NAELGAS, GLENN MARK O.

BACHELOR OF SCIENCE IN NURSING B

NCM101: HEALTH ASSESSMENT

DEAN DIONESIA M. NAVALES RN, MAED, MAN.
FULL TRANSCRIPTION

OUTLINE Evolution of the Nurse’s Role in Health Assessment

I. NURSING DATA B. Assessing Head and Physical assessment has been an integral part of
COLLECTION, Neck nursing since the days of Florence Nightingale
DOCUMENTATION, C. Assessing Eyes
AND ANALYSIS D. Assessing Ears LATE 1800s-EARLY 1900s
A. Nurse’s Role in Health E. Assessing Mouth, ⎯ Nurses relied on their natural senses; the client's face
Assessment Throat, Nose, and and body would be observed for "changes in color,
B. Collecting Data Sinuses temperature, muscle strength, use of limbs, body output,
C. Thinking Critically to F. Assessing Thorax and and degrees of nutrition, and hydration" (Nightingale,
Analyze Data and Lungs 1992).
Make Informed G. Assessing Breasts ⎯ Palpation was used to measure pulse rate and quality
Nursing Judgements and Lymphatic System and to locate the fundus of the puerperal woman
H. Assessing Heart and (Fitzsimmons & Gallagher, 1978).
II. INTEGRATIVE Neck Vessels ⎯ Examples of independent nursing practice using
HOLISTIC I. Assessing Peripheral inspection, palpation, and auscultation have been
NURSING Vascular System recorded in nursing journals since 1901. Some examples
ASSESSMENT J. Assessing Abdomen reported in the American Journal of Nursing (1901-1938)
A. Assessing General K. Assessing include gastrointestinal palpation, testing eighth cranial
Health Status and Musculoskeletal nerve function, and examination of children in school
Vital Signs System systems.
B. Assessing Pain: L. Assessing Neurologic 1930-1949
The Fifth Vital Sign System ⎯ The American Journal of Public Health documents
M. Assessing Male routine client and home inspection by public health
III. NURSING Genitalia and Rectum nurses in the 1930s.
ASSESSMENT OF N. Assessing Female ⎯ This role of case finding, prevention of communicable dis-
PHYSICAL SYSTEM Genitalia, Anus, and eases, and routine use of assessment skills in poor inner
A. Assessing Skin, Hair, Rectum city areas were performed through the Frontier Nursing
and Nails Service and the Red Cross (Fitzsimmons & Gallagher,
1978).
I. NURSING DATA, COLLECTION, 1950-1969
DOCUMENTATION, AND ANALYSIS ⎯ Nurses were hired to conduct pre-employment health
Health Assessment stories and physical examinations for major companies,
A systematic and continuous collection, organization, such as New York Telephone, from 1953 through 1960
validation, and documentation of data coupled with a plan of (Bews & Baillie, 1969; Cipolla & Collings, 1971).
care with specific need of a person and how those needs will be 1970-1989
carried out by a health care provider. ⎯ The early 1970s prompted nurses to develop an active
role in the provision of primary health services and
Purpose of Assessment expanded the professional nurse role in conducting
1. To collect date pertinent to patient’s health status health histories and physical and psychological
2. Help to identify client’s needs and clinical problems and assessments (Holzemer, Barkauskas, & Ohison, 1980;
deviation from normal Lysaught, 1970).
3. Identify the client’s strengths, limitations, and coping ⎯ Joint statements of the American Nurses Association and
resources the American Academy of Pediatrics agreed that in-depth
4. To identify the different factors that places the client at client assessments and on-the-spot diagnostic judgments
risk of health problem (internal and external factors) would enhance the productivity of nurses and the health
5. To build and establish rapport with the client and his care of clients (Bullough, 1976; Fagin & Goodwin, 1972).
family ⎯ Acute care nurses in the 1980s employed the "primary
6. Helps to evaluate responses of the client to health care" method of delivery of care. Each nurse was
problems and interventions autonomous in making comprehensive initial
NG PROCESS STEP 1: ASSESSMENT assessments from which individualized plans of care
A. NURSE’S ROLE IN HEALTH ASSESSMENT: were established.
COLLECTING AND ANALYZING DATA 1990-PRESENT
Data Analysis: 2nd step of the nursing process, and the result of ⎯ Over the last 20 years, the movement of health care from
the nursing assessment. the acute care setting to the community and the
proliferation of baccalaureate and graduate education
“An accurate and thorough Health Assessment reflects the solidified the nurses' role in holistic assessment.
KNOWLEDGE & SKILL of a Professional Nurse. Therefore, ⎯ Downsizing, budget cuts, and restructuring were the
the nurse should think critically about what to assess “ priorities of the 1990s. In turn, there was a demand for
documentation of client assessments by all health care
PROCESS OF DATA ANALYSIS providers to justify health care services.
• Identify abnormal data and strengths. ⎯ In the 1990s, critical pathways or care maps guided the
• Cluster the data client's progression, with each stage based on specific
• Draw interferences and identify problems. protocols that the nurse was responsible for assessing
• Propose possible nursing diagnoses. and validating.
• Check for defining characteristics of those diagnoses. ⎯ Advanced practice nurses have been increasingly used in
• Confirm or rule out nursing diagnoses. the hospital as clinical nurse specialists and in the
• Document conclusions. community as nurse practitioners.
⎯ While state legislators and the American Medical
Association struggled with issues of reimbursement and
prescriptive services by nurses, government and societal

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 recognition of the need for greater cost accountability in I. Initial Comprehensive
the health care industry launched the advent of Assessment: collection of
diagnosis-related groups (DRGs) and promotion of health subjective data
care coverage plans such as health maintenance ⎯ Also called admission
organizations (HMOS) and preferred provider assessment
organizations (PPOs). ⎯ Performed when the client
enters the health care facility.
ASSESSMENT: STEP 1 OF THE NURSING PROCESS ⎯ To establish data-base
⎯ The first and most critical phase of the nursing identification and future
process. comparison
⎯ If data collection is inadequate or inaccurate, incorrect
nursing judgements may be made that adversely affect II. Ongoing or Partial
the remaining phases of the process: diagnosis, Assessment: mini-overview
planning, implementation, and evaluation. of the client’s body systems
⎯ It is analyzing and synthesizing data, making and holistic health patterns as
judgements about effectiveness of nursing follow up on health status
interventions, and evaluating client care outcomes. ⎯ Performed
whenever and
PHASES OF THE NURSING PROCESS wherever the nurse
PHASE TITLE DESCRIPTION or another health
I Assessment Collecting subjective and care professional
objective data has encounter with
II Diagnosis Analyzing subjective and the client.
(Nursing) objective data to make a Example:
professional nursing judgment A partial assessment of a client admitted to the hospital with lung
(nursing diagnosis, cancer requires a frequent assessment of RR, Osat, lung
collaborative problem, or sounds, skin color, and capillary refill.
referral)
II Planning Determining outcome criteria
and developing a plan III. Focused or Problem-oriented Assessment: ongoing
IV Implementation Carrying out the plan process integrated with nursing care.
V Evaluation Assessing whether outcome ⎯ To determine the status of a specific problem
criteria have been met and and to identify new or overlooked problems.
revising the plan as necessary Example:
Nursing Process should be thought and implemented of as An hourly intake and output measurements.
circular, not linear.
Intake: everything that the client takes in liquid form
▪ Orally
▪ NGT (Nasogastric Tube) nose
▪ OGT (Orogastric tube) mouth
▪ IVF (Intravenous Fluids)
Output
▪ Urine
▪ Watery Stools
▪ Vomitus
▪ Secretions

Rationale:
▪ More intake less output – edema
▪ Less intake more output – dehydration

IV. Emergency
Assessment: done during
physiological or psychological
crisis of the patient.
SAMPLE NURSING PROCESS: ⎯ The major purpose is to
A Febrile T- 39.2 save the life of the patient.
D Increased body temperature related to presence of ⎯ To identify life-threatening
infection problems
P After 30 mins of nursing intervention, the temperature of ⎯ To determine what action
the patient will decrease from 39.2 to 37.8 can be done.
I (Independent Nursing Management) Example:
Render tepid sponge bath (TSB) A rapid assessment of patient’s ABC (airway, breathing, and
Apply cold compress over the forehead. circulation)
Encourage to increase fluid intake. V. Time-lapse assessment: done several days after last
T- rechecked 38.8 assessment.
(Dependent Nursing Management) ⎯ To compare current status to baseline data previously
Administer 500mg Paracetamol PRN q4/ p.o. as ordered obtained.
E After 30 mins of nursing intervention, patient’s Example:
temperature went down from 39.2 to 37.9 Reassessment of patient’s functional health patterns at home

Optional: “Despite everything having been done (independent,

dependent NM), if the patient has shown no sign of improvement
of health or worsen, the nursing care plan should be revised; or
If symptoms persist, MD should be notified and wait for orders.”
TYPES OF ASSESSMENT

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 COMPUTATIONS
INTRAVENOUS FLUID
Formula: 3. VALIDATION OF DATA: crucial part
𝒗𝒐𝒍𝒖𝒎𝒆 (𝒊𝒏 𝒄𝒄) 𝒅𝒓𝒐𝒑 𝒇𝒂𝒄𝒕𝒐𝒓 (𝟏𝟓 𝒐𝒓 𝟐𝟎) of assessment that often occurs along
𝒙 with collection of subjective and
𝒏𝒐. 𝒐𝒇 𝒉𝒐𝒖𝒓𝒔 𝟔𝟎
Example: objective data.
1L D5W to consume in 10hrs. How many drops per minute will
you regulate if the drop factor is 20?
4. DOCUMENTATION OF
Solution: DATA: it forms the
1000𝑐𝑐 20 20000 database for the entire
𝑥 = = 33.3 𝑜𝑟 𝟑𝟑 − 𝟑𝟒 𝒅𝒓𝒐𝒑𝒔/𝒎𝒊𝒏𝒖𝒕𝒆
10 60 600 nursing process and
provides data for all
other members of the
Macrodrip tubing: delivers 15 to 20gtts/mL and is used to healthcare team.
infuse large volumes or to infuse fluids quickly

Microdrip tubing: delivers 60ugtts/mL and is used for small ANALYSIS OF ASSESSMENT DATA/ NURSING
or very precise amounts of fluid, as with neonates or pediatric DIAGNOSIS: STEP 2 OF THE NURSING PROCESS
patients. ⎯ Analysis of data (often called nursing diagnosis) is the
second phase of the nursing process.
1 macrdrop = 3-4 microdrops ⎯ The purpose of assessment is to arrive at conclusions
about the client’s health.
TEMPERATURE CONVERSION ⎯ To achieve the goal or anticipated outcome of the
Formula: assessment, the nurse makes sure that the data collected
𝟗
A. (℃ 𝒙 ) + 𝟑𝟐 = ℉ are as accurate and thorough as possible.
𝟓
B. (℉ − 𝟑𝟐) 𝒙
𝟓
= ℃ ⎯ A nursing diagnosis is defined by the North American
𝟗 Nursing Diagnosis Association (NANDA, 2012–2014) as
“a clinical judgment about individuals, family or community
Example: responses to actual and potential health problems and life
Temperature of the patient was checked, and it reads 37℃. What processes. A nursing diagnosis provides the basis for
is the temperature of the patient in ℉? Recheck or convert the selecting nursing interventions to achieve outcomes for
answer back to ℃. which the nurse is accountable”.
Solution: PROCESS OF DATA ANALYSIS
Celsius to Fahrenheit Fahrenheit to Celsius 1. Identify abnormal data and strengths.
9 5 2. Cluster the data.
(37℃ x ) + 32 = ℉ (98.6℉ − 32) 𝑥 = ℃
5 9 3. Draw inferences and identify problems.
5 4. Propose possible nursing diagnoses.
= 66.6 𝑥
= 66.6 + 32 9 5. Check for defining characteristics of those diagnoses.
= 𝟗𝟖. 𝟔 ℉ = 𝟑𝟕 ℃ 6. Confirm or rule out nursing diagnoses.
7. Document conclusions.
STEPS OF HEALTH ASSESSMENT
Before meeting B. COLLECTING DATA
the client, and beginning
the nursing health ▪ Subjective Data: collected through interview.
assessment, there are ⎯ Data verbalized by the client.
several things you should ⎯ Can only be elicited and verified by the client.
do to prepare. It is helpful ⎯ Consist of:
to review the client’s o Sensation or Symptoms
medical record, if o Feelings
available. o Perceptions
o Desires
o Preferences
THE ASSESSMENT PHASE OF THE NURSING PROCESS o Beliefs
HAS FOUR MAJOR STEPS: o Ideas
1. COLLECTION OF o Values
SUBJECTIVE DATA: sensations o Personal Information
or symptoms (e.g., pain, hunger),
feelings (e.g., happiness, ▪ Objective Data: done through physical examination or
sadness), perceptions, desires, observation.
preferences, beliefs, ideas, ⎯ Data can be seen, felt, and heard from the
values, and personal information patient
that can be elicited and verified ⎯ Seen: vomiting, chilling, grimaced face,
only by the client. bleeding
⎯ Felt: fever, tympanic, presence of mass
2. COLLECTION OF ⎯ Heard: cardiac rate, breathing
OBJECTIVE DATA:
obtained by general a) cardiac rate
observation and by using ▪ Normal: adult 60 – 80 bpm
the four physical ▪ Tachycardia: fast heart/ pulse rate (reg; irreg)
examination techniques; ▪ Bradycardia: slow heart/ pulse rate (red; irreg)
inspection, palpation, b) breathing sounds
percussion, and ▪ normal: adult 16 – 20 bpm
auscultation. ▪ Tachypnea: fast breathing
▪ Bradypnea: slow breathing
▪ Apnea: absence of breathing
Lung sounds
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 Rales: rattling sounds in the lung, heard when person inhales
Rhonchi: sounds that resembles snoring PHASES OF INTERVIEW
Stridor: wheeze-like sound heard when a person breath. THREE BASIC PHASES OF INTERVIEW:
Wheezing: high-pitched sound produced by narrowed airway 1. PREINTRODUCTORY PHASE: nurse reviews the
medical record before meeting with the client.
COMPARING SUBJECTIVE AND OBJECTIVE DATA
Subjective Objective Example: the record may indicate that the client has
Description Data elicited and Data directly or difficulty hearing in one ear. This information will guide
verified by the indirectly observed the nurse as to which side of the client would be best to
client through measurement conduct the interview.
Sources Client Observations and However, there may not be a medical record
physical assessment established in some instances. The nurse will then need
findings of the nurse or to rely on interview skills to elicit valid and reliable data
other health care from the client and that individual’s family or significant
Client record professionals other.
Documentation of
assessments made in 2. INTRODUCTORY PHASE: After introducing himself to
Other health care client record. the client, the nurse explains the purpose of the
professionals Observations made by interview, discusses the types of questions that will be
the client's family or asked, explains the reason for taking notes, and
significant others assures the client that confidential information will
Methods Client interview Observation and remain confidential.
used to physical examination a. WORKING PHASE: During this phase, the
obtain data nurse elicits the client’s comments about
Skills needed Interview and Inspection major biographic data, reasons for seeking
to obtain data therapeutic- Palpation care, history of present health concern, past
communication health history, family history review of body
skills Percussion systems for current health problems, lifestyle
Caring ability and and health practices, and developmental
empathy Auscultation level.
Listening skills
Examples "I have a Respirations 16 per 3. SUMMARY AND CLOSING PHASE: the nurse
headache." minute summarizes information obtained during the working
"It frightens me." BP 180/100, apical phase and validates problems and goals with the
"Í am not hungry." pulse 80 and irregular client.
X-ray film reveals a. Finally, the nurse makes sure to ask if
fractured pelvis anything else concerns the client and if there
are any further questions.
METHODS OF ASSESSMENT
▪ Observing (Objective): a conscious, deliberate skill SPECIAL CONSIDERATIONS DURING THE INTERVIEW
that is developed only through and with an organized ▪ Silence: it allows the patient to continue talking and
approach. will give you the chance to assess his ability to
Example: organize thoughts.
A client’s data observed through the four senses: vision, smell, ▪ Facilitation: encourages the patient to continue his
hearing, and touch. story.
⎯ Using phrases like; “please continue,” “go on,” or even
▪ Interviewing (Subjective): planned communication or “uh-huh,” to show that you’re attentively listening.
conversation with a purpose. ▪ Confirmation: ensures that you and your patient are in
Example: History Taking the same track.
⎯ Choose a quiet, private, well-lighted interview ⎯ Using a phrase like, “if I am correct, you said,”
setting away from distraction. ▪ Reflection: repeating what the patient has said.
⎯ Make sure the patient is comfortable, and ▪ Clarification: use to clear up confusion
you are facing the patient ▪ Summarization: restarting the information the patient
⎯ Introduce yourself and give the purpose of gave you ensures the data you have collected is
your interview. accurate and complete.
▪ Conclusion: signaling to the patient that you are ready
⎯ Reassure the patient that everything he says
to conclude the interview.
will be kept confidential.
⎯ Provides the opportunity for the patient to gather his
⎯ Assess the patient if communication barriers
thoughts and make final pertinent statements.
exist.
⎯ If your patient has hearing impairment, make
When interviewing, you can use:
sure the venue is well lit, face him and speak
▪ Closed questions (when, where, who)
slowly and clearly so that he can read your
▪ Open-ended questions (what, how, why)
lips.
▪ Neutral questions – q’s that the patient is not
⎯ Address the patient by full name. Don’t call pressured to answer.
him by his first name unless they allow you to ▪ Leading questions – the nurse directs the patient’s
do so. answer.
▪ Examining: evaluating objective anatomic findings
Example:
through the use of observation, palpation, percussion,
You didn’t finish the course of antibiotics the doctor
and auscultation
prescribed, did you? Rather than, “did you finish the course of
Example:
antibiotics…”
Checking the client’s vital signs: blood pressure, breathing rate,
pulse rate, temperature, height, and weight. Vision acuity: testing
the sharpness or clarity of vision from a distance. Head, eyes,
ears, nose and throat exam: inspection, palpation, and testing,
as appropriate.

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 COMPLETE HEALTH HISTORY
⎯ The importance of the health history lies in its ability to
provide information that will assist the examiner in
identifying areas of strength and limitation in the
individual’s lifestyle and current health status.
⎯ The complete health history is modified or shortened
when necessary.
Example: if the physical assessment will focus on the
heart and neck vessels, the subjective data collection
would be limited to the data relevant to the heart and
neck vessels.

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 ⎯ Pattern (What makes it better? What makes it
worse?)
⎯ Associated factors (What other symptoms do you
have with it? Will you be able to continue doing your
work or other activities (leisure or exercise]?)

COMPONENTS OF THE COLDSPA SYMPTOM ANALYSIS

MNEMONIC
The COLDSPA example here provides a sample application of
the COLDSPA mnemonic adapted to analyze back pain
Mnemonic Question
Character Describe the sign or symptom (feeling,
appearance, sound, smell, or taste if
applicable).
“What does the pain feel like?”
Onset When did it begin?
“When did this pain start?”
Location Where is it? Does it radiate? Does it occur
anywhere else?
“Where does it hurt the most? Does it
radiate or go to any other part of your
body?”
Duration How long does it last? Does it recur?
“How long does the pain last? Does it
come and go or is it constant?”
Severity How bad is it? How much does it bother
you?
“How intense is the pain? Rate it on a
scale of 1 to 10.”
Pattern What makes it better or worse?
“What makes your back pain worse or
better? Are there any treatments you’ve
tried that relieve the pain?”
Associated What other symptoms occur with it? How
Nursing Health History Format Summary (Used for Client
factors/How it does it affect you?
Care Plan)
Affects the “What do you think caused it to start?
▪ Biographic Data
client Do you have any other problems that
⎯ Name
seem related to your back pain? How
⎯ Address does this pain affect your life and daily
⎯ Phone activities?”
⎯ Gender
⎯ Provider of history (patient or other) ▪ Past Health History
⎯ Birth date ⎯ Problems at birth
⎯ Place of birth ⎯ Childhood illnesses
⎯ Race or ethnic background ⎯ Immunizations to date
⎯ Primary and secondary languages (spoken and ⎯ Adult illnesses (physical, emotional, mental)
read) ⎯ Surgeries
⎯ Marital status ⎯ Accidents
⎯ Religious or spiritual practices ⎯ Prolonged pain or pain patterns
⎯ Educational level ⎯ Allergies
⎯ Occupation ⎯ Physical, emotional, social, or spiritual weaknesses
⎯ Significant others or support persons (availability) ⎯ Physical, emotional, social, or spiritual strengths
▪ Baseline Data/ Vital Signs ▪ Family Health History
⎯ Weight: lbs;kg (1kg = 2.2 lbs) ⎯ Age of parents (Living? Date of death?)
⎯ Height: feet, inches, centimeters (1in = 2.54cm) (1ft ⎯ Parents' illnesses and longevity
= 12in) ⎯ Grandparents' illnesses and longevity
⎯ Temperature: oral, axilla, rectal, temporal ⎯ Aunts' and uncles' ages and illnesses and longevity
⎯ Respiratory Rate: breaths per minute ⎯ Children's ages and illnesses or handicaps and
⎯ Pulse Rate/ Cardiac Rate: beats per minute longevity
⎯ Blood Pressure: mmhg Example: Genogram of a 40-year-old male client
▪ Reasons for Seeking Health Care
Reason for seeking health care (major health problem or
concern)
Feelings about seeking health care (fears and past experiences)

▪ History of Present Health Concern Using COLDSPA

⎯ Character (How does it feel, look, smell, sound,
etc.?)
⎯ Onset (When did it begin, is it better, worse, or the
same since it began?)
⎯ Location (Where is it? Does it radiate?)
⎯ Duration (How long does it last? Does it recur?)
⎯ Severity (How bad is it on a scale of 1 [barely
noticeable] to 10 [worst pain ever experienced]?)

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▪ Review of Systems for Current Health Problems ▪ Developmental Level
⎯ Skin, hair, and nails: color, temperature, condition, ⎯ Young adult: intimacy versus isolation
rashes, lesions, excessive sweating, hair loss, ⎯ Middlescence: generativity versus stagnation
dandruff ⎯ Older adult: ego integrity versus despair
⎯ Head and neck: headache, stiffness, difficulty
swallowing, enlarged lymph nodes, sore throat PREPARING FOR EXAMINATION
⎯ Ears: pain, ringing, buzzing, drainage, difficulty ⎯ The physical examination may take place in a variety of
hearing, exposure to loud noises, dizziness, settings such as a hospital room, outpatient clinic,
drainage physician’s office, school health office, employee health
⎯ Eyes: pain, infections, impaired vision, redness, office, or a client’s home.
tearing, halos, blur-ring, black spots, flashes, double ⎯ It is important that the nurse strive to ensure that the
vision examination setting meets the following conditions:
⎯ Mouth, throat, nose, and sinuses: mouth pain, o Comfortable, warm room temperature:
sore throat, lesions, hoarseness, nasal obstruction, Provide a warm blanket if the room
sneezing, coughing, snoring, nosebleeds temperature cannot be adjusted.
⎯ Thorax and lungs: pain, difficulty breathing, o Private area free of interruptions from others:
shortness of breath with activities, orthopnea, cough, Close the door or pull the curtains if possible.
sputum, hemoptysis, respiratory infections o Quiet area free of distractions: Turn off the
⎯ Breasts and regional lymphatics: pain, lumps, radio, television, or other noisy equipment.
discharge from nipples, dimpling or changes in
breast size, swollen and tender lymph nodes in axilla EQUIPMENT NEEDED FOR PHYSICAL EXAMINATIONS
⎯ Heart and neck vessels: chest pain or pressure, FOR ALL EXAMINATIONS
palpitations, edema, last blood pressure, last ECG
⎯ Peripheral vascular: leg or feet pain, swelling of
feet or legs, sores on feet or legs, color of feet and
legs
⎯ Abdomen: pain, indigestion, difficulty swallowing,
nausea and vomiting. Gas, jaundice, hernias
⎯ Male genitalia: painful urination, frequency or GLOVES GOWNS
difficulty starting or maintaining urinary system, To protect examiner in any part of the examination when
blood in urine, sexual problems, penile lesions, the examiner may have contact with blood, body fluids,
penile pain, scrotal swelling, difficulty with erection or secretions, excretions, and contaminated items or when
ejaculation, exposure to STIs disease-causing agents could be transmitted to or from
⎯ Female genitalia: pelvic pain, voiding pain, sexual the client.
pain, voiding problems (dribbling, incontinence), age FOR VITAL SIGNS EXAMINATION
of menarche or menopause (date of last menstrual
period), pregnancies and types of problems,
abortions, STIs, HRT, birth control methods
⎯ Anus, rectum, and prostate: pain, with defecation,
hemorrhoids, bowel habits, constipation, diarrhea,
blood in stool Sphygmomanometer to Thermometer (oral, rectal,
⎯ Musculoskeletal: pain, swelling, redness, stiff measure diastolic and tympanic) to measure body
joints, strength of extremities, abilities to care for self systolic blood pressure. temperature
and work Stethoscope to
⎯ Neurologic: mood, behavior, depression, anger, auscultate blood
headaches, concus-sions, loss of strength or sounds when
sensation, coordination, difficulty with speech, measuring blood
memory problems, strange thoughts or actions, pressure
difficulty reading or learning

▪ Lifestyle and Health Practices

⎯ Description of a typical day (AM to PM)
⎯ Nutrition and weight management
⎯ 24-hour dietary intake (foods and fluids)
⎯ Who purchases and prepares meals Watch with second hand
⎯ Activities on a typical day to time heart rate, pulse Pain rating scale to determine
⎯ Exercise habits and patterns rate perceived pain level
⎯ Sleep and rest habits and patterns FOR NUTRITIONAL STATUS EXAMINATION
⎯ Use of medications and other substances
(caffeine, nicotine, alcohol, recreational
drugs)
⎯ Self-concept
⎯ Self-care responsibilities
⎯ Social activities for fun and relaxation Flexible tape measure to
⎯ Social activities contributing to society Skinfold calipers to measure mid-arm
⎯ Relationships with family, significant others, measure skinfold circumference.
and pets thickness of
⎯ Values, religious affiliation, spirituality subcutaneous tissue
⎯ Past, current, and future plans for education Platform scale
with height
⎯ Type of work, level of job satisfaction, work
attachment
stressors
to measure height
⎯ Finances
and weight
⎯ Stressors in life, coping strategies used
⎯ Residency, type of environment, Skin marking pen to mark
neighborhood, environmental risks measurements.

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FOR SKIN, HAIR, AND NAIL EXAMINATION

Penlight Mirror for

client’s self- Tongue depressor to
examination of depress tongue to view Otoscope with wide-tip
skin throat, check looseness attachment to view the internal
of teeth, view cheeks, nose
and check strength of
Examination light tongue

FOR THORACIC AND LUNG EXAMINATION

Metric ruler to Magnifying glass Wood’s light to

measure size of to enlarge visibility test for fungus
skin lesions of lesion Metric ruler and skin marking pen
Stethoscope to measure diaphragmatic excursion
(diaphragm) to
auscultate breath
sounds

FOR HEART AND NECK VESSEL EXAMINATION

Braden Scale for Pressure Ulcer Scale for

Predicting Pressure Healing (PUSH)
Sore Risk
FOR HEAD AND NECK EXAMINATION Stethoscope Two metric rulers to measure jugular
(bell and venous pressure
diaphragm) to
auscultate
heart sounds

Penlight FOR PERIPHERAL VASCULAR EXAMINATION

Newspaper to
test near vision
Snellen E chart to
Flexible metric
test distant vision Sphygmomanometer and measuring tape to
stethoscope to measure blood measure size of
pressure and auscultate extremities for edema
vascular sounds

Opaque card to test for Ophthalmoscope to view the

strabismus red reflex and
to examine the retina of the eye
FOR EAR EXAMINATION
Doppler
Tuning fork to detect vibratory ultrasound
sensation device and conductivity
gel to detect pressure and
weak pulses not easily
heard with a stethoscope
FOR ABDOMINAL EXAMINATION

Tuning fork to test for Otoscope to view the ear canal

bone and air conduction and tympanic membrane
of sound
FOR MOUTH, THROAT, NOSE, AND SINUS EXAMINATION Stethoscope to Two small pillows to
detect bowel place under knees
sounds and head to promote
Flexible metric relaxation of
measuring tape abdomen
Penlight 4 × 4-inch small gauze pad to and skin
grasp tongue to examine mouth marking pen to
measure size
and mark the
area of
percussion of
organs

8
FOR MUSCULOSKELETAL EXAMINATION through and vaginal pool
dilatation of the sample
vaginal canal

Flexible metric measuring

tape to measure size of
pH paper Feminine
extremities
Goniometer to measure napkins
degree of flexion and
extension of joints
FOR NEUROLOGIC EXAMINATION Liquid Pap medium

Physical Examination Techniques

4 Basic Techniques
▪ INSPECTION: involves using the senses of
Cotton-tipped vision, smell, and hearing
Ophthalmoscope
applicators to
put salt or Newspaper to test Use the following guidelines as you practice
sugar on for near vision the technique of inspection:
tongue to test ⎯ Make sure the room is a comfortable temperature. A too
taste cold or too hot room can alter the normal behavior of the
client and the appearance of the client's skin.
⎯ Use good lighting, preferably sunlight. Fluorescent lights
can alter the true color of the skin. In addition,
Flexible metric abnormalities may be overlooked with dim lighting.
Objects to feel,
measuring tape such as a coin or key Reflex ⎯ Look and observe before touching. Touch can alter
to test for (percussion) appearance and distract you from a complete, focused
stereognosis (ability hammer to test observation.
to recognize objects deep tendon ⎯ Completely expose the body part you are inspecting
by touch) reflexes while draping the rest of the client as appropriate.
⎯ Note the following characteristics while inspecting the
client: color, patterns, size, location, consistency,
symmetry, movement, behavior, odors, or sounds.
⎯ Compare the appearance of symmetric body parts (e.g.,
eyes, ears, arms, hands) or both sides of any individual
body part.

▪ PALPATION: using hands to touch and feel the body

Characteristics:
⎯ Texture (rough/smooth)
Cotton ball and
Substances to
Snellen E chart ⎯ Temperature (warm/cold)
paper clip to test
smell and taste to ⎯ Moisture (dry/wet)
for light, sharp,
test for ⎯ Mobility. (fixed/movable/still/vibrating)
and dull touch
smell and taste ⎯ Consistency (soft/hard/fluid filled)
and two-point
perception ⎯ Strength of pulses (strong/weak/thready/bounding).
discrimination
⎯ Size (small/medium/large)
⎯ Shape (well defined/irregular)
⎯ Degree of tenderness

Tongue depressor Tuning fork to PARTS OF HANDS USED FOR PALPATION

Penlight 1) FINGER PADS: used in pulses, texture, size,
to test for rise of detect vibratory
uvula and gag reflex sensation consistency, and shape.
2) ULNAR/PALMAR: Vibrations, thrills, fremitus
FOR MALE GENITALIA AND RECTUM EXAMINATION 3) DORSAL: temperature

INSTRUCTIONS ON HOW TO PERFORM THE FOUR TYPES

OF PALPATION:
▪ Light palpation: To perform light
Gloves and Penlight for scrotal palpation, place your dominant hand lightly on
water-soluble illumination the surface of the structure.
lubricant to • There should be very little or no
promote Specimen card depression (less than 1 cm).
comfort for for occult blood • Feel the surface structure using a
client circular motion. Use this technique to feel
FOR FEMALE GENITALIA AND RECTUM EXAMINATION pulses, tenderness, surface skin texture,
temperature, and moisture.

▪ Moderate palpation: Depress the

skin surface 1 to 2 cm, (0.5 to 0.75
Bifid spatula, in) with your dominant hand and use
Vaginal endocervical Large swabs for a circular motion to feel for easily
speculum and broom to obtain vaginal palpable body organs and masses.
water-soluble endocervical swab examination • Note the size, consistency,
lubricant to and cervical scrape and mobility of structures you palpate.
inspect cervix

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 ▪ Deep palpation: Place your dominant
hand on the skin surface and your
nondominant hand on top of your
dominant.

THRILL: abnormal vibration that is felt on the skin overlying a loud

cardiac murmur or an arteriovenous fistula
⎯ A tingling or shivering sensation of tremulous
excitement as from pain, pleasure, or horror

FREMITUS - Refers to the assessment of the lungs by either the

vibration intensity felt on the chest wall (tactile fremitus); or heard
by a stethoscope on the chest wall with certain spoken words
(vocal resonance)

▪ PERCUSSION: involves tapping body parts to produce

sound waves.
Several Different Assessment Uses, Including:
⎯ Eliciting pain: Percussion helps detect inflamed
underlying structures. If an inflamed area is
percussed, the client's physical response may
indicate or the client will report that the area feels
tender, sore, or painful.
⎯ Determining location, size, and shape:
Percussion note changes between borders of an
organ and its neighboring organ can elicit
information about location, size, and shape.
⎯ Determining density: Percussion helps These guidelines should be followed as you
determine whether an underlying structure is filled practice the technique of auscultation:
with air or fluid or is a solid structure. ⎯ Eliminate distracting or competing noises from
⎯ Detecting abnormal masses: Percussion can the environment (e.g., radio, television,
detect superficial abnormal structures or masses. machinery).
Percussion vibrations penetrate approximately 5 ⎯ Expose the body part you are going to
cm deep. Deep masses do not produce any auscultate. Do not auscultate through the
change in the normal percussion vibrations. client's clothing or gown. Rubbing against the
⎯ Eliciting reflexes: Deep tendon reflexes are clothing obscures the body sounds.
elicited using the percussion hammer. ⎯ Use the diaphragm of the stethoscope to listen
for high-pitched sounds, such as normal heart
PERCUSSION SOUNDS sounds, breath sounds, and bowel sounds,
1) FLATNESS: bone or muscle and press the diaphragm firmly on the body
2) DULLNESS: heart, liver, spleen part being auscultated.
3) RESONANCE: air-filled lungs (hollow) ⎯ Use the bell of the stethoscope to listen for
4) HYPERRESONANCE: emphysematous lung low-pitched sounds such as abnormal heart
5) TYMPANY: air-filled stomach (drum-like) sounds and bruits (abnormal loud, blowing, or
murmuring sounds). Hold the bell lightly on the
SOUNDS PRODUCED BY PERCUSSION body part being auscultated.
1) SOUND: Tympany
2) INTENSITY: loud
3) PITCH: high
4) DURATION: moderate
5) QUALITY: drum like
6) COMMON LOCATION: air-containing space, enclosed
area, gastric air bubble, puffed-out-cheek.

▪ ASCULTATION: requires the use of stethoscope.

⎯ NORMAL LUNGS
1. SOUND: resonance
2. INTENSITY: moderate to loud
3. PITCH: Low
4. DURATION: Long
5. QUALITY: Hollow

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▪ OLFACTION: the nurse should be familiar with the nature
and source of body odors.

C. THINKING CRITICALLY TO ANALYZE DATA AND

MAKE INFORMED NURSING JUDGMENTS
⎯ Keep an open mind.
⎯ Use rationale to support opinions or decisions.
⎯ Reflect on thoughts before reaching a conclusion.
⎯ Use past clinical experiences to build knowledge.
⎯ Acquire an adequate knowledge base that continues to
build.
⎯ Be aware of the interactions of others.
⎯ Be aware of the environment.

THE DIAGNOSTIC REASONING PROCESS

▪ STEP ONE—IDENTIFY ABNORMAL DATA AND

STRENGTHS: the nurse should compare collected
assessment data with findings in reliable charts and
reference resources that provide standards and values for
physical and psychological norms (i.e., height, nutritional
requirements, growth and development)

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 • Requires the nurse to have and use a knowledge ▪ STEP FOUR—PROPOSE POSSIBLE NURSING
base of anatomy and physiology, psychology, and DIAGNOSES: If resolution of the situation requires
sociology. primarily nursing interventions, you would hypothesize and
generate possible nursing diagnoses.
• The nursing diagnoses may be wellness, or health
promotion, diagnoses; risk diagnoses; or actual
diagnoses, and syndrome diagnoses (NANDA, 2012).
 A wellness diagnosis, or a health
promotion nursing diagnosis, indicates that
▪ STEP TWO—CLUSTER DATA: the nurse looks at the the client (individual, family, community) has
identified abnormal findings and strengths for cues that are the motivation to increase well-being and
related enhance health behaviors.
• For example, a client may have a nonproductive  A risk diagnosis indicates the client does not
cough with labored respirations at a rate of 24 per currently have the problem but is at high risk
minute. However, you have gathered no data on for developing it (e.g., risk for impaired skin
the status of breath sounds. In such a situation, you integrity related to immobility, poor nutrition,
would need to assess the client’s breath sounds to and incontinence).
formulate an appropriate nursing diagnosis or  An actual nursing diagnosis indicates that
collaborative problem. the client is currently experiencing the stated
▪ STEP THREE—DRAW INFERENCES: requires the nurse problem or has a dysfunctional pattern (e.g.,
to write down hunches about each cue cluster. impaired skin integrity: reddened area on right
• For example, based on the cue cluster presented in buttocks).
step two—rash on face, neck, chest, and back;  When a cluster of nursing diagnoses is related
patchy alopecia; “so ugly”—you would write down in a way that they occur together, a syndrome
what you think these data are saying and diagnosis is made.
determine whether it is something that the nurse ▪ STEP FIVE—CHECK FOR DEFINING
can treat independently. Your hunch about this data CHARACTERISTICS: the nurse must check for defining
cluster might be: “Changes in physical appearance characteristics for the data clusters and hypothesized
are affecting self-perception.” This is something for diagnoses in order to choose the most accurate diagnoses
which the nurse would intervene and treat and delete those diagnoses that are not valid or accurate
independently. Therefore, the nurse would move to for the client.
step four: analysis of data to formulate a nursing • This step is often difficult because diagnostic labels
diagnosis. overlap, making it hard to identify the most
DIFFERENTIATING NURSING DIAGNOSES AND appropriate diagnosis.
COLLABORATIVE PROBLEMS • For example, the diagnostic categories of impaired
gas exchange, ineffective airway clearance, and
ineffective breathing patterns all reflect respiratory
problems but each is used to describe a very different
human response pattern and set of defining
characteristics.
▪ STEP SIX—CONFIRM OR RULE OUT DIAGNOSES: If
the cue cluster data do not meet the defining
characteristics, you can rule out that particular diagnosis
▪ STEP SEVEN—DOCUMENT CONCLUSIONS: Be sure to
document all of your professional judgments and the data
that support those judgments
• Nursing diagnoses are often documented and worded
in different formats.

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 II. INTEGRATIVE HOLISTIC NURSING
ASSESSMENT

A. ASSESSING GENERAL HEALTH STATUS AND

VITAL SIGNS
The general survey provides the nurse with an overall
impression of the client's health, including their physical
development, gender and sexual development, skin condition,
dress and hygiene, posture and gait, and vital signs.
VITAL SIGNS
▪ TEMPERATURE
⎯ For the body to function at a cellular level, a core
body temperature between 36.5°C and 37.7°C
(96.0°F and 99.9°F orally) must be maintained.
⎯ Body temperature is lowest early in the morning
(4:00 to 6:00 AM) and highest late in the evening
(8:00 PM to midnight).
⎯ Hypothermia (lower than 36.5°C or 96.0°F) may
be seen in prolonged exposure to the cold,
hypoglycemia, hypothyroidism, or starvation.
⎯ Hyperthermia (higher than 38.0°C or 100°F) may
be seen in viral or bacterial infections,
malignancies, trauma, and various blood,
endocrine, and immune disorders

▪ PULSE
⎯ Several characteristics should be assessed when
measuring the radial pulse: rate, rhythm,
amplitude and contour, and elasticity.
⎯ Amplitude can be quantified as follows:
• 0 Absent
• 1+ Weak diminished (easy to obliterate)
• 2+ Normal (obliterate with moderate
pressure)
• 3+ Bounding (unable to obliterate or requires
firm pressure)
⎯ If abnormalities are noted during assessment of
the radial pulse, perform further assessment.
▪ RESPIRATIONS
⎯ Observe respirations without alerting the client by
watching chest movement while continuing to
palpate the radial pulse.
⎯ Notable characteristics of respiration are rate,
rhythm, and depth.
▪ BLOOD PRESSURE
⎯ measurement of the pressure of the blood in the
arteries when the ventricles are contracted
(systolic blood pressure) and when the ventricles
are relaxed (diastolic blood pressure).
⎯ A client's blood pressure is affected by several
factors:
• Cardiac output
• Elasticity of the arteries
• Blood volume
• Blood velocity (heart rate)
• Blood viscosity (thickness)
⎯ The difference between systolic and diastolic
pressure is termed pulse pressure: it measures
the stroke volume (the volume of blood ejected
with each heartbeat)

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 II Muffled or swishing;
these sounds are
softer and longer than
phase I sounds. They
also have the quality of
an intermittent murmur.
They may temporarily
subside, especially in
hypertensive people
The loss of the sound
during the latter part of
phase I and during
phase II is called the
auscultatory gap. The
gap may cover a range
as much of 40 mmHg;
failing to recognize this
gap may cause serious
errors of
underestimating
systolic pressure or
overestimating diastolic
pressure
III A return of distinct,
crisp, and louder
sounds as the blood
flows relatively freely
through an increasingly
open artery.
IV Muffled, less distinct,
and softer (with a
blowing quality)
V Sounds, disappearing
completely. The last
sound heard before
this period of
continuous silence is
the onset of Phase V
and is the pressure
commonly considered
to define the diastolic
measurement. (Some
clinicians still consider
the last sounds of
Phase IV the first
diastolic value)

B. ASSESSING PAIN: THE 5TH VITAL SIGN

IDENTIFYING KOROTKOFF’S SOUNDS

PHASE DESCRIPTION ILLUSTRATION
I The first appearance of
faint, clear, repetitive
tapping sounds that
gradually intensify for
at least two
consecutive beats.
This coincides
approximately with the
resumption of a
palpable pulse. The
number on the
pressure gauge at
which you hear the first
tapping sound is the
systolic pressure.

14
 ▪ Increased heart rate; peripheral, systemic, and coronary
vascular resistance; increased blood pressure
▪ Increased respiratory rate and sputum retention, resulting
in infection and atelectasis.
▪ Decreased gastric and intestinal motility.
TRANSDUCTION, TRANSMISSION, PERCEPTION AND ▪ Decreased urinary output, resulting in urinary retention,
MODULATION OF PAIN. fluid overload, depression of all immune responses.
▪ Increased antidiuretic hormone, epinephrine,
norepinephrine, aldosterone, glucagon’s; decreased
insulin, testosterone.
▪ Hyperglycemia, glucose intolerance, insulin resistance,
protein catabolism
▪ Muscle spasm, resulting in impaired muscle function and
immobility, perspiration.

CLASSIFICATION
⎯ Pain is classified in several ways.
⎯ Duration, location, etiology, and severity are four of these.
⎯ Duration and etiology are often classified together to
differentiate:
o Acute pain: usually associated with a recent injury
o Chronic nonmalignant pain: usually associated with a
specific cause or injury and described as a constant pain
that persists for more than 6 months
o Cancer pain: often due to the compression of peripheral
nerves or meninges or from the damage to these
structures following surgery, chemotherapy, radiation,
or tumor growth and infiltration
⎯ Pain location classifications include:
o Cutaneous pain (skin or subcutaneous tissue)
o Visceral pain (abdominal cavity, thorax, cranium)
o Deep somatic pain (ligaments, tendons, bones, blood
vessels, nerves)
o Another aspect of pain location is whether it is perceived
at the site of the pain stimuli if it is (perceived both at the
source and extending to other tissues) or referred
(perceived in body areas away from the pain source.

AREAS OF REFERRED PAIN. ANTERIOR VIEW (TOP).

POSTERIOR VIEW (BOTTOM).

Pain: combination of physiologic phenomena but with

psychosocial aspects that influence perception of pain.

PHYSIOLOGIC RESPONSES TO PAIN

Pain elicits a stress response in the human body that triggers the ⎯ PHANTOM PAIN can be perceived in nerves left by a
sympathetic nervous system, resulting in physiologic responses missing, amputated, or paralyzed body part.
such as: ⎯ NEUROPATHIC PAIN - Pain that results from damage or
▪ Anxiety, fear, hopelessness, sleeplessness, thoughts of dysfunction of the nervous system. It is often described as
suicide burning, shooting, or tingling and can be difficult to treat.
▪ Focus on pain, reports of pain, cries and moans, frowns, ⎯ NOCICEPTIVE PAIN - Pain that results from tissue damage
and facial grimaces. or inflammation. It can be either acute or chronic and is
▪ Decrease in cognitive function, mental confusion, altered typically responsive to pain medications
temperament, high somatization, and dilated pupils.

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⎯ PSYCHOGENIC PAIN – pain related to psychological or
emotional factors, such as anxiety, depression, or stress.
⎯ IDIOPATHIC PAIN – pain that has no known origin. It can be
either acute or chronic and difficult to diagnose and treat.
⎯ BREAKTHROUGH PAIN – a sudden intense flare-up of pain
that occurs despite ongoing pain management. It may
require additional medication or intervention to manage.
⎯ INTRACTABLE PAIN – pain that is resistant to treatment
and persists despite multiple interventions. It can be PAIN ASSESSMENT TOOLS
extremely debilitating and may require specialized pain
management techniques.

THE SEVEN DIMENSIONS OF PAIN

1. Physical Dimension: Physiologic impacts. Involves
patient's pain perception and body response.
2. Sensory Dimension: Pain quality and intensity. Patient's
pain perception involves location, intensity, and quality.
3. Behavioral Dimension: In reaction to pain, patients exhibit
verbal and nonverbal behaviors.
4. Sociocultural Dimension: Patient's social and societal
background affects their pain experience.
5. Cognitive Dimension: Beliefs, attitudes, intentions, and
motivations are impacted by all dimensions, but cognition is
involved in pain management.
6. Affective Dimension: Emotions and pain perception are
interconnected.
7. Spiritual Dimension: Attributes to the pain, self, others,
and the divine

III. NURSING ASSESSMENT OF PHYSICAL

SYSTEMS

NASA BOOK PAGE 247 – 672

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