeks, forehead and across the nose
after comprehensive database is
 increase production of melanocytes by
established.
the pituitary gland (MSH) >> mini overview of the client's body

VAGINAL INFECTION - itchiness, burning systems and holistic health patterns as a

follow up health status.

sensation and abnormal characteristics of
>> REASSESSMENT to detect new problem
the discharges of vagina

3. Focused or problem-oriented assessment

Nursing Process >> performed when a comprehensive database

exists for a client who comes to the health

G - Goal oriented
care agency WITH A SPECIFIC PROBLEM.
O - Organized
>> consists of thorough assessment of a
S - Systematic
particular client problem and does not
H - Humanistic Care
cover areas not related to the problem.

>> Approach for efficient and effective

4. Emergency assessment
provision of nursing care.
>> very rapid assessment performed in life
Effective: able to assess the patient's
threatening situations.
condition
>> immediate assessment to provide prompt
Efficient: able to establish a medical
treatment.
intervention to change the patient's
>> major and only concern is to determine
condition
the status of client's life sustaining

physical functions.
Phase I - Assessment

>> collecting subjective and collective

data Needed Info for interview:

>> the purpose of health assessment is to -History of present health concern

collect holistic subjective and objective -Personal Health history

data to determine a client's overall level -Family History

of functioning in order to make a -Lifestyle and health practices

professional clinical judgment.

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Health Assessment | NCMA 121 First Year | Second Sem

-Pre introductory: just the nurse, prepare

Steps of Health Assessment thyself.

-Introductory: where you will establish the

Preparation of the assessment:
rapport. make the patient comfortable
>> review the medical records if available
-Working Phase: interview phase
>> know c's basic biographical data
-Summary and Closing phase
>> activities of daily living

>> C's previous and current health status

Communication during interview
(patient and family)

>> Keep an open mind and refrain from Non-Verbal

premature judgment - Appearance, Demeanor, Facial Expression,
>> Educate self Attitude, Silence, Listening
>> reflect on your own feelings
Verbal
>> obtain and organize materials that you
- Open-ended and close ended questions,
will need for assessment.
Laundry list, Rephrasing, inferring

(nursing interpretation but be careful and

4.1 Collection of Subjective data
be sure to be knowledgeable enough before
> anything that a patient can verify.
telling the patient), Providing
> Information verbalized by the patient and
Information
only the patient can identify.
*usually uses an open-ended question.

- Biographical info, health history,

What to avoid:
personal health history, family history,
NV: Excessive/insufficient eye contact,
health and lifestyle practices, and primary
distraction or distance, standing
info.
V: Biased/leading questions, rushing

through the interview, reading the question

Subjective data includes:
* 2-3 ft from interviewee.
= sensations, symptoms, feelings,

perceptions, desire, preferences, beliefs,

4.2 Collection of objective data
ideas, values, personal information
>> anything that can be examine and

quantify.

>> all laboratory results

How to collect subjective data:
>> This type of data can be obtained by
: established a rapport and trusting
general observation and by using the four
relationship.
physical examination techniques:
: gathering info on the client's
inspection, palpation, percussion, and
developmental, psychological, physiologic,
auscultation.
social, sociocultural, and spiritual
>> Another source for objective data is the
statuses to identify deviations that can
client's medical record.
be treated with nursing and collaborative
>> May be observations noted by the family
interventions or strengths that can be
or significant others.
enhance through nurse-client

collaboration.
> Physical characteristics
> Vital Signs
Phases of Interview
> Appearance

> Behaviors
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Health Assessment | NCMA 121 First Year | Second Sem

> Measurements 7. Document Conclusions

> Result of laboratory testing

Types of Nursing Diagnoses

4.3 Validation of data

4.4 Document data

: Problem-Focused - Ineffective Breathing

Pattern
3.
: Risk - Risk for Infection/ preventing an
C - Character (describe how does it feels)
infection to happen
O - Onset (when did it begin)
: Health Promotion - Readiness for Enhanced
L - Location (where does the pain occur)
Family Coping/ mostly health
(is it radiating in other parts beside the
education/discharge planning
main location)
: Syndrome - Chronic Pain Syndrome/ the
D - Duration (how long does it last) (does
patient has known illness/ most of the time
it re-occur)
cannot be changed
S - Severity (quantify the pain felt) (pain

scale 1-10) (how bad is it)

Components of NANDA-I Nursing Diagnosis
P - Pattern (actions that lessen or
i. Problem - main problem (acute pain)
aggravate the pain)
ii. Etiology - reason of the problem
A - Associated Factor (reason for the
(related to tissue ischemia)
problem)
iii. Signs and Symptoms (evidenced by

statement of 'i feel severe pain on my

Phase II - NURSING DIAGNOSIS
chest)
>> analyzing subjective and objective data
to make a professional nursing judgment.
Problem and definition
- analysis of data.
> describes the client's health problem or
- Analysis of the collected data goes hand
response for which nursing therapy is given
and hand with the rationale assessment.
as concisely as possible.
- Analyze and synthesize data to determine
A diagnostic label usually has two parts:
whether the data reveal a nursing concern
QUALIFIER and FOCUS OF THE DIAGNOSIS
(nursing diagnosis) a collaborative
Qualifier: Deficient, Imbalanced,
concern (collaborative problem) or a
Impaired, Ineffective Risk for
concern that needs to be referred to
Focus of the Diagnosis: Fluid volume,
another discipline
Nutrition, Gas Exchange, Tissue Perfusion,
- Clinical judgement about individuals,
Injury
family or community responses to actual and
potential health problems and life
How to write Diagnostic Statement
processes.
One-Part: Health Promotion - Readiness for

Enhanced Breastfeeding
Process of Data Analysis
Two-Part: focused on Risk - Risk of
1. Identify abnormal data and strengths
Infection / related to compromised host
2. cluster the data
defenses
3. Draw inferences and identify problems
Three-Part: Problem-focused - Impaired
4. Propose possible nursing diagnosis
Physical Mobility / related to decreased
5. Check for defining characteristics of
muscle control / as evidenced by inability
those diagnoses
to control lower extremities.
6. Confirm or rule out nursing diagnoses
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Health Assessment | NCMA 121 First Year | Second Sem

Phase III: Planning

>> determining outcome criteria and Vital Signs

developing a plan
> Client's pulse r, respiration r, blood
>> how to manage the problem
pressure, oxygen saturation (95-100), and
>> based on the assessment and diagnosis,
temperature are the body's indicator of
the nurse sets measurable and achievable
health.
short- and long-range goals
> Usually when a vital sign/s is abnormal,
> short term goals >long term goals
something is wrong in at least one of the

body systems.
S - Specific
= today, pain is considered to the 5th vs.
M - Measurable

A - Attainable
Normal Vital Signs
R - Realistic
Adult Newborn
T - Time-bound
Temperature: 36.5-37.2 Temp: 36.5-37.2

Adult PR: 60-100 bpm PR: 120-160 bpms

Phase IV: Implementation/Intervention and
Respiration: 16-20 Respi: 20-60 rpm
Rationale
BP: 90/60-120/80 BP: 64/41 (nb)
>> carrying out the plan
95/58 (1m-2yo)
>> Putting plan into action

>> Involves carrying out your plan to Bradycardia: slower than a normal heart

achieve goals and outcomes rate. less than 60 bpm

>> the DOING phase Tachycardia: a heart rate over 100 bpm

Rationale: why the action is done / the

Vital Signs
reason why the intervention is done
> Cardinal Signs

> first step in physical examination

Phase V: Evaluation
> establish baseline values
>> assessing whether outcome criteria have
> an essential nursing function, is
been met and revising the plan as
performed on every client
necessary.
> measurement of vital signs and execution
>> the outcome of the patient after the
is done as part of the assessment process
interventions were rendered.
> to gather information regarding

physiological functioning of the body.

Validating and Documenting Data
When
Validation: ensures that the assessment
: upon admission
process is not ended before all relevant
: change in health status
data have been collected. It helps to
: pre and post op procedure
prevent documentation of inaccurate data.
: pre and post medication administration

: before and after any nursing intervention

>>Documentation of assessment data is an
that could affect the vital signs
important step of assessment because it
; hospital/institutional policy (routine
forms the database for the entire nursing
: physicians order
porcess and provides data for all other
member of the health care team.
Temperature

> 36.5-37.2
*What is not documented is not done.

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Health Assessment | NCMA 121 First Year | Second Sem

> factors that may affect body temperature: : up in set point triggers up muscle

strenuous exercise, stress, and ovulation contractions

may raise temperature

> lowest in them morning (4:00 am to 6:00 Types of Heat Transfer

am) > Conduction: Transfer heat from one

> highest in the evening (8:00-12:00 mn) molecule to a molecule of a lower

temperature

Hypothermia: seen in prolonged exposure to : Ice compress, ice pack

cold, hypoglycemia (decreased glucose in > Radiation: Transfer of energy in the form

blood), hypothyroidism (decreased of waves and particles

thyroxine level), starvation : without contact. -body heat

> Convection: The dispersion of heat by air

Hyperthermia (fever): viral or bacterial
currents
infection, trauma, and various blood,
: need an air current -electric fan
endocrine and immune disorders
> Vaporization/Evaporation: A continuous

evaporation of moisture from the

Factors affect heat production
respiratory tract and from the mucosa of
(Hyperthermia)
the mouth from the skin.
1. BMR:Basal Metabolic Rate

:Rate of energy utilization in the body

Factors affecting body temperature
required to maintain essential activities.
*age >newborns, older people
:Cool someone down and their metabolic
*Diurnal variations >temp normally change
rate slow down, heat them up and their
throughout the day
metabolism increases up
*exercise
2. Muscle Activity
>hormones -especially ladies, increase of
: Increases metabolic rate
estrogen, ovulation may ^temp
: Using Large muscles to make heat rather
>Stress -may ^temp,too
than movement.
>environment
: Strenuous exercises cause normal

variations in the body temp

Alterations in Body Temperature
3. Thyroxine Output
=Pyrexia- a body temp above the usual
: A thyroid hormone for regulation of
range. Hyperthermia or fever.
metabolism (BMR)
-Hyperpyrexia -have a fever, very high
: Increased Thyroxine output increases
temp level
metabolism (chemical thermogenesis)-
-Febrile -have fever
hyperthyroidism (feel warm or hot) -
-Afebrile -no fever
hypothyroidism (feel cold)

4. Epinephrine, Norepinephrine,
Type of Fevers
Sympathetic Stimulation
Intermittent: alternates at regular
: adrenaline : Sympathetic NS
intervals between periods of fever and
: important in maintaining core body temp
periods of normal/subnormal temps.
thru thermoregulatory process
: a period in a day where a patient's temp
5.Fever
varies from high to normal. -malaria
: up in body temp's set point

: up in Cellular Metabolic Rate

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Health Assessment | NCMA 121 First Year | Second Sem

Remittent: wide range of temp fluctuations > Antipyretics: paracetamol, ibuprofen,

all of which are above normal. medications that can help in lowering

: patient’s temp experiences fever temperature

throughout the day and fluctuates above or

more than 1 d Celsius within 24 hrs.
Relapsing: short febrile periods of a few
days and are intersped with periods of 1
or 2 days of normal temp.
: repeated episodes of fever
Assessing Temperature
1. establish baseline data for subsequent
evaluation
2. identify whether the core temp is within
normal range
3. determine changes in core temperature

in response to specific changes

Constant: fluctuates minimally but always
4. monitor clients at risk for imbalanced
remain above normal.
body temperature
: not fluctuates more than 1 d cel. -uti,

pneumonia
>Tympanic Thermometer >Disposable

>Infrared >Digital
Clinical Onset of Fever
where: oral -the most accessible, this
Onset/Chill: set point increases form
might injure oral mucosa
normal to higher than normal.
rectal -the most reliable bcoz it is
: feeling when some1's abt to get sick, not
closest to core temp, uncomfortable for the
feeling well
patient. newborn,child -to see if there's
:^ heart rate :Cyanotic nail beds
an opening on the anus
:^ RR :Gooseflesh
axillary -safest, non-invasive but least
:Shivering :Cessation of sweating
accurate of the four ,
:Cold, pallid skin
tympanic -fastest way to get the p's temp

but it is not accurate as other sites

Course/Plateau: already have a fever.

Doesn't feeling well.

Pulse Rate
:Absence of Chills :^ thirst
>an indirect measurement of cardiac output
:SKin that feels warm :Dehydration
obtained by counting the number of apical
:Photosensitivy
or peripheral pulse waves over a pulse
:Drowsiness,restlessness,delirium
point.
:Glassy eyes appearance:Loss of appetite
>normal: 60-100 bpm
:^ PR& ^ RR :Malaise

-Compliance :the ability of the arteries

Defervescence: critical. :occurs when the
to contract and expand. Circulation of o2
cause of fever is suddenly removed/healed.
blood.
:sudden vasodilation.(bp will decreased)
-Cardiac Output :the volume of blood pumped
:Flushed skin :Decreased Shivering
into the artery by the heart. An important
:Sweating :Possible dehydration
indicator on how efficiently the heart can
Nursing Intervention
pumped blood.
> Monitor vital signs and skin color
SV - Stroke Volume (amount of blood the
> Monitor lab values
heart releases every pump/beat)* Heart
> Provide adequate nutrition and fluids
Rate/min
> Oral hygiene
SV = 65ml * 70 bpm = 45550 ml = 4.55 L/min
> Tepid sponge bath
Normal Cardiac Output = 4L-8L of blood
> Dry clothing and linens
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Health Assessment | NCMA 121 First Year | Second Sem

-Peripheral Pulse :the pulses located AWAY Accessory muscle

from the heart. wave of the pulse. can be Chest upward & downward

felt. to know if the heart's pumping =Abdominal/Diaphragmatic

adequate blood to body. Contraction and relaxation of diaphragm

-Apical Pulse :CENTRAL pulse. at the APEX Movement of the abdomen

of the heart.
*Diaphragmatic breathing is the most
*there should be no difference between
efficient because greater expansion and
apical and peripheral.
ventilation occurs in the lower part of the

lung where blood perfusion is the greatest

Pulse Deficit :difference between the

apical pulse and the peripheral pulse. Major Physical Pulmonary Function

> Ventilation: in flow and out flow of air

Pulse Volume - a measurement of the between the atmosphere and lungs.
strength or aplitude of force exreted by > Circulation: quantity of blood flowing
the ejected blood against the arterial wall through the lungs. 4-6L of blood every min
with each contraction. circulating in the body.

> Diffusion: exchange of O2 and CO2 between

Sites where you can feel your peripheral
alveoli and blood.
pulse:
> Transport: carrying of o2 and co2 in the
>Carotid >Brachial >Dorsalis Pedis
blood and blood tissue.
>Radial >Femoral >Temporal

>Poplietal >Posterior Tibial Assessing Respiration

*check for full minute Sites:
1. Chest Wall 2.Thorax 3.Nose and mouth

Bradycardia: slower than a normal heart

Altered Breathing Pattern/Sounds
rate. less than 60 bpm
Rate
Tachycardia: a heart rate over 100 bpm
1.Tachypnea: increased in respiratory rate
Respiration 2.Bradypnea: decreased in respiratory rate
> act of breathing. 3.Apnea: the cessation/absence of
> External Respiration: interchange of o2 breathing.
and c02 between the alveoli and pulmonary 4.Eupnea: the normal breathing pattern
blood. From alveoli the blood is now
Volume
oxygenated and then it is pumped throughout
1.Hyperventilation: removing too much CO2
the body.
in the body. Not good cause body still
> Internal Respiration: interchange of o2
needs an acceptable amount of it to
and co2 in between the circulatory blood
maintain homeostasis.
and body tissue. Supplying Oxygenated blood
2.Hypoventilation: not enough O2 supply in
to the tissues, cells, organs.
the body.
> Inhalation: intake of air from lungs to
Effort
the atmosphere
1.Dyspnea: difficulty in breathing
> Exhalation: exhale co2
2.Orthopnea: difficulty in breathing while
> Ventilation: movement of air in and out
patient is lying down. Indication that the
of the lungs.
patient has too much fluid accumulation in
=Costal/Thoracic the lungs.
Exter/interal costal muscles

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Health Assessment | NCMA 121 First Year | Second Sem

*Normal Breath Sound = Vesicular Breath -Blood volume - normal= 4-6L/min low bv =

Sound low bp

-Blood viscosity - measurement of

Sounds
thickness/stickiness of the blood.
1.Stridor = a shrill harsh sound during
Component of the blood. viscous=elevated bp
expiration. Might have a laryngeal

obstruction. vasoconstriction: elevated blood pressure

2.Crackling/Crackles = the snoring vasodilation: decreased blood pressure

respiration. *90/60 - 120/80

> An obstruction in the upper airway.

> alveoli Factors that Affect Blood Pressure

3.Wheeze (expiratory) = can be heard when >Age - rises with age then declines due to

the patient has an asthma attack. > Chronic physiologic changes

obstructive pulmonary diseases. >Exercise - 20-30 mins after

> A narrowing in the airway. >Stress -Sympathetic NS, Cardiac Output

> narrowing of bronchus >Gender - Hormonal Variations

4.Bubbling/Rhonchi = respiratory or mucous >Medications

secretion. inflammatory >Obesity

>Diurnal Variations
Chest Movement
>Disease process - conditions that affect
1.Intercostal Retractions: infants, uses
cardiac output, blood viscosity, volume,
an extensive accessory muscle just to
arteries
breath in air. Having difficulty in
breathing.
> Sphygmomanometer Manual/analog
2.Substernal Retractions: infants,
Cuff - covering
difficulty of breathing
Bladder - inflates/deflates
3.Suprasternal Retractions: adults, usage
>Bulb >Manometer
of a lot of accessory muscle in breathing.

Secretions Site

1.Hemoptysis: cough out blood. Secretions 1. Arm (Brachial Artery) 2. Thigh

of blood.
Methods
2.Productive Cough
1. Direct (Invasive) = a catheter is
3.Non-productive Cough
inserted into the brachial, radial, or

femoral artery.
Blood Pressure
2. Indirect = Auscultation - usage of
> the measure of pressure exerted as blood
sphygmo and Palpation - usage of light to
flows through the artery.
moderate pressure to palpate the pulsations
> measured in terms of millimeters of
of the artery as the pressure of cuff is
mercury (mmHg) and written in fraction
released.
form.

> Normal: 120 (systolic)/80 (diastolic)

Assessing the BP

Normotension = normal BP
Determinants of Blood Pressure
Hypotension = below normal BP
-Pumping action of the heart
Hypertension = above normal BP
-Peripheral vascular resistance

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Health Assessment | NCMA 121 First Year | Second Sem

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