Health Assessment NAIRA

1. Definition of nursing
The diagnosis and treatment of human responses to actual and potential health problems.

2. Nursing process
1. Nursing process composed of 5 phases.

1. Assessment

2. Nursing diagnosis

3. Planning

4. Intervention

5. Evaluation

2. Nursing assessment
Is the first stage of the nursing process in which the nurse should carry out a complete and holistic
nursing assessment by obtaining a health history and performing a physical examination to the patient.

3. When is assessment carried out?

• On patient admission.

• During emergency.

• Changes in health status.

4. Who should carry out assessment?

Various members of the healthcare team such as

- Nurses.

- Doctors.

- Health assessment course, Technical Nurse Program

- Physiotherapists.

- Nutritionists.

- Social workers.

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5. Purpose of assessment
1. To validate a diagnosis

2. To provide basis for effective nursing care.

3. It helps in effective decision making

4. Basis for accurate diagnosis

5. It promote holistic nursing care

6. To provide effective and innovative nursing care

7. To collecting data for nursing research

8. To evaluation of nursing care

6. Types of Assessment
1. Initial assessment

2. Focus Problem assessment

3. Emergency Assessment

4. Time-lapsed Assessment

7. Comprehensive
• Detailed assessment of one body system or many body systems. including those not directly involved
in presenting problem or admission diagnosis

• Used for head-to-toe assessment.

8. When and Where Performed?

• Onset of care in primary or ambulatory care setting

• On admission to hospital or long-term care setting

• On initial home care visit.

9. Focused
• Abbreviated assessment that focuses on one or more body systems that are the focus of care

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Health Assessment NAIRA

• Includes an assessment related to a specific problem (e.g., pneumonia, specific abnormal laboratory
findings)

• Monitors for signs of new problems.

10. When and Where Performed

• Throughout hospital admission-

• at beginning of a shift and as needed throughout shift

• Revisited in ambulatory care

• setting or home care setting

1. Initial assessment (admission assessment).

Is performed when the client enters a health care.

The purposes are to

• Evaluate the client's health status

• Identify functional health patterns

• Provide an in-depth, comprehensive database for evaluating changes in the client's health stans in
subsequent assessments

2. Problem-focused assessment
• Have a narrower scope & a shorter time frame than the initial assessment.

• Collects data about a problem that has already been identified.

3. Emergency assessment
• Takes place in life-threatening situations.

• Patient difficulties involve airway, breathing and circulatory problems (the ABCs).

• Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to
violent acts) can also initiate an emergency.

A: AIRWAY:

Ensure airway is patent and protected,

B. BREATHING:

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Health Assessment NAIRA

Determine the ease/effort and rate.

C:CIRCULATION

Assess tissue perfusion by checking pulses, skin temperature and color of the extremities.

4. Time-lapsed assessment or Ongoing assessment

• Time lapsed reassessment takes place after the initial assessment to evaluate any changes in the
patient functional health.

11. Steps Of Assessment

1. Collection of data

- Subjective data collection

- Objective data collection

- Validation of data

2. Organization of data

3. Recording/documentation of data

12. Types of Data

The database includes both subjective and objective data.

- Subjective data

• Also known as symptoms, are collected by interviewing the patient and or caregiver during the nursing
history.

• This type of data includes information that can be described or verified only by the patient or
caregiver. It is what the person tells you either spontaneously or in response to direct questioning.

- Objective data
• Also known as signs are data that can be observed or measured. You obtain this type of data using
inspection, palpation, percussion, and auscultation during the physical examination.

• Objective data are also acquired by diagnostic testing. Usually subjective data are obtained by
interview, and objective data are obtained by physical examination.

13.Data Collection Methods

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Health Assessment NAIRA

1. Interviewing

. 2. Examining

3. Observing

4. Head-to-toe approach

14. Physical Examination

The physical examination is the systematic assessment of a patient's physical status.

-Techniques

-examination

-techniques

-auscultation

-assessment

15. Defintion of Inspection

is the visual examination of a part or region of the body to assess normal conditions or deviations.
Inspection is more than just looking. This technique is deliberate, systematic, and focused.

16. Defintion of Palpation

is the examination of the body using touch. Using light and deep palpation

For example, use the palmar surface (base of fingers) to feel vibrations. the dorsa (backs) of your hands
and fingers to assess temperature, and tips of your fingers to palpate the abdomen.

17. Defintion of Percussion

is a technique that produces a sound and vibration to obtain information about the underlying area,

18. Defintion of Auscultation

• is listening to sounds produced by the body with a stethoscope to assess normal conditions and
deviations from normal.

• The bell of the stethoscope is more sensitive to low pitched sounds (e.g.,heart murmurs). The
diaphragm of the stethoscope is more sensitive to high-pitched sounds

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Health Assessment NAIRA

19. Guidelines for documentation

• Document legibly or print neatly in unerasable ink

• Use correct grammar and spelling

• Avoid wordiness that creates redundancy

• Use phrases instead of sentences to record data

• Record data findings, not how they were obtained

• Write entries objectively without making premature judgments or diagnosis.

• Record the client's understanding and perception of problems

• Avoid recording the word "normal" for normal findings

• Record complete information and details for all client symptoms or experiences

20. Components of a nursing assessment

1. Biographic data-name, address, age, sex, martial status, occupation, religion.

2. Reason for visit/Chief complaint - primary reason why client seek consultation or hospitalization.

3. History of present Illness - includes: usual health status, chronological story, family history, disability
assessment.

4. Past Health History- includes all previous immunizations, experiences with illness.

5. Family History-reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental
illness).

6. Review of systems - review of all health problems by body systems

21. Positions
Each position has it's specialty for parts of examination. Draping during assessment is used to prevent
unnecessary exposure. Drapes may be paper, cloth, or bed linens

I. Sitting position

II. Supine position

III. Dorsal position:

IV. Lithotomy position

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Health Assessment NAIRA

V. Sims' position

VI. Prone position

VII. Knee-chest position

1. Sitting position
• Areas Assessed.

Head and neck, back, posterior thorax and lungs, anterior thorax and lungs, breasts, axially, heart, vital
signs, and upper extremities

• Rationale:

Sitting upright provides full expansion of lungs and provides better visualization of symmetry of upper
body parts.

• Limitations:

Physically weakened client may be unable to sit. Examiner should use supine position with head of bed
elevated instead.

2. Supine position
• Areas Assessed

Head and neck anterior thorax and lungs, breasts, we, heart, abdomen, extremities, and pulse

• Rationale: This is most normally relaxed position. It prevents contracture of abdominal muscles and
provides easy access to pulse sites.

3• Dorsal position:

• Areas Assessed.

Head and neck, anterior thorax and lungs, Breasts, axillae and heart.

• Rationale.

Clients with painful disorders are more comfortable with knees flexed.

4. Lithotomy position:

• Areas Assessed.

Female genitalia and genital tract

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Health Assessment NAIRA

• Rational.

This position provides maximal exposure of genitalia and facilitates insertion of vaginal speculum.

5. Sims' position:
• Areas Assessed: Rectum and vagina

• Rationale: Flexion of hip and knee improves exposure of rectal area.

6. Prone position:

• Areas Assessed: Musculoskeletal system

• Rationale: This position is used only to assess extention of hip joint

Knee-chest position :

• Areas Assessed: Rectum.

• Rationale: This position provides maximal exposure of rectal area.

22. What is Pain?

- An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage

- Pain is always subjective.

- The patient's self-report of pain is the single most reliable indicator of pain.

- The clinician must accept the patient's self report of pain.

23. Considered to be the 5th Vital Sign

Assessment of pain should include:

1. Location does it radiate

2. Intensity-best to assess with a scale.

3. Character - is it sharp, dull, throbbing, burning

4. Onset/Duration - when did it start, how long does it last

24. Pain Assessment :

- Initial Pain Assessment should include:

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Health Assessment NAIRA

• Location(s)

• Intensity

• Sensory quality

• Alleviating and aggravating factors

• Any new onset of pain requires a new comprehensive pain assessment.

• Every 8 hours minimally

• Following the administration of pain medications to determine the effectiveness of the medication
and/or need for further intervention.

• IV within 15 mins of administration

• PO/IM/SC within hour of administration

25. Descriptions of Pain

• Classification of Pain according to duration

1. Acute

2. Chronic

• Classification of Pain according to type

1. Somatic

2. Visceral

3. Bone Pain

4. Neuropathic

26• Acute Pain

- Categories of Pain by Duration :

.• Acute pain presents most often with a clear cause, relatively brief in duration and subsides as healing
takes place.

• Acute pain is often accompanied by observable objective signs of pain :

1. increased pulse rate

2. increased blood pressure

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Health Assessment NAIRA

3. Non-verbal signs and symptoms such as facial expressions -and-tense-muscles

27. Categories of Pain by Duration :

- Acute Pain

"Brief duration, goes away with healing, usually 6 months or less"

• Not necessarily more severe than chronic

• May be sudden onset or slow in onset

• Examples are broken bones, strep throat, and pain after surgery or injury

- Chronic Pain

"Categories of Pain by Duration"

• Pain that is persistent and recurrent.

• When pain persists, it serves no useful purpose and may dramatically decrease the quality of life and
function.

• Chronic pain rarely has any observable or behavioral signs although persons may appear anxious or
depressed.

28• Chronic Non-Malignant Pain

"Pain has no predictable ending"

• Difficult to find specific cause

• Often can't be cured

• Frequently undertreated

29. • Chronic Cancer Pain

"Pain is expected to have an end, with cure or with death."

• Aggressive treatment

• Addiction not a concern.

30• Cancer Pain

• Pain that is associated with cancer or cancer treatment.

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Health Assessment NAIRA

• May be attributed to :

- Tumor location

- Chemotherapy

- Radiation therapy

- Surgical treatment

31• Descriptions of Pain

Categories of Pain by type

• Classification of Pain according to type

1. Somatic

2. Visceral

3. Bone Pain

4. Neuropathic

1- Somatic
• Source: Skin, muscle, and connective tissue

• Examples: Sprains, headaches, arthritis

• Description: Localized, sharp/dull, worse with movement or touch

• Pain med: Most pain meds will help, if severe, need a stronger medication

2- Visceral
• Source: Internal organs

• Examples: Tumor growth, gastritis, chest pain

• Description: Not localized, refers, constant and dull, less affected with movement

• Pain Med: Stronger pain medications

3- Bone Pain
• Source: Sensitive nerve fibers on the outer surface of bone

• Examples: Cancer spread to bone, fx, and severe osteoporosis

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Health Assessment NAIRA

• Description: Tends to be constant, worse with movement

• Pain med : Stronger pain meds, opiates with NSAIDS as adjunct

4- Neuropathic :

• Source: Nerves

• Examples: Diabetic neuropathy, limb pain, cancer spread to nerve plexis

• Description: Burning, stabbing, pins and needles, shock-like, shooting

• Pain Meds: Opiates+tricyclic antidepressants or other adjuvant

32• What happens if pain isn't properly treated?

1. Poor appetite and weight loss

2. Disturbed sleep

3. Withdrawal from talking or social activities

4. Sadness, anxiety, or depression

5. Physical and verbal aggression, wandering, acting-out behavior, resists care

6. Skin ulcers

7. Incontinence

8. Increased risk for use of chemical and physical restraints

9. Decreased ability to perform ADL's

10.Impaired immune function

33• Indicators of Pain

1. Breathing

2. Negative Vocalization

3. Facial Expression

4. Body Language

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34• When to assess/observe for pain

1. At admission

2. Every shift (two times per 24 hours)

3. After therapies (when should you see an effect?)

Neurological Assessment

35. When examining the nervous system, ask the following:

1. Any past history of head injury? (location, loss of consciousness)

2. Do you have frequent or severe headaches? (when, where, how often)

3. Any dizziness or vertigo? (frequency, precipitating factors, gradual or sudden)

4. Ever had/or do you have seizures? (when did they start, frequency. course and duration, motor
activity associated with, associated signs, postictal phase, precipitating factors, medications, coping
strategies)

5. Any difficulty swallowing? (solids or liquids, excessive saliva)

6. Any difficulty speaking? (forming words or actually saying what you intended)

7. Do you have any coordination problems? (describe)

8. Do you have any numbness or tingling? (describe)

9. Any significant past neurologic history? (cerebral vascular accident, spinal cord injuries, neurologic
infections, congenital disorders)

10. Environmental or occupational hazards? (insecticides, lead, organic solvents, illicit drugs, alcohol)
(Jarvis, 2008)

36. Cranial nerves

12 Cranial Nerves :

1- Cranial Nerve I : Olfactory

2- Cranial Nerve II : Optic

3- Cranial Nerves III, IV, & VI: Oculomotor, Trochlear, & Abducens

4- Cranial Nerve V: Trigeminal

5- Cranial Nerve VII: Facial Nerve

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Health Assessment NAIRA

6- Cranial Nerve VIII: Acoustic (Vestibulocochlear)

7- Cranial Nerve IX & X: Glossopharyngeal and Vagus

8- Cranial Nerve XI: Spinal Accessory

9- Cranial Nerve XII: Hypoglossal

37. The head, ears, eyes, nose, mouth, and throat.

-Ask the following questions:

1. Do you get frequent or severe headaches?

2. Any past history of head injury?

3. Do you frequently get dizzy?

4. Do you have any neck pain, swelling, or lumps?

5. Do you have a history of head or neck & surgery?

Look for :

1. General facial symmetry

2. Hair distribution

3. General facial expressions

4. Lymph nodes or lesions

38. Assessment of the Eyes

- Ask the following questions

1. Any vision changes or difficulty?

2. Any eye pain?

3. Do you have double vision?

4. Any redness, swelling or discharge?

5. Do you have a history of glaucoma?

6. Do you wear glasses or contacts (Jarvis, 2008)?

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Health Assessment NAIRA

Look for:

1. Visual acuity

2. Visual fields (confrontation test)

3. Extraocular muscle function (nystagmus, abnormal corneal light reflex)

4. Conjunctiva and sclera (redness, irritation)

5. Pupil (shape, symmetry, light reflexes, accommodation)

6. Ocular fundus (red reflex, optic disc, retinal vessels, macula

39. Assessment of the Ears

- Ask the following questions

1. Have you had many ear infections?

2. Do you have any discharge from your ears?

3. Do you have-any-hearing difficulty

4. Do you have any environmental or occupational exposure to loud noises?

5. Any ringing in your ears (tinnitus)?

6. Any dizziness (vertigo)?

Look for:

1. Size, shape, skin condition, and tenderness

2. External canal (redness, swelling, discharge)

3. Tympanic membrane [color & characteristics (amber, redness). air fluid levels]

4. Hearing acuity (also examined as you collect the patient's history

40. Assessment of the Nose

- Ask the following questions

1. Any nasal discharge?

2. Do you get frequent colds?

3. Do you have sinus pain?

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Health Assessment NAIRA

4. Do you get nose bleeds?

5. Do you have allergies?

6. Have you had a change in sense of smell (Jarvis, 2008)?

Look for:

1. Nasal cavity (discharge, thinnorhea, swollen, boggy, mucosa)

2. Sinuses (tenderness and transillumination) (Jarvis, 2008)

41. Assessment of the Mouth & Throat

1. Skin integrity (lesions or blisters)

2. Teeth (discoloration, bleeding or swollen gums)

3. Tongue (color, surface characteristics, moisture, lesions)

4. Buccal mucosa (discoloration, Koplik's spots, leukoplakia)

5. Uvula (midline)

• Throat (tonsils, Cranial Nerve XII by sticking out tongue)

Look For:

1. Do you have any sores or lesions in your mouth or throat?

2. Do you have a sore throat and hoarseness?

3. Do you have a toothache or get bleeding gums?

4. Any difficulty swallowing?

5. Do things taste differently than usual?

6. Do you smoke, drink or chew tobacco (Jarvis, 2008)?

42. Cardiovascular Assessment :

- ASK about the following:

1. Any chest pain? (use PQRST pneumonic)

2. Do you ever get short of breath? (associated with what)

3. How many pillows do you sleep on at night? (orthopnea)

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Health Assessment NAIRA

4. Do you have a cough? (describe, frequency, timing, severity, sputum production)

5. Are you frequently fatigued? (morning or night)

6. Do you have any swelling or skin color changes? (edema, cyanosis,pallor)

7. How often do you get up at night to urinate? (nocturia)

8. Do you have a past history of cardiac or cardiovascular events or disorders?

9. Do you have a family history of cardiovascular disease?

10. Assess cardiac risk factors?

43. When assessing the cardiovascular system, examine the following:

1. Palpate and auscultate the carotid artery (strength of pulsation,bruits, murmurs),

2. Inspect and palpate the jugular veins (jugular vein distention).

3. Inspect the precordium (heaves, lifts).

4. Palpate the precordium (location of apical impulse, presence of thrill).

5. Percuss cardiac borders.

6. Auscultate heart sounds.

7. Auscultate in a Z-pattern listening over the aortic, pulmonic, mitral, and tricuspid valves and over
Erb's point). Listen to S1 and S2 separately (split S1 or S2).

8. Palpate peripheral pulses: brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial (strength
and symmetry).

9. Inspect extremities (color, capillary refill, edema, ulcerations)

44. Respiratory Assessment

When examining the pulmonary system, ask the following for both abbreviated and complete
examinations:

1. Do you have a cough? (use PQRST pneumonic)

2. Do you frequently get short of breath? (position, associated night sweats, related to any triggering
event)

3. Pain with breathing? (constant or periodic. describe the quality.treatment)

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Health Assessment NAIRA

4. Any past history of breathing trouble or lung disease? (frequency and severity of colds, allergies,
asthma family history, smoking. environmental or occupational risk factors).

When examining the pulmonary system,

1. Inspect the thoracic cage (symmetry of expansion, anterior- posterior diameter, any areas of
retractions) (See appendix for retraction sites)

2. Palpate the thoracic cage (tactile fremitus)

3. Percuss the thoracic cage (hyperressonance, dullness, diaphragmatic excursion)

4. Auscultate the anterior and posterior chest

5. Have patient breath slightly deeper than normal through their mouth

6. Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should
auscultate between every rib.

7. Listen for bronchial, bronchovesicular, and vesicular breath sounds

8. Identify any adventitious breath sounds, in relation to the cardiac cycle (crackles and wheezes or
rhonchi).

45. Gastrointestinal Assessment

1. Any difficulty swallowing? (dysphagia)

2. Any abdominal pain? (use PQRST pneumonic)

3. Any nausea or vomiting? (color, odor, presence of blood, food intake in past 24 hours)

4. Any change in bowel habits? (constipation, diarrhea, blood in stool, or dark, tarry stools)

5. Do you have any hemorrhoids? (bleeding, treatment)

6. Any past history of abdominal problems? (gall bladder, liver, pancreas, digestion, elimination

When examining the GITsystem

When assessing the abdomen, examine the following:

1. Inspect for bulges, masses, hernias, ascites, spider nevi, veins, pulsations or movements, inability to
lie flat.

2. Auscultate after inspection so you do not produce false bowel sound through percussion or palpation.
Auscultate for bowel sounds (normal, hyper- or hypo-active) and bruins

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Health Assessment NAIRA

3. Percuss for general tympany, liver span, splenic dullness (dullness over the spleen), costovertebral
angle tenderness, presence of fluid wave and shifting dullness with ascites.

46. Nutritional-Metabolic
1. Describe your usual daily food and fluid intake.

2. Do you take any supplemental vitamins or minerals?

3. Have you experienced any changes in appetite or food tolerance?

4. Has there been a weight change in the past 6-12 mo?

5. Are you allergic to any foods?

47. Elimination
1. Describe the frequency and time of day you have bowel movements, What is the consistency of the
bowel movement?

2. Do you use laxatives or enemas?* If so, how often?

3. Have there been any recent changes in your bowel pattern?"

4. Describe any skin problems caused by GI problems.

5. Do you need any assistive equipment, such as ostomy equipment, raised toilet seat, commode?

48. Activity-Exercise
Do you have limitations in mobility that make it difficult for you to procure and prepare food?

49. Sleep-Rest
1. Do you experience any difficulty sleeping because of a GI problem?

2. Are you awakened by symptoms such as gas, abdominal pain, diarrhea,or heartburn?

50. Right Upper Quadrant

• Liver and gallbladder

• Pylorus

• Duodenum

• Head of pancreas

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Health Assessment NAIRA

• Right adrenal gland

• Portion of right kidney

• Hepatic flexure of colon

• Portion of ascending and transverse colon

51. Left Upper Quadrant

• Left lobe of liver

• Spleen

• Stomach

• Body of pancreas

• Left adrenal gland

• Portion of left kidney

• Splenic flexure of colon

• Portion of transverse and descending colon

52. Right Lower Quadrant

• Lower pole of right kidney

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Health Assessment NAIRA

• Cecum and appendix

• Portion of ascending colon

• Bladder (if distended)

• Right ovary and salpinx

• Uterus (if enlarged)

• Right spermatic cord

• Right ureter

53. Left Lower Quadrant

• Lower pole of left kidney

• Sigmoid flexure

• Portion of descending colon

• Bladder (if distended)

• Left ovary and salpinx

• Uterus (if enlarged)

•Left spermatic cord

•Left ureter

54. Mouth
- Moist and pink lips

- Pink and moist buccal mucosa and gingivae without plaques or lesions

- Teeth in good repair

- Protrusion of tongue in midline without deviation or fasciculations

- Pink uvula (in midline), soft palate, tonsils, and posterior pharynx

- Swallows smoothly without coughing or gagging

55. Abdomen

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Health Assessment NAIRA

- Flat without masses or scars; no bruises

- Bowel sounds in all quadrants

- No abdominal tenderness; nonpalpable liver and spleen

- Liver 10 cm in right midclavicular line

- Generalized tympany

56. Anus
- Absence of lesions, fissures, and hemorrhoids

- Good sphincter tone

- Rectal walls smooth and soft

- No masses

- Stool soft, brown, and heme negative

57. FOCUSED GASTROINTESTINAL ASSESSMENT

Subjective
Ask the patient about any of the following and note responses

1. Loss of appetite

2. Abdominal pain

3. Changes in stools (eg, color, blood, consistency.frequency)

4. Nausea, vomiting

5. Painful swallowing

Objective: Diagnostic

Check the following laboratory results for critical values.

- Endoscopy: colonoscopy, sigmoidoscopy, esophagogastroduodenoscopy CT scan

- Radiologic series: upper GI, lower GI

- Stool for occult blood or ova and parasites

- Liver function tests

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Health Assessment NAIRA

Objective: Physical Examination

Inspect
- Skin for color, lesions, scars, petechiae, etc.

- Abdominal contour for symmetry and distention

- Perianal area for intact skin, hemorrhoids

Auscultate
Bowel sounds

Palpate
- Abdominal quadrants using light touch

- Abdominal quadrants using a deep technique

58. Musculoskeletal System

When examining the musculoskeletal system, ask the following:

1. Any joint pain or problems? (Use PQRST pneumonic.)

2. Any stiffness in your joints? Any swelling, heat or redness in your joints?

3. Any limitation of movement in your joints?

4. Which activities are difficult? (Assess functional ability.)

5. Any muscle problems (pain, cramping, aches, weakness, atrophy)?

6. Any bone problems (bone pain, deformity, history of broken bones)?

When assessing the musculoskeletal system,examine the following:

1. Inspect the size and shape of any problem joints (color, swelling, masses,deformities).

2. Palpate each joint for temperature and range of motion (heat, tenderness,swelling, masses, limitation
in range of motion, crepitation).

3. Test muscle strength and strength against resistance of the major muscle groups of the body.

4. Assess the temporomandibular joint (swelling, crepitus, pain).

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Health Assessment NAIRA

5. Assess the cervical spine (alignment of head and neck, symmetry of muscles, tenderness, spasms,
range of motion).

6. Inspect and assess upper extremity strength and range of motion for the shoulders, elbows, wrists,
and hands.

7. Inspect and assess lower extremity strength and range of motion for the hips, knees, ankles and feet

59. Urinary system :

Subjective Data

Important Health Information

Past health history, pregnancy, infection, Medications: Antibiotics, Surgery or other treatments.

Functional Health Patterns

• Health perception

• Nutritional

• Elimination

• Cognitive-perceptual

• Sexuality

Objective Data

General
- Fever, chills, dysuria

Urinary

Hematuria : cloudy, foul smelling urine

60. Nervous System assessment

Health Perception-Health Management

1- What are your usual daily activities?

2- Do you use alcohol, tobacco, or recreational drugs?

3- What safety practices do you perform in a car? On a motorcycle? On a bicycle?

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Health Assessment NAIRA

4- Do you have hypertension? If so, is it controlled?

5- Have you ever been hospitalized for a neurologic problem?

61. Nutritional-Metabolic
1- Are you able to feed yourself?

2- Do you have any problems getting adequate nutrition because of chewing or swallowing difficulties,
facial nerve paralysis, or poor muscle coordination?

3- Give a 24-hr dietary recall.

62. Elimination
1- Do you have incontinence of your bowels or bladder?

2- Do you ever experience problems with hesitancy, urgency, retention?

3- Do you postpone defecation?

4- Do you take any medication to manage neurologic problems? If so, what?

63. Activity-Exercise
1- Describe any problems you experience with usual activities and exercise as a result of a neurologic
problem.

2- Do you have weakness or lack of coordination?

3- Are you able to perform your personal hygiene needs independently

64. Sleep-Rest
1- Describe your sleep pattern.

2- When you have trouble sleeping, what do you do?

65. Cognitive-Perceptual
1- Have you noticed any changes in your memory?

2- Do you experience dizziness, heat or cold sensitivity, numbness, or tingling?

3- Do you have chronic pain?

4- Do you have any difficulty with verbal or written communication?

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Health Assessment NAIRA

5- Have you noticed any changes in vision or hearing?

66. Self-Perception-Self-Concept
1- How do you feel about yourself, about who you are?

2- Describe your general emotional pattern.

67. Role-Relationship
1- Have you experienced changes in roles such as spouse, parent, or breadwinner?

68. Sexuality-Reproductive
1- Are you dissatisfied with sexual functioning?

2- Are problems related to sexual functioning causing tension in an important relationship?

3- Do you feel the need for professional counseling related to your sexual nctioning?

69. Coping-Stress Tolerance

1- Describe your usual coping pattern.

2- Do you think your present coping pattern is adequate to meet the stressors of your life?

3- What needs are unmet by your current support system?

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70. NORMAL PHYSICAL ASSESSMENT OF NERVOUS SYS

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TEM

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