HEALTH ASSESSMENT
- HEALTH ASSESSMENT is an evaluation of the health
status of an individual by performing a physical
examination after obtaining a health history. Various
laboratory tests may also be ordered to confirm a
clinical impression or to screen for dysfunction.
- The depth of investigation and the frequency of the
assessment vary with the condition and age of the
client and the facility in which the assessment is
performed.
- The person's response to any dysfunction present is
observed and noted.
- The techniques of the health assessment include
INSPECTION, PALPATION, PERCUSSION, and
AUSCULTATION.
- Health assessments are performed by nurses in a
variety of settings, including at health fairs, in the
community, and at schools and hospitals. It involves
interviewing a patient, inspecting and observing her
body and actions, and palpating and percussing parts
of her body.
PURPOSE OF HEALTH ASSESSMENT
- A HEALTH ASSESSMENT is a plan of care that
identifies the specific needs of a person and how those
needs will be addressed by the healthcare system or
skilled nursing facility. Health assessment is the
evaluation of the health status by performing a
physical exam and taking a health history.
• Information
Health assessments are used by nurses to gather
information about a patient's condition. This
information is used to formulate a nursing plan of
care for the patient.
• Nursing Diagnoses and Care Planning
A nurse takes note of actual or potential problems
her patient may have during a health
assessment. From the list of problems, she
formulates diagnoses, which she uses to create a
care plan.
• Managing Problems
The nurse continuously does a health
assessment on her patient to see if her care plan
is having the desired effect. If not, she makes
changes to her care plan to address the patient's
health problems.
• Evaluation
Evaluation of a patient's health status is done
through health assessments. Evaluations
determine if a patient has responded to nursing
care sufficiently enough to be recommended for
discharge.
• Discharge Teaching
During a health assessment, a nurse may
become aware that a patient is lacking
information that may help improve his condition.
This provides the nurse with an opportunity to
impart this information before he is discharged.
• Advocate
When a nurse performs a health assessment, she
may find a problem that requires the expertise of
other members of the health care team. In this
case, the nurse notifies the proper health care
team member of the problem and makes sure the
patient receives the expert care that they need.
NURSING PROCESS
- In 1958, Ida Jean Orlando started the nursing process
that still guides nursing care today. Defined as a
systematic approach to care using the fundamental
principles of critical thinking, client-centered approaches
to treatment, goal-oriented tasks, evidence-based
practice (EDP) recommendations, and nursing intuition.
- Holistic and scientific postulates are integrated to
provide the
- basis for compassionate, quality-based care.
- The nursing process functions as a systematic guide to
client-centered care with 5 sequential steps., diagnosis,
planning, implementation, and evaluation.
- A.D.P.I.E.
Nursing Process
The nursing process is a scientific method used by nurses
to ensure the quality of patient care. This approach can
be broken down into FIVE SEPARATE STEPS.
1. Assessment Phase
The first step of the nursing process is
assessment. During this phase, the nurse gathers
information about a patient’s psychological,
physiological, sociological, and spiritual status.
This data can be collected in a variety of ways.
Generally, nurses will conduct a patient interview.
Physical examination referencing a patient’s
health history, obtaining a patient’s family history
and general observation can also be used to
gather assessment data. Patient interaction is
generally the heaviest during this evaluative
phase.
2. Diagnosing Phase
The diagnosing phase involves a nurse making
an educated judgement about a potential or
actual health problem with a patient. Multiple
diagnoses are sometimes made for a single
patient. These assessments not only include an
actual description of the problem but also whether
or not a patient is at risk of developing further
problems. These diagnoses are also used to
determine a patient’s readiness for health
improvement and whether or not they may have
developed a syndrome. The diagnoses phase is
a critical step as it is used to determine the course
of treatment.
3. Planning Phase
Once a patient and nurse agree on the diagnoses
a plan of action can be developed. If multiple
diagnoses need to be addressed, the nurse will
prioritize each assessment and devote attention
to severe symptoms and high-risk factors. Each
problem is assigned a clear, measurable goal for
the expected beneficial outcome (SMART).
4. Implementing Phase
The implementation phase is where the nurse
follows through on the decided plan of action.
This plan is specific to each patient and focuses
on achievable outcomes. Actions involved in a
nursing care plan include monitoring the patient
for signs of change or improvement, directly
caring for the patient or performing necessary
medical tasks, educating and instructing the
patient about further health management, and
referring or contacting the patient for follow-up.
Implementation can take place over the course of
hours, days, weeks, or even months.
5. Evaluation Phase
Once all nursing intervention actions have taken
place, the nurse completes an evaluation to
determine if the goals for patient wellness have
been met. The possible patient outcomes are
generally described under these three terms:
patient's condition improved, patient's condition
stabilized, and patient's condition deteriorated,
died, or discharged. In the event the condition of
 the patient has shown no improvement, or if the
wellness goals were not met, the nursing process
begins again from the first step.
*All nurses must be familiar with the steps of the
nursing process. If you’re planning on studying to
become a nurse. BE PREPARED TO USE THESE
PHASES EVERYDAY IN YOUR CAREER.
HEALTH ASSESSMENT IN NURSING PRACTICE
- In order to effectively determine a diagnosis and
treatment for a patient, nurses make four types of
assessments. INITIAL, FOCUSED, TIME – LAPSED,
AND EMERGENCY.
- One of the most important parts of nursing education, as
well as the health care industry overall, is the group of
routine procedures and processes involved with patient
assessment and care.
- As a result, nurses and other health care professionals
are able to quickly assess and determine the best
treatment for an ailing patient.
- Health assessment in the nursing process is the
evaluation of the health status of an individual along the
health continuum. The purpose of the health
assessment is to establish where on the health
continuum the individual is because this guides how to
approach and treat the individual.
- The health continuum approaches range from
preventive, to treatment, to palliative care in relation to
the individual's status on the health continuum.
TYPES OF HEALTH ASSESSMENT
• Initial Assessment
- The initial assessment, also known as triage, helps
to determine the nature of the problem and
prepares the way for the ensuing assessment
stages.
- Components may include obtaining a patient's
medical history through a physical exam or
preparing a psychosocial assessment for a mental
health patient.
- Other components may include obtaining a
patient's vital signs and taking subjective
statements form the patients, as well as double –
checking the subjective symptoms with the
objective signs of the condition.
• Focused or Problem Oriented Assessment
- The focused assessment is the stage in which the
problem is exposed and treated.
- Due to the importance of vital signs and their ever-
changing nature, they are continuously monitored
during all parts of the assessment.
- Depending on the disease/disorders, initial
treatment for pain and long-term treatment for the
root cause of the problem is administered and
monitored.
- Part of the goal of the focused assessment is to
diagnose and treat the patient in order to stabilize
her condition. Focused assessments may also use
other types of tests and laboratories.
- You use clinical experience, knowledge, expertise,
and judgement to determine priorities. Life –
threatening situations or any issue that needs
immediate attention are addressed first.
• Time-Lapsed Assessment
- Once the treatment has been implemented, a time
– lapsed assessment must be conducted to ensure
that the patient is recovering from his problem and
his condition has stabilized.
- Depending on the nature of the problem, the time –
lapsed assessment may span the length of one or
two hours or a couple of months.
- During the time – lapsed assessment, the current
status of the patient is compared to the previous
baseline during and prior to treatment.
- Similar to the focused assessment, the time –
lapsed assessment may also include lab work, X –
rays, or other diagnostic medical testing.
• Emergency Assessment
- During emergency procedures, a nurse is focused
on rapidly identifying the root causes of concern for
the patient and assessing the airway, breathing,
and circulation (ABCs) of the patient.
- Once the ABCs are stabilized, the emergency
assessment may turn into an initial or focused
assessment, depending on the situation.
- If the nurse is not in a health care setting,
emergency assessments must also include
assessment for a scene safety so that no other
individuals, including the nurse himself, are hurt
during the rescue and emergency response
process.
RESPONSIBILITIES OF THE NURSE
1. The nurse has the responsibility to carry out health
assessment on every person under his/her care.
2. The nurse should regularly perform focused
assessments in response to client needs.
3. The nurse needs to obtain client's consent prior to
health assessment.
4. The nurse should demonstrate a caring attitude,
respect and concern for each client when doing a
health assessment.
5. The nurse has the responsibility in keeping
confidentiality about the data being collected from
his/her client.
6. The nurse obtains information on a client using various
techniques and tools, such as history taking, physical
examination, reviewing clients records and results of
diagnostic tests. He/she has to draw interference form
data collected in order to make appropriate and sound
clinical judgement.
7. The nurse has to acquire specialized skills and
competence in collecting accurate and relevant
information on the patient's health in performing health
assessment in order to make sound clinical judgement
8. The nurse should document the results of health
assessment, analyze the data collected, evaluate the
 client's response to health problems and interventions, information about surgical procedures and social
and provide feedback to the client as appropriate. history.
9. The nurse should continuously advance their - Taken all data, the data collected provides A HEALTH
competence in health assessment throughout one's HISTORY that gives the health care professional an
nursing career. opportunity to assess health promotion practices and
10. The nurse who takes up an advance practice role has offer patient education (Stephen et al., 2012).
the responsibility to prepare himself/herself in order to
perform advanced and focused health assessment. HEALTH HISTORY
- The purpose of obtaining a health history is to gather
FOUR MAIN GOALS OF NURSING subjective data from the patient and/or the patient's
• To promote health (state of optimal functioning or well family so that the health care team and the patient can
– being with physical, social, spiritual, and mental collaboratively create a plan that will promote health,
components). address acute health problems, and minimize chronic
• To prevent illness (primary, secondary, and tertiary). health conditions.
• To treat human responses to health or illness. - The health history is typically done on admission to
• To advocate for individuals, families, communities, hospital, but a health history may be taken whenever
and populations. additional subjective information from the patient may
be helpful to inform care (Wilson & Giddens, 2013).
METHODS OF HEALTH ASSESSMENT
The following are the primary methods in performing Steps Additional Information
proper health assessment: Determine the ff:
• OBSERVING (the use of senses) 1. Biographical Data • Source of history
• INTERVIEWING (different sources) • Name
• EXAMINING (techniques) • Age
• Occupation (past or
present)
STEPS OF HEALTH ASSESSMENT
2. Reason for seeking • Chief complaint
COLLECTION OF DATA THROUGH?
care and history of • Onset of present health
• Interview present health concern concern
• Subjective data • Duration
• Objective Data • Course of health concern
• Biographic data • Signs, symptoms, and
• Reason for seeking Health Care related problems
• Chief Complaint • Medications or treatments
• Health History used (ask how effective they
• Present and Past Illness/Health History were)
• Family Health History • What aggravates this health
• Medications concern
• Lifestyle • What alleviates the
symptoms
• Developmental Level
• What caused the health
• Psychosocial History concern to occur
• Related health concerns
COLLECTION OF DATA 3. Past health history • Allergies (reaction)
SUBJECTIVE DATA are information from the client's • Serios or chronic illness
point of view (“symptoms''), including feelings, • Recent hospitalizations
perceptions, and concerns obtained through interviews. • Recent surgical procedures
OBJECTIVE DATA are observable and measurable data • Emotional or psychiatric
(“signs") obtained through observation, physical problems (if pertinent)
examination, and laboratory and diagnostic testing. • Current medications:
prescriptions, over-the
COLLECTION OF SUBJECTIVE DATA counter, herbal remedies
1. SUBJECTIVE DATA • Drug/alcohol consumption
• Personal Profile 4. Family History • Pertinent health status of
• Biographic data family members
• Reason for seeking Health Care • Pertinent family history of
• Chief Complaint heart disease, lung disease,
• Health History cancer, hypertension,
• Present and Past Illness/Health History diabetes, tuberculosis,
arthritis, neurological
• Family Health History
disease, obesity, mental
• Medications illness, genetic disorders
• Lifestyle 5. Functional • Activity/exercise, leisure
• Developmental Level assessment (including and recreational activities
• Psychosocial History activities of daily living) (assess for falls risk)
- Subjective data is information reported by the patient • Sleep/rest
and may include signs and symptoms described by the • Nutrition/elimination
patient but not noticeable to others. • Interpersonal
- Subjective data also includes demographic relationship/resources
information, patient and family information about past • Coping and stress
and current medical conditions, and patient management
 • Occupational/environmental - Aside from the hospital room and office, physical
hazards examination may occur in a variety of other settings
where it is difficult to establish privacy and quiet.
6. Developmental tasks • Current significant physical - The best resource available to the health care
and psychosocial providers to set the stage for the physical examination
changes/issues is to communicate respect and a genuine interest in
7. Cultural assessment • Cultural/health – related the patient's welfare.
beliefs and practices - The patient should be addressed politely and asked to
• Nutritional considerations perform the required maneuvers of the examination, a
related to culture technique far preferable to imperative language such.
• Social and community - Patients should be prepared for unpleasant portions of
considerations the examination.
• Religious affiliation/spiritual
beliefs and/or practices THINGS TO REMEMBER IN PERFORMING P.E.
• Language communication - Aside from explanations and reassurance, it is not
necessary to maintain a continuous conversation
MEDICATIONS AND LIFESTYLE with the patient during the examination.
• Current medication (Purpose, Date Started, Dosage) - Avoid embarrassing the patient.
• Taking any Supplement - Be certain that draping material is used appropriately
• Treatment of any illnesses and that personal areas are not subjected to undue
• Physical Exercise exposure.
• Smoking - An examination that ends abruptly may diminish the
• Alcohol Intake value of the doctor-patient relationship and may
• Socialization destroy its therapeutic content.
• Food Preferences - The patient may benefit from a brief summary of
relevant findings and may require reassurance about
COLLECTION OF OBJECTIVE DATA what has and has not been found.
2. COLLECTION OF OBJECTIVE DATA
OBJECTIVE DATA are observable and measurable data MATERIALS NEEDED FOR P.E.
(“signs") obtained through observation, physical • Consent (Legal Person/s)
examination, and laboratory and diagnostic testing. • Quiet, and room with privacy
OBJECTIVE DATA INCLUDES: • The single most useful device for optimal
• PHYSICAL EXAMINATION performance of the physical examination is an
• DIAGNOSTIC/LABORATORY PROCEDURES inquisitive and sensitive mind.
• OTHER SOURCES • Next most useful is mastery of the techniques of
• PATIENT CHART observation, palpation, percussion, and
• REFERRALS FROM PREVIOUS HEALTH CARE auscultation.
PROVIDERS • Important are the tools required for the
examination.
1. PHYSICAL EXAMINATION
- A PHYSICAL EXAMINATION is a routine test where COMPONENTS/TECHNIQUES OF P.E.
the primary care provider performs to check the overall • In a physical examination, there are many things
health of the patient. that the healthcare provider can find out by using
- This may be conducted by a doctor, a nurse the different components or technique of
practitioner, or a physician assistant. assessment.
- The PE is performed to both sick and healthy • From the use of their hands to feel (PALPATE),
individuals. stethoscope and ears to listen (AUSCULTATE),
- The physical exam is a good time to ask the health and eyes to see (INSPECTION), or the use of
providers questions about the health or discuss any their hands to “tap” on an area of your body
changes or problems that the patient has noticed. (PERCUSSION).
- There are different tests that can be performed during • Findings that are present on the physical exam
the physical examination. may by themselves diagnose, or be helpful to
- Depending on the different factors such as age or diagnose, many diseases or abnormalities of the
medical or family history, the PCP may recommend genitourinary system.
additional testing such as laboratory examinations.
The Components/Techniques of Physical
PHYSICAL EXAMINATION Examination
- PHYSICAL EXAMINATION is the process of • Inspection
evaluating objective anatomic findings through the use • Palpation
of OBSERVATION, PALPATION, PERCUSSION, • Auscultation
AND AUSCULTATION. • Percussion
- The information obtained must be thoughtfully The Components/Techniques of Physical
integrated with the patient's history and Examination
pathophysiology. 1. INSPECTION
- Moreover, it is a unique situation in which both patient • The examiner will look at, or “inspect” specific
and physician understand that the interaction is areas of the body for normal color, shape, and
intended to be diagnostic and therapeutic. consistency.
- The physical examination, thoughtfully performed,
should yield necessary and important data needed for
patient diagnosis and management.
 • Certain findings on inspection” may alert the
healthcare provider to focus other parts of the
physical exam on certain areas of the body.
• This technique uses the sense of sight.
• For example, your legs may be swollen. Your
healthcare provider will then pay special
attention to the common things that cause leg
swelling, such as extra fluid caused by your
heart, and use this information to help them
make a diagnosis.
2. PALPATION
• This is when the examiner uses their hands to
feel for abnormalities during a health
assessment.
• This technique uses the sense of touch.
• Things that are commonly palpated during an
exam include your lymph nodes, chest wall (to
see if your heart is beating harder than normal),
and your abdomen.
• You will use palpation to see if there are any
masses or lumps, anywhere in the body.
3. PERCUSSION
• This is when the examiner uses their hands to
"tap" on an area of the patient's body.
• The "tapping" produces different sounds.
• Sounds depends on the kind of sounds that are
produced over the abdomen, on the back or
chest wall.
• Healthcare provider may determine anything
from fluid in the lungs, or a mass in the stomach.
• This will provide further clues to a possible
diagnosis.
4. AUSCULTATION
• This is an important physical examination
technique used by the healthcare provider,
where he or she will listen to the heart, lungs,
neck or abdomen.
• This is to identify if any problems are present.
• Auscultation is often performed by using a
STETHOSCOPE.
• The stethoscope will amplify sounds heard in
the area that is being listened to. If there is an
abnormal finding on the examination, further
testing may be suggested.
POSITIONING
- Positioning patients properly in performing physical
examination is critical to providing the best care
possible and protecting against complications against
complications such as nerve damage, and accident
such as fall.
- These preventable injuries can be devastating to the
patient and have significant consequences.
- In performing Physical Examination, correct position/s
is required in able to accomplish assessment of the
patient's physical body correctly and accurately.
- Proper position will also help the health care provider
to collect data from the physical examination with
eased, and be able to perform the assessment quickly.
DIFFERENT POSITIONS:
SITTING
- The patient sits at the edge of the examining table
without back support. The physician examines the
patient's head, neck, heart, back, and arms.
SUPINE
- The patient lies flat on the back. The physician
examines head, neck, chest, heart, abdomen, arms,
and legs.
DORSAL RECUMBENT
- The patient lies face up, with his back supporting all
his weight. The patient's knees are drawn up and the
feet are flat on the table. The physician may examine
the head, neck, chest, and heart.
LITHOTOMY
- The patient lies on her back with her knees bent and
her feet in stirrups attached to the end of the examining
table. This position is used during exam of the female
genitalia.
TRENDELENBURG’S
- The patient is supine on a tilted table with the head
lower than the legs. This position is used in certain
surgical procedures or emergencies, and also on
patients with low blood pressure or a patient
experiencing shock.
FOWLER’S POSITION
- The patient lies back on an examining table on which
the head is elevated. The doctor may examine the
head, neck, and chest areas, it is one of the best
positions for examining patients who are experiencing
shortness of breath, or lower-back injury.
PRONE POSITION
- The patient lies flat on the table, facedown. The
patient's head is turned to one side, and his arms are
placed at his sides or bent at the elbows. The
physician can examine the back, feet, or
musculoskeletal system.
SIM’S POSITION
- The patient lies on the left side. His or her left leg is
slightly bent, and the left arm is placed behind the back
so that the patient's weight is resting primarily on the
chest. It is used during anal or rectal exams.
KNEE – CHEST POSITION
- The patient is lying on the table facedown, supporting
the body with the knees and chest. The patient should
have the thighs at a 90-degree angle to the table and
slightly separated, the head turned to one side, and the
arms are placed to the side or above the head. It is
used during exams of the anal and perineal areas and
during certain proctologic procedures.
2. DIAGNOSTIC/LABORATORY PROCEDURES
• A medical test or DIAGNOSTIC/LABORATORY
PROCEDURES are a medical procedure performed to
DETECT, DIAGNOSE, or MONITOR DISEASES,
DISEASE PROCESSES, SUSCEPTIBILITY, OR TO
DETERMINE A COURSE OF TREATMENT.
 • Medical tests relate to clinical chemistry and molecular
diagnostics, and axe typically performed in a medical 3. PATIENT CHART
laboratory • A PATIENT’S CHART or also known as
• A technician or your health care provider analyses the MEDICAL CHARTS is a complete record of a
test samples to see if your results fall within the normal patient’s key clinical data and medical history,
range. such as demographics, vital signs, diagnoses,
• The tests use a range because what is normal differs medications, treatment plans, progress notes,
from person to person. Many factors affect test results. problems, immunization dates, allergies,
• Laboratory tests are performed to help diagnose radiology images, and laboratory and test results.
diseases or other health conditions. • A medical chart is comprised of medical notes
• A diagnostic test are procedures performed or made by a physician, nurse, lab technician or any
determine the presence of disease in an to confirm other member of a patient's healthcare team.
individual suspected of having a disease, usually • Accurate and complete medical charts ensure
following the report of symptoms, or based on other systematic documentation of a patient's medical
medical test results. history, diagnosis, treatment and care.
DIAGNOSTIC/LABORRTORY PROCEDURES are THE CHART INCLUDES:
performed to: • Surgical history (e.g., operation dates, operation
• Identify changes in the health condition before any reports, operation narratives)
symptoms occur • Obstetric history: (e.g., pregnancies, any
• Diagnose or aid in diagnosing a disease or condition complications, pregnancy outcomes)
• Plan management and treatment for a disease or • Medications and medical allergies
condition • Family History (e.g., immediate family member
• Evaluate the patient's response to a treatment health status, cause of death, common family
• Monitor the course of a disease over time. diseases)
DIAGNOSTIC OR LABORATORY TEST • Social History (e.g., community support, close
• BLOOD EXAMINATION relationships, past and current occupation)
• BLOOD SUGAR • Habits (e.g., smoking, alcohol consumption,
• BLOOD CHEMISTRY (Cholesterol, Uric Acid, exercise, diet, sexual history)
Electrolytes) • Immunization Records (e.g., vaccinations,
• BLOOD TYPING (ABO, Rh TYPING) immunoglobulin test)
• ARTERIAL BLOOD GAS LEVEL (ABGs) • Developmental History (e.g., growth chart, motor
• PRESENCE OF INFECTION IN THE BLOOD: development, cognitive/intellectual development,
o HEPATITIS B, C, D social-emotional development, language
o MALARIA development)
o SYPHILIS • Demographics (e.g., race, age, religion,
o S.T.I. occupation, contact information)
o DENGUE • Medical encounters (e.g., hospital admissions,
• NEWBORN SCREENING TEST specialist consultations, routine checkups)
• URINE ANALYSIS WHO HAS ACCESS TO MEDICAL/ PATIENT'S
o Components of Urine CHARTS?
o Presence of Infection • Only the patient and the health care providers
o Acidity directly involved in her or his care can view a
o Kidney Status medical chart.
• FECAL/STOOL ANALYSIS • The medical chart belongs to the patient, and she
o Occult Blood Test (Blood in the Stool) or he has the right to make sure the charts are
o Presence of parasites (Worms, Ascaris) accurate or grant another party access to them.
o Bacteria • Patients can petition their providers for
o Viruses amendments to inaccurate medical charts.
• CULTURE AND SENSITIVITY
o TYPE OF BACTERIA/VIRUSES - 4. REFERRALS FROM PREVIOUS HEALTH CARE
SENSITIVITY TEST checks to see what PROVIDERS
kind of medicine, such as an antibiotic, • In medicine, referral is the transfer of care for a
will work best to treat the illness or patient from one clinician or clinic to another by
infection. request.
▪ SPUTUM, URINE, BLOOD • It is an important tool to emphasize other
• TISSUE SAMPLE TEST objective data regarding the patient.
o Biopsy (Benign or Malignant) • Consist of management or treatment performed
o Abnormal Cell Formation • Used for continuity of care
• SCAN/RADIOLOGICALEXAMINATION • Includes important details about the patient's
o X-RAYs health condition
o ULTRASOUND • Gives better understanding of the patient's health
o COMPUTED TOMOGRAPHY SCAN needs.
o MAMMOGRAPHY • This prevent redundancy on activities, laboratory
o BONE SCAN test, medication, and other management of the
patient's health.
Other Sources of Objective Data
• PATIENT CHART NURSING DOCUMENTATION
• REFERRALS FROM PREVIOUS HEALTH - NURSING DOCUMENTATION is the record of
CARE PROVIDERS nursing care that is planned and delivered to
 individual clients by qualified nurses or other
healthcare providers.
- It contains information in accordance with the steps
of THE NURSING PROCESS.
- Nursing documentation is the principal clinical
information source to meet LEGAL AND
PROFESSIONAL REQUIREMENTS, and one of the
most significant components in nursing care.
- Quality nursing documentation plays a vital role in
the delivery of quality nursing care services through
supporting BETTER COMMUNICATION BETWEEN
DIFFERENT CARE TEAM MEMBERS to facilitate
continuity of care and safety of the clients.
NURSING DOCUMENTATION
- Nursing documentation is essential for good clinical
communication.
- Appropriate legible documentation provides an
accurate reflection of nursing assessments,
changes in conditions, care provided and
pertinent patient information to support the
multidisciplinary team to deliver great care.
- Documentation provides EVIDENCE OF CARE and
is an important PROFESSIONAL AND MEDICO
LEGAL requirement of nursing practice.
PURPOSE OF DOCUMENTATION
1. COMMUNICATION WITH OTHER PROFESSIONALS
- Patient documentation frequently is used by
professionals and health care providers who are
directly involved with the patient's care.
- However, it can also be used by those who are not
directly involved with patient care such as lawyers,
and significant others.
- If patient documentation is not timely, accurate.
accessible, complete, legible, readable, and
standardized, it will interfere with the ability of those
who were not involved in and are not familiar with the
patient's care to use the documentation.
2. CREDENTIALING
- Nursing documentation, such as patient care
documents, assessments of processes, and
outcome measures across organizational settings,
serve to monitor performance of health care
practitioners' and the health care facility's
compliance with standards governing the profession
and provision of health care.
- Such documentation is used to determine what
credentials will be granted to health care
practitioners within the organization.
3. LEGAL PURPOSES
- Patient clinical reports, providers' documentation,
administrators' records, and other documents
related to patients and organizations providing
and supporting patient care are important
evidence in legal matters.
- Documentation that is incomplete, inaccurate,
untimely, illegible or inaccessible, or that is false
and misleading can lead to a number of
undesirable outcomes, including:
• Impeding legal fact finding
SUBPOENA DUCES TECUM
- A command by the court to a witness to produce
documents.
- A writ or process of the same kind as the
subpoena ad testificandum including a clause
requiring the witness to bring with him and
produce to the court, books, papers, patient's
record or chart in his hands, to elucidate the
matter in issue.
4. REGULATION AND LEGISLATION
- Audits of reports and clinical documentation provide
a method to evaluate and improve the quality of
patient care, maintain current standards of care, or
provide evaluative evidence when standards require
modification in order to achieve the goals, legislative
mandates, or address quality initiatives.
5. RESEARCH
- Data from documentation provides information about
patient characteristics and care outcomes.
- Evaluation and analysis of documentation data are
essential for attaining the goals of evidence-based
practice in nursing and quality health care.
FORMAT OF DOCUMENTATION
1. WRITTEN NOTES/DOCUMENTATION
2. ELECTRONIC HEALTH RECORDS/ (EHRS)
DOCUMENTATION
GUIDELINES FOR DOCUMENTATION
The 20 fundamental principles of Documentation:
• Don’t erase what is recorded.
• Record all relevant information.
• Don’t write critical comments.
• Don’t leave white space.
• Record in black or blue ink.
• Clarify orders and treatment.
• Chart your own nursing process.
• Only use approved abbreviations.
• Date/time/sign.
• Write legibly.
• Use ‘late entries’ notation.
• Don’t write in anticipation.
• Follow organization policies.
• Record telephone calls.
• Complete action and outcomes.
• Co – signing.
• Use 24 – hour clock.
• Monitoring.
• Confidentiality/security.
CONFIDENTIALITY/SECURITY
- Health care professionals should view the security of
client documentation as a serious issue.
- Failure to comply with legislation, falsifying
information or providing information without the client
or agency’s consent may constitute professional
misconduct.
- Sharing confidential information is only acceptable in
an effort to support the provision of quality care with
health care team members who are a part of the
client’s circle of care.
- Documentation in any format should be maintained
in areas where the information cannot be easily
accessed by casual observers or those not directly
involved in the care of the client.
- Health record maintained in a client’s home should
be stored in a manner to reduce the risk of family
members or others (e.g., visitors, guests) accessing
confidential information.
- Agencies should have policies outlining who has
access of the health records and how clients and
their family members are made aware of the
importance of maintaining confidentiality.
- Technology does not change a client’s rights to
privacy of their health information. Maintaining
confidentiality (including access, storage, retrieval,
and transmission) of the client’s health record is
essential regardless of its format.
DATE, TIME, SIGNATURE AND DESIGNATION
- Documentation in the health record begins with date
and time and ends with the recorder's signature and
designation.
 - Signatures and initials need to be identifiable and
follow specific agency policy.
- Personal initials can only be used if a master list
matching the caregiver's initials with a signature and
designation is maintained in the health record.
VERBAL ORDERS AND TELEPHONE ORDERS
- Authorized prescribers are expected to write orders
whenever possible.
- Verbal orders should only be accepted in emergent
or urgent situations where the prescriber cannot
document their medication orders.
- Telephone orders should be limited to situations
when the prescriber is not present.
- The prescriber may be accountable to review and co-
sign their verbal or telephone orders as soon as
reasonably possible or within the timeframe indicated
in an agency's policy that is usually within 24 hours
time.
TEXT MESSAGE AND EMAIL ORDERS
- Increasing numbers of health care professionals are
using mobile devices to communicate prescriber
orders by text message or email.
- This type of communication is discouraged due to the
risk of violation of confidential health information and
incomplete communication of client status.
- Unauthorized disclosure of client's personal health
information (PHI) is a risk because mobile devices
can store and retain data on the device itself. Also,
mobile devices are vulnerable to loss and theft
because of their small size and portability (CNPS,
2013).
- Encryption and the use of strong passwords are the
most effective way to safeguard a client's PHI.
Without encryption, any emails, voicemails, pictures
or text could be inappropriately accessed or
disclosed if the mobile device is lost, stolen or
inadvertently viewed by another person.
- Vital information related to the context of the client
assessment may be lost when using text or email to
communicate. Text can be subject to interpretation
and lead to inappropriate incomplete or insufficient
prescriber orders.
- Text or email should not be used for provider
convenience; however, if text or email
communication is the only way health professionals
can communicate in the best interest of the client,
agencies must have policies to support this practice.
Policies, protocols and systems should enable health
care practitioners to use secured wireless devices to
interact with each other and to access client records.
AVOID BIAS AND LABELS
- Only document conclusions that can be supported by
data and avoid value judgments or unfounded
conclusions.
- Select neutral terminology or describe observed
behaviors.
- For example, rather than stating that the "client was
drunk” it would be correct to state, "noted an odor of
alcohol and speech was slurred". Instead of noting,
"client is aggressive" it would be correct to state,
"client has been shouting and using obscene
language".
LATE ENTRIES
- Documentation should occur as soon as possible
after an event has occurred.
- When it is not possible to document at the time of or
immediately following an event, or if extensive time
has elapsed, a late entry is required.
- Late entries or corrections incorporating omitted
information in a health record should be made only
when a nurse can accurately recall the event or care
provided.
- Late entries must be clearly identified, individually
dated and follow agency policy.
- They should reference the actual time recorded as
well as the time when the care/event occurred and
must be signed by the nurse involved. If extensive
time has elapsed between the care and the
documentation entry, seek guidance from your
employer before adding notes (CRNBC, 2017).
REMEMBER
- Nurses should recognize that the documentation of
their nursing decisions and actions is equally as
valuable, professionally and legally, as the direct
care provided to clients.
- Quality documentation is an important element of A
Nursing practice, essential to positive client
outcomes and a key component of meeting their
Standards of Practice.
"WHAT IS NOT DOCUMENTED (WRITTEN) IS
CONSIDERED UNDONE/UNPERFORMED".
OBJECTIVE DATA INCLUDES:
• PHYSICAL EXAMINATION
• DIAGNOSTIC/LABORATORY PROCEDURES
• OTHER SOURCES
o PATIENT CHART
o REFERRALS FROM PREVIOUS
HEALTH CARE PROVIDERS
DIAGNOSTIC/LABORATORY PROCEDURES
• A medical test or DIAGNOSTIC/LABORATORY
PROCEDURES are a medical procedure
performed to DETECT, DIAGNOSE, or
MONITOR DISEASES, DISEASE
PROCESSES, SUSCEPTIBILITY, OR TO
DETERMINE A COURSE OF TREATMENT.
• Medical tests relate to clinical chemistry and
molecular diagnostics, and axe typically
performed in a medical laboratory
• A technician or your health care provider
analyses the test samples to see if your results
fall within the normal range.
• The tests use a range because what is normal
differs from person to person. Many factors
affect test results.
• Laboratory tests are performed to help diagnose
diseases or other health conditions.
• A diagnostic test are procedures performed or
determine the presence of disease in an to
confirm individual suspected of having a
disease, usually following the report of
symptoms, or based on other medical test
results.
DIAGNOSTIC/LABORRTORY PROCEDURES are
performed to:
• Identify changes in the health condition before
any symptoms occur
• Diagnose or aid in diagnosing a disease or
condition
• Plan management and treatment for a disease
or condition
• Evaluate the patient's response to a treatment
• Monitor the course of a disease over time.
DIAGNOSTIC OR LABORATORY TEST
• BLOOD EXAMINATION
• BLOOD SUGAR
• BLOOD CHEMISTRY (Cholesterol, Uric Acid,
Electrolytes)
 • BLOOD TYPING (ABO, Rh TYPING)
• ARTERIAL BLOOD GAS LEVEL (ABGs)
• PRESENCE OF INFECTION IN THE BLOOD:
o HEPATITIS B, C, D
o MALARIA
o SYPHILIS
o S.T.I.
o DENGUE
• NEWBORN SCREENING TEST
• URINE ANALYSIS
o Components of Urine
o Presence of Infection
o Acidity
o Kidney Status
• FECAL/STOOL ANALYSIS
o Occult Blood Test (Blood in the Stool)
o Presence of parasites (Worms, Ascaris)
o Bacteria
o Viruses
• CULTURE AND SENSITIVITY
o TYPE OF BACTERIA/VIRUSES -
SENSITIVITY TEST checks to see what
kind of medicine, such as an antibiotic,
will work best to treat the illness or
infection.
▪ SPUTUM, URINE, BLOOD
• TISSUE SAMPLE TEST
o Biopsy (Benign or Malignant)
o Abnormal Cell Formation
• SCAN/RADIOLOGICALEXAMINATION
o X-RAYs
o ULTRASOUND
o COMPUTED TOMOGRAPHY SCAN
o MAMMOGRAPHY
o BONE SCAN
Other Sources of Objective Data
• PATIENT CHART
• REFERRALS FROM PREVIOUS HEALTH
CARE PROVIDERS
PATIENT CHART
• A PATIENT’S CHART or also known as
MEDICAL CHARTS is a complete record of a
patient’s key clinical data and medical history,
such as demographics, vital signs, diagnoses,
medications, treatment plans, progress notes,
problems, immunization dates, allergies,
radiology images, and laboratory and test
results.
• A medical chart is comprised of medical notes
made by a physician, nurse, lab technician or
any other member of a patient's healthcare
team.
• Accurate and complete medical charts ensure
systematic documentation of a patient's medical
history, diagnosis, treatment and care.
THE CHART INCLUDES:
• Surgical history (e.g., operation dates, operation
reports, operation narratives)
• Obstetric history: (e.g., pregnancies, any
complications, pregnancy outcomes)
• Medications and medical allergies
• Family History (e.g., immediate family member
health status, cause of death, common family
diseases)
• Social History (e.g., community support, close
relationships, past and current occupation)
•Habits (e.g., smoking, alcohol consumption,
exercise, diet, sexual history)
• Immunization Records (e.g., vaccinations,
immunoglobulin test)
• Developmental History (e.g., growth chart, motor
development, cognitive/intellectual development,
social-emotional development, language
development)
• Demographics (e.g., race, age, religion,
occupation, contact information)
• Medical encounters (e.g., hospital admissions,
specialist consultations, routine checkups)
WHO HAS ACCESS TO MEDICAL/ PATIENT'S
CHARTS?
• Only the patient and the health care providers
directly involved in her or his care can view a
medical chart.
• The medical chart belongs to the patient, and
she or he has the right to make sure the charts
are accurate or grant another party access to
them.
• Patients can petition their providers for
amendments to inaccurate medical charts.
REFERRALS FROM PREVIOUS HEALTH CARE
PROVIDERS
• In medicine, referral is the transfer of care for a
patient from one clinician or clinic to another by
request.
• It is an important tool to emphasize other
objective data regarding the patient.
• Consist of management or treatment performed
• Used for continuity of care
• Includes important details about the patient's
health condition
• Gives better understanding of the patient's
health needs.
• This prevent redundancy on activities, laboratory
test, medication, and other management of the
patient's health.
Purpose of a Nutritional Assessment
• Identify individuals who are malnourished
• Provide data for designing a nutrition plan of care that
will prevent or minimize the development of
malnutrition
• Identifying those who are at risk for malnutrition
• Establish a baseline data for evaluating the efficacy
of nutritional care
Nutrients – measured by kilocalorie
Carbohydrates – 50 – 60% of daily caloric intake
Proteins – supply nine essential amino acids, 10 – 20%
of caloric intake
Fats – 20 – 30% of daily caloric intake
Vitamins – fat soluble and water soluble
Minerals – macromolecules (large amount) and
microminerals (small amount)
Water – 50 – 60% of body weight, average adult needs
8 – 12 glasses of water per day
Components of a Nutritional Assessment
• Nutritional history
• Physical assessment
• Anthropometric measurement
• Laboratory data
• Diagnostic data
Nutritional History
• Food intake history
 - 24 – hour recall – the easiest and most • GI procedures
popular method for obtaining information Social History
about dietary intake • Alcohol use
- food diary • Drug use
• Calorie Count • Travel history
• Evaluation of adequacy of diet • Home and work environments
• Hobbies and leisure activities
Anthropometric measurement • Economic status
• Height
• Weight Health Maintenance Activities
• Ideal body weight, percent IBW • Sleep
- a practical marker of optimal weight for • Diet
height and an indicator of obesity or protein • Exercise
calorie malnutrition • Stress management
- percent ideal body weight = (current • Use of safety devices
weight/ideal weight) x 100 • Health check – ups
• Body mass index
- BMI Normal – 18.5 – 24.9 Assessment of the Abdomen
- BMI Underweight: <18.5 • Equipment
- BMI Overweight: >25.0
• Order
• Percent weight change o Inspection
• Waist to hip ratio o Auscultation
• Assess body fat distribution as an indicator of o Percussion
health risk o Palpation
Skinfold thickness
- Common side – Triceps skinfold (TSF) Inspection
- Mid – arm muscle circumference (MAMC) • Striae
• Respiratory movement
Abdominal Assessment (IPPA to IAPP) • Masses or nodules
• Identify the physiological function of the • Visible peristalsis
gastrointestinal organs
• Pulsation
• Assess the health status of a patient with a
• Umbilicus
gastrointestinal complaint
• Demonstrate the techniques of gastrointestinal Inspection: Normal Findings
assessment
• Abdomen is flat or round, symmetrical
• Relate abnormal physical gastrointestinal findings to
• Uniform in color and pigmentation
pathological processes
• No scars or striae present
Health History • No respiratory retractions
• Patient profile • No masses or nodules
o Age • Ripples of peristalsis may be visible
▪ Child to young adult: • Nonexaggerated pulsation of the abdominal
appendicitis aorta may be present
▪ Adult: peptic ulcers, • Umbilicus is depressed
cholecystitis, diabetes mellitus
o Gender Auscultation
▪ Female: gallbladders disease • Bowel sounds
▪ Male: GI cancers, cirrhosis, o Assess all four quadrants
duodenal ulcers o Listen for at least 5 minutes before
concluding bowel sounds are absent
Common Chief Complaints • Vascular sounds
• Nausea and vomiting • Venous hum
• Diarrhea or constipation • Friction rubs
• Abdominal distension
• Abdominal pain Auscultation: Normal Findings
• Increased eructation or flatulence • Bowel sounds
• Dysuria o Are heard in all four quadrants
• Nocturia o Usually are high pitched
• Incontinence o Occur 5 to 30 times per minute
Characteristic of Chief Complaint • Vascular sounds: no audible bruits
• Quality • No venous hum
• Quantity • No friction rub
• Associated manifestations
Auscultation: Abnormal Findings
• Aggravating factors
• Absent, hypoactive, or hyperactive bowel
• Alleviating factors
sounds
• Setting
• Pathophysiological indications
• Timing
o Absent and hypoactive bowel sounds
may indicate decreased motility and
Past Health History
possible obstruction
Medical
o Hyperactive bowel sounds indicate
• Abdomen specific increased motility and possible diarrhea,
• Nonabdomen specific gastroenteritis
Surgical

Percussion
• Percuss all four quadrants
• Assess liver span, liver descent, margins of
spleen, stomach, kidneys, liver, bladder
• Sounds heard: tympany or dullness
Percussion: Normal Findings
• No tenderness elicited over kidneys and liver
• Empty bladder is not percussable above the
symphysis pubis
Percussion: Abnormal Findings
• Dullness over areas where tympany is normally
heard
o May indicate a mass or tumor,
pregnancy, ascites, full intestine
• Liver span > 12cm or < 6cm
o May indicate hepatomegaly or cirrhosis
• Liver descent > 2 to 3cm
o May indicate hepatomegaly or cirrhosis
• Spleen dullness > 8cm line
o May indicate splenic enlargement
• Costovertebral angle tenderness
o May indicate pyelonephritis
• Ability to percuss a recently emptied bladder
o May indicate urinary retention
Palpation
• Light vs deep
• Palpate all quadrants
• Normal findings
o No tenderness
o Smooth with consistent softness
o No muscle guarding
Palpation: Abnormal Findings
• Tenderness on palpation
o May indicate inflammation, masses, or
enlarged organs
• Muscle guarding on expiration
o May indicate peritonitis
• Presence of masses, bulges, or swelling
o May indicate enlarged organs,
cholecystitis, hepatitis, cirrhosis
• Liver is palpable below costal margin
o May indicate CHF, hepatitis, cirrhosis,
encephalopathy, cancer
• Spleen is palpable
o May indicate inflammation, CHF, cancer,
cirrhosis, mononucleosis
• Kidneys are palpable
o May indicate hydronephrosis,
neoplasms, polycystic kidney disease
• Aorta width > 4cm
o May indicate abdominal aortic aneurysm
• Able to palpate recently emptied bladder
o May indicate urinary retention
• Palpable inguinal lymph noes > 1cm in diameter
or tender
o May indicate systemic infections, cancer
Advanced Techniques
• Rebound tenderness
• Rovsing’s sign
• Iliopsoas muscle test
• Obturator muscle test
• Ballottement
Abdominal Assessment
• Patient needs to be exposed from above the
xiphoid process to the symphysis pubis.
• Also, make sure your patient does not have a full
bladder.
• Place patient in a supine position: pillow under
the head and knees.
• Helps to relax abdominal muscles.
• Have patient point out any areas of pain or
tenderness.
• Examine these last.
• During exam continue to monitor your patient’s
facial expression for pain and discomfort.
• Use inspection, auscultation, percussion, and
palpation to perform the exam.
• Always auscultate before percussing or
palpating.
• These manipulations may alter your patient’s
bowel mobility and resulting bowel sounds.
Abdominal Assessment
• Inspect the skin of the abdomen and flank’s for:
1. Scars
2. Dilated veins
3. Stretch marks
4. Rashes
5. Lesions
6. Pigmentation changes
Abdominal Assessment
• Look for discoloration over the umbilicus:
1. Cullen’s Sign: discoloration over the
umbilicus
2. Grey Turner’s Sign: discoloration over
the flanks
• These are both late signs suggesting intra –
abdominal bleeding.
Abdominal Assessment
• Assess the size and shape of your patient’s
abdomen to determine:
1. Scaphoid (concave)
2. Flat
3. Round
4. Distended
• Ask the patient if it is its usual size and shape
• Check for:
1. Bulges
2. Hernias
3. Distended flanks
• Ascites appears as bulges in the flanks and
across the abdomen and indicates edema
caused by CHF, or liver failure.
• Look at your patient’s umbilicus
• Note location and contour and observe for any
signs of herniation or inflammation.
• Check for:
1. Visible pulsation
2. Visible peristalsis (wavelike motion of
organs moving their contents through
the digestive tract). May indicate bowel
obstruction.
3. Visible masses
• Next auscultate for bowel sounds and other
sounds such as bruits throughout the abdomen.
• Gently place the diaphragm on your patient’s
abdomen and proceed systematically, listening
for bowel sounds in each quadrant.
• Note location, frequency, and character
• Normal bowel sounds consist of a variety of high
– pitched gurgles and clicks that occur every 5 –
15 seconds.
• More frequent sounds indicate increased bowel
motility in conditions such as diarrhea or an early
intestinal obstruction.
 • You may hear loud, prolonged, gurgling sounds
known as borborygmi.
• These indicate hyperperistalsis.
• Decreased or absent sounds suggest a paralytic
ileus or peritonitis.
Abdominal Assessment
• Percussing the abdomen produces different
sounds based on the underlying tissues.
• Sound help you detect excessive gas and solid
or fluid – filled masses
• Also help you determine the size and position of
solid organs such as the liver and spleen
• Percuss the abdomen in the same sequence
you used for auscultation
• Palpate the abdomen last to detect:
1. Tenderness
2. Muscular rigidity
3. Superficial organs and masses
• Before you begin, palpation, ask your patient if
he has any pain or tenderness.
• Palpate that area last, using gentle pressure with
a single finger.
• Ask him to cough and tell you if and where he
experiences nay pain
• This is typical for peritoneal inflammation.
• If you note a protruding abdomen with bulging
flanks and dull percussion sounds in dependent
areas, you might perform two tests for ascites.
GENITOURINARY SYSTEM
• The Genitourinary System or Urogenital System is the
organ system of the reproductive organs and the
urinary system.
• These are grouped together because of their proximity
to each other, their common embryological origin and
the use of common pathways, like the male urethra.
• Also, because of their proximity, the systems are
sometimes imaged together.
• GENITOURINARY is a word that refers to the urinary
and genital organs.
TERMS TO REMEMBER:
Urology: is the branch of medicine concerned with the
urinary tract in both genders and the genital tract of the
reproductive system in males.
Nephrology: is the branch of medicine concerned with
the kidney.
Genetic/Hereditary: this refers to acquiring a condition
from a family member.
Congenital: inborn, or a condition started while still in the
womb.
Idiopathic: term used to describe some acquired diseases
from UNKNOWN CAUSE.
Dysuria: defined as painful urination.
Pyuria: presence of puss in the urine.
Polyuria: frequent urination.
Oliguria: difficulty of urination.
Nocturia: frequent urination usually occurs at night.
Hematuria: presence of blood in urine.
Melena: black tarry stools, occurs as a result of upper
gastrointestinal bleeding.
Hematochezia: fresh blood through the anus, usually in
or with stools.
Menarche: first menstruation.
Occult Blood Test: laboratory test to detect presence of
blood in the stool.
Goal/Purpose
• The goal of the clinical evaluation of the
GENITOURINARY SYSTEM is the diagnosis of
disorders and diseases of the entire urinary tract and the
genital tract.
• From the production of urine by the nephrons to the
eventual elimination of urine via the external urethral
meatus, malfunctions of the urinary tract may become
manifest in a variety of ways.
• This transport of urine to the outside embodies the most
important functions of the kidneys, ureters, bladder, and
urethra.
• Problems with the urinary or reproductive systems can
not only affect these systems but they can trigger
problems in other body systems.
• In addition, difficulties with these systems can affect the
patient’s quality of life and sense of well – being.
• Early detection of problem with these systems can help
our patient to recover and prevent further complication
to arise.
• Proper assessment will lead the health provider to
appropriate managements.
System Overview
1. Reproductive System
• The reproductive system or genital system is a
system of sex organs within an organism which
work together for the purpose of sexual
reproduction.
• Biological function is to perpetuate the species.
• The reproductive role of the male is to
manufacture sperm and to deliver them to the
female reproductive tract.
• The female, in turn, produces eggs.
• If the time is suitable, the combination of sperm
and egg produces a fertilized egg.
• Once fertilization has occurred, the female
uterus provides a nurturing, protective
environment in which the embryo, later called
the fetus, develops until birth.
Problem/Disorders of Reproductive System:
• Reproductive system disease: these are any of the
diseases and disorders that affect the human
reproductive system such as:
• Abnormal Hormone Production by the ovaries or the
testes.
• Conditions/Disorders of the Endocrine Glands, such
as the pituitary, thyroid, or adrenals.
• Genetic or Family History
• Congenital Abnormalities
• Infections
• Mass or Tumors
• Disorders of unknown cause (Idiopathic)
2. Urinary System
• The excretory/kidney/urinary system is a passive
biological system that removes excess, unnecessary
materials from the body fluids of an organism, so as
to help maintain internal chemical homeostasis and
prevent damage to the body.
• The dual function of excretory systems is the
elimination of the waste products of metabolism and
to drain the body of used up and broken – down
components in a liquid and gaseous state.
• Metabolism of nutrients by the body produces wastes
that must be removed from the body.
 • Although excretory processes involve several organ
systems (the lungs excrete carbon dioxide, and skin
glands excrete salts and water), it is mainly the
urinary system that removes nitrogenous wastes
from the body.
• The kidneys also maintain the electrolyte, acid –
base, and fluid balances of the blood, and
considered as the major homeostatic organ of the
body.
• Preventing the buildup of wastes and extra fluid.
• Regulation of electrolyte balance such as sodium,
potassium, calcium and magnesium which affect and
regulate hydration of the body as well as blood pH.
• Producing blood pressure regulating hormones.
• Help regulate blood pressure in the body.
• Act as filters and homeostasis regulators.
• Help in the production of red blood cells, which are
used to carry oxygen around the body.
• Help maintain healthy bones.
The Main Structures of the Urinary System
Two Kidneys – which lie behind the other major organs
in the lower back area. They are bean – shaped organs
and measure about 11cm long, 6cm wide and 3cm deep.
They have 5 main functions, which will be discussed at a
later stage.
Two Ureters – (tube – like features) which run from the
kidneys to the bladder carrying urine.
One Bladder – which collects urine from the kidneys, via
the ureters, and stores it temporarily.
One Urethra – through which the urine is excreted out of
the body, allowing the bladder to empty and dispose of
the waste.
Two Sphincter Muscles – circular muscles that help
keep urine from leaking by closing tightly like a rubber
band around the opening of the bladder.
Problem/Disorders of Urinary System:
• In children, problems of the urinary system
include acute and chronic kidney failure, urinary
tract infections, obstructions along the urinary
tract, and abnormalities present at birth.
• Diseases of the kidneys often produce a
temporary or permanent change to the small
functional structures and vessels inside the
kidney. Frequent urinary tract infections can
cause scarring to these structures leading to
renal (kidney failure).
• Disorders of the urinary tract are often related to
blockage that prevents complete emptying of the
bladder and often leads to reverse flow of urine.
A urinary tract obstruction can cause damage to
the urinary tract and kidneys because urine backs
– up and pools in various areas along the tract.
Pooling of urine in the bladder, ureters, or kidneys
can lead to infections, scarring, and long – term
kidney failure.
Physical and Health Assessment
• In a physical examination, there are many things
that the healthcare provider can find out by using
the different components or technique of
assessment.
• From the use of their hands to feel (PALPATE),
stethoscope and ears to listen (AUSCULTATE),
and eyes to see (INSPECTION), or the use of
their hands to “tap” on an area of your body
(PERCUSSION).
• Findings that are present on the physical exam
may by themselves diagnose, or be helpful to
diagnose, many diseases or abnormalities of the
genitourinary system.
The Components/Techniques of Physical
Examination
5. INSPECTION
• The examine will look at, or “inspect” specific
areas of the body for normal color, shape, and
consistency.
• Certain findings on inspection” may alert the
healthcare provider to focus other parts of the
physical exam on certain areas of the body.
• This technique uses the sense of sight.
• For example, your legs may be swollen. Your
healthcare provider will then pay special
attention to the common things that cause leg
swelling, such as extra fluid caused by your
heart, and use this information to help them
make a diagnosis.
6. PALPATION
• This is when the examiner uses their hands to
feel for abnormalities during a health
assessment.
• This technique uses the sense of touch.
• Things that are commonly palpated during an
exam include your lymph nodes, chest wall (to
see if your heart is beating harder than normal),
and your abdomen.
• You will use palpation to see if there are any
masses or lumps, anywhere in the body.
7. PERCUSSION
• This is when the examiner uses their hands to
"tap" on an area of the patient's body.
• The "tapping" produces different sounds.
• Sounds depends on the kind of sounds that are
produced over the abdomen, on the back or
chest wall.
• Healthcare provider may determine anything
from fluid in the lungs, or a mass in the stomach.
• This will provide further clues to a possible
diagnosis.
8. AUSCULTATION
• This is an important physical examination
technique used by the healthcare provider,
where he or she will listen to the heart, lungs,
neck or abdomen.
• This is to identify if any problems are present.
• Auscultation is often performed by using a
STETHOSCOPE.
• The stethoscope will amplify sounds heard in
the area that is being listened to. If there is an
abnormal finding on the examination, further
testing may be suggested.
HEALTH ASSESSMENT
• ASSESSMENT is a key component of nursing
practice, required for planning and provision of patient
and family centered care.
• "Conducts a comprehensive and systematic nursing
assessment, plans nursing care in consultation with
individuals/ groups, significant others & the
interdisciplinary health care team and responds
effectively to unexpected or rapidly changing situation.
DATA COLLECTION
• HEALTH ASSESSMENT is an evaluation of the
health status of an individual by performing the
two most important parts of assessment that
includes:
 1. Physical Examination • Testicular pain
2. Obtaining health history • Poor stream
• History of UTI
TYPES OF DATA • Abnormal color and odor of urine
• SUBJECTIVE DATA are information from the client's • And history of urinary catheterization
point of view ("symptoms”), including feelings,
perceptions, and concerns obtained through PHYSICAL EXAMINATION OF THE GENITOURINARY
interviews. SYSTEM
• OBJECTIVE DATA are observable and measurable Assessment of the Genitourinary system includes the
data ("signs") obtained through observation, physical different parts of the patient's body
examination, and laboratory and diagnostic testing. • FEMALE GENITALIA
o VULVA
SOURCE OF DATA o CLITORIS
• PRIMARY SOURCE: The patient is the main source o LABIA
of information. o URETHRAL ORIFICE
• SECONDARY SOURCES: sources of information o VAGINAL ORIFICE
come from the significant others, guardians or • MALE GENITALIA
relatives, laboratory examination. o PENIS (Shaft Gland)
o TESTES SCROTUM
EVALUATIION PHASE • INGUINAL AREA
• In the evaluation phase of assessment, the health care • PUBIC HAIR
provider ensures the information collected is complete,
accurate and documented appropriately. This also includes Problem in the Physical and History of:
• The nurse must draw on critical thinking and problem • SEXUAL
– solving skills to make clinical decisions and plan care • MENSTRUAL CYCLE
for the patient being assessed. • OBSTETRICAL
• If any abnormal findings are identified; the nurse must
ensure that appropriate action is taken. FEMALE GENITALIA
• This may include communicating the findings to the • Presence of Infection
medical team, or to relevant allied health team. • Prolapse (Uterus, Labia)
• Patients should be continuously assessed for changes • Vaginal discharges (Blood, Pus)
in condition and assessments are documented • Abnormal odor
regularly.
• Pruritus (Itchiness)
• Lesions
ASSESSMENT OF THE GENITOURINARY SYSTEM
• Pain on palpation
An assessment of the renal system includes all aspects of
urinary elimination such as: • Inflammation
• Urinary pattern, incontinence, frequency, urgency, • Nodes
dysuria. • History of sexually transmitted diseases
• Hydration status including fluid balance. VULVA/URETHRA/VAGINAL ORIFICE
• Blood Pressure and weight. • Observe for lesions
• Growth and feeding, diet or fluid restrictions. • Note for any discharge for the urethral meatus or
vaginal orifice.
• Skin condition: temperature, skin turgor and moisture.
MENSTRUAL
• Urine output (Normal U/ O: CHILDREN: <2yrs is
Menstrual:
between 2-3m1/kg/hr, >2yrs is between 0.5-
• Age of onset
1m1/kg/hr) (ADULT: 30cc per Hour).
• Regularity
• Urinalysis (pH, ketones, protein, blood, leukocytes,
specific gravity). • Menarche
• Review blood chemistry results, urea, creatinine, • Menopause (date of onset)
electrolytes, albumin and hemoglobin. • Post-menopausal bleeding
• Last menstrual period (LMP) date
HEALTH HISTORY TAKING • Amount of flow (number of pads/tampons/day)
Assessing the Health History of the patient with problems • Duration of menses
and conditions of the Genitourinary system includes • PMS
History of: • Dysmenorrhea
• Urinary Hesitancy OBSTETRICAL
• Urinary Frequency Obstetrical:
• Urgency • Chronological sequence of pregnancies (weight and
• Dysuria sex of each child)
• Pyuria • Abortion
• Polyuria • Miscarriages
• Oliguria • Blood transfusions
• Nocturia • Stillbirths
• Hematuria • Complications of pregnancies
• Renal or urethral calculi • Rh sensitivity history
• Incontinence
• Urinary retention MALE GENITALIA
• Dribbling • PENIS (Shaft, Gland)
• TESTES
 • SCROTUM
MALE GENITALIA -MAKE THE LYMPH NODES VISIBLE
• Lesions
• Nodes / Lump 2. TO ASSESS FOR MUSCLE STRENGTH, YOU NEED
TO ASK THE CLIENT TO SHRUG THE SHOULDERS
• Pain on palpation
AGAINST THE RESISTANCE OF YOUR HANDS. THIS
• Prostate problems DETERMINES THE FUNCTION OF WHAT MUSCLE
• Masses or Tumors
• Presence of infections –TRAPEZIUS MUSCLE
• Abnormal Odor
• Discharges 3.FOR CLIENTS WHI HAVE LUNGS PROBLEMS, YOU
PENIS, SCROTUM and TESTES NEED TO PALPATE ALL THORAX AREAS FOR
• Note whether or not the patient is circumcised and if BULGES, TENDERNESS, OR ABNORMAL
the foreskin refracts completely MOVEMENTS. HOWEVER, DEEP PALPATION FOR
PAINFUL AREA IS AVOIDED, ESPECIALLY IF A
• Observe for SMEGMA (a whitish substance under
FRACTURED RIB IS SUSPECTED BECAUSE
the foreskin).
• Note the appearance of the urethral meatus and -IT COULD LEAD TO DISPLACEMENT OF THE BONE
whether or not there is a discharge. FRAGMENT AGAINST THE LUNGS
• Palpate the testes for tenderness or masses.
• The testes are normally equal in size, however when 4. NURSE EVEN IS AWARE THAT THE RATIONALE
the male is standing, it is normal for one testicle to be FOR THORAX PERCUSSION IS TO:
lower in the scrotal sac than the other.
• Observe the penis and testes for any lesions or -COMPARE FINDINGS AT EACH POINT WITH THE
rashes. CORRESPONDING POINT ON THE OPPOSITE SIDE
OF THE THORAX
• Scrotal Hernia
• Testicular pain 5. CRANIAL NERVE RESPONSIBLE FOR MUSCLE
PUBIC HAIR and PUBIC AREA MOVEMENT THAT PERMITS SHRUGGING OF
PUBIC HAIR: SHOULDERS BY TRAPEZIUS MUSCLES AND
• Assess for normal hair distribution TURNING HEAD AGAINST RESISTANCE BY
• Amount and characteristic STERMASTOID MUSCLE
• Presence of body lice
• Parasites -CRANIAL NERVE XI
• Inflammation, swelling, and lesions in the pubic area
SEXUAL 6. TEMPOROMANDIBULAR JOINTS ARE TWO
JOINTS THAT CONNECT THE LOWER JAW AND THE
SEXUAL:
SKULL. HOW DO YOU PALPATE
• Dyspareunia (painful intercourse in the female) TEMPOROMANDIBULAR JOINT?
• Birth control used
• Degree of sexual activity -PLACE THE INDEX FINGER OVER THE FRONT OF
• Frequency of Intercourse EACH EAR AS YOU ASK THE PATIENT TO OPEN
• Sexual preference THE MOUTH
• Multiple Partner
REMEMBER 7. A NURSE IS ASSESSING A CLIENT WITH
Assessment of the Genitourinary System is very HYPERTHYROIDISM FOR THE PRESENCE OF A
BRUIT. WHICH ASSESSMENT TECHNIQUE SHOULD
sensitive, this is because we are going to assess sensitive
THE NURSE USE?
area of the body of our client/patients.
In doing this, we must NOT forget to DO the following: -INSPECTION
• Review the patient's chart if there is a need of
Genitourinary Assessment 8. MANG ISKO IS A 75-YEAR OLD PATIENT WITH A
• Obtain consent from our patient or Guardian DIAGNOSED CASE OF PNEUMONIA. WHICH DATA
• Explain the procedure WOULD BE OF GREATEST CONCERN TO THE
• Observed the patient's right NURSE WHEN PERFORMING THE ASSESSMENT?
• Maintained a caring atmosphere
• Respect the patient -BUCCAL CYANOSIS AMD CAPILLARY REFILL
GREATER THAN 3SECS
• Provide Privacy and
• Maintained Confidentiality 9. DURING ASSESSMENT, WHICH SATA SPEAKS
INFORMATION ABOUT HEALTH BELIEFS?

-USE OF PRESCRIBED AND OVER-THE-COUNTER

MIDTERMS MEDICATIONS

HEALTH ASSESSMENT 10. IN OBSERVING THE HEAD MOVEMENT, YOU

1. AS A NURSE, IT IS YOUR RESPONSIBILITY TO
ASSESS THE HEAD AND NECK TO A PATIENT WHO
JUST ARRIVED AT THE ER COMPLAINING FEVER.
BEFORE YOU PALPATE THE ENTIRE NECK FOR
ENLARGED LYMPH NODES, FACE THE PATIENT,
AND BEND THE PATIENT'S HEAD FORWARD
SLIGHTLY OR TOWARD THE SIDE BEING EXAMINED
TO:
NEED TO ASK THE PATIENT TO MOVE HIS CHIN TO
THE CHEST TO DETERMINE THE FUN CTION OF
WHAT MUSCLE?
-STERNOCLEIDOMASTOID MUSCLE
11. LYKA WAS PLANNED FOR A PHYSICAL
ASSESSMENT. WHEN PERCUSSING THE PATIENT'S
THORAX, THE NURSE WOULD EXPECT TO FIND
WHICH ASSESSMENT DATA AS NORMAL SIGN
OVER HIS LUNGS?
-DULLNESS
12. GAILE VISITED THE CLINIC FOR AN ANNUAL
ASSESSMENT. WHICH STATEMENT WOULD BE THE
BEST WAY TO END THE HISTORY INTERVIEW?
-WOULD YOU DESCRIBE YOUR OVERALL HEALTH
AS GOOD?
13. KAITE UNDERWENT AN OPEN REDUCTION AND
INTERNAL FIXATION OF THE RIGHT HIP. ONE DAY
AFTER THE OPERATION, THE PATIENT IS
COMPLAINING OF PAIN. WHICH DATA WOULD
CAUSE THE NURSE TO STOP FROM
ADMINISTERING THE PAIN MEDICATION AND TO
NOTIFY THE ATTENDING PHYSICIAN
IMMEDETIATELY?
-LEFT FOOT COLD TO TOUCH; NO PALPATE PEDAL
PULSE
14. WHICH PATIENT HAS A HIGHER CHANCE TO
HAVE PALPATE LYMPH NODES IN THE NECK?
-MALE, 61 WITH RHEUMATIC FEVER
15. PATIENT TESS WAS CURIOUS ABOUT LYMPH
NODES ASSESMENT. SHE ASKED NURSE TOM
ABOUT NORMAL LYMPH NODES. HE IS CORRECT
WHEN HE STATES THAT IT IS:
-NON PALPABLE
16. WHICH OFNTHE FOLLOWING IS AN ABNORMAL
FINDING FOR THE NECK MUSCLES?
-COORDINATED, SMOOTH MOVEMENTS
17. WHILE PERFORMING AN EXAMINATION OF THE
REGIONAL LYMPH NODES IN THE NECK AREA, YOU
PALPATE A LYMPH NODE THAT FEELS HARD AND
FIXED. WHAT IS THE APPROPRIATE NURSING
ACTION?
-ASK RHE PATIENT IF HE HAS FELT THIS NODE
BEFORE AND IF IT IS PAINFUL
18. TO COMPLETE A HEALTH HISTORY, NURSE
EDITH SHOULD IDENTIFY RISK FACTORS ABOUT
THORAX PROBLEMS BY ASKING WHICH OF THE
FOLLOWING:
-ALL OF THE ABOVE
19. LUNG AUSCULTATION ASSESSES FOR NORMAL
BREATH SOUNDS AND FOR ABNORMAL
(ADVENTITIOUS) BREATH SOUNDS. ABNORMAL
BREATH SOUNDS INDICATE WHICH OF THE
FOLLOWING?
-BRONCHITIS
20. NURSE WILLIAM KNOWS THAT THE FOLLOWING
FINDINGS ARE NORMAL EXCEPT:
-VISIBLE DIFFUSENESS IN THE THYROID GLAND
21. WHICH OF THE FOLLOWING IS AN
ENLARGEMENT OF THE HEAD AND BONY FACIAL
STRUCTURES CAUSED BY EXCESSIVE SECRETION
OF GROWTH HORMONE?
-ACROMEGALLY
22. IN INSPECTING THE SPIANL ALIGNMENT FOR
DEFORMITIES, ASK THE CLIENT TO STAND. FROM
A LATERAL POSITION, THESE THREE CURVATURES
ARE OBSERVED EXCEPT:
-COCCYGEAL
23. A TYPE OF BREATH SOUND FOUND BETWEEN
THE SCAPULAE AND LATERAL TO THE STERNUM
AT THE FIRST AND SECOND INTERCOSTAL
SPACES WITH MODERATE-INTSENSITY AND
MODERATE PITCHED 'BLOWING' SOUNDS
CREATED BY AIR MOVING THROUGH LARGER
AIRWAY
-BRONCHIAL (TUBULAR)
24. A TYPE OF BREATH SOUND THAT HAS
SUPERFICIAL GRATING OR CREAKING SOUNDS
HEARD DURING INSPIRATIONNAND EXPIRATION,
HEARD MOST OFTEN IN AREAS OF GREATEST
THORACIC EXPANSION
-FRICTION (RUB)
25. A CONTINOUS, HIGH-PITCHED, SQUEAKY
MUSICAL SOUNDS CAUSED BY AIR PASSING
THROUGH A CONSTRICTED BRONCHUS AS A
RESULT OF SECRETIONS, SWELLING, TUMORS
-WHEEZE
26. THIS IS THE PREFERRED POSITION WHEN
ASSESSING THE THORAX BECAUSE IT MAXIMIZES
THORAX EXPANSION
-SITTING
27. UPON INSPECTING THE SHAPE AND SYMMETRY
OF THE THORAX FROM POSTERIOR AND LATERAL
VIEWS, YOU FOUND THAT THE
ANTEROPOSTERIOR TO TRANSEVERSE DIAMETER
INRM RATIO OF 1:2. THIS MEANS:
-NORMAL FINDING
28. IN INFANTS REGARDING THE SKULL THE
DEVELOPMENT OF WHICH TWO BONES IS THE
MOST IMPORTANT?
-ANTERIOR AND POSTERIOR CRANIAL BONES.
29. WHEN DOING A HEALTH HISTORY ON A
PATIENT'S HEAD AND NECK AREA, WHICH IF THE
FOLLOWING THE NURSE SHOULD ASSESS FOR?
-HEADACHE, HEAD INJURY, NECK PAIN, SWELLING,
LIMITATION OF MOVEMENT, DIZZINESS
30. WHEN ASSESSING A PATIENT WITH HEADACHE,
WHICH OF THE FOLLOWING SHOULD THE NURSE
ASK?
-ALL OF THE ABOVE
31. A NURSE NEEDS TO PALPATE A CLIENT'S
SUBMANDIBULAR LYMPH NODES. WHERE SHOULD
THE NURSE PLACE HER HANDS TO DO THIS?
-ON THE POSTERIOR BASE OF THE MANDIBLE
32. WHICH OF THE FOLLOWING CONDITION IS
KNOWN AS ACUTE FACIAL STROKE WITH CLINICAL
PRESENTATION OF FACIAL MUSCLE WEAKNESS
AND DROOPING ON ONE SIDE OF THE FACE?
-BELL'S PALSY
33. WHICH OF THE FOLLOWING THE NURSE
SHOULD DOCUMENT FOR ABNORMAL FINDINGS OF
THYROID GLAND?
-MASS, ENLARGED GLAND, PRESENCE OF NODULE
34. THIS CONDITION IS CAUSED BY EXCESSIVE
PRODUCTION OF THYROID HORMONES WITH
CLINICAL MANIFESTATIONS LF EXOPHTHALMOS,
WEIGHT LOSS, FINE HAIR AND DIARRHEA.
-GRAVE'S DISEASE
35. THE FOLLOWING ARE THE LOCATIONS OF THE
LYMPH NODES EXCEPT:.
-TEMPORAL
36 WHEN ASSESSING THE LYMPH NODES, THE
NURSE SHOULD DOCUMENT AS A NORMAL
FINDING?
-UNABLE TO PALPATE NODES
37. THIS CONDITION IS CHARACTERIZED BY AN
ENLARGED HEAD, BULGUNG FONTANEL AND
DILATED SCALP VEINS.
-HYDROCEPHALUS
38. WHICH IF THE FOLLOWING WOULD INDICATE
THAT YOUR PATIENT HAS DIFFICULTY OF
BREATHING
-RESPIRATORY RATE OF 18 BREATHS PER MINUTE
39. WHEN AUSCULTATING PATIENT WITH
PNEUMONIA, WHICH OF THE FOLLOWING BREATH
SOUNDS ARE HEARD MORE COMMONLY WITH
INSPIRATION?
-RHONCHI
40. WHEN PALPATING THE THORAX, WHICH OF THE
FOLLOWING WOULD BE AN ABNORMAL FINDING?
-MASSES
41. NURSE IZZA IS KNOWLEDGEABLE THAT THE
NORMAL BREATH SOUNDS INCLUDE WHICH OF
THE FOLLOWING?
-VESICULAR SOUNDS
42. WHEN ASSESSING THE THORAX AND LUNGS, IT
IS IMPORTANT TO:
-COMPARE EACH SIDE BILATERALLY ON
AUSCULTATION
43. ACCORDING TO THE AUTHORS, AN
OUTSTANDING FEATURE IN ASSESSING A PATIENT
WHO HAS FINDINGS CONSISTENT WITH
EMPHYSEMA IS:
-ALL OF THE ABOVE
44. WHEN PERFORMING A PATIENT HISTORY
ASSESSMENT, WHAT SHOULD BE DONE TO OBTAIN
NECESSARY DATA?
-QUESTIONING
45. WHEN A NURSE PERFORMS AN ASSESSMENT
OF THE SCALP, WHAT CARDINAL TECHNIQUES
SHOULD BE USED?
-INSPECTION AND PALPATION
46. AFTER PERFORMING THE PROCEDURE, WHAT
IS THE LAST STEP TO DO TO BE USED FOR
FURTHER REFERENCE?
-DOCUMENT
47. IF THE ASSESSMENT REVEALS THE
OBJECTIVES WERE NOTBACHIEVED, WHAT
INTERVENTIONS SHOULD BE DONE?
-REPORT THE FINDINGS IMMEDIATELY TO THE
PHYSICIAN
48. THIS IS A METABLOIC DISORDER CAUSING
ENLARGED THYROID DUE TO IODINE DEFICIENCY
-HYPOTHYROIDISM
49. NURSE CHESKA NEEDS TO PALPATE A
CLIENT'S SUBMANDIBULAR LYMPH NODES. WHERE
SHOULD THE NURSE PLACE HERE HANDS TO DO
THIS?
-ON THE POSTERIOR BORDER OF THE MANDIBLE
50. TO PERCUSSS DOR DIAPHRAGMATIC
EXCURSION, YOU SHOULD PERFORM THE
FOLLOWING EXCEPT:
-USE YOU MOST CONVENIENT PATTERN IN
PERCUSSION
Finals
NCM 101 (HEALTH ASSESSMENT LEC) FINALS
1. All sensitive and personal information is
published as included in the Data Privacy Act
except in certain circumstances, exception to this
law includes the following, except?
a. Necessity to protect the possession of a
person.
b. Necessity to protect the lawful rights of data
subjects in court proceedings.
c. Necessity to protect life and health of a
person
d. Pursuant to law that does not require
consent. (?)
2. This aspect of holistic assessment may include
Review of potential stressors and mental problem
that might exacerbate the ailment?
a. Nutritional status
b. Developmental
c. Sociological
d. Spiritual
e. Psychological
f. Cultural
g. Physiological
3. Two numbers are recorded when measuring
blood pressure. Among these, you know that this
refers to the pressure inside the artery when the
heart contracts and pumps blood through the
body.
 a. Anatolic b. spiritual
b. Pulse pressure c. Psychological
c. Diastolic d. Nutritional status
d. Cytolysis e. Cultural
e. Systolic f. Sociological
4. Medical term used for respiratory rate below the g. Physiological
normal rate is? 11. You also know that taking blood pressure, this
a. Hypothermia refers to the pressure inside the artery when the
b. Bradypnea heart is at rest and is filling with blood?
c. Bradycardia a. Cytolysis
d. Eupnea b. Diastolic
e. Tachycardia c. Systolic
f. Dyspnea d. Pulse pressure
g. Hypertension e. Anatolic
h. Hypotension 12. This is a command by the court to a witness to
i. Hyperthermia produce document. A writ or process requiring
j. Tachypnea the witness to bring with him and produce to the
k. Apnea court, books, papers, patient’s record or Chart in
5. The law defines personal information included to his hands, tending to elucidate the matter in
the Data Privacy Act of 2012, this includes the issue?
following except? a. Subpoena Ileus Tecum
a. Organizational chart, and line of commands b. Subpoena Dulche Tecum
of an incorporation. c. Subpoena Duces Tecnor
b. About an individual’s health, education, d. Subpoena Duces Tecum
genetic sexual life if a person. 13. In acquiring consent for a certain procedure or
c. About an individual’s race, ethnic group, management, the following except for one is not
marital status, age, color, and religious, a qualification to obtain consent to other
philosophical or political affiliations. individual aside from the patient?
d. Issued by government agencies “peculiar” a. Patient is asleep
(unique) to an individual such as social b. Physically incapacitated
security number. c. Mentally incapacitated
6. In assessing the level of pain of a patient, which d. Minors
of the following pain scale shows a series of faces 14. This aspect of holistic assessment may include
ranging from a happy face at 0 or “no hurt” to a the ability of those levels to maintain normal
crying face at 10 which represents “hurts like the metabolic integrity?
worst pain imaginable”? a. Nutritional status
a. The wong – baker faces pain rating scale b. Physiological
b. FLACC pain scale c. Psychological
c. Numerical rating pain scale d. Sociological
d. Color analog pain scale e. Developmental
7. Documentation could be done by the nurse using f. Spiritual
different format, which include the following g. Cultural
except? 15. According to the Data Privacy Act of 2012, it is
a. Electronic health records shown as a subset of security breach that actually
b. Computer – based recording leads to “accidental or unlawful destruction, loss,
c. Verbal documentation alteration, unauthorized disclosure of, or access
d. Written notes documentation to, personal data transmitted, stored, or otherwise
8. Medical term used for high temperature is? processed?
a. Hyperthermia a. Personal data breach
b. Hypothermia b. Breach of confidentiality
c. Bradycardia c. Living breach
d. Tachycardia d. Breach of action
e. Dyspnea 16. One popular acronym tool is assessing the
9. SITUATION: In handling patient while performing spiritual status of a person is the FICA model.
Health assessment, the Nurse must always These are the areas of assessment and possible
remember and convey the different Ethico – questions that could be asked to assess the
Legal consideration such as Informed consent, spiritual aspect, these includes the following,
Patient’s bill of rights, and Data privacy act law, to except?
prevent any violation against the patient’s rights a. Importance and influence
and the law. b. Fear or fright
You are the Nurse on duty, you were asked about c. Address
documents or other recordings such as a living d. Community
will or a health care power of attorney that 17. Medical term used for respiratory rate above the
communicates a person’s wishes about health normal rate is?
care decisions, you know that this is known as? a. Tachypnea
a. Health care power of attorney 18. SITUATION: In handling patient, while
b. Advance Directives performing Health assessment, the Nurse must
c. Living will always remember and convey the different Ethico
d. Advance direction – Legal consideration such as Informed consent,
e. Living testament Patient’s bill of rights, and Data privacy act law, to
f. Legal incapacity prevent any violation against the patient’s rights
10. This aspect of holistic assessment may include and the law.
assessment of communication with other A document, sometimes called a medical
individual and interpersonal relationship? directive, that expresses a person’s wishes
a. Developmental regarding future medical interventions when the
 person no longer has the capacity to make health 29. The final implementing rules and regulations
care decisions is called? came into force, adding specificity to the privacy
a. Living will act was implemented on?
b. Health care power of attorney a. December 9, 2016
c. Living testament b. October 9, 2015
d. Advance directives c. September 9, 2016
e. Legal incapacity (incompetency) d. September 9, 2015
f. Advance direction e. October 9, 2016
19. The patient asked you about this temperature of 30. It is an unpleasant sensory and emotional
98. 2 F, as his nurse, your interpretation on his experience, associated with or expressed in
queries will be? terms of actual or potential tissue damage?
a. Hypothermia a. Pain
b. Hyperthermia 31. Cultural assessment is also part of taking health
c. Hypovolemic shock history of your patient, as a nurse with knowledge
d. Normal temperature about it, you know that which of the following are
20. Another Core Value of Nursing that reflects a true regarding cultural sensitivity?
commitment to continuous growth, improvement, a. Patient’s response to signs and
and understanding. It is a culture where symptoms are independent of their
transformation is embraced, and the status quo cultural values. (?)
and mediocrity are not tolerated? b. Cultural and ethnic diversity have no impact
a. Integrity in health care.
b. Loyalty c. All member of one cultural group behaves in
c. Excellence exactly same manner.
d. Caring d. As a nurse, it is important to identify and
e. Diversity examine our own cultural and ethnic beliefs.
21. Medical term used for normal breathing? 32. This aspect of holistic assessment may include
a. Eupnea psychosocial and cognitive that may affect the
22. This aspect of holistic assessment may include patient’s response to the health issue?
the use of FICA model? a. Psychological (?)
a. Psychological b. Spiritual
b. Cultural c. Sociological
c. Physiological d. Nutritional status
d. Sociological e. Cultural
e. Developmental f. Developmental
f. Spiritual g. Physiological
g. Nutritional status 33. Medical term used for elevated blood pressure?
23. Medical term used for no breathing? a. Hypertension
a. Apnea 34. This aspect of holistic assessment may include
24. Which of the following purposes of Nursing assessment of religious practices and determine
Document wherein patient care documents, if nursing care will need to be altered?
assessments of processes, and outcome a. Cultural
measures across organizational settings, serve to b. Developmental
monitor performances if health care practitioners’ c. Physiological
and the health care facility’s compliance with d. Nutritional status
standard governing the profession and provision e. Psychological
of health care? f. Spiritual
a. Regulation and legislation g. Sociological
b. Legal purposes 35. In 2012, the Philippines passed this Republic Act,
c. Research comprehensive and strict privacy legislation “to
d. Credentialing protect the fundamental human right of privacy, of
e. Communication with other professional communication while ensuring free flow of
25. This aspect of nutritional assessment wherein information, also known as Data Privacy Act?
Physical examination is perform? a. RA No. 10123
a. Clinical methods/ Evaluation b. RA No. 0123
b. Biochemical/ Biophysical Parameters c. RA No. 10173
c. Developmental Evaluation d. RA No. 10183
d. Anthropometric Measurement e. RA No. 101173
26. Another core value of Nursing considered as a 36. Among four major core values of Nursing,
fundamental part of the nursing profession, respecting the dignity and moral wholeness of
characterizes our concern and consideration for every person without limitation, and a principle of
the whole person, our commitment to the open communication, ethical decision – making,
common good, and our outreach to those who are and humility are encourage, and demonstrated
vulnerable? consistently is integrated to?
a. Diversity a. Loyalty
b. Caring b. Integrity
c. Excellence c. Diversity
d. Loyalty d. Excellence
e. Integrity e. Caring
27. Medical term used for pulse rate below normal 37. Medical term used for fast or difficulty of
rate is? breathing?
a. Bradycardia a. Tachypnea
28. Medical term used for low temperature is? 38. This aspect of nutritional assessment, the patient
a. Hypothermia is sent to the laboratory examination to assess
nutrients form the body?
a. Biochemical/ Biophysical Parameters (?)
 b. Chemical Methods/ Evaluation This is where the patient is unable to manage
c. Anthropometric Measurement one’s own affairs because of injury or disability,
d. Developmental Evaluation as determined by a legal proceeding?
39. Junior, a pediatric patient asked you about the a. Living testament
different site of the body to acquire body b. Advance direction
temperature, you know that a person’s body c. Health care power of attorney
temperature can be taken in any of the following d. Legal incapacity
ways and site, except for? e. Advance directives
a. Skin f. Living will
b. Orally 49. Another measurement used to assess pain for
c. Axillary children between the ages of 2 months and 7
d. Apical years or individuals that are unable to
e. Rectally communicate their pain. This scale is scored in a
f. Tympanic range of 0 – 10 with 0 representing no pain. This
40. Nutritional Assessment is the interpretation of scale has five criteria which are assigned a score
clinical and dietary to determine whether a person of 0.
or groups of people are well nourished or a. Numerical rating pai scale
malnourished. Nutritional assessment can be b. Color analog pain scale
done using the ABCD methods. These refer to the c. The wong – baker faces pain rating scale
following except? d. FLACC pain scale
a. Developmental Evaluation 50. Nurse always make a difference every day
b. Anthropometric Measurement because of we are guided by the different goals
c. Clinical method/ Evaluation of nursing, the following are the four main goals
d. Biochemical/ Biophysical Parameters of nursing, except for one?
41. This measurement of the height and weight of a a. To prevent illness
patient is needed to acquire the body mass index, b. To advocate
this include to which of the following? c. To treat human illness
a. Anthropometric Measurement d. To promote health
b. Developmental Evaluation
c. Clinical method/ Evaluation
d. Biochemical/ Biophysical Parameters
42. Core Value of Nursing affirming the uniqueness
of and differences among persons, ideas, values,
and ethnicities is?
a. Diversity
b. Caring
c. Integrity
d. Excellence
e. Loyalty
43. Both the systolic and diastolic pressures in are
recorded by the nurse using which symbol below
which means millimeters of mercury?
a. mm Hg
44. Medical term used for pulse rate above the
normal rate is?
a. Tachycardia
45. This aspect of holistic assessment may include
assessment of values or ethnicity?
a. Physiological
b. Cultural
c. Sociological
d. Nutritional status
e. Psychological
f. Spiritual
g. Developmental
46. Medical term used for decrease or low blood
pressure?
a. Hypotension
47. Junior went to the clinic where you are working as
a nurse. He is an athlete, a runner, who do a lot
of cardiovascular conditioning, his cardiac rate is
50 BPM, as a nurse, your correct interpretation
for this is?
a. Cardiac Arrest
b. Bradycardia
c. Tachycardia
d. Normal Cardiac rate
48. SITUATION: In handling patient, while
performing Health assessment, the Nurse must
always remember and convey the different Ethico
– Legal consideration such as Informed consent,
Patient’s bill of rights, and Data privacy act law, to
prevent any violation against the patient’s rights
and the law.