3) Implement the nursing

THE NURSING interventions

4) Supervise delegated care
PROCESS 5) Document nursing activities

ASSESSMENT Reminder: “Something that is not written is

= collecting, validating, organizing, considered as not done”
and recording the patient’s health
status EVALUATION
Activities: = is assessing the patient’s response
1) Collect data to nursing interventions and then
2) Verify data comparing the response to
3) Organize data predetermine standards or
4) Identify patterns outcome criteria.
5) Report & record data Activities:
1) Collect data about the patient’s
DIAGNOSIS response
= process which results to a 2) Compare the patient’s response
diagnostic statement of nursing to goals and outcome criteria
diagnosis 3) Relate nursing actions to client
= a clinical act of identifying problems goals/outcomes
=uses critical thinking skill of analysis 4) Draw conclusions about problem
and synthesis status
Activities: 5) Continue, modify, or terminate the
1) Analyze Data clients care plan
2) Identify health problems, risks and
strengths
CHARACTERISTICS OF THE
NURSING PROCESS
PLANNING
=refers to formulating and 1. Problem oriented
documenting measurable, 2. Goal Oriented
realistic, patient-focused goals 3. Systematic
=provides the basis for evaluating 4. Open to accepting new
nursing diagnosis information during its application
Activities: 5. Interpersonal
1) Prioritize problems/diagnosis 6. Permit creativity among nursing
2) Formulate goals/desired practitioners
outcomes 7. Cyclical
3) Select nursing interventions 8. Universal
4) Write nursing interventions
BENEFITS OF NURSING PROCESS
IMPLEMENTATION FOR THE NURSING
= is putting the nursing care plan into 1. Consistent and systematic nursing
action education
Activities: 2. Job satisfaction
1) Reassess the client 3. Professional growth
2) Determine the nurse’s need for 4. Avoidance of legal action
assistance 5. Meeting professional nursing
standards
 6. Meeting standards of accredited
hospital
TYPES OF DATA
1. SUBJECTIVE(SYMPTOMS)
- can be described only by the
person experiencing it.
- (e.g. vertigo, pain, anxiety and
weakness)
2. OBJECTIVE (SIGNS)
- can be observed and measured
- (e.g. paleness, poor skin turgor,
jaundice)
PHYSICAL EXAMINATION
GUIDELINES
PREPARATION GUIDELINE FOR
SETTING
1) The examination room should be
adequately ventilated,
comfortable, quiet, private with
adequate lighting
2) Position the examination table so
that both sides of the patient are
easily accessible
3) The examination table should be
at a height that prevents the
examiner from stooping and
should be equipped to raise the
head up to 45 degrees
4) A bedside stand or table should
be available to lay out all
equipment needed.
PREPARATION GUIDELINE FOR
EQUIPMENTS
1) Make all the needed equipment
for the procedure readily
available.
2) ‘Place the equipment in the area
where the examination will be
performed
3) This promotes organization and
prevents the nurse from leaving
the client in search for a piece of
equipment
4) It saves time and effort
PREPARATION GUIDELINE FOR
PATIENT
1) Prepare the patient physically and
psychologically to ally anxiety
2) Provide privacy to prevent
feelings of embarrassment.
Curtain the unit as necessary.
3) Provide adequate information
about the procedure, what to
expect during the procedure, and
what is expected of the client, to
gain his cooperation
4) Provide a new clean gown
3 TYPES OF PHYSICAL
EXAMINATION
1) COMPLETE ASSESSMENT
= ex: when a client is admitted to a
health care agency
=cephalocaudal; head to toe
2) EXAMINATION OF A BODY SYSTEM
= ex: the cardiovascular system
3) EXAMINATION OF A BODY AREA
= ex: the lungs, when difficulty with
breathing is observed
PURPOSES OF PHYSICAL
EXAMINATION
● To obtain a baseline data about
the client’s functional abilities
● To supplement, confirm or refute
data obtained in the nursing
history
● To obtain data that will help
establish nursing diagnosis and
plans of care
● To evaluate the physiological
outcomes of health care and thus
the progress of a client’s health
problem
● To make clinical judgment about
clients health status.
● To identify areas for health
promotion and disease
prevention.
● The clients energy and time need
to be considered
● Conducted in a systematic and
efficient manner that results in
 the fewest position changes for
client
PHYSICAL ASSESSMENT
➢ A structured physical examination
that allows a nurse to obtain a
complete assessment of the
client.
➢ Ift requires four major skills
1) Inspection
2) Palpation
3) Percussion
4) Auscultation
➢ May be conducted starting at the
head and proceeding in a
systematic manner downward
(head-to-toe assessment)
➢ The procedure can vary
according to:
1) Individual’s age
2) Severity of illness
3) Preferences of the nurse
4) Location of examination
5) Agency’s priorities and
procedures
6) Client’s energy and time
need to be considered
7) Conducted in a systematic
and efficient manner that
results in the fewest
position changes for the
client
BASIC REQUIREMENTS IN
PHYSICAL ASSESSMENT
1) EQUIPMENTS
For all examinations:
To protect the examiner in any part
of examination when the
examiner may have contact with
blood, body fluids, secretions,
excretions and contaminated
items.
● Gloves
● Gown
Vital signs:
● Sphygmomanometer- measure
diastolic and systolic bp
● Stethoscope- auscultate blood
sounds when measuring bp
● Thermometer- body temp
● Watch with 2nd hand- take heart
rate, pulse rate
● Pain rating scale- determine
perceived pain level
Nutritional Status Examination:
● Skinfold calipers- measure
skinfold thickness of
subcutaneous tissue
● Flexible tape measure- measure
midarm circumference
● Skin-marking pen- mark
measurements
● Platform scale- measure height
and weight
Skin, hair and nail examination:
● Examination light, penlight-
provide adequate lighting
● Mirror- client’s self examination of
skin
● Metric ruler- measure size of skin
lesions
● Magnifying glass- enlarge visibility
of lesion
● Wood’s light- test for fungus
● Braden scale- for predicting one’s
risk to develop pressure sore
● Pressure ulcer scale for healing-
determine the degree of healing
of a pressure ulcer
Head and Neck Examination:
● Stethoscope- auscultate the
thyroid
● Small cup of water- help client
swallow during thyroid gland
examination
Eye Examination:
● Tuning Fork- test for bone and air
conduction of sound
● Otoscope- view the ear canal and
tympanic membrane

Mouth and Throat Examination:
● Penlight- provide light to view the
mouth and throat
● 4x4 in small gauze pad- grasp
tongue to examine the mouth
● Tongue depressor- to depress
tongue to view throat, check
looseness of teeth, view cheeks,
and check strength of tongue
● Otoscope with wide-tip
attachment-to view the internal
nose
Thoracic and Lung Examination:
● Stethoscope(diaphragm)-
auscultate breath sounds
● Metric ruler- measure
diaphragmatic excursion
Heart and Neck Vessel Examination:
● Stethoscope (bell and diaphragm)-
auscultate heart sounds
● Two metric rulers- measure
jugular venous pressure
Peripheral Vascular Examination:
● Sphygmomanometer &
stethoscope- measure blood
pressure and auscultate vascular
sounds
● Flexible metric measuring tape-
measure size of extremities of
edema
● Tuning fork - to detect vibratory
sensation
● Doppler ultrasound device and
conductivity gel- to detect
pressure and weak pulses not
easily heard with a stethoscope
Abdominal Examination:
● Stethoscope- to detect bowel
sounds
● Flexible metric measuring tape
and skin marking pen - measure
size and mark the area of
percussion of organ
● Two small pillows ( to place under
knees and head)- promote
relaxation of abdomen
Musculoskeletal Examination:
● Flexible metric measuring tape-
to measure size of extremities
● Goniometer- to measure degree
of flexion and extension of joints
Neurologic Examination:
● Cotton-tipped applicators- to put
salt or sugar on tongue to test
taste
● Newspaper to test for near vision
● Objects to feel, such as a coin or
key to test for stereognosis
(ability to recognize objects by
touch)
● Reflex (percussion) hammer -to
test deep tendon reflexes
● Cotton ball and paper clip- to test
for light, sharp, and dull touch and
two-point discrimination
● Substances to smell and taste- to
test for smell and taste
perception
● Snellen E chart
● Penlight
● Tongue depressor- to test for
rise of uvula and gag reflex
● Tuning fork- to test for vibratory
sensation
Male Genitalia and Rectum
Examination
● Gloves and water-soluble
lubricant- to promote comfort for
client
● Penlight- for scrotal illumination
● Specimen card for occult blood
Female Genitalia and Rectum
Examination
● Vaginal speculum and water-
soluble lubricant- to inspect
cervix through dilatation of the
vaginal canal
● Bifid spatula, endocervical broom-
to obtain endocervical swab and
 cervical scrape and vaginal pool
sample
● Large swabs- for vaginal
examination
● Liquid Pap medium- pap smear
● Specimen card- detect occult
blood
● Feminine pads and pH paper
2) PREPARATION OF THE
SETTING, ONESELF, AND THE
CLIENT
SETTINGS
• Comfortable, warm room
temperature:Provide a warm
blanket if the room temperature
cannot be adjusted.
• Private area free of interruptions
from others: Close the door or
pull the curtains if possible.
• Quiet area free of distractions:
Turn off the radio, television, or
other noisy equipment
• Adequate lighting: best to use
sunlight (when available) but
good overhead lighting is
sufficient.
• Firm examination table or bed at a
height that prevents stooping: A
roll-up stool may be useful when it
is necessary for the examiner to
sit for parts of the assessment.
• A bedside table/tray to hold the
equipment needed for the
examination
ONESELF
Assess your own feelings and
anxieties before examining the
client and prevent transmission of
infectious agents
APPROACHING AND PREPARING THE
CLIENT
Establish a nurse-client relationship; it
helps alleviate any tension or
anxiety that the client is
experiencing. Respect the client’s
desires and requests related to
physical examination.
3)PERFORMANCE OF THE 4
PHYSICAL EXAMINATION
TECHNIQUES (IPPA)
INSPECTION
= involves using the senses of vision,
smell, and hearing to observe and
detect any normal or abnormal
findings
= hands aren’t used yet
=should be deliberate, purposeful,
and systematic
= used from the moment that you
meet the client and continues
throughout the examination
PALPATION
= using parts of the hand to touch and
feel the following characteristics:
● Texture (rough/smooth)
● Temperature (warm/cold)
● Moisture (dry/wet)
● Mobility
(fixed/movable/still/vibrating)
● Consistency (soft/hard/fluid filled)
● Strength of pulses
(strong/weak/thready/bounding)
● Size (small/ medium/ large)
● Shape (well defined/irregular)
● Degree of Tenderness ( a
symptom; when you touched the
client’s body and he/she said that
it hurts; told by a patient)
● Vibration (of a joint)
● Distention (of urinary bladder)
= 3 different parts of the hand are
used:
● Fingerpads
> fine discriminations: pulses,
texture, size, consistency, shape,
crepitus
● Ulnar/palmar surface
> vibrations, thrills, fremitus
● Dorsal surface
> temperature
= palpation has 2 main types:
1) Light Palpation
> place the dominant hand lightly
on the surface of the structure
> very little/ no depression (less
than 1cm)
> feel the surface using circular
motion
> used to feel pulses, tenderness,
surface skin texture, temperature
and moisture
● Moderate Palpation
> depress skin surface to 1-2 cm
with dominant hand
> use a circular motion to feel for
easily palpable body organs and
masses
> note the size, consistency, and
mobility of structures palpated
2) Deep Palpation
> place dominant hand on the skin
surface and nondominant hand on
top of dominant hand to apply
pressure
> surface depression between 2.5
and 5 cm
> allows us to feel very deep
organs or structures covered by
thick muscle
● Bimanual Palpation
> use two hands, placing one on
each side of the body part
> use one hand to apply pressure
and the other hand to feel the
structure (uterus, breasts, spleen)
> note the size, shape,
consistency, and mobility of the
structures you palpate
PERCUSSION
= tapping the body parts to produce
sound waves
= striking the body surface to elicit
sounds that can be heard or
vibrations
= has 2 types:
1) Direct
> direct taping of a body part with
1 or 2 fingertips to elicit possible
tenderness
> nurse strikes the area to be
percussed directly with the pads
of two, three, or four fingers or
with pad of the middle finger
> strikes are rapid, and
movement is from wrist
● Blunt
> type of direct percussion
> detect tenderness over organs
by placing 1 hand flat on the body
surface and using the fist of the
other hand to strike back of the
hand flat on body surface; for
kidneys
2) Indirect or mediate
> most commonly used percussion
method
> striking of an object held
against the body area to be
examined
> produces a sound or tone that
varies with density of underlying
structures
> increasing density=quiet tone
sound
> solid tissue: soft tone
> fluid: louder tone
> air: even louder tone
> tones are classified according
to origin, quality, itensity, and
pitch
> middle finger of nondominant
hand, referred as pleximeter, is
pressed firmly on the client’s skin
> plexor (middle finger of other
hand) strikes the pleximeter
= has several different assessment
uses:
● Eliciting Pain
 > percussion detect inflamed
underlying structures; client can
report that the area feels
tender,sore, or painful
● Determining location, size, and
shape
> note changes between borders
of an organ and its neighboring
organ
● Determining density
> determine whether the
underlying structure is filled with
air or fluid or a solid structure
● Detecting abnormal masses
> detect superficial or abnormal
structures or masses
● Eliciting reflexes
> deep tendon reflexes are
elicited using percussion hammer
AUSCULTATION
= require the use of stethoscope to
listen for heart sounds, movement
of blood through the
cardiovascular system, bowel
movement, and air movement
through the respiratory tract
= sounds detected are classified
according to:
● Intensity (loud/soft)
● Pitch (high/low)
● Duration (length)
● Quality (musical,crackling, raspy)
= has 2 types:
1) Direct Auscultation
> performed using the unaided ear;
ex:listening to a respiratory
wheeze or the grating of moving
joint
2) Indirect Auscultation
> performed using stethoscope
> a steth is used primarily to listen
sounds within the body, such as
bowel sounds or valve sounds of
the heart and blood pressure
> Diaphragm
- for high-pitched sounds (normal
heart sounds, breath sounds and
bowel sounds)
- should be 1.5 wide for adults
> Bell
-low-pitched sounds (abnormal heart
sounds and bruits blowing,abnormal loud,
murmuring)
-1 inch wide
CLIENT POSITIONS
SITTING POSITION
= client should sit upright on
the side of examination
table
= this position is good for
evaluating the head,
neck, lungs, chest, back,
breasts, axillae, heart,
vital signs and upper extremities
= permits full expansion of the lungs
= allows the examiner to assess
symmetry of upper body parts
SUPINE POSITION
= client lied down with legs together
on the examination table/bed
= allows abdominal muscles to relax
and provides easy access to
peripheral pulse sites
= areas assessed in this position are:
head, neck, chest, breasts, axillae,
abdomen, heart, lungs and all
extremities
DORSAL RECUMBENT POSITION
= client lies down on the examination
table or bed with the knees bent,
the legs separated, and the feet KNEE-CHEST POSITION
flat on table/ bed = client kneels on the
=areas that may be assessed with the examination table
client in this position include head, with the weight of
neck, chest, axillae, lungs, heart, the body
extremities, breasts, and supported by the
peripheral pulses chest and knees
=abdomen should not be assessed = 90-degree angle
because the abdominal muscles should exist
are contracted in this position between the body and the hips
= useful for examining the rectum

SIMS’ POSITION
=client lies on the right or left side
with the lower arm placed behind
the body and the upper arm
flexed at the shoulder and elbow
= useful for assessing the rectal and
vaginal areas; the client may need
some assistance getting into this
position
LITHOTOMY POSITION
= client lies on the back with the hips
at the edge of the examination
table and the feet supported by
stirrups
= used to examine the female
genitalia, reproductive tracts, and
the rectum
= keep the client well draped during
the examination and to perform
the examination as quickly as
possible

STANDING POSITION
= client stands still in a normal,
comfortable, resting
posture
= allows the examiner to assess
posture, balance, and gait
= also used for examining the
male genitalia

PRONE POSITION
= client lies down on the abdomen
with the head to side
= used primarily to assess the hip
joint
= back can also be assessed