Health Assessment Lecture

PRELIMS REVIEWER

LESSON 3: DATA COLLECTION, PHASES OF INTERVIEW:

ANALYSIS AND DOCUMENTATION 1. INTRODUCTORY PHASE

> Essential to develop rapport and gain

METHODS OF DATA COLLECTION:
trust.
Observation
Interview > Explain purpose, reason for taking
Physical Assessment notes and assure client confidentiality
of the information.
TYPES OF DATA:
2. WORKING PHASE
Subjective Data
Objective Data > Nurse uses critical thinking to
interpret and validate information.
SUBJECTIVE DATA
> Nurse and client collaborate to
> Can be elicited and verified only by the
identify the client’s problems and
client.
goals.
> Provides clues to possible physiologic,
> Nurse elicits comments on
psychological and sociologic problems.
biographical data.
> Obtained through interviewing.
> Reasons for seeking care
> also includes:
> History of present health concern.
Sensations Beliefs
past health history
Feelings Ideas
Perceptions Values
> Family history
Desires Personal
Preferences information
> Review of body systems for current
health problems
INTERVIEWING
> Method of obtaining a valid nursing > Lifestyle
health history.
> Health practices and developmental
> Requires professional, interpersonal and level
interviewing (communication) skills.
3. SUMMARY & CLOSING PHASE
FOCUS OF NURSING INTERVIEW: > Nurse summarizes information.
Establishing rapport and trusting
relationship with the client. > Identifies with client possible plans
Gathering information on the client’s to resolve the identified problems.
developmental, psychological,
physiologic, sociocultural and spiritual
statuses to identify strengths and
weaknesses.
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PRELIMS REVIEWER
COMMUNICATION DURING
INTERVIEW
The client interview involves two types
of communication — nonverbal and
verbal.
Several special techniques and certain
general considerations will improve
both types of communication as well as
promote an effective and productive
interview.
NON-VERBAL
COMMUNICATION
> It is as important as verbal
communication.
> Facilitate eye level contact.
> Never overlook the importance of
communication or take it for granted.
POINTERS TO CONSIDER IN NON-
VERBAL COMMUNICATION
1. APPEARANCE
First take care to ensure that your
appearance is professional.
The client is expecting to see a
health professional; therefore, you
should look the part.
2. DEMEANOR/BEHAVIOR
When you enter a room to interview a
client, display poise.
Focus on the client and the upcoming
interview and assessment.
3. FACIAL EXPRESSION
Often an overlooked aspect of
communication.
Often show what you are truly
thinking.
Keep your expression neutral &
friendly.
4. ATTITUDE
One of the most important nonverbal
skills to develop as a health care
professional is a nonjudgmental
attitude.
All clients should be accepted,
regardless of beliefs, ethnicity,
lifestyle, and health care practices.
5. SILENCE
Periods of silence allow you and the
client to reflect and organize
thoughts, which facilitate more
accurate reporting and data
collection.
6. LISTENING
The most important skill to learn
and develop fully in order to collect
complete and valid data from your
client.
To listen effectively, you need to
maintain good eye contact, smile or
display an open, appropriate facial
expression, and maintain an open
body position.
VERBAL COMMUNICATION
> Effective verbal communication is
essential to a client interview.
> The goal of the interview process is to
elicit as much data about the client’s
health status as possible.
TYPES OF QUESTIONS AND
TECHNIQUES TO USE DURING
THE INTERVIEW
1. OPEN ENDED QUESTIONS
> Used to elicit the client’s feelings
and perceptions.
> Typically starts with “how” or
“what”
> Encourage description and may
reveal data about the client’s health
status .
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PRELIMS REVIEWER

EXAMPLES:
How have you been feeling lately
What do you feel about going to
chemo twice a week?
2. CLOSE ENDED QUESTIONS
> Used to obtain facts and to focus
on specific information.
4. INFERRING
> Inferring information from what the
client tells you and what you observe
in the client’s behavior may elicit
more data or verify existing data.
> Be careful not to lead the client to
answers that are not true.

> This technique, if used properly,

> Typically begins with “when” or
“did”
> Can be used to clarify or obtain
more accurate information about
issue disclosed in response to open
ended question.
EXAMPLES:
When was the first time you felt this
pain in your abdomen?
Did you consult?
Did you find relief on the medication
prescribed?
OTHER EFFECTIVE MEANS TO
COMMUNICATE
1. LAUNDRY LIST
> To provide the client with a list of
words to choose from in describing
symptoms, conditions, or feelings.
> Helps you to obtain specific
answers and reduces the likelihood
of the client perceiving or providing
an expected answer.
helps to elicit the most accurate data
possible from the client.
5. PROVIDING INFORMATION
> Provide the client with information
as questions and concerns arise.
> Make sure that you answer every
question as thoroughly as you can.
> If you do not know the answer,
explain that you will find out.
SPECIAL CONSIDERATIONS:
Age
Culture
Emotional variations
FOCUS QUESTION
> More specific toward the problem.
HOW TO DEAL WITH ANXIOUS,
ANGRY, DEPRESSED, &
MANIPULATIVE PATIENTS
1. ANXIOUS

2. REPHRASING Structure info

Explain who you are, your role, and
> An effective way to communicate
purpose of visit
during the interview.
Ask simple, concise questions
Nurse needs to stay relax
> Helps you to clarify information the
Do not hurry and decrease external
client has stated.
stimuli
3. WELL-PLACED PHRASES
> The nurse can encourage client
verbalization by using well-placed
phrases.
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PRELIMS REVIEWER

2. ANGRY
Calm, in-control mannerisms and
tone
Let patient ventilate their feelings
If excessive, do not touch or argue
back
Obtain help from other health
professionals as much as needed
Provide personal space

3. DEPRESSED
Show interest and understanding to
client and situation
Do not be upbeat or encouraging

4. MANIPULATIVE
Provide structure and limitations
Differentiate between manipulation
and a reasonable request.
If you are not sure whether you are
being manipulated, obtain an
objective opinion from other nursing
colleagues.
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PRELIMS REVIEWER

LESSON 4: COMPLETE HEALTH REASON/S FOR SEEKING

HISTORY HEALTH CARE
> Reason for seeking health care (major
COMPLETE HEALTH health problem or concern).
HISTORY
> Feelings about seeking health care (fears
> Lays the groundwork for identifying and past experiences).
nursing problems and provides a focus
for physical examination. > This category includes two questions:
“What is your major health problem
> The importance of the health history or concern at this time?"
lies in its ability to provide information “How do you feel about having to
that will assist the examiner in seek health care?”
identifying areas of strength and
limitation in the individual’s lifestyle and > The first question assists the client in
current health status. focusing on the most significant health
concern.
8 SECTIONS OF HEALTH
HISTORY: > The second question encourages the
1. Biographical data client to discuss fears or other feelings
2. Reasons for seeking health care about having to see a health care provider.
3. History of present health concern
4. Personal health history HISTORY OF PRESENT HEALTH
5. Family health history CONCERN
6. ROS for current health problems
> When the symptoms started (state in how
7. Lifestyle and health practices profile
many days/weeks/months prior to
8. Developmental level
admission)
BIOGRAPHICAL DATA
> Characteristics of symptoms (ex. onset,
> Usually include information that location, intensity etc.)
identifies the client.
> Aggravating or alleviating factors
> includes:
Name > Associated symptoms
Address
Phone > Management done? Effective?
Gender
Provider of history > What prompted admission or consult?
Birth date
Support persons > Use of mnemonics (COLDSPA)
Place of birth
Race or ethnic background COLSDPA:
Educational level
Occupation CHARACTER
> How does it feel, look, smell,
sound, etc.?
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ONSET > Accidents and injuries (how, when, where,

> When did it begin? type of injury, treatment received,
> Is it better, worse, or the same complications)
since it began?
> Hospitalizations (reason, dates,
LOCATION treatment, surgery performed, course of
> Where is it? recovery, complications)
> Does it radiate?
> Medications (all currently used,
DURATION previously used
> How long does it last?
> Does it recur? FAMILY HEALTH HISTORY
> family genogram reflecting the age and
SEVERITY
current state of health of siblings, parents
> How bad is it on a scale of 1 [barely
and grandparents
noticeable] to 10 [worst pain ever
experienced]?
> causes of death in the family
PATTERN
> occurrence of hereditary diseases such
> What makes it better?
as heart disease, cancer, diabetes,
> What makes it worse?
hypertension, obesity, mental disorders
ASSOCIATED FACTORS
EXAMPLE OF GENOGRAM
> What other symptoms do you have
with it?
> Will you be able to continue doing
your work or other activities?

OTHER SAMPLE QUESTIONS

When did you first feel the pain?
How long have you been
experiencing it?
Where does it hurt more?
Rate the pain from a scale of 1
to 10

PAST HEALTH HISTORY LIFESTYLE AND HEALTH

> Childhood illnesses (chickenpox, PRACTICES
mumps, measles, rubella and other
> A very important section of the health
significant illnesses)
history because it deals with the client’s
human responses.
> Childhood immunizations

> Each area is discussed briefly, then

> Allergies (type of reaction, how reaction
followed by a few sample questions.
is treated)
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Description of a typical day

Nutrition/ Weight Management
24 hour dietary intake
Who purchases and prepares
meals
Exercise habits and patterns
Sleep and rest habits and
patterns
Use of medications/current
medications and other substances
Self-concept & self-care
responsibilities
Social activities for fun and
relaxation
Social activities contributing to
society
Relationships with family, special
ones and pets
Family members influence the
health habits of each other
Children mostly pick up the eating
habits of their parents
Adolescents whose parents or
siblings smoke are more likely to
pick up the habit
Values, religious affiliation YOUNG ADULT
Past, current and future plans for 18-25 years old
education Intimacy VS Isolation
Type of work, level of job Ability to relate well with other people
satisfaction
Finances MIDDLE AGED ADULT
Stressors in life and coping
25-65 years old
strategies used
Generativity VS Stagnation
Residency, type of environment
Have self confidence, able to juggle
their various lives

DEVELOPMENTAL LEVEL THE OLDER ADULT

Feels good about the life choices he or
SUMMARY OF FREUD’S AND
she has made
ERIKSON’S THEORIES OF
PERSONALITY DEVELOPMENT
COLLECTING SUBJECTIVE
DATA/FUNCTIONAL ASSESSMENT OF
ELDERLY CLIENT
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LAWTON SCALE FOR 6. MODE OF TRANSPORTATION

INSTRUMENTAL ACTIVITIES OF Travels independently on public
DAILY LIVING (IADL) transportation or drives own car
Arranges own travel via taxi but
1. ABILITY TO TELEPHONE
does not otherwise use public
Operates telephone on own transportation
initiative Travels on public transportation
Answers telephone and dials a few with assistance
well known numbers Travel is limited to taxi, automobile
Answers telephone but does not with assistance
dial Does not travel at all
Does not uses telephone at all
7. RESPONSIBILITY FOR OWN MEDICATION
2. SHOPPING
Responsible for taking medication
Takes care of all shopping needs
in correct dosages at all time
independently
Takes responsibility if medication
Shops independently for small
is prepared in advance, in
purchases
separated dosage
Needs to be accompanied on any
Is not capable of dispensing own
shopping trip
medication
Completely unable to shop
8. ABILITY TO HANDLE FINANCES
3. FOOD PREPARATION
Manages financial matters
Plans, prepares and serves
independently; collects and keeps
adequate meals independently
tract of income
Prepares adequate meals if
Manages day to day purchases but
supplied with ingredients
needs help with banking, major
Heats and serves prepared meals
purchases, controlled spending
or prepare meals but does not
Incapable of handling money
maintain adequate diet
Needs to have meals prepared and KATZ ACTIVITIES OF DAILY
served LIVING
4. HOUSEKEEPING
Maintains house alone or with
occasional assistance
Performs light daily task such as
dishwashing and bed making
Performs light daily task but cannot
maintain acceptable level of
cleanliness
Needs help with all home
maintenance tasks
Does not participate in any
housekeeping task
5. LAUNDRY
Does personal laundry completely
Launders small items; rinses socks
and stockings
All laundry must be done by others
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ASSESSMENT IN PREGNANCY
LAST MENSTRUAL PERIOD (LMP)
> First day of the last menstrual cycle

> Data needed to compute for expected

date of birth (EDB)

NAEGEL'S RULE
> LMP +9+7 (Jan-March)

> Example LMP: January 5, 2010

1-05-2010 + 9+07
EDB = 10/12/2010

NEWBORN AND CHILDREN

FUNCTIONAL ASSESSMENT PSYCHOSOCIAL HISTORY
> Evaluation of an individual's mental
Materials Needed: health and social well-being.
Gloves
Stethoscope > Used to determine if the patient is in a
Tape measure state of mental health or mental illness.

Stress
APGAR SCORE ASSESSMENT Hostility
Depression
Hopelessness

A - Appearance
P - Pulse
G - Grimace
A - Activity
R - Respiration
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LESSON 5: PREPARING ONE SELF

PHYSICAL ASSESSMENT > The nurse should do hand hygiene and
observe appropriate infection control
Colleting Objective Data (personal protective equipment)

> The nurse prepares the equipment

OBJECTIVE DATA needed for the assessment
> Include information about the client
that the nurse directly observes during
PREPARATION OF THE EQUIPMENT
interaction with him and information 1. All equipment must be ready and
elicited through physical assessment available.
techniques. 2. Equipment should be kept warm.
3. All equipment must be checked to make
> Also includes: sure that they function properly.
Observation report 4. Equipment to prepare depends on
Vital signs which part of the body to be assessed.
Physical assessment findings 5. Make sure it's ready when you enter the
(head to toe or system focused) examination/client’s room.
Diagnostic test result /
Laboratory tests EQUIPMENTS:
Other sources such as client Cotton Ruler Safety Pin
chart (ex. freq./amount of urine, applicators Sphygmomanometer
stool, vital signs since Drapes and cuff
admission, etc.) Eye chart (e.g. Stethoscope
Snellen’s chart) Swabs or sponge
OBSERVATION REPORT Flash forceps
light/penlight Tape measure
> How a client dresses /spot light Thermometer
> How a client walks Forms (e.g. Tissues
> How a client speaks physical, Tongue depressor
> Facial expression laboratory) Tuning fork
Gloves (sterile Vaginal speculum
and clean) Wristwatch with
PHYSICAL ASSESSMENT Gown for client second hand
Water – soluble
> A head to toe review of each body
lubricant
system that offers objective information
Opthalmoscope
about the client and allows the nurse to
Otoscope
make clinical judgments.
Paper towels
Percussion
PREPARATION FOR hammer

PHYSICAL EXAMINATION FLASHLIGHT/PENLIGHT

> To assist viewing of the pharynx and
cervix or to determine the reactions of
the pupils of the eye.
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LARYNGEAL/DENTAL MIRROR
> To observe pharynx and oral cavity.
NASAL SPECULUM
> For visualization of the lower and
middle turbinates.
OPHTHALMOSCOPE
> To visualize the interior of the eye.
OTOSCOPE
> To visualize the ear drum and external
auditory canal.
PERCUSSION/REFLEX HAMMER
> To test reflex.
TUNING FORK
> To test hearing acuity and vibratory
sense.
VAGINAL SPECULUM
> To assess cervix and vagina.
COTTON APPLICATORS
> To obtain specimens.
DISPOSABLE PADS
> To absorb liquid.
GLOVES
(sterile & unsterile)
> To prevent contamination.
LUBRICANT
> To ease insertion of instruments.
TONGUE BLADES/DEPRESSORS
> To depress the tongue.
PREPARATION OF THE CLIENT:
A. PHYSICAL
Make sure that the client is
comfortable for physical comfort.
The client should be dressed and
draped properly.
Position the client properly.
B. PSYCHOLOGICAL
Thorough explanation of what will
be done and what to expect should
be given to the client.
When the client and the examiner
are of opposite sexes, it is helpful
to have a third person of the
client’s sex inside the room.
PREPARATION OF THE
ENVIRONMENT:
1. Physical assessment is conducted in a
quiet, well – lit room with consideration
for the patient’s privacy and comfort.
Good lighting is needed for proper
illumination of the different body parts.
2. Be sure that the room is well-equipped
for all necessary procedures.
3. The room must be well – ventilated.
ETHICO-LEGAL CONSIDERATION:
1. Procedure and purpose should be
clearly explained
2. Client had consented
3. Privacy and confidentiality must be
observed at all times
4. Documentation should be complete,
timely, factual
INFORMED CONSENT
> Informed consent to medical treatment
is fundamental in both ethics and law.
> The process by which the treating health
care provider discloses appropriate
information to a competent patient to
understand the purpose, benefits,
potential risks, and other options of the
test or treatment, medical or surgical
intervention, so that the patient may make
a voluntary choice to accept or refuse
treatment.
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> Then the doctor or nurse must get the DATA PRIVACY ACT OF 2012
patient's consent / authorization or
agreement to undergo a specific medical (Republic Act 10173)
intervention before starting.
Personas Defined in the Law:
PATIENTS BILL OF RIGHTS
A. Data Subject
1. The patient has the right to considerate
and respectful care. > Individual whose personal
2. The patient has the right to obtain from information is being processed.
his physician complete and current B. Personal Information Controller
information concerning his diagnosis,
> Person or organization who controls
treatment, and prognosis in terms the
collection, holding, processing or use
patient can reasonably expect to
of personal information.
understand.
3. The patient has the right to receive from
> Including those who instructs other
the physician information necessary to
to do so.
give informed consent prior to the start
of any procedure and/or treatment. C. Personal Information Processor
4. The patient has the right to refuse
> Natural/juridical person to whom a
treatment and to be informed of the
personal information controller may
medical consequences of his action.
outsource the processing of personal
5. The patient has the right to every
data pertaining to a data subject.
consideration of his privacy concerning
his own medical care program.
6. The patient has the right to expect that
POSITIONING CLIENT
all communications and records A. SITTING
pertaining to his care should be treated
as confidential. > Can evaluate head, neck, lungs,
7. The patient has the right to expect chest, back, breasts, armpits, heart,
within its capacity, a hospital must take vital sign, arms.
reasonable response to the request of a
patient for service. > Also useful because it permits full
8. The patient has the right to obtain expansion of the lungs.
information as to any relationships his
hospital has to other health care and > It allows the examiner to assess
educational institutions insofar as his symmetry of upper body parts.
care is concerned.
9. The patient has the right to be advised if > The client should sit upright on the
the hospital propose to engage in or side of the examination table.
perform human experimentation affecting
his care or treatment. > An alternative position is for the
1 0 .T h e p a t i e n t h a s t h e r i g h t t o e x p e c t client to lie down with head
reasonable continuity of care. elevated.
11. The patient has the right to examine and
receive an explanation of his bill.
1 2 .T h e p a t i e n t h a s t h e r i g h t t o k n o w w h a t
hospital rules and regulations apply to
his conduct as a patient.
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B. SUPINE
> Flat on back, legs together
> Evaluate head, neck, chest, breast,
armpits, abdomen, heart, lungs,
limbs, peripheral pulses
> This position allows the abdominal
muscles to relax and provides easy
access to peripheral pulse sites.
> A small pillow may be placed under
the head to promote comfort.
C. DORSAL RECUMBENT
> Client lies on back, knees bent,
legs separated, feet flat
> Most comfortable for people with
back or abdomen pain.
> Assess: head, neck, chest, armpits,
lungs, heart, limbs, breasts,
peripheral pulses
D. SIM'S POSITION
> The 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 the
elbow.
> The lower leg is slightly flexed at
the knee while the upper leg is
flexed at a sharper angle and pulled
forward.
> Useful for assessing the rectal and
vaginal areas.
E. STANDING
> Assess: posture, balance, gait,
male’s genitalia.
> The client stands still in a normal,
comfortable, resting posture.
F. PRONE
> Flat on stomach, head to one side.
> Assess the hip joint, back.
> Clients with cardiac and respiratory
problems cannot tolerate this
position.
G. KNEE-CHEST
> The client kneels on the examination
table with the weight of the body
supported by the chest and the knees.
> The arms are placed above the
head, with the head turned to one
side.
> Useful for assessing rectum.
> Elderly clients and clients with
respiratory and cardiac problems may
be unable to tolerate this position.
H. LITHOTOMY
> Lays on back, hips at end of table,
feet in stirrups (at the gyne).
> Assess: female genitalia,
reproductive tracts, rectum
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PHYSICAL EXAMINTATION 1. Finger Pads

> Sensitive to:
TECHNIQUES fine discrimination
pulses
A. INSPECTION
texture
> Involves using the senses of vision, size
smell and hearing to observe and consistency
detect any normal or abnormal shape
findings. crepitus
2. Ulnar/Palmar Surface
> May necessitate the use of special
equipment. > Sensitive to:
vibrations
> Precedes the other methods of thrills
examination. fremitus
3. Dorsal/Back Surface
GUIDELINES AS YOU PRACTICE THE
TECHNIQUE OF INSPECTION: > Sensitive to:
temperature
Make sure the room temperature is just
right. TYPES OF PALPATION:
Use good lighting.
Look and observe before touching. 1. Light Palpation
Completely expose the body part you > Hand is placed lightly on the
are inspecting while draping the rest of structure.
the client.
Note the following characteristics while > Very little or no depression.
inspecting the client: color, patterns,
size, location, consistency, symmetry, > Use this technique to feel for
movement, behavior, odors, or sounds. pulses, tenderness, surface skin
Compare the appearance of symmetric texture, temperature, and moisture.
body parts.
2. Moderate Palpation
B. PALPATION > Depress the skin surface 1 to 2 cm
(0.5 to 0.75 in) with your dominant
> Consists of using parts of the hand
hand, and use a circular motion to
to touch and feel for the following
feel for easily palpable body organs
characteristics:
and masses.
Texture
Temperature 3. Deep Palpation
Moisture > Place dominant hand on skin
Mobility surface and your non dominant hand
Consistency on top of your dominant hand to
Strength of pulses apply pressure.
Size
Shape > Surface depression between 2.5
Degree of tenderness and 5 cm (1 to 2 inches)

DIFFERENT PARTS OF THE HANDS: > This allows you to feel very deep
organs or structures that are covered
by thick muscle.
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4. Bimanual Palpation
> Use two hands, placing one on each
side of the body part being palpated.
> Use one hand to apply pressure and
the other hand to feel the structure.
C. PERCUSSION
> Involves tapping body parts to
produce sound waves to assess
underlying structures.
> Use one hand to apply pressure and
the other hand to feel the structure.
PERCUSSION NOTE
> Tones produced in percussion.
> Varies with origin, quality and intensity.
USE OF PERCUSSION IN ASSESSMENT:
1. Eliciting Pain
> Percussion helps detect inflamed
underlying structures.
2. Determining Location, Size & Shape
> Percussion note changes between
borders of an organ and its
neighboring organ can elicit
information about location, size, and
shape.
3. Determining Density
> Percussion helps determine whether
an underlying structure is filled with
air or fluid or is a solid structure.
4. Detecting Abnormal Masses
> Percussion can detect superficial
abnormal structures or masses.
> Percussion vibrations penetrate
approximately 5 cm deep.
5. Eliciting Reflexes
> Deep tendon reflexes are elicited
using the percussion hammer.
TYPES OF PERCUSSION:
1. DIRECT PERCUSSION
> Direct tapping of a body part with
one or two fingertips to elicit
possible tenderness.
2. BLUNT PERCUSSION
> Detect tenderness over organs by
placing one hand flat on the body
surface and using the fist of the other
hand to strike the back of the hand
flat on the body surface.
3. INDIRECT PERCUSSION
> Also called as mediate percussion.
> The most commonly used method of
percussion.
> Place the middle finger of your non
dominant hand on the body part to
percuss.
> Use the pad of your middle finger of
the other hand to strike the middle
finger of the non dominant hand.
> Deliver two quick taps and listen for
tone.
D. AUSCULTATION
> requires the use of a stethoscope
to listen for heart sounds, movement
of blood through the cardiovascular
system, movement of the bowel, and
movement of air through the
respiratory tract.
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TYPES OF AUSCULTATION:
1. Direct Auscultation
> use of unaided ear.

2. Indirect Auscultation
> use of stethoscope.

CLASSIFICATION OF SOUND PRODUCED

IN AUSCULTATION
1. Intensity (loud/soft)
2. Pitch (high/low)
3. Quality (musical/cracking/raspy)
4. Duration (length)

GUIDELINES IN AUSCULTATION:
1. Eliminate competing noise from the
environment
2. Expose the body parts to auscultate
3. Use the diaphragm for high pitched
sound
4. Use the bell for low pitched sound
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LESSON 6: RESPONDING TO
THE CLIENT UNDERGOING
DIAGNOSTIC TESTING
DIAGNOSTIC TESTS
> Are tests used to establish medical
diagnosis, critical element of assessment.
> Determined by the findings from a
thorough history and physical exam.
KINDS OF DIAGNOSTIC TESTS
1. Non Invasive
> The body is not entered with any
type of instruments.
2. Invasive
> Accessing the body’s tissue, organ
or cavity through some type of
instrumentation procedure.
LABORATORY TESTS
> Simple measurements to determine how
much or how many ANALYTES (a substance
dissolved in a solution) are present in a
specimen.
> Results are based on normal range
values.
VENIPUNCTURE
> The puncturing of a vein with a needle to
aspirate blood.
TESTS USING BLOOD SAMPLE
FROM A VEIN
Complete blood count
Blood culture
Blood urea nitrogen/creatinine height
index
Liver profile tests
BLOOD CULTURE AND
SENSITIVITY TEST
> Identifies presence of microorganism.
BLOOD CHEMISTRY
> Basic electrolytes – Na, K, Ca, Cl, Mg.
> BLOOD UREA NITROGEN - test for kidney
function.
> CREATININE HEIGHT INDEX– checks renal
status.
> Liver profile – SGPT, SGOT
ARTERIAL BLOOD GASES
> Reveals ability of the lungs to exchange
gases by measuring the partial pressure of
oxygen (PO2) carbon dioxide (PCO2) and
evaluates the pH of arterial blood.
CAPILLARY PUNCTURE
> Skin punctures are performed when small
amount of capillary blood is needed for
analysis or if client has poor veins.
> Commonly performed for blood glucose
analysis.
SITES FOR CAPILLARY PUNCTURE
1. HEEL
> neonates and infant.
2. FINGERTIP
> inner aspect of palmar fingertip used
most commonly in children and adult.
3. EARLOBE
> when the client is in shock or the
extremity is edematous.
CENTRAL LINES
> Refers to a venous catheter inserted into
the superior vena cava through the
subclavian, internal or external jugular vein.
> Inserted when a peripheral route cannot
be obtained, for treatment and to withdraw
blood for analysis.
TYPE & CROSSMATCH
> Identifies the client’s blood type and
determines the compatibility of blood
between a potential donor and recipient.
 Health Assessment Lecture
PRELIMS REVIEWER
BASIC BLOOD TYPES
A positive & negative
B positive & negative
AB positive & negative
O positive & negative
URINE MAY BE COLLECTED FOR
Analysis /Urinalysis
Specific gravity
Presence of white blood cells
Presence of bacteria & blood
Presence of pus cells
NURSING INDICATIONS FOR
URINALYSIS
SPECIMEN: Clean voided
PRETEST: Give clean vial and instruct to
void directly into the specimen bottle
INTRATEST: Allow a 10 ml collection
POST-TEST: Prompt delivery to
laboratory
NURSING INDICATIONS FOR
URINE CULTURE
SPECIMEN: Clean catch, midstream or
catheterized urine
PRETEST: Instruct to wash and dry
genitalia/perineum with soap and water.
(M)- circular motion, (F)-front to back
direction
INTRATEST: Midstream urine, 30-60 ml
POST-TEST: Cap and label, prompt
delivery and documentation
STOOL COLLECTION
> Stools are collected for examination for
presence of blood, bacteria and parasites.
GUIDELINES IN STOOL
COLLECTION
Client should defecate into a clean bed
pan or container.
If needed over a prolonged period of
time, must be refrigerated.
Label with client’s name, date, time and
the test to be performed on the
specimen.
NURSING INDICATIONS FOR
STOOL COLLECTION
SPECIMEN: Determine purpose/s, obtain
gloves, container and tongue blade
INTRATEST:
Instruct to defecate in clean bed
pan
Void before collection
Do not discard tissue in bedpan
Obtain 2.5 (1 inch) formed stool
15-30 ml of liquid stool
POST-TEST: Prompt delivery
SPUTUM EXAMINATION
PRETEST: Morning specimen is collected
INTRATEST:
Mouthwash with plain water
Deeply inhale x 2 then cough
Wear gloves in collecting specimen
Expectorate needed- 1-2 Tbsp or
15-30 ml
POST-TEST: Oral care and prompt
delivery to lab
RADIOLOGIC STUDIES
A. RADIOGRAPHY
> Study of x rays or gamma ray
exposed film through the action of
ionizing radiation.
B. CHEST X RAY
> Includes the use of radiation and
imaging
> Non invasive and non contrasted.
> Multiple view of the chest to assess
the entire lung field.
CHEST FILMS MAY INDICATE
Lesions (tumor, cyst, masses)
Inflammation (pneumonia,
tuberculosis)
Fluid accumulation (pulmonary
edema, hemothorax, pleural
effusion
Bone deformities and fractures of
ribs and sternum
Air accumulation in the lungs
 Health Assessment Lecture
PRELIMS REVIEWER
C. IV CHOLECYSTOGRAPHY
> X-ray visualization of the gallbladder
after administration of contrast media
intravenously.
NURSING INDICATIONS FOR
IV CHOLECYSTOGRAPHY
PRETEST: Allergy to iodine and seafoods
INTRATEST: Ensure patent IV line
POST-TEST: Increase fluid intake to
flush out the dye, Assess for delayed
hypersensitivity reaction to the dye like
chills and N/V
D. ORAL CHOLECYSTOGRAPHY
> X-ray visualization of the gallbladder
after administration of contrast media.
> Done 10 hours after ingestion of
contrast tablets.
> Done to determine the patency of
biliary duct.
E. MAMMOGRAPHY
> Low dose radiologic study of breast
tissue.
> Recommended annually for women
aged 50 y/o and even earlier for those
with history of breast cancer.
ANGIOGRAPHY
> Allows visualization of the vascular
structures through the use of fluoroscopy
with contrast medium.
> Reveals blood flow to the heart, lungs,
brain, kidneys and lower extremities.
NURSING INDICATIONS FOR
ANGIOGRAPHY
PRETEST: Informed consent, allergy to
dyes, seafood and iodine
INTRATEST: Monitor vital signs
POST-TEST: Maintain pressure dressing
over puncture site
Immobilize for 6 hours
COMPUTED TOMOGRAPHY
(CT)
> Radiologic scanning of the body with x
ray beams and radiation detectors that
transmit data to a computer that
transcribes the data into quantitative
measurement and multidimensional images
of the internal structures.
> Requires written consent & cooperation
of client.
> Client who will receive contrast medium
need to be kept NPO 2 to 4 hours before
the test.
> Should void prior.
MONITOR FOR ALLERGIC
DYE REACTIONS
Respiratory distress
Urticaria & Hives
Nausea & Vomiting
Decreased production of urine
ULTRASOUND
> Non invasive study that uses high
frequency sound waves to visualize deep
body structures.
> A coupling agent is placed on the surface
of body area to increase contact between
the skin and the transducer.
> Done during pregnancy to evaluate size
of fetus and placenta.
USED TO EVALUATE:
Brain & Heart
Thyroid gland
Vascular structure
Abdominal aorta
Spleen, Liver & Gallbladder
Pancreas and pelvis
ECHOCARDIOGRAM
> Non-invasive test that studies the
structural and functional changes of the
heart with the use of ultrasound.
> No special preparation is needed.
 Health Assessment Lecture
PRELIMS REVIEWER

ELECTROCARDIOGRAPHY GIT VISUALIZATION

(ECG) Esophagogastroscopy
PRETEST: Informed consent, NPO for 8
> Graphic recording of the heart’s
hours, warn that gag reflex is abolished
electrical activity.
INTRATEST: Position on LEFT side during
scope insertion
> Electrodes are applied to the chest wall
POST-TEST: NPO until gag returns.
and extremities.
Monitor for complications
> Test can reveal abnormal transmission BRONCHOSCOPY
of impulse and electrical position of the
PURPOSE: Diagnostic and therapeutic
heart’s axis.
PRETEST: Consent, NPO, client teaching,
anti anxiety drugs
> Client may be asked: not to smoke or
INTRATEST: Gag reflex is abolished,
drink caffeinated beverages 24 hours
instruct to remain still during procedure,
before the test.
FOWLER or SUPINE
ENDOSCOPY POST-TEST: NPO until gag reflex returns,
monitor patient for complication like
> Visualization of a body organ or cavity
perforation/bleed.
through a scope.
BRONCHOSCOPE
> Performed with an endoscope (metal or > Used to view the airways & check for any
fiberoptic) being inserted directly into a abnormalitites.
body structure to be studied
ARTHROSCOPY
NURSING CONSIDERATIONS
> Insertion of fiber optic scope into the
BEFORE joint to visualize it, perform biopsy.
Sign consent form
Obtain baseline vital signs before > Performed under OR condition.
administering sedative agents
> After care: Dressing over the puncture
AFTER
site for 24 hours to prevent bleeding.
Monitor Vital Signs
Bleeding
> Limit activity for several days, 7 days
Check gag reflex
usually.
EXAMPLE: MRI
COLONOSCOPY - examine large intestine > Magnetic Resonance Imaging
> A flexible fiberoptic scope is
inserted through the anus and the > Imaging techniques that uses radio waves
interior of the bowel can be directly and a strong magnetic field to make
viewed on a television monitor. continuous cross sectional images of the
body.
Maintain clear liquid diet 48 hours
before the test
> Non iodine contrast agent may be used.
Take prescribed laxative the evening
before examination
> Reveals lesion and changes in the body’s
Clinical Significance – identify origin
organs, tissues, vascular and skeletal
of bleeding or lesions, evaluate
structures.
ulcerative or inflammatory bowel
disease
> Painless, non-invasive, no radiation.

> Creates a magnetic field.

 Health Assessment Lecture
PRELIMS REVIEWER

MRI CONTRAINDICATIONS:
(+) pacemaker
(+) metal prosthesis

MRI CLIENT TEACHING:

Lie still during the procedure
for 60-90 minutes
Earplugs to reduce noise
discomfort
Claustrophobia
No radiation

LUMBAR PUNCTURE
INTRATEST:
Site used-between L4/L5
Position- flexion of the trunk

POST-TEST:
Flat on bed (8-12 hours)
Offer fluids to 3 Liters
Oral analgesic for headache
Monitor bleeding, swelling and
changes in neurologic status
 Health Assessment Lecture
PRELIMS REVIEWER

LESSON 7: HOLISTIC NURSING BODY TEMPERATURE

ASSESSMENT > A core body temperature between
36.5°C & 37.7°C (96.0°F & 99.9°F orally).
GENERAL STATUS &
HYPOTHERMIA
VITAL SIGNS
> May be seen in prolonged exposure to
the cold, hypoglycemia or starvation.
GENERAL SURVEY
> First part of the physical examination > lower than 36.5°C or 96.0°F
that begins the moment the nurse meets
the client. HYPERTHERMIA
> May be seen in viral or bacterial
INITIAL OBSERVATIONS
infections, trauma and immune disorders.
Client's physical appearance
Mood & behavior
> higher than 38.0°C or 100°F
Speech patterns & voice intonations
Signs & symptoms of distress FACTORS AFFECTING BODY
Vital signs TEMPERATURE
Height and weight AGE
VITAL SIGNS EXERCISE - increase heat production up
to 41 C.
> The signs of life. HORMONE LEVEL - women generally
experience greater fluctuations in body
> Outward clue to what is going on in the temperature than men.
patient’s body. CIRCADIAN RHYTHM - highest BT (8am-
12mn), lowest (4am-6am)
> Also known as the CARDINAL SIGNS. STRESS - stimulates sympathetic
KINDS OF VITAL SIGNS nervous system.
ENVIRONMENT
Temperature of the Body
Pulse Rate
Respiratory Rate PYREXIA - Elevated body temperature.
Blood Pressure HYPERPYREXIA - Body temp above 41 C.
Pain INTERMITTENT FEVER - Body temp
Oxygen Saturation alternated regularly between periods of
fever, normal or subnormal temperature.
WHEN TO TAKE VITAL SIGNS REMITTENT FEVER - Fluctuations of
On admission several degrees above normal but not
Change in health status reaching normal between fluctuations.
Before and after surgery CONSTANT FEVER - Consistently
Before, during, and after giving elevated & fluctuated very little.
medications. RELAPSING FEVER - Temp is elevated for
Before and after nursing intervention few days, alternated with 1 or 2 days of
influencing vital signs. normal temperature.
When the client reports any CRISIS/FLUSH/DEFERVESCENT STAGE -
nonspecific symptoms of physical Elevated BT returns to normal suddenly
distress. indicated impaired hypothalamic
function.
MEASUREMENT OF FEBRILE - A client who has a fever.
BODY TEMPERATURE AFEBRILE - A client without fever.
LYSIS - Gradual decline of fever
indicated the body is able to maintain
homeostasis.
 Health Assessment Lecture
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STAGES OF FEVER:
A. First Stage of Fever
> Patient complains of feeling cold.

> Also called as onset/chill/cold

stage.

> Characterized by low febrile

temperatures.

> Typical signs and symptoms indicate

the body’s compliance mechanism to
increase and conserve heat:
NORMAL ADULT Chills
Shivering
TEMPERATURE RANGES
Vasoconstriction
Cyanotic nail beds
VASOCONSTRICTION
> Decreases blood supply to the skin.
BODY TEMPERATURE NURSING MANAGEMENT
(ACC. TO WEBER) Aim is to minimize heat loss
ORAL: 36.5-37.0C Do NOT apply TEPID SPONGE BATH
AXILLARY: 0.5C lower than the oral because this would make patient
temperature progress to SHOCK
RECTAL: 0.4C-0.5C higher than the Provide additional clothing as necessary
normal oral temperature Provide additional blankets as
necessary
CARE OF THE THERMOMETERS Provide something warm to drink
BEFORE USING These measures would result to a
> bulb to stem gradual increase in body temperature
B. Second Stage of Fever
AFTER USING > Also called as Coarse Stage of
Fever or Peak Stage of Fever.
> stem to bulb

> Patient does not feel hot or cold.

FEVER
> Normally, the hypothalamus is able to > Skin is warm to touch & flushed.
adjust body temperatures between 37°C
to 40°C. > Fever blisters are present.

> Due to the presence of pyrogenic
materials like the following:
Pathogenic microorganisms
Toxins
Foreign substances
Any substance capable of
increasing body temperature
> Absence of shivering & possible
dehydration.
> For every increase of temperature,
there is a corresponding increase in
pulse rate.
> Increased oxygen demand also
leads to an increase in respiratory
rate.
 Health Assessment Lecture
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PATIENT COMPLAINS OF: > It can be AUSCULTATED (Central) and

PALPATED (Peripheral).
Loss of appetite
Myalgia or muscle pains due to NURSE SHOULD BE AWARE OF
increased catabolism
THE FOLLOWING:
RATIONALE Medication that affect the heart rate
Increase in temperature results in an Whether the client has been physically
increase in pulse rate due to increased active
metabolic rate Any baseline data about the normal heart
Increased metabolic rate increases rate for the client
oxygen demand Whether the client should assume a
Due to increased oxygen demand of particular position
susceptible brain cells, CONVULSIVE
SEIZURES may occur. These may also be
due to irritation of nerve cells – FEBRILE
CONVULSIONS
NURSING MANAGEMENT
Tepid Sponge Bath
Cooling Bed Bath
TEPID SPONGE BATH (TSB)
> Temperature of water is 32°C, this
temperature is maintained throughout the
procedure.
HOW TO APPLY: Done by patting
RATIONALE: To avoid friction, which
increases temperature.
IMPORTANT CONCEPT: Do not use PULSE POINTS (PERIPHERAL)
alcohol when applying TSB
RATIONALE: Alcohol dries the skin and
leads to irritation.
KEY CONCEPT: TSB should not be done
hurriedly
RATIONALE:
When done hurriedly, TSB will
stimulate shivering
Shivering would lead to increased
muscle activity
Increased muscle activity would
lead to increased temperature

ASSESSMENT OF
PULSE
PULSE
> The wave of blood created by the
contraction of the LEFT SIDE OF THE
HEART.

> ANS (Autonomic Nervous System) -

regulating center.
 Health Assessment Lecture
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APICAL PULSE BRACHIAL ARTERY

> Also known as PMI (Point of Maximal > Felt on the inner side of the biceps.
Impulse).
> Major artery that supplies the arm
> LOCATION: 4th to 5th intercostal space,
Left Mid clavicular Line.
RADIAL ARTERY
> Located on the radial bone side of the
> INDICATIONS: wrist below the thumb.
For children up to 3 years of age ULNAR ARTERY
If there is Pulse deficit
> Located on the medial aspect of the
FACTORS AFFECTING wrist.
THE PULSE
> Deeper pulse and may not be easily
1. AGE - is INVERSELY PROPORTIONAL to
palpated.
pulse.
2. SEX/GENDER - after puberty M<F. FEMORAL ARTERY
3. EXERCISE- increase metabolic rate. > Located on the groin.
4. FEVER
5. MEDICATIONS > Used in case of cardiac arrest.
6. HEMORRHAGE- increases pulse rate
7. STRESS - sympathetic nervous system > To monitor circulation to a leg.
stimulation.
8. POSITION CHANGES > Major supplier of blood to the legs.
HOW TO MEASURE APICAL
POPLITEAL ARTERY
PULSE
> Located behind the knee.
Warm the stethoscope in your hands.
Place the stethoscope at the apex POSTERIOR TIBIAL PULSE
(pointed end) of the heart, in the left > Located behind the inner ankle.
center of the chest, just below the
nipple. The pulse can usually be heard
DORSALIS PEDIS
best at the apex. > Can be palpated on the great-toe side of
Count the pulse for one full minute. the top of the foot.

TEMPORAL ARTERY
A. CARDIAC OUTPUT
> At the temple above and to the outer
> Amount of blood pumped into the
side of the eye.
arteries for each minute.

> Used when radial pulse is not accessible. B. STROKE VOLUME

> Amount of blood pumped into the
CAROTID ARTERY arteries for each contraction.
> Place the index and middle finger just to
the side of the Adam's apple, in the soft
C. TACHYCARDIA
hollow area. > Pulse rate above normal range.
D. BRADYCARDIA
> Used during cardiac arrest/shock. > Pulse rate below normal range.

> Used to determine circulation to the E. DYSRHYTHMIA/ ARRHYTHMIA

brain > Irregular rhythm.
F. PULSE DEFICIT
> Centrally located arterial pulse. > Difference between central and
peripheral pulse.
 Health Assessment Lecture
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ASSESSMENT PARAMETERS TYPES OF BREATHING

1. RATE – number of beats per minute
NEWBORN: 80/120 - 160/180 bpm
ADULTS/ELDERLY: 60 - 100 bpm
2.RHYTHM - pattern or regularity of beats
and interval between each beater.
PULSUS REGULARIS - Equal rhythm
ARRHYTHMIA - Irregular rhythm
PREMATURE BEAT - Occurs between
normal beats
HEART RHYTHM - Time interval
between each heartbeat
A. COSTAL (THORACIC)
> Involves movement of the chest.
B. DIAPHRAGMATIC (ABDOMINAL)
> Involves movement of the abdomen.
RESPIRATORY CENTERS
A. Medulla Oblongata
> Primary respiratory center.
> Responds to LOW CARBON DIOXIDE.
B. Pons

3.VOLUME/AMPLITUDE – amount of blood C. Carotid & Aortic Bodies

pumped with each heartbeat. > Secondary respiratory center.
+4 - BOUNDING, felt by exerting only
> Responds to LOW OXYGEN.
light pressure over artery.
+3 - NORMAL D. Proprioreceptors
+2 - WEAK > Found in muscles and joints.
+1 - FEEBLE/THREADY, difficult to
feel & easily obliterated by pressure. FACTORS AFFECTING RESPIRATION
0 - ABSENT Exercise Medications
Acute pain Neurologic injury
ASSESSMENT OF RESPIRATIONS Anxiety Hemoglobin function
Smoking Cardiac illness
RESPIRATION Body position

> The act of breathing. ASSESSMENT PARAMETERS

1. RATE – number of breaths per minute
> PURPOSE: The purpose of respiration is
to maintain an adequate oxygen level in NEWBORN: 30 - 60 bpm
the blood to support cellular life. ADULTS: 12-20 bpm
2.RHYTHM - regularity of respiration,
KINDS OF RESPIRATION inhalation & exhalation are evenly spaced.
EXTERNAL
REGULAR: Effortless, quiet
> Mechanical act of breathing and is
IRREGULAR: Abnormal
accomplished by expansion of the
chest, both vertically and horizontally. 3. DEPTH
Assessed by watching the movement
INTERNAL
of the chest.
> Oxygen and carbon dioxide are
Maybe normal, deep or shallow.
exchanged between the cells and
blood vessels. 4. QUALITY/CHARACTER
Effort and sound of breathing.
VENTILATION
> Also called as Inhalation & Expiration
 Health Assessment Lecture
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EUPNEA ASSESSMENT OF BLOOD

> Normal, effortless breathing rate at
PRESSURE
12-20 cpm.
TACHYPNEA BLOOD PRESSURE
> Quick, shallow breathing more than
> Measurement of pressure exerted by the
20 cpm.
blood through the arteries.
BRADYPNEA
> Slow, shallow breathing, less than 12 > CONTROL CENTER: Vasomotor Center
cpm.
APNEA
HOW TO GET BLOOD
> Cessation of breathing. PRESSURE
HYPERPNEA CARDIAC OUTPUT X TOTAL PERIPHERAL
> Labored and deeper breathing at RESISTANCE
normal rate.
SYSTOLIC BLOOD PRESSURE
HYPERVENTILATION
> Pressure of the blood flow when the
> Deep rapid respiration or breath
heart beats.
> Overexpansion of lungs
> Excess carbon dioxide
> The pressure when the first sound is
> Also called as HYPERCAPNIA
heard.
HYPOVENTILATION
> Slow, shallow respiration DIASTOLIC BLOOD PRESSURE
> Under expansion of lungs > Pressure between heartbeats.
> Low level of carbon dioxide
> Also called as HYPOCAPNIA > The pressure when the last sound is
KUSSMAUL’S RESPIRATION heard.
> Labored and deeper breathing at EXAMPLE
abnormal rate.
> SYSTOLIC
CHEYNE- STOKE
> Periods of hypo and hyperventilation > DIASTOLIC
with apneic episodes.
BIOT’S RESPIRATION
> Periods of hypoventilation with apneic
FACTORS AFFECTING BLOOD
episodes.
PRESSURE
DYSPNEA
1. AGE - directly proportional to age
> Difficulty of breathing with irregular
2. EXERCISE - increase BP
intervals at abnormal rate.
3. STRESS - increase BP
ORTHOPNEA 4. GENDER - after puberty and before 65 y
> Difficulty of breathing while lying o M>F; after 65 y o F>M.
down, relieved by sitting/standing. 5. MEDICATION
PLATYPNEA 6. DIURNAL VARIATIONS - lowest in the
morning, highest in the afternoon and
> Difficulty of breathing while sitting or
early evening.
standing, relieved by lying down.
7. OBESITY & DISEASE PROCESS
 Health Assessment Lecture
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AUSCULTATED BP THINGS TO ASSESS FOR

> Listening for both the systolic and CHECKING THE MENTAL STATUS
diastolic values. Consciousness Orientation (x3)
Language Attention
> FOR MALE: 100 + Age (up to 50) over 80 Mood & Affect Memory

> FOR FEMALE: 90 + Age (up to 50) over MAJOR COMPONENTS OF

80 MENTAL STATUS
Appearance
> FOR CHILD: 94-100 over 56-64
> posture, body movements, dress,
grooming & hygiene
> FOR INFANT (birth): 60-80 over 40-76
Behavior
> FOR INFANT (6months): 90 over 40-76 > level of consciousness, facial
expression, speech, mood and affect
PALPATED BP
Cognition
> Feeling for the systolic pressure.
> orientation, attention span, recent
HYPERTENSION and remote memory, judgement

> Abnormally high blood pressure over 140 Thought Process

mm Hg systolic and or above 90 mm Hg > thought content, perceptions, screen
diastolic. for suicidal thoughts, when indicated

TWO CONSECUTIVE READINGS: PSYCHOSOCIAL ASSESSMENT

Primary > Evaluation of an individual's mental health
> Essential and idiopathic. and social well-being.

Secondary > Used to help the nurse determine if the

> With known disease process.
HYPOTENSION
> Abnormally low blood pressure below 90
mm Hg systolic and or below 60 mm Hg
diastolic.
patient is in a state of mental health or
mental illness.
> Health, employment, finances, education,
religion, stress and support network,
including friends and family.

PULSE PRESSURE COGNITIVE ASSESSMENT

> Difference between the systolic and > Assessments of the cognitive capabilities
diastolic pressures. of humans that include various forms of IQ
tests.
> NORMAL - 30-40 mm Hg
> Includes:
MENTAL STATUS Reasoning
> Assessing the emotional and cognitive Perception
functioning of the person. Memory
Verbal
Mathematical ability
Problem solving
 Health Assessment Lecture
PRELIMS REVIEWER

MORAL DEVELOPMENT FACTORS AFFECTING RESPONSE

> The process through which a person
develops proper attitudes and behaviors
toward other people in society, based on
social and cultural norms, rules, and laws.
> Involves the formation of a system of
values on which to base decisions
concerning "right" and "wrong, " or "good"
and "bad."
THEORY OF MORAL DEVELOPMENT
BY LAWRENCE KOHLBERG
& TOLERANCE TO PAIN
Social-Cultural Influences
Age
Gender
Support people
Past pain experiences
Environment
SYSTEMATIC PAIN ASSESSMENT
Ask about pain regularly, Assess
systematically.
Believe the patient’s and family reports
about pain.
Choose pain control options appropriate
to the patient, the family, and setting.
Deliver interventions in a timely, logical,
coordinated fashion.
Empower patients and families, enable
them to control their course in the
greatest extent possible.

PAIN ASSESSMENT TOOLS

Numerical Rating Scale
Wong-Baker Faces Scale
Verbal Graphic Rating Scale

PAIN
> An unpleasant sensory and emotional
experience arising from actual or potential
tissue damage.

> Defined subjectively based on person’s

own experience, fifth vital sign.

AGE DIFFERENCES AND THE OLD CART BREAKTHROUGH

PAIN EXPERIENCE PAIN ASSESSMENT TOOL
Health care providers should realize O: Onset of pain
that pain in the absence of disease is L: Location (s) of pain
not a normal part of aging D: Duration of pain
More than half of the people over 65 C: Characteristics
years of age have arthritic pain A: Aggravating factors
There is a mild age-related increase in R: Relieving factors
the pain threshold T: Time factor
Pain symptoms may not be typical for
the elderly for myocardial conditions,
intra-abdominal infections, various
types of cancers and some acute
inflammatory conditions
Regular use of standardized tools and
consistent documentation are most
important elements in pain assessment
 Health Assessment Lecture
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VIOLENCE
> Health problems that nurses must
assess, document, and report because it
has serious effects in all dimensions of a
person’s life and health.
> The use of physical force to harm
someone, to damage property.
CATEGORIES OF
FAMILY VIOLENCE
A. Intimate Partner Violence
> Physical abuse, sexual (with
force/threat), psychological abuse,
emotional abuse.
B. Child Abuse
> Failure to provide child’s basic
needs, physical abuse, sexual abuse,
emotional abuse.
C. Elder Abuse
> Failure to provide basic needs
including health care & medications,
physical abuse, psychological abuse,
financial abuse.
CULTURE & ETHNICITY
> Totality of socially transmitted
behavioral patterns, arts, beliefs, values,
customs, life ways and all other products
of human work and thought characteristic
of a population or people that guide their
worldview and decision making.
BASIC CHARACTERISTICS
OF CULTURE & ETHNICITY
Culture is learned
Culture is shared
Culture is associated with
adaptation to the environment
Culture is universal
INFLUENCE OF CULTURE
ON HEALTH
CULTURAL FACTORS
Determines the worth of behavior
If when applied to health, affects
individual’s expectations of
health care
CULTURAL BOUND SYNDROMES
Illnesses defined as such by a
specific cultural group but
interpreted differently or not
perceived as illnesses by other
groups.
CULTURAL DESIRE
> The sincere desire to acquire the
cultural knowledge and skill necessary for
effectively assessing the client.
CULTURAL AWARENESS
> Deliberate cognitive process in which
the healthcare provider becomes
appreciative and sensitive to the values,
beliefs, life ways, practices and problem
solving strategies of a client’s culture.
CULTURAL SKILL
> Ability to collect relevant cultural data
regarding the client’s health history and
presenting problem as well as accurately
performing a physical assessment.
CULTURAL KNOWLEDGE
> Process of seeking and obtaining a
sound educational foundation concerning
the various world views of different
cultures.
CULTURAL ENCOUNTERS
> Process that allows the healthcare
provider to engage directly in face-to-face
interactions with clients from culturally
diverse backgrounds.
SPIRITUALITY
> Search for meaning and purpose in life.
> It seeks to understand life’s ultimate
question in relation to the sacred
RELIGION
> Rituals, practices and experiences
shared within a group that involve a search
for the sacred.
 Health Assessment Lecture
PRELIMS REVIEWER

GENERAL RECOMMENDATIONS
WHEN TAKING SPIRITUAL
HISTORY
Consider spirituality as an important
component of a client’s well-being.
Address spirituality at each examination
Respect a client’s privacy regarding
beliefs, do not impose your own beliefs.
Make referrals to chaplains, spiritual
director.
Be aware of your own spiritual beliefs.

NUTRITIONAL STATUS
Diet recall 24 – hour recall
Eating habits and current appetite
Food allergies and intolerance
Daily intake of caffeine