Notre Dame University respiratory rate and complains of headache.
College of Health Science You take temperature using a thermometer
RLE-NCM 101
Hanna Teresa C. Salgado,
RN
INTRODUCTION ON HEALTH
ASSESSMENT
Nursing: Scope and Standards of Practice
states as Standard 1 that "The registered nurse
collects comprehensive data pertinent to the
patient's health or situation" (ANA, p.21).
To accomplish this pertinent and
comprehensive data collection, the nurse
collects data in a systematic and ongoing
process.
ASSESSMENT
― is collecting, validating, organizing
and recording data about the patient's
health status.
― If data collection is inadequate or
inaccurate, incorrect nursing
judgments may be made.
Health assessment is more than just
gathering information about the health status
of the client
Health assessment is more than just taking
the vital signs like the temperature, pulse rate,
respiratory rate and blood pressure,
interpreting laboratory and diagnostic test
results to be normal or abnormal, taking the
past and present patient history and
performing head-to-toe assessment.
HEALTH ASSESSMENT is the analyzing
and synthesizing of data, making judgments
about the effectiveness of nursing
interventions and evaluating client care
outcomes.
Health assessment has a wider scope than
mere assessment or data collection. It is a
total care of the client.
Health assessment involves critical thinking
in the analyzing of the data collected from
Patient A for example, observing if nursing
care given to her has been effective or not and
evaluating if she gets well or gets worse.
EXAMPLE:
Patient Joanna upon your assessment has skin
warm to touch or hot skin with rapid
RM-C3
that had been kept for a long time and it reads
36.5.
Using your critical thinking, you might
wonder and ask yourself, "How come the
temperature is normal when Patient Joanna
showed signs and symptoms of fever?"
Look at your patient, not just the
thermometer.
Solutions:
 You may give Patient Joanna a
Paracetamol like Tempra syrup as
ordered by the doctor.
 Let her take a lukewarm water bath
to lower the body temperature.
 Do tepid sponge bath
 Let her wear light clothes, not thick
ones to promote heat loss.
 Give her plenty of water to drink to
prevent dehydration
 Observe if your interventions have
been effective by re-checking the
temperature of Patient Joanna 30
minutes to 1 hour after giving her
Paracetamol.
If Patient Joanna's temperature shows 37
degrees Celsius and her skin not warm to
touch then it means her fever has subsided
and your interventions were effective.
CRITICAL THINKING is one component of
nursing health assessment aside from
collection of data.
FOCUS OF HEALTH ASSESSMENT IN
NURSING
― A comprehensive health assessment
consists of both a health history and
physical examination.
PURPOSE OF NURSING HEALTH
ASSESSMENT:
― To collect holistic subjective and
objective data to determine a client's
overall level of functioning in order
to make a professional clinical
judgment.
The nurse collects physiologic, psychological,
socio- cultural, developmental, and spiritual
data about the client. Thus the nurse performs
holistic data collection.
NURSE'S ROLE IN HEALTH
ASSESSMENT
 The nurse's role in health assessment
has changed significantly over the
years. Nurses from numerous
countries are expanding their
assessment and nursing diagnosis
skills.
 The nurse, in particular, focuses on
how the client's health status affects
activities of daily living (ADL) and
how those activities of daily living
affect the client's health.
For example, a client with asthma may have
to avoid extreme temperatures and may not be
able to enjoy recreational camping.
If this client walks to work in a smoggy
(smoky) environment, it may affect this
person's asthma.
 In addition, the nurse assesses how
clients interact within their family
and community, and how the client's
health status affects the family and
community.
For example, a diabetic client may not be able
to eat the same foods that the rest of the
family enjoys.
 If this client develops complications
of diabetes and has an amputation,
the client may not be able to carry
out the family's responsibility of
maintaining the yard.
 The client may no longer be able to
work in the community as a bus
driver.
 The nurse also assesses how family
and community affect the individual
client's health status.
A supportive creative family may find
alternative ways of cooking tasteful foods that
are healthy for the entire family.
 Nurse have different assessment
roles.
RM-C3
- The acute care nurse performs a
focused assessment, and then
incorporates assessment findings
with a multidisciplinary team to
develop a comprehensive plan of
care.
- Critical care outreach nurses need
enhanced assessment skills to safely
assess critically ill clients who are
outside the structured intensive care
environment.
- Ambulatory care nurses assess
and screen clients determine the
need for physician referrals.
- Home health nurses make
independent nursing diagnoses and
referrals for collaborative problems
as needed
- Public health nurses assess the
needs of communities, school
nurses monitor the growth and
health of children, and hospice
nurses assess the needs of
terminally ill clients and their
families.
- In all settings, the nurse increasingly
documents and retrieves assessment
data through sophisticated
computerized information system.
Lesson: Functional Assessment
NEWBORN
APGAR SCORING
― An assessment of the infant’s ability
to adapt to extrauterine life
― Dr. Virginia APGAR
― Also known a Newborn Scoring
System
― Done at 1 minutes and at 5 minutes
after delivery
― If with abnormalities, an additional
APGAR score at 10 minutes after
delivery is taken
SCORING:
8-10 = NORMAL
 4-7 = MAY NEED RESUSCITATIVE ― Detection of developmental
MEASURES disabilities
3 below = IMMEDIATE ― Children 6 ½ years and below
RESUSCITATION
What is MMDST?
― Simple and clinically useful tool
― To determine early serious
developmental delays in children
ASSESS FOR: between 2 weeks and 6½ years old
Example: 0 1 2
1. A baby boy was born at 7:35 am via ACTIVITY Flaccid Some Well
normal spontaneous vaginal delivery. (Muscle tone) flexion flexed
Immediately upon delivery, the nurse PULSE Absent <100 bpm >100
observed that he had irregular (heart rate) bpm
respirations, grimaces and has active GRIMACE No Grimace Cough
movement of the extremities. His (Reflex respons ,
fingers and toes were also observed irritability) e sneeze,
to be purplish in color. And data cry
after pulse taking revealed that his APPEARAN Blue / Acrocyanosi norma
pulse rate is 115 beats per minute. CE pale all s l
What is the baby’s APGAR Score? (Color) over
RESPIRATI Absent Slow, Good,
ON irregular, strong
(Respiratory weak cry cry
2. 5 minutes after, apical rate remained effort)
stable. He also had active flexion and ― Dr. William K. Frankenburg
had a good strong cry. A marked ― Modified and standardized by Dr.
improvement was also seen in his Phoebe D. Williams DDST to
extremities as this became pinkish in MMDST
color. What is the APGAR Score? ― Developed for health professionals
― It is NOT AN INTELLIGENCE
TEST.
― MMDST is a screening instrument to
INFANT AND CHILDREN determine if child’s development is
within normal.
METRO MANILA DEVELOPMENTAL PURPOSES:
SCREENING TEST ― Measures developmental delays
― Evaluates 4 sectors of development

Overview
― Screening is a presumptive
identification of unrecognized
disease or defect
― Early detection model
― Test children with problem
― Facilitates early referral and
treatment
FOUR SECTORS OF DEVELOPMENT
• Personal-Social – tasks which
indicate the child’s ability to get
along with people and to take care of
himself

RM-C3
 • Fine-Motor Adaptive – tasks which
indicate the child’s ability to see and
use his hands to pick up objects and
to draw
• Language – tasks which indicate the
child’s ability to hear, follow
directions and to speak
• Gross-Motor – tasks which indicate
the child’s ability to sit, walk and
jump
MMDST KIT
 Manual
 Sample test form
 Test materials
 MMDST bag
Test Materials
• A bright red yarn pom-pom
• A rattle with narrow handle
• Eight 1-inch colored wooden
blocks (red, yellow, blue green)
• A small clear glass/bottle with 5/8-
inch opening
• A small bell with 2 ½ inch-diameter
mouth
• A rubber ball 12 ½ inches in
circumference
• Cheese curls
• A pencil
IMPORTANT CONSIDERATION
― Child’s age is crucial = initial step in
test administration
― Test items will be dependent on age
of child
― Age = guide the selection of test
items and subsequent interpretation
of results
CALCULATING THE CHILD’S AGE
DRAWING THE AGE LINE
― Use age scale shown at the top and
bottom of the form
― Mark the age and draw a line through
all four sectors
― Location of age must be accurate
interpretation depends on correct
placement of the line
― Space between age –--
2 weeks until 14 mos
1 mo from 14 to 24 mos
From 24 mos to 5 yrs spaces
between represent 3 mos and
thereafter 6 mos
ADJUSTING FOR PREMATURITY
• Prematurity affect ability to perform
that normal child pass at the same
age
• Adjust for children 2 years or
younger
• For two or three weeks earlier,
subtract the number of weeks from
actual age
• Draw age line based on adjusted age
THE TEST FORM
• Made of 105 items written in the
range of development of children
between birth and six years of age
• Across the top and bottom of form
are age scales
• Age is marked in months 1-24, and
age in years from 2 ½ to 6.
• Each item is represented in the test
form by a bar
• The bar is placed along the age scale
to show when 25%, 50% (indicated
by the hatch mark) 75% and 90% of
the normal children are able to pass
the item.

YEAR MONTH DAY

DATE OF 21 11 22
THE TEST
BIRTH -17 -3 -17
DATE
4 8 5

RM-C3

• Some items have a small footnote
number at the left end of the bar
• Footnote indicates corresponding
instruction for administering the item
found at the test form
• Some items may be passed by report
of the parent (R)
• Only items with an R on the form
can be passed by report
• However, whenever possible tester
should observe what the child can
perform
• The item, equal movements, has an
asterisk (*) at the right end of its bar
• Indicates 100% of normal children
pass this item at birth
• It is the only item with an * (fine-
motor adaptive sector
• 9 items have arrows () at the right
end of these bars
• This includes the items, defines
words and composition of ___.
• Arrows indicate that normal children
may pass these items even beyond 6
½ y.o.
MMDST
Administration and Scoring Directions
Selecting Items to be administered
• Administer first those through which
child’s chronological age line passes
• If failure occurs in any items,
proceed to administer items to the
left of the age line until you obtain 3
passes then stop
What to keep in mind?
• All items crossing the age line
should be administered
RM-C3
• Child should have a minimum of
three passes to the left of any failure:
and
• Each sector should have at least 3
passes and three failures
THE TEST PROCEDURE
• Preliminary Phase
– Establish rapport
– Make the child as
comfortable as possible
• If infant…on
mother’s lap
• Materials should
be accessible
• If child is one year older, put child at
ease
– Show toys…etc.
― Start with Personal-social sector
― Gives child chance to get used to
tester
― Gives tester chance ask parents
which can be scored based on report
and can also directly observe it
― Fine motor-adaptive sector follows
― Child can perform tasks even without
having to directly talk to tester
― Filipino child…. warming up
― Third is, language sector
― This time child is more comfortable
with you (tester)
― Will talk as much to you
― Lastly, gross-motor sector
― Many children are too shy at the
beginning of the test
What may not be changed?
• Manner in which each test is
administered
• Words or direction may not be
changed.
Scoring the Test
• Passed (P)
• Failed (F)
• Refused (R)
• No opportunity (NO)
― Use of No Opportunity i.e. pedals
tricycle
― Child never had any opportunity to try a
bicycle…. never failed nor refused
― Items scored NO are not considered in
the overall test scores.
― Test item that is failed and which falls
completely to the left of age line is
considered a delay.
― Means, child failed to pass an item
which 90% of children normally can
pass at younger age
― Delays are used to interpret the total
MMDST results.
― Delays on the test form are emphasized
by shading the right end of the bar of the
delayed item.
― If age line touches the right end of the
bar, the item is not considered a delay.
SCORING DELAYS IN DEVELOPMENT
TEST DIRECTION
PERSONAL – SOCIAL
• REGARDS FACE – (12 inches)
• SMILES RESPONSIVELY (r)
1. Try to get the child to smile
by smiling, talking, or waving to
him. Do not touch him.
• SMILES SPONTANEOUSLY (r)
• PERSONAL - SOCIAL
• REGARDS FACE – (12 inches)
• SMILES RESPONSIVELY (r)
2. When the child is playing with
toy, pull it away from him.
Pass if he resists.
RM-C3
• PLAYS PEEK A BOO
• WORKS FOR TOY OUT OF
REACH
• INITIALLY SHY WITH
STRANGERS (r)
• PLAYS PAT A CAKE (r)
• PLAYS BALL WITH EXAMINER
• INDICATES WANTS (not cry) (r)
• DRINKS FROM CUP (r)
• REMOVES GARMENTS (r)
• IMITATES HOUSEWORK (r)
• USES SPOON SPILLING LITTLE
(r)
• HELPS IN HOUSE – SIMPLE
TASKS (r)
• PUTS ON CLOTHING (r)
• WASHES AND DRIES HANDS (r)
• PLAYS INTERACTIVE GAMES
(r)
• SEPARATES FROM MOTHER
EASILY (r)
• DRESSES WITH SUPERVISION
(r)
• BUTTONS UP (r)
• DRESSES WITHOUT
SUPERVISION (r)
3. Child does not have to be able
to tie shoes or button in the
back
FINE MOTOR ADAPTIVE
• FOLLOWS TO MIDLINE
4. Move yarn slowly in an arch
from one side to the other,
about 6” above child’s face.
Pass if the eyes follow 90o
to midline. (past midline; 180o)
• EQUAL MOVEMENTS
• FOLLOWS PAST MIDLINE (4)
• FOLLOWS 180°
• HANDS TOGETHER (r)
• GRASP RATTLE
5. Pass if the child grasps
rattle when it is touched
to the back or tips of fingers
• REGARDS CHEESE
CURLS
• REACHES FOR OBJECTS (r)
• SIT, LOOK FOR YARN
 6. Pass if the child continues to look
where yarn disappeared or tries to
see where it went. Yarn
should be dropped quickly from
sight from tester’s hand without
arm movement

• SIT, TAKES 2 CUBES (r) • PICKS LONGER LINE

• RAKES CHEESE CURLS 10. Which line is longer (not
• PASSES CUBES HAND TO HAND bigger) Turn the paper upside
(r) down on repeat (3/3 or 5/6)?
• BANGS 2 CUBES HELD IN
HANDS (r)
• THUMB FINGER GRASP
7. Pass if the child picks up cheese
curl with any part of the thumb
and finger • COPIES +
11. Pass any
• NEAT PINCER GRASP crossing line
8. Pass if child picks up cheese curl
with the ends of thumb and index
finger using an over hand
approach
• COPIES
• SCRIBBLES SPONTANEOUSLY • IMITATES DEMONSTRATED
(r) 12. Have child copy first. If failed,
• TOWER OF 2 CUBES demonstrate
• TOWER OF 4 CUBES
• TOWER OF 8 CUBES
• IMITATES VERTICAL LINE
• DUMPS CHEESE CURLS FROM
BOTTLE – SPONTANEOUSLY
• DUMPS CHESSE CURLS FROM
BOTTLE - DEMONSTRATED
• IMITATES BRIDGE • DRAWS MAN 3-PARTS
13. When scoring, each pair (2 arms,
2 legs, etc.) counts as one part
• DRAWS MAN 6-PARTS (13)

• COPIES LANGUAGE
9. Pass any enclosed form. Fail
continuous round motion. • RESPONDS TO BELL
• VOCALIZES (not crying) (r)
• LAUGHS (r)
Note • SQUEALS (r)
When giving items 9, 11 and • TURNS TO VOICE
12, do not name the forms. Do • DADA OR MAMA, nonspecific (r)
• IMITATES SPEECH SOUND (r)
not demonstrate 9 and 11.
• DADA OR MAMA, specific
• 3 WORDS OTHER THAN MAMA
OR DADA
RM-C3
 • COMBINES 2 DIFFERENT
WORDS (r)
• NAMES ONE PICTURE
14. Point to picture and have the child
name it. (No credit is given for
sounds only)
• FOLLOWS DIRECTION
15. Tell the child to: give block to
mommy; put block on table; put
block on floor. Pass 2 of 3. (Do not
help child by pointing, moving head
or eyes.)
• USES PLURALS (r)
• GIVES FIRST AND LAST NAME
(r)
• COMPREHENDS COLD, TIRED
AND HUNGRY
16. Ask child: What do you do when you
are cold? Hungry? Tired? Pass 2 of
3.
• COMPREHENDS PREPOSITIONS
17. Tell child to: Put block on table;
under table; in front of chair, behind
chair. Pass 3 of 4. (Do not
help child by pointing, moving head
or eyes.)
• RECOGNIZES COLORS (r)
• OPPOSITE ANALOGIES
18. Ask child: If fire is hot, ice is?
Mother is a woman, Dad is
a? a horse is big, a mouse is?
Pass 2 of 3.
• DEFINES WORDS
19. Ask child: What is a ball? River?
Desk? House? Banana? Curtain?
Roof? Fence? Street? Pass if
defined in terms of use, shape, what
is it made of or its general category
(such as banana is a fruit, not just
yellow). Pass 6 of 9.
• COMPOSITION OF
20. Ask child: What is a spoon made of?
A shoe made of. A door made of. (no
other objects can be substituted.)
Pass 3 of 3.
RM-C3
GROSS MOTOR
• STOMACH LIFTS HEAD (r)
• STOMACH HEAD UP 45°
• STOMACH HEAD UP 90°
• STOMACH CHEST UP, ARM
SUPPORT
21. When placed on stomach, child lifts
chest off table with support of
forearms and/or hands.
• PULL TO SIT, NO HEAD LAG
22. While child is on back, grasp his
hands and pull him to sitting.
Pass if head does not hang
back
• SIT-HEAD STEADY
• ROLLS OVER (r)
• BEAR SOME WEIGHT ON LEGS
• SITS WITHOUT SUPPORT
• STANDS HOLDING ON (r)
• PULLS SELF TO STAND (r)
• GETS TO SITTING (r)
• WALKS HOLDING ON TO
FURNITURE (r)
• STANDS MOMENTARILY (r)
• STANDS ALONE WELL (r)
• STOOPS AND RECOVERS (r)
• WALKS WELL (r)
• WALKS BACKWARDS (r)
• WALKS UP STEPS (r)
23. Child may use wall or rail only, not
person. May not crawl.
• KICKS BALL FORWARD (r)
• THROWS BALL OVERHAND
24. Child must throw ball overhand 3
feet to within arm’s reach of tester
• BALANCES ON 1 FOOT 1
SECOND
• JUMPS IN PLACE
• BROAD JUMP (r)
25. Child must perform standing broad
jumps over width of test sheet (8 ½
inches)
• PEDALS TRICYCLE (r)
 • BALANCE ON 1 FOOT 5 • Count the number of scores that
SECONDS have 1 delay with no passes
• BALANCE ON 1 FOOT 10 intersecting the age line in the
SECONDS same sector
• HEEL TO TOE WALK  Step 4
26. Tell child to walk forward, heel • Interpret the result using the
within 1 inch of toe. Tester following criteria
may demonstrate. Child must walk 4 • Next slide please
consecutive steps, 2 out of 3 trials.
CRITERIA INTERPRETATI
• HOPS ON 1 FOOT ON
• CATCHES BOUNCED BALL
27. Bounce ball to child who should 2 or more sectors with 2 or ABNORMAL
stand 3 feet away from tester. more delays
Child must catch ball with 1 sector with 2 or more ABNORMAL
hands, not arms, 2 out of 3 trials. delays plus 1 or more
sectors with 1 delay and
• BACKWARD HEEL TO TOE in that same sector, no
28. Tell child to walk backward toe passes intersecting the
within 1 inch of heel. Tester age line
may demonstrate. Child must walk 4
consecutive steps, 2 out of 3 trials.
1 sector with 2 or more QUESTIONAB
IMPORTANT delays LE
• Date and Behavioral Observations
o How child feels at time of 1 or more sectors with QUESTIONAB
1 delay and in that LE
test, relations to tester,
sector, no passes
attention span, verbal
intersecting the age
behavior, self- confidence,
line
etc.)

INTERPRETING THE TEST RESULTS When REFUSALS UNTESTABLE

occur in numbers large
• MMDST result is interpreted enough to cause the
as NORMAL, QUESTIONABLE, test result to be
ABNORMAL OR UNTESTABLE QUESTIONABLE or
depending on the number of delays ABNORMAL if
• Remember!!!!!! That a delay is any these were scored as failures
failure that completely falls to the
Any condition not listed NORMAL
left of the age line
above
 To properly interpret the result of the
test, follow the steps listed
 Step 1 • At the bottom of the age line,
• Mark each delay by heavily indicate the test result and
shading right end of the bar interpretation
 Step 2 • E.g. Abnormal, reasons: 2 sectors
• Count the number of sectors have 2 delays
that have 2 or more delays
 Step 3 DISCUSSING THE TEST RESULT

RM-C3
 • At the end of the test, ask parent
whether child’s performance is
typical of his ability and behavior.
• Why? Sometimes child may be too
shy, ill, tired, or upset when tested to
show what he can actually perform
• Overall interpretation should be
given to parent in general terms
rather than using the labels
ABNORMAL, QUESTIONABLE
OR NORMAL
• Praise child if child done well and
assure mother child is developing as
he should be
• If, the child has a number of delays,
remind that this is just a screening
test and that you would like to test
the child again after approximately
two weeks
RETESTING
• To retest draw on the same form the
age line using another color of pencil
• Write the date at the top of new age
line
• If, a child is abnormal, questionable,
or untestable on second test should
be referred to pediatrician or health
personnel for further evaluation
• Nurses can be trained to teach
parents skills in developmental
stimulation
• Continued surveillance and periodic
retesting should be done
DIFFICULT TEST SITUATIONS
• THE SHY CHILD
> icebreaker (offer cheese
curls, toys)
> ask with items scored by
report
> ask parent to administer
some of the test
> if all fails, retest 2-3 weeks
later
• THE UNCOOPERATIVE CHILD
> the same as shy child
> ask parent to leave the room
OR ask parent to turn away
> reverse psychology
RM-C3
• THE OVERACTIVE CHILD
> mastery of test items
> limit distractions
> bring out only materials
needed
> keep bag behind you / tell
him that you have a surprise
> direct the child’s attention
> be firm and calm – TELL,
DO NOT ASK
> hold the child or sit next to
the child
• THE CHILD WITH MANY
SIBLINGS
> test each child individually
and separately
• THE INTERFERING PARENT
> explain what MMDST is
> if the parent interferes,
repeat the explanation of
MMDST
> if the parent still interferes,
ask them to leave the room
or reschedule
ADULTS
GORDON’S TYPOLOGY OF
FUNCTIONAL HEALTH PATTERNS
MANAGEMENT PATTERN
1. History
a. How has general health been?
b. Any colds in past year? When
appropriate: absences from work?
c. Most important things you do to
keep healthy. Think these things
make a difference to health?
(Include family folk remedies when
appropriate.) Use of cigarettes,
alcohol, drugs? Breast self-
examination?
d. Accidents (home, work,
driving)?
 2. Examination—general health
appearance
NUTRITIONAL-METABOLIC
PATTERN
1. History
a. Typical daily food intake?
b. Typical daily fluid intake?
c. Weight loss or gain? weight
loss or gain?
d. Appetite?
e. Food or eating: Discomfort?
Swallowing? Diet restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions?
Dryness?
h. Dental problems?
2. Examination
Skin, Oral mucous membranes, Teeth,
Actual weight, Height, temperature,
Intravenous feeding–parenteral feeding
ELIMINATION PATTERN
1. History
a. Bowel elimination pattern?
Frequency? Character?
Discomfort? Problem in
control? Laxatives?
b. Urinary elimination pattern?
Frequency? Problem in
control?
c. Excessive perspiration? Odor
problems?
d. Body cavity drainage, suction,
and so on?
2. Examination—when indicated:
examine excreta or drainage, color,
and consistency.
ACTIVITY-EXERCISE PATTERN
1. History
a. Sufficient energy for desired or
required activities?
b. Exercise pattern? Type?
Regularity?
c. Spare-time (leisure) activities?
Child: play
d. activities?
e. Perceived ability (code for
level) for ADLs:
RM-C3
f. Feeding Dressing Cooking
2. Examination
Gait, Posture, Range of motion, hand grip
SLEEP-REST PATTERN
1. History
a. Generally rested and ready for
daily activities after sleep?
b. Sleep onset problems? Aids?
Dreams (nightmares)? Early
awakening?
c. Rest-relaxation periods?
2. Examination
a. When appropriate: Observe sleep
pattern.
COGNITIVE-PERCEPTUAL PATTERN
PATTERN
1. History
a. hearing difficulty? hearing aid?
b. Vision? Wear glasses? Last
checked? When last changed?
a. Any change in memory lately?
b. Important decision: easy or
difficult to make?
c. Easiest way for you to learn
things? Any difficulty?
2. Examination
a. Orientation.
b. hears whisper? Reads newsprint?
c. Grasps ideas and questions
(abstract, concrete)?
d. Language spoken.
e. Vocabulary level. Attention
span.
SELF-PERCEPTION—SELF-CONCEPT
PATTERN
1. History
a. how do you describe self?
b. Changes in body or things you
can’t do?
c. Changes in way you feel about
self or body?
d. Things frequently make you
angry. Annoyed?
e. Fearful? Anxious?
f. Ever feel you lose hope?
2. Examination
a. Eye contact. Attention span
(distraction).
 b. Voice and speech pattern. Body c. Female: When menstruation started?
posture Last menstrual period? Menstrual
problems? Para? Gravida?
SELF-PERCEPTION—SELF-CONCEPT 2. Examination
PATTERN
1. History COPING-STRESS TOLERANCE
a. How do you describe self? PATTERN
b. Changes in body or things you
can’t do? 1. History
c. Changes in way you feel about a. Any big changes in your life in
self or body? the last year or two? Crisis?
d. Things frequently make you b. Who’s most helpful in talking
angry? Annoyed? things over? Available to you
e. Fearful? Anxious? now?
f. Ever feel you lose hope? c. Tense or relaxed most of the
2. Examination time? When tense, what helps?
a. Eye contact. Attention span d. Use any medicines, drugs,
(distraction). alcohol?
b. Voice and speech pattern. Body e. When (if) have big problems
posture (any problems) in your life,
how do you handle them?
ROLES-RELATIONSHIPS PATTERN f. Most of the time is this (are
1. History these) way(s) successful?
a. Live alone? Family? Family
structure (diagram)? VALUES-BELIEFS PATTERN
b. Any family problems you have 1. History
difficulty handling? a. Generally get things you want
c. Family or others depend on you from life? Important plans for the
for things? future?
d. When appropriate: How family b. Religion important in life? When
or others feel about illness or appropriate: Does this help when
hospitalization? difficulties arise?
e. When appropriate: Problems c. When appropriate: Will being
with children? Difficulty here interfere with any religious
handling? practices?
f. Belong to social groups? Close
friends? Feel lonely? PURPOSE OF ASSESSING ELDERLY
2. Examination ADULTS
a. Interaction with family • to maximize function and limit
member(s) or others. disability by correctly identifying
and describing that person’s ability
SEXUALITY-REPRODUCTIVE to perform daily activities.
PATTERN • to empower clients to maintain the
PATTERN relationships, activities, and events
1. History that they find meaningful.
a.When appropriate to age and
situations: Sexual relationships
satisfying? Changes? KATZ ACTIVITIES OF DAILY
Problems? LIVING
b. When appropriate: Use of
contraceptives? Problems? ACTI INDEP DEPE
RM-C3
VITIE ENDE NDE garment
S NCE NCE s
(1 (0 complet
point) point) e with
POIN NO WITH fastener
TS supervi superv s. May
sion, ision, have
directiodirecti help
n, or on, tying
persona person shoes.
l al TOIL Goes to Needs
assistanassista ETIN toilet, help
ce nce, or G gets transfe
total on and rring
care off, to
BATH Bathes Needs arrange the
ING self help s toilet,
complet with clothes, cleani
ely or bathin cleans ng
needs g more genital
help in than area
bathing one without
only a part of help.
single the TRAN Moves Needs
part of body SFER in and help in
the getting ING out of movin
body in bed or g from
such as or out chair bed to
the of unassist chair
back, the tub ed, or
genital or Mechan requir
area, or showe ical es
disable r. transfer a
d Requir ring compl
extremi es aides ete
ty. total are transfe
bathin accepta r.
g. ble
DRES Gets Needs CONT Exercis is
SING clothes help INEN es partial
from with CE complet ly or
closets dressi e totally
and ng self self- inconti
drawers or control nent of
and needs over bowel
puts to be urinatio or
on compl n and bladde
clothes etely defecati r.
and dresse on.
outer d. FEED Gets Needs

RM-C3
ING food partial 5 – NEEDS HELP
from or 10 – INDEPENDENT
plate total  TRANSFERS
into help 0 – UNABLE, NO SITTING BALANCE
mouth with 5 – MAJOR HELP (1 OR 2 PEOPLE)
without feedin 10 – MINOR HELP
help. g or 15 – INDEPENDENT
Prepara requir
tion of es  MOBILITY
food parent 0 – IMMOBILE
may be eral 5 – WHEELCHAIR INDEPENDENT
done by feedin 10 – WALKS WITH HELP
another g. 15 – INDEPENDENT (but may use aids)
person.
 STAIRS
6 = FULL FUNCTION 0 – UNABLE
3-5 = MODERATE IMPAIRMENT 5 – NEEDS HELP
2 OR LESS = SEVERE FUNCTIONAL 10 – INDEPENDENT
IMPAIRMENT
 FEEDING TOTAL (0-100)
BARTHEL ADL INDEX
0 – UNABLE LAWTON SCALE FOR
5 – NEEDS HELP INSTRUMENTAL ACTIVITIES OF
10 – INDEPENDENT DAILY LIVING (IADL)
 BATHING Ability to Telephone
0 – DEPENDENT 1. Operates telephone on own initiative
5 – INDEPENDENT looks up and dials numbers, etc.
2. Answers telephone and dials a few
 GROOMING well-known numbers.
0 – NEEDS HELP 3. Answers telephone but does not dial.
5 – INDEPENDENT 4. Does not use telephone at all.

 DRESSING Shopping
0 – DEPENDENT 1. Takes care of all shopping needs
5 – NEEDS HELP independently.
10 – INDEPENDENT 2. Shops independently for small
purchases.
 BOWELS 3. Needs to be accompanied on any
0 – INCONTINENT shopping trip.
5 – OCCASIONAL ACCIDENT 4. Completely unable to shop.
10 – CONTINENT
Food Preparation
1. Plans, prepares, and serves adequate
 BLADDER
meals independently.
0 – INCONTINENT
2. Prepares adequate meals if supplied
5 – OCCASIONAL ACCIDENT
with ingredients.
10 – CONTINENT
3. heats and seizes prepared meals or
 TOILET USE
prepares meals but does not maintain
0 – DEPENDENT
adequate diet.
RM-C3
 4. Needs to have meals prepared and 3. Incapable of handling money,
served.

Housekeeping
1. Maintains house alone or with
occasional assistance.
2. Performs light daily tasks such as
dishwashing and bedmaking.
3. Performs light daily tasks but cannot
maintain acceptable level of
cleanliness.
4. Needs help with all home
maintenance tasks.
5. Does not participate in any
housekeeping tasks.

Laundry
1. Does personal laundry completely.
2. Launders small items; rinses socks,
stockings, and so on.
3. All laundry must be done by others.

Mode of Transportation
1. Travels independently on public
transportation or drives own car.
2. Arranges own travel via taxi but does
not otherwise use public UNIVERSAL PRECAUTION
transportation. -control guidelines designed to protect workers
3. Travels on public transportation from exposure to diseases spread by blood &
when assisted or accompanied by other body fluids
another.
4. Travel is limited to taxi, automobile, 2 PURPOSES:
or ambulette, with assistance. 1. PROTECT THE PATIENTS
5. Does not travel at all. 2. PROTECT THEMSELVES
Responsibility for Own Medication
1. Is responsible for taking medication WHY FOLLOW UNIVERSAL PRECAUTION?
in correct dosages at correct time. -microorganisms present in human blood can cause
2. Takes responsibility if disease in humans
medication is prepared in advance, in
separated dosages. HIGHLY INFECTIOUS:
3. Is not capable of dispensing own -BLOOD
medication. -SEMEN
-VAGINAL SECRETION
Ability to Handle Finances -CSF
1. Manages financial matters -SYNOVIAL FLUID
independently (budgets, writes -AMNIOTIC FLUID
checks, pays rent and bills, goes to -OTHER BODY FLUIDS
bank); collects and keeps track of
income.
STANDARD PRECAUTION
2. Manages day-to-day purchases but
needs help with banking, major on.
RM-C3
-minimum infection prevention practice apply to all
patient care regardless of suspected or confirmed
infection status of the patient in any setting where
healthcare is declined.

CDC or Centers for Disease and Control

PPE - reduce risks from infectious disease

Protective Barriers/Equipment
-disposable items (such as gloves & mask)
-googles
-isolation gown
-face shield

RM-C3