1 | HEALTH ASSESSMENT
✔ Before & after surgical or invasive
VITAL SIGNS TAKING
● Indicator of body physiological statue &
response to physical, environment &
psychological stressors
● It is a routine physical assessment
TERMS
● Blood pressure (BP): is the force exerted by
the blood against the vessel wall.
● Bradycardia: slow heart action
● Cardiac Output: amount of blood pumped by
the heart per minute
● Cone Temperature: measure of heat work,
not temperature
● Dyspnea: difficulty of breathing
● Heat stroke: severe heat illness
● Hypertension: long-term medical condition
where BP is persistently elevated
● Hyperthermia: group of heat-related
conditions (high body temp)
● Hypotension: low blood pressure
● Hypothermia: body loses heat faster than it
can produce heat
● Orthopnea: shortness of breath while lying
down kaya a person needs to have a certain
position in order to breathe
● Orthostatic Hypotension: decrease in BP
within 3 mins of standing when compared with
BP from sitting or supine position
● Oximetry: monitoring person’s oxygen
saturation
● Pulse pressure: difference between systolic
and diastolic blood pressure
● S1 - the sound of tricuspid & mitral valves
closing (systole)
● S2 - sound of the pulmonic & aortic valves
closing (diastole)
● Diastolic Pressure - minimal pressure
exerted against 100/80 the arterial wall of all
times
● Systolic Pressure - peak pressure occurs
when the hearts ventricular contraction forces
blood under high pressure into the aorta
When to take Vital Signs
✔ during client’s admission to a healthcare
facility
✔ In a hospital or healthcare facility on a
routine schedule according to physician’s
order or instructor’s standard of practice
✔ Assessing client during home health visits
diagnostic procedure
✔ Before & after the administration of
medication on application of therapies that
affect the cardiovascular respiratory &
temp-control functions
✔ When clients general physical condition
changes (e.g. loss of consciousness or
increased severity of pain)
4 Elements of Vital Signs
1. Temperature
2. Pulse
3. Respiratory Rate
4. Blood Pressure
HEAT PRODUCTION
✔ Primary source of metabolism
✔ Hormones muscle contraction & exercise
increase metabolism
✔ Epinephrine and norepinephrine are
released & after metabolism
✔ Energy production & heat production
increases sources of heat loss
✔ Skin (primary source)
✔ Evaporation of sweat
✔ Naming and humidifying inspired air
✔ Eliminating urine & feces
TRANSFER OF BODY HEAT TO EXTERNAL
ENVIRONMENT
Via thermoregulation:
● Conduction: Transfer of heat by direct
contact
● Convection: Cooler air current removes
heat from the surface of skin, warmer air
currents make the skin hotter.
● Evaporation: Transfer of heat by
evaporation of water (perspiration)
● Radiation: Transfer of heat by infrared
waves.
Steps for Assessing Temperature
✔ Tympanic Membrane
✔ Oral
✔ Rectal
✔ Axillary
Types of Thermometers
✔ Infrared thermometer
✔ Dual sensor thermometer
✔ Tempa Dot

✔ Digital thermometer
2 Ways to Measure Body Temperature:
● Core temperature
o Temperature at deep tissues.
o Examples are: oral cavity, ear
canal, rectum
● Surface temperature
o Temperature of surface skin tissues
o Examples: forehead, armpit (axilla)
Infants and Children below 6 y/o: ear, rectal,
forehead, armpit
Infants and Children 6 y/o and above:
a. Cooperative: oral, ear, rectal, forehead,
armpit
b. Uncooperative: ear, forehead
c. Unconscious: ear, rectal, forehead, armpit
Conversion of °F to °C: Deduct 32, then multiply
by 5, then divide by 9.
Conversion of °C to °F: Multiply by 9, then divide
by 5, then add 32.
I. Assessment
A. TEMPERATURE
✔ Determine the need to measure client’s
body temp.
✔ Assess factors that normally influence
temp (age, exercise hormones stress,
environmental temp-medications)
✔ Assess the site most appropriate for clients
temp. measurement
✔ Determine previous baseline temp. and
measurement from client’s record
Normal Findings:
Oral Temperature: 37°C, 98.6°F
✔
✔ Axilla Temperature: 36.5°C, 97.6°F
✔ Rectal Temperature: 37.5°C, 99.5°F
✔ Tympanic Temperature: 37.5°C, 99.5°F
✔ Forehead Temperature: 34.4°C, 94.0°F
✔ Hypothermia: 34-35°C
Tympanic daw pinaka-accurate pero safest ang
axilla.
B. PULSE
● Assess need to assess radial pulse
● Assess factors that influence radial pulse
rate and rhythm
● Determine client’s previous baseline pulse
rate
Pulse Physiology
2 | HEALTH ASSESSMENT
● Regulated by the autonomic Nervous
System through cardiac sinoatrial node
● Parasympathetic stimulation - decreases
heart rate.
● Sympathetic stimulation - increases
heart rate.
Pulse Sites
✔ Temporal - to assess pulse in children
✔ Carotid - to assess character of peripheral
pulse used during physiological shock or
cardiac arrest when other sites are not
palpable
✔ Apical - site for auscultation of heart sound
✔ Radial - common site to assess characters
of peripheral
✔ Ulnar - to assess status of circulation to
ulnar side of hand
✔ Femoral - to assess the character of pulse
during physiological shock or cardiac arrest
✔ Popliteal - to assess status of circulation
✔ Dorsalis Pedis - Posterior Tibialis
Normal Findings: 60-100 bpm
C. RESPIRATION
✔ Determine the need to assess client’s
respiration
✔ Assess for factors that influence character
of respiration
✔ Assess pertinent laboratory values
✔ Determine previous baseline resp. rate
from client’s record
Rate and Depth of Breathing:
● Changes in response to body temperature
● Controlled by respiratory centers in the
medulla and pons
● Activated by impulses from
chemoreceptors
Factors Affecting Respiration:
● Exercise
● Respiratory and Cardiovascular disease
● Alteration in fluid, electrolyte and acid
balances
● Medications
● Trauma
● Infection
● Pain
● Anxiety
Assessing Respiration:
✔ Inspection
✔ Listening w/ stethoscope
✔ Monitoring arterial blood gas results
✔ Using a pulse oximeter
Alterations in Breathing Pattern:
 3 | HEALTH ASSESSMENT

● Bradypnea High Normal 130-139 80-85

● Tachypnea Hypertension
● Hyperpnea Stage 1 140-159 90-99
● Apnea Stage 2 160-179 100-109
● Cheyne-Stoke Respiration Stage 3 >180 >110
● Kuss maul’s respiration MEDICAL HANDWASHING
● Biot’s respiration
To avoid contaminating the patient as well as the
Normal Findings: 12-24 bpm nurse.
D. BLOOD PRESSURE Procedure: (after lathering the soap):
Physiology of Blood Pressure ✔ Rubs hands 5 times as follows kada step,
● Force of the blood against arterial walls for a total of 20-30 seconds:
● Controlled by a variety of mechanisms to a. Nakapatong right palm sa kaliwang
kamay and vice versa.
maintain and adequate tissue perfusion
b. Rub hands/palms
● Pressure rises as ventricle contracts and
c. Interlock the fingers
falls as heart relaxes
d. Back of the finger to the hand and vice
● Highest Pressure - “systolic” versa.
● Lowest Pressure - “diastolic” e. Twisting of the thumb
Factors Affecting Blood Pressure f. Nakapulupot kamay then rubs the
palm.
✔ Age, gender, race
g. Then wrist.
✔ Food intake
✔ After that, rinse thoroughly with water
✔ Exercise
(elbow to wrist) hands apart from each
✔ Weight
other.
✔ Emotional state
✔ Body Position
✔ Drugs/Medication
ASSISTING WITH RANGE OF
Assessing Blood Pressure
MOTION EXERCISES
● Listening for Korotkoff’s sound w/ Range of Motion Exercise (ROM): movement of
stethoscope a joint to the extent possible without causing pain.
● First sound is systolic pressure
● Change or cessation of sounds occurs Purpose:
diastolic pressure ● Promote and maintain joint mobility
● The brachial artery and popliteal artery are ● Prevent contractures and shortening of
commonly used muscles and tendons
● Increase circulations
Equipment for Assessing the Blood Pressure ● Facilitate comfort
● Stethoscope and sphygmomanometer - 3
sizes of cuffs Benefits:
● Doppler Ultrasound ● Muscle Strength
● Electronic or Automated ● Improves Circulation
● Maintains Flexibility
Selecting a Blood Pressure Cuff Size ● Reduces Pain
● Distance around Arm Blood Pressure Cuff
size Principles of Body Mechanics
● 7-9 inches small adult cuff ● Mechanics - coordinated efforts of
● 7-13 inches standard adult cuff musculoskeletal and nervous systems to
● 13-17 inches large adult cuff maintain balance, posture and body
alignment during lifting, bending, moving,
Normal Findings: 120/80 mmHg and performing Activities of Daily Living.
(ADL)
Classification of BP for Adults age 18 y/o and
● Proper use of body mechanics reduces risk
older:
for injury and ensures safe care
Category Systolic Diastolic o Posture
Optional (mmHg) (mmHg) o Base of Support
<120 <80 o Center of Gravity
<130 <85 o Using Large Muscle Groups

o Pushing instead of Pulling
Pathological Influences of Immobility
● Postural Abnormalities
● Impaired Muscle Development
Systemic Changes Associated with Immobility
1. Metabolic changes:
● Endocrine metabolism affected (decrease
in BMR)
● Disrupts metabolic functioning
● Fluid & Electrolyte Imbalances
● Decreased calories & protein
● Negative Nitrogen Balance
● Calcium Resorption
● Functioning of GI tract
2. Respiratory Changes
Lack of exercise & movement put client at risk
for:
● Atelectasis - collapse of alveoli leading to
partial collapse of lung
● Hypostatic Pneumonia - inflammation of
lung tissue from stasis or pooling of
secretions
● Both decrease oxygenation, prolong
recovery, and add to discomfort
3. Cardiovascular Changes
● Orthostatic hypotension
● Increased workload of heart due to
decrease in venous return to the heart
● Risk for thrombus (blood clot)
4. Musculoskeletal Changes
● Muscle effects (muscle atrophy (decrease
in the mass of the muscle)
● Skeletal effects - Disuse osteoporosis,
contractures and foot drop
5. Urinary Elimination Changes
● Stasis and pooling of urine in renal pelvis
lead to increased risk for infection and
renal calculi
● Risk for dehydration and decreased
urine output
● UTI’s due to Foley catheter
6. Other Changes
● Integumentary changes (Risk assessment
tool for skin breakdown, proper skin
hygiene)
● Psychosocial effects (Depression from
immobility)
● Developmental Changes
4 | HEALTH ASSESSMENT
● Damage to CNS
● Direct Trauma to M/S System
ROM Movements:
✔ FLEXION – movement of body part that
decreases the angle of a joint
✔ EXTENSION – the action of moving a limb
into a straighter position increasing the
angle
✔ ABDUCTION – moving of a limb away
from the midline of the body
✔ ADDUCTION – movement of a limb
towards the midline of the body
✔ ROTATION – to rotate/turn a limb around
an axis
o Internal Rotation – rotation towards
the center of the body/medial rotation
o External Rotation – rotation away
from the center of the body/lateral
rotation
✔ CIRCUMDUCTION – movement of a limb
or extremity so that the distal end
describes a circle and the proximal end
remains fixed
Practice Guidelines - w/pt. consent
● Remove things that will hinder movement
● Ensure patient dignity is maintained
● Use correct body mechanics
● Position bed at the correct height
● Remove things that will hinder movement
● Ensure patient dignity is maintained
● Use correct body mechanics
● Position bed at the correct height
● Support client’s limbs above or below the
joint
● Move the body parts slowly and
rhythmically.
● Support client’s limbs above or below the
joint
● Move the body parts slowly and
rhythmically
MOVING, LIFTING AND
TRANSFER
Body Balance: is achieved when a relatively low
center of gravity is balanced over a wide, stable
base of support and a vertical line falls from the
center of gravity through the base of support.

✔ Body Alignment: refers to the relationship
of one body part to another part along a
horizontal or vertical line
✔ Body Mechanics: is the coordinated effort
of the musculoskeletal and nervous
systems to maintain balance, posture,
body alignment during lifting, bending,
moving, and performing activities of daily
living.
CENTER OF GRAVITY
The midpoint or center of weight of a body or
object.
● Hemiparesis – muscular weakness of one
half of body
● Hemiplegia – paralysis of one side of the
body
● Paraplegia - is an impairment in motor or
sensory function of the lower extremities.
● Orthostatic Hypotension – or postural
hypotension, occurs when a patient stands
after sitting or lying down
● Paralysis – the loss of muscle use or loss
of feeling, or both
● Posture – the position of the body with
respect to the space around it
● Paresis – muscle weakness or paralysis
unilaterally or bilaterally
● Paresis - is the reduced ability and
paralysis is the inability to activate motor
neurons
● Pressure Ulcer - is an area of skin that
breaks down when you stay in one position
for too long without shifting your weight.
STAGES OF PRESSURE ULCER
✔ Stage 1 – A reddened area on the skin
that, when pressed, is "non-blanchable"
(does not turn white). This indicates that a
pressure ulcer is starting to develop.
✔ Stage 2 – The skin blisters or forms an
open sore. The area around the sore may
be red and irritated.
✔ Stage 3 – The skin breakdown now looks
like a crater where there is damage to the
tissue below the skin.
✔ Stage 4 – The pressure ulcer has become
so deep that there is damage to the muscle
and bone, and sometimes tendons and
joints.
Principles of Body Mechanics
● The wider the base of support, the greater
the stability of the nurse
● The lower the center of gravity, the greater
the stability of the nurse
5 | HEALTH ASSESSMENT
● The equilibrium of an object is maintained
as long as the line of gravity passes
through its base of support
● Facing the direction of movement prevents
abnormal twisting of the spine
● Dividing balanced activity between arms
and legs reduces the risk of back injury.
Purpose:
● Prevents physical injury of nurse and client
● Promotes correct body alignment
● Facilitates coordinated, efficient muscle
use when moving clients
● Conserves energy of caregiver for
accomplishment of other tasks
● Physical activity maintains and improves
joint motion
● Increases strengths
● Promotes circulation
● Relieves pressure on skin, improves
urinary and respiratory function
Equipment:
1. Transfer belt, sling or lap board (as
needed), nonskid shoes, bath blankets,
pillows
2. Wheelchair: Position chair at 45 –degree
angle to bed, lock brakes, remove footrest, lock
bed brakes
3. Stretcher: Position at right angle (90
degrees) to bed. lock brakes on stretcher, lock
bed brakes
4. Mechanical/ hydraulic lift: Use frame,
canvas strips or chains, and hammock or canvas
strips.
Assessment:
● Assess client’s weight, age, level of
consciousness, disease process, and
ability to cooperate
● Assess strength of muscles and mobility of
joints to be used by observing client
movement in bed and by applying gradual
pressure to a muscle group
● Assess need for analgesic medication 30
to 60 minutes before position changes
● Assess for tubes, incisions, and equipment
● Assess client’s body alignment and comfort
level while client is lying down
● Assess for risk factors that may
contribute to complications of
immobility:
o Paralysis: Hemiparesis resulting
from CVA; decreased sensation
o Impaired mobility

o Impaired circulation
o Age
✔ Assess client’s physical ability to help with
moving and positioning
✔ Assess ability and motivation of client,
family members, and primary caregiver to
participate in moving and positioning client
in bed in anticipation of discharge to home
✔ Assess level of endurance:
o Assess ability to use arms and legs
for moving up and down in bed and
repositioning.
o Assess level of fatigue during activity.
o Assess vital signs.
✔ Assess client’s proprioceptive function
(awareness of posture and changes in
equilibrium):
o Ability to maintain balance while
sitting in bed or on side of bed
o Tendency to sway to or position self
to one side
Nursing Diagnosis
✔ Activity intolerance r/t to fatigue
✔ Impaired physical mobility r/t intolerance to
activity and neuromuscular or
musculoskeletal impairment
✔ Impaired skin integrity r/t physical
immobilization
✔ Risk for impaired skin integrity
Planning
1. Expected outcomes following completion of
procedure:
● Clients retains ROM
● Client’s comfort is increased
● Client’s level of independence in
completing ADL is increased
● Client displays no evidence of physical
injury, such as new bruises, tears, or
skeletal trauma after moving.
2. Get extra help as needed
3. Explain procedure to client
SPECIAL CONSIDERATIONS:
Pediatric
● Opportunity, materials, or objects to
stimulate activity, encouragement, and
participation of others must be available
6 | HEALTH ASSESSMENT
● Children not able to move will need
passive exercise and movement.
Geriatric
● Provide support to avoid strain on joints,
tendons, ligaments, and muscles
● Frequent repositioning and a regular
program of ROM exercises are essential
● Physical therapy or occupational therapy in
the presence of thin, fragile skin and/or
nutritionally
● compromised state, lubricants or protective
films or padding can reduce friction injury
● Use pull sheet to avoid shearing forces that
damage client tissues
Long-Term Care Considerations
● Frequent assessment and turning more
often is necessary
● Use lift (draw) sheet as often as possible to
prevent shearing force on fragile skin
● Allow client to assist with moving and
positioning whenever possible to promote
independence.
Home Care Considerations
● Teach family members body mechanics
● Consider the need for a bed that places the
bedridden client at caregiver’s waist level
● Teach caregivers to change client’s
position every one to two hours if possible
● Develop a realistic turning schedule
that is posted.
Evaluation
● Were desired outcomes achieved?
● Examples of evaluation includes:
o Desired outcome met: Client’s
demonstrated comfort
o Desired outcome met: Client’s
shows no evidence of skin
breakdown
o Desired outcome met: Client’s
level of independence in
completing ADL is increased.
Unexpected Outcomes:
● Joint contractures develop or worsen
● Skin shows areas of erythema, breakdown
and irritation
● Client avoids moving
● Client complains of discomfort from
stretching because of altered alignment

● Client turns back to same position
frequently and expresses discomfort with
alternate positions.
● Client complains of respiratory distress.
RECORDING AND REPORTING
● Position client was moved from
● Position client was moved to
● Supportive devices used
● Condition of skin on pressure points
● Instructions given to client and/or family
● Client’s tolerance of change in position
Sample Documentation
● 08:00 Turned from back to left lateral
position.
● Area of erythema approximately 3 cm in
diameter noted over coccyx. Blanches
easily.
● Urged client not to lie on back.
● 10:00 Found client lying on back. Turned to
right side and supported with pillows.
Coccyx remains reddened, blanches to
fingertip pressure.
● 11:00 Continues on right side watching
television. Denies discomfort.
ORAL CARE
Purpose:
● Decreases microorganisms in mouth and
on teeth
● Reduces the risk of cavities and mouth
disease
● Decreases buildup of food residue on teeth
● Improves appetite and taste of food
● Promotes comfort
● Stimulates circulation on oral tissues,
tongue, and gums
● Improves appearance and self-esteem
Assessment
✔ Client’s desire and need for oral care
✔ Client’s usual routine for oral hygiene
✔ Client’s knowledge of purpose and
procedure
✔ Client’s ability to understand and follow
instructions
✔ Presence of dentures
✔ Status of palate, floor of mouth, throat,
cheeks, tongue, gums, and teeth
Nursing Diagnoses
7 | HEALTH ASSESSMENT
✔ Impaired oral mucous membranes related
to inadequate oral cleaning
✔ Impaired dentition related to lack of
knowledge regarding dental health
Outcome Identification and
Planning
● Oral intake increased from 10% to 50%
● Mucous membranes and lips are intact
● Oral passage and teeth are clean
SPECIAL CONSIDERATIONS IN PLANNING
AND IMPLEMENTATION
General:
● use soft toothbrush or toothette for client
receiving anticoagulant therapy (heparin,
warfarin/coumadin)
● dilute mouthwash for clients with oral
lesions or sensitive oral tissues
Geriatric:
✔ Extra care: Loose teeth due retracting
gums
✔ Encourage client to perform as much oral
care as possible and encourage family
members to assist, when necessary
✔ If the patient is helpless make certain that
the patient's mouth receives care as often
as necessary to keep it clean and moist, as
often as every 1 or 2 hours if necessary.
✔ The nurse should wear disposable gloves,
and normally saline solution; moisten the
mouth with water (if allowed) and lubricate
the lips often enough to keep the
membranes well moistened.
✔ A patient receiving chemotherapy
medication may have bleeding gums and
extremely sensitive mucous membranes.
✔ Use sponge toothette for cleaning or
substitute a salt water rinse. (1/2 tsp salt in
1 cup of warm water) for brushing of teeth
DENTURE CARE
● Dentures should not be wrapped in toilet
tissue or disposable wipes because these
are likely to be thrown away.
● Dentures should be stored in water to
prevent drying and warping of plastic
materials.
Materials and Supplies
● Padded tongue depressors
● Cotton balls/cotton applicators
● Mouthwash diluted in water
● Clean gloves
 8 | HEALTH ASSESSMENT

● Towel ● Normal Findings: pink, soft, and

● Petrolatum jelly moist mucous membrane, pink and
● Asepto syringe dry lips thus the usage of the
● Kidney Basin petrolatum jelly. No foul odor was
observed as well as no presence of
PROCEDURE AND RATIONALE: ORAL CARE thrush or sores.
1. Wash hands
Rationale: Reduces transfer of
microorganisms
SHAVING BEARD AND
2. Prepare materials and supplies
Rationale: Promotes efficiency MOUSTACHE
3. Position client to Semi-Fowler’s near the nurse The removal of hair, by using a razor or any other
with client’s head to the side. kind of bladed implement, to slice it down to the
Rationale: Decreases risks of aspiration level of the skin.
4. Place towel under the patient’s face and chin
Purpose:
Rationale: Prevents the client from water
spills ✔ Improve client’s appearance and
5. Place kidney basin close to the client’s chin self-esteem
Rationale: Promotes drainage of ✔ Increases client’s sense of well-being
mouthwash from mouth.
Assessment
6. Wears clean disposable gloves
Rationale: Prevents exposure to body Assessment should focus on the following:
fluids
✔ Condition of the skin (nicks, bruises, thin
7. Use non-dominant hand, place padded tongue and fragile)
Rationale: To keep mouth open depressor
✔ Contraindications to shaving
on lower teeth.
✔ Type of razor or shaver to be used
8. Moisten padded tongue depressor/cotton ✔ Use of anticoagulants
applicator with mouthwash ✔ Knowledge of procedure for care
Rationale: Freshen mouth
9. Clean mouth starting with chewing, inner Nursing Diagnosis
surface of the teeth, outer surfaces of the May include the following:
teeth, then the roof of the tongue.
Rationale: Decreases microorganism ● Grooming self-care deficit related to
growth in mouth, inside the cheeks and the neurotransmuscular impairment
lips, and lastly, the tongue. ● Risk for injury, bleeding, related to use of
10. Rinse mouth with water using a clean anticoagulant
applicator/padded tongue depressor.
11. Use asepto syringe to aspirate excess water Outcome Identification and
in the mouth.
Planning
12. Remove kidney basin and towel
13. Dry the lips with a towel Sample desired outcome include the following:
14. Discard used gloves ● Client expresses satisfaction with
15. Applies petrolatum jelly (per Doctor’s order) grooming.
with a moisturizer on the lips in a clean cotton ● Client demonstrate a face that is clean and
applicator. shaved without any evidence of cuts and
bruises.
16. Place client to comfortable position
17. Clean used articles and discards disposable SPECIAL CONSIDERATIONS
materials
General:
Rationale: Promotes clean environment
18. Wash hands ● If client is taking an anticoagulant, check
the agency’s policy about the need to
19. Document

obtain a special doctor’s order prior to
shaving.
● When assessing drug profile, note drugs
that contain aspirin or drugs that are not
classified as anticoagulant but may cause
bleeding.
Geriatric: Be gentle when shaving. Shave only as
often as necessary.
End-of-Life Care: Include shaving as part of a
client’s grooming as indicated.
Transcultural:
● When in doubt about client’s shaving
practices, consult the client or family
member.
Jainism, Hinduism and Buddhism: shaving is a
symbol of their renunciation of worldly fashion and
esteem.
Jewish: restricts shaving with a blade against the
skin
Muslim: prohibits shaving to maintain clear
distinction between the two genders because it
forbidden for any of the two sexes to imitate the
other in appearance.
Cost-Cutting Tip: Encourage the family member
to perform shaving when acceptable to client.
PROCEDURE AND RATIONALE
1. Informs the client
Rationale: Promotes cooperation and
assistance.
2. Washes hands
Rationale: Reduces microorganism
transfer
3. Prepares necessary materials and supplies:
Rationale: Promotes efficiency
4. Provides privacy if necessary
Rationale: Promotes emotional and
physical comfort.
5. Assists patient to a Semi-Fowler’s or
comfortable position and adjust height of bed.
Rationale: Provides access to the shaving
area.
6. Places wash basin 2/3 full of water (with a
temperature of 115°F/46°C) on top of a
newspaper lined overbed table.
9 | HEALTH ASSESSMENT
Rationale: Promotes efficiency;
newspaper absorbs excess water,
preventing the client from getting wet.
7. Adjusts lighting and offered a mirror to the
client (if desired)
Rationale: Provides comfortable
environment for working and provides
opportunity for the patient to cooperate.
8. Places bath towel over chest
Rationale: Prevent client from getting wet
9. Wears clean disposable gloves
Rationale: Prevents contact with body
fluids
10. Washes client’s face then, applied wet
washcloth to face 3-5 mins.
Rationale: Softens area to avoid cuts.
11. Applies shaving cream/soapsuds to the face
with hands.
Rationale: Softens area to avoid cuts and
facilitates movement of razor.
12. Starts shaving by stretching the skin in the
area to be shaved with one hand. Shaves
towards the direction of hair growth using
shorter strokes around the chin and upper lips.
Rationale: Holding skin taunt helps
prevent razor cuts and discomfort during
shaving. – follows natural hair direction to
avoid nicks, cuts, or bruises; avoid
irritation.
13. Rinses razor blade after or wipe with a tissue
as necessary.
Rationale: Removes hair debris and
excessive cream or soap to facilitate
smooth stroke and keep cutting surface
razor blade clean.
14. Washes off and dries face thoroughly with a
towel.
Rationale: Provides a positive effect for
comfort and self-esteem.
15. Applies after shave lotion if available and if
client desires.
Rationale: Provides comfort and reduces
the risk of skin irritation from rubbing.
16. Removes towel over chest. Removes and
discards gloves.
Rationale: Avoid spread of
microorganisms.
17. Places client on a comfortable position.
Rationale: Provides comfort and safety.
18. Cleans and returns equipment to proper place.
Rationale: For future use.
19. Washes hands

Rationale: Reduce possibility of
microorganism transfer.
20. Documents the procedure.
Rationale: To meet professional and legal
standards.
Evaluation
● Were desired outcomes achieved?
● Examples of evaluation include:
✔ Desired outcome met: Client
demonstrate clean, shaved face
without any cuts or bruises.
✔ Desired outcome met: Client
expresses comfort after
procedures.
Documentation
The following should be noted on the client’s
chart:
✔ Type of razor used
✔ Response to shave
✔ Condition of skin
✔ Nicks or bruises present
✔ Lotion or aftershave applied
SAMPLE DOCUMENTATION
● Date:11/03/10
● Time: 10:00
● Face shaved using electric razor with
doctor’s order, as client is taking
Coumadin. No bruising or cuts noted.
Client verbalized comfort after procedure.
BED SHAMPOO
● This is the process of washing of the
patient’s hair while in bed.
● This is done to cleanse hair and scalp of
patient.
Purposes:
✔ It stimulates blood circulation in the scalp
✔ Prevent infection from lice
✔ Cleanse hair after application of lice
exterminator
✔ Remove excess oil and treat dandruff
✔ Increase client’s comfort
Important things to remember:
10 | HEALTH ASSESSMENT
✔ The nurse must secure the doctor’s order
for hair shampoo (in some health condition
this is needed).
✔ Consult the head nurse before giving a
patient a hair shampoo to see if there may
be any contraindication to the procedure.
✔ The procedure must be explained to the
patient.
✔ Observe close door / screen process to
maintain the patient’s privacy.
✔ Prepare and assemble the equipment
before starting the procedure.
✔ Keep the patient warm and avoid draft for
several hours after the procedure.
Hygiene: is self-care by which people attended to
such function as bathing, oral care, grooming hair,
cleaning fingernails, genital area, ear and eye
care.
Hygiene involves cleansing of the:
Skin, Mouth, Teeth, Hair, Nails, Eyes, Ears, Nose,
Perineal Area, Feet
Kinds of Hygiene
1. Early Morning Care: washing face, hands,
oral care and bed making.
2. Morning Care: is providing after client has
breakfast such as baths, back massage,
oral and nails care.
3. After Noon Care: includes provide
bedpan, urinal, hand washing and face.
4. Hours of Sleep (HS) Care: they provide to
client before they retire for night,
elimination need and oral care.
5. As Needed (PRN) Care: is provided as
required by client.
HAIR
● “Crowning glory of beauty”
● Lanugo (newborn) – fine hair on the body
of the fetus “down or woolly hair” over their
shoulders, back, and sacrum
● Oily (adolescents) – sebaceous glands
increase in activity as a result of increased
hormone level
● Elder Adults – Thinner, grows more
slowly, and loses its color as a result of
aging tissues and diminishing circulation
● Appearance reflects a person’s feelings of
self-concept and socio-cultural well being
● Becoming familiar with hair care needs
and practices that maybe different from our
own is an important aspect of providing
competent nursing care to all clients.
● Reflect state of health (e.g., excessive
coarseness and dryness maybe

associated with endocrine disorders
such as hypothyroidism)
Assessment
Determine:
● Routinely used shampoo products
● Activity tolerance of the client
● History conditions or therapies; recent
chemotherapy, hypothyroidism, radiation of
the head, unexplained hair loss and growth
of excessive body hair
● Usual hair care practices and routinely
used hair care products (e.g., hair spray,
shampoo, conditioners hair oil preparation,
hair dye, curling or straightening
preparations)
● Whether wetting the hair will make it
difficult to comb. Kinky hair is easier to
comb when wet and is very difficult to
comb when it dries (Jackson, 1998, p. 102)
● Evenness of hair growth over the scalp, in
particular, any patchy loss of hair: hair
texture, oiliness, thickness, or thinness;
presence of lesions, infections, or
infestations on the scalp; presence of
hirsutism.
● Self-care abilities (e.g., any problems
managing hair care).
Abnormal Findings:
● Dandruff – diffuse scaling of the scalp;
often accompanied by itching usually
treated effectively with a commercial
shampoo
● Hair loss - permanent thinning of hair
normally occurs with aging
● Alopecia – hair loss
● Ticks – small gray-brown parasites that
bite into tissue and suck blood
● Pediculosis (Lice) – parasitic insects that
infest mammals
INTERVIEW
✔ What are your usual hair care practices?
✔ What hair care products do you routinely
use (e.g., hair spray, lubricant, shampoo,
conditioners, hair dye, curling or
straightening preparations)?
✔ Past or current hair problems
✔ Self-care abilities
✔ Do you have any problems managing
self-care abilities?
✔ Have you had any of the following
conditions or therapies; recent
11 | HEALTH ASSESSMENT
chemotherapy, hypothyroidism, radiation of
the head, un explained loss of hair, growth
of excessive body hair?
Nursing Diagnosis
1. Self-Care Deficit:
Grooming, related to:
✔ Activity intolerance
✔ Imposed immobility (bed rest)
✔ Pain in upper extremities
✔ Altered level of consciousness
✔ Lack of motivation associated with
depression.
2. Impaired Skin Integrity related to:
✔ Scalp laceration
✔ Insect bite
3. Disturbed body image related to Alopecia
PROCEDURE:
1. Inform client of the procedure.
2. Wash hands.
3. Prepare necessary supplies and materials: bath
towel, trough/Kelly pad/plastic square, face towel,
basin/pail, cotton balls, shampoo, bath blanket,
clean bed linens, bath thermometer, comb/brush,
clean hospital gown, small pillow
4. Provides for privacy.
5. Fanfolds the top linen towards the foot of the bed
and replaces it with bath blanket.
6. Removes pillow and brought client’s head
close to edge of bed. Places a small pillow covered
with bath towel underneath patient’s shoulder and
neck to slightly extend and tilt head back
7. Inserts the Kelly pad/plastic square under client’s
head, trough directed towards the pail.
8. Brushes or combs hair to remove tangles and
snarls, protects eyes with face towel and plugs
ears with cotton balls.
9. Wears gloves.
10. Moistens hair thoroughly with water with
temperature between 43– 44oC or 110oF.
11. Pours a small amount of diluted shampoo
over hair and scalp. Works up a rich lather starting
from hairline toward the back and massages using
the ends or tips of fingers not the nails.
12. Rinses hair thoroughly and squeezes off
excess water (repeats procedure if necessary).
13. Dries face with face towel and removes ear
plugs.
14. Raises head with one hand, the other hand
removes the Kelly pad and drops it to the pail.
Wraps hair with towel underneath the neck to
prevent dripping
 12 | HEALTH ASSESSMENT

15. Removes gloves.

16. Dries hair well, moves back client’s head at
the center of the bed then, combs one section at a
time.
17. Replaces bath blanket with top linen.
Changes bed linens and hospital gown (if needed)
and makes the client comfortable.
18. Cleans and returns materials and supplies.
19. Washes hands.
20. Documents observations as to hair texture,
presence of masses or lesions on scalp, presence
of lice or dandruff, and other pertinent data.

Evaluation
✔ Conduct ongoing assessments for
problems such as dandruff, alopecia,
pediculosis, scalp lesions, or excessive
dryness or matting.
✔ Evaluate effectiveness of medicine (e.g.,
for treating pediculosis), if appropriate.