INTRODUCTION TO HEALTH ASSESSMENT

The first assessment begins in (1992) by American medical association.

In (1995) Health Assessment considered as basic human right
HEALTH

According to “WHO” Health is a state of complete physical, mental and social

well-being and not merely the absence of disease
ASSESSMENT
Assessment is defined as “The systematic collection of all data and information
relevant to the care of patients, their problems and needs.
(Taber’s 2009)
A health assessment: is a plan of care that identifies the specific needs of a
person and how those needs will be addressed by the healthcare system or
skilled nursing facility.

Data Collection:
Data collection is defined as the ongoing systematic collection, analysis, and
interpretation of health data necessary for designing, implementing, and
evaluating public health prevention programs. Data Collection: A Holistic
Approach.

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Types of data
Subjective: “Symptoms” that the patient describes; e.g. “I can’t do anything for
myself”
Objective: Signs that can be observed, measured, and
verified; e.g. swollen joints
Sources of data:

Primary: The patient; is always the best source

Secondary: Everything/everybody else.

Data Collection Methods

1. Observing: to observe is to gather data by using the senses.
2. Interviewing: an interview is a planned communication or conversation with
a purpose.
3. Examining: Performance of a physical examination. The physical
examination is often guided by data provided by the patient.

TYPES OF ASSESSMENT:
 Initial assessment
 Problem focused
 Emergency assessment
 Time lapsed assessment

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 INITIAL COMPREHENSIVE ASSESSMENT:
An initial assessment, also called an admission assessment, is performed when
the client enters a health care from a health care agency.
The purposes are:
To evaluate the client’s health status.
To identify functional health patterns .
For evaluating changes in the client’s health status .

PROBLEM-FOCUSED ASSESSMENT:
A problem focus assessment collects data about a problem that has already
been identified.
 In focus assessments, nurse determine whether the problems still exists
and whether the status of the problem has changed (i.e. improved,
worsened, or resolved).
 In intensive care units, may perform focus assessment every few minute.
EMERGENCY ASSESSMENT:
Emergency assessment takes place in life threatening situations in which the
preservation of life is the top priority.
Often the client’s difficulties involve airway, breathing and circulatory
problems (the ABCs). Emergency assessment focuses on few essential health
patterns and is not comprehensive.
TIME LAPSED ASSESSMENT OR ONGOING ASSESSMENT:
Time lapsed reassessment, another type of assessment, takes place after the
initial assessment to evaluate any changes in the clients functional health.
The health history interview is a conversation with a purpose.

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PROCESS OF INTERVIEW

•Greeting the patient and establishing rapport

•Inviting the patient’s story
•Establishing the agenda for the interview
•Expanding and clarifying the patient’s story; generating and testing diagnostic
hypotheses
•Creating a shared understanding of the problem(s)
•Negotiating a plan (includes further evaluation, treatment, and patient
education)
•Planning for follow-up and closing the interview.

Principles of interviewing
• Active listening
• Adaptive questioning
• Nonverbal communication
• Facilitation
• Echoing
• Empathic responses
• Validation
• Reassurance
• Summarization
• Highlighting transitions

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Principles for Physical Examination
Preparing for a Physical Assessment
• Stand on the right side of the patient
• Perform the assessment in a head-to-toe approach.
• Always compare the right- and left-hand sides of the body for symmetry.
• Always dress in a clean, professional manner
• Remove all bracelets, necklaces, or earrings that can interfere with the
physical assessment.
• Be sure that your fingernails are short and your hands are warm for
maximum patient comfort.
• Be sure your hair will not fall forward and obstruct your vision or touch the
patient.
• Arrange for a well-lit, warm, and private room.
• Ensure that all the necessary equipment is ready for use and within reach.
• Introduce yourself to the patient: “My name is______. I am the nurse
• Clarify with the patient how he or she wishes to be addressed: Miss Jones,
• Explain what you plan to do and how long it will take; allow the patient to ask
questions.
• Allow the patient to undress privately; inform the patient when you will
return to start the assessment.
• Have the patient void prior to the assessment.
• Wash your hands in front of the patient to show your concern for cleanliness.
• Observe standard precautions and transmission-based precautions, as
indicated.
• Enlist the patient’s cooperation by explaining what you are about to do,
where it will be done, and how it may feel.
• Warm all instruments prior to their use (use your hands or warm water).
• Examine the unaffected body part or side first if a patient’s complaint is
unilateral.
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• Explain to the patient why you may be spending a long time performing one
particular skill: “Listening to the heart requires concentration and time.”
• Conduct the assessment in a systematic fashion every time. (This decreases
the likelihood of forgetting to perform a particular assessment.)
• Thank the patient when the physical assessment is concluded; inform the
patient what will happen next.
• Document assessment findings in the appropriate section of the patient
record.

Equipments:
The equipment needed to perform a complete physical examination of the
adult patient includes
• Pen and paper
• Marking pen
• Tape measure
• Clean gloves
•Penlight or flashlight
• Thermometer
• Sphygmomanometer
• Tongue depressor
• Stethoscope
• Otoscope
• Nasal speculum
• Ophthalmoscope
• Transilluminator • Visual acuity charts

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Assessment techniques
• Inspection
• Palpation
• Percussion
• Auscultation
Inspection

• Inspection is an ongoing process that you use throughout the entire physical
assessment and patient encounter. Inspection is the use of one’s senses of
vision and smell to consciously observe the patient.

Types of Inspection
• Direct inspection: involves directly looking at your patient.
• Indirect inspection: involves using equipment to enhance visualization. E.g.
ophthalmoscope allows better visualization of the ears and eyes.

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[Link]
• The second assessment technique is palpation, which is the act of touching a
patient in a therapeutic manner to elicit specific information
Types of Palpation
There are two distinct types of palpation:
• Light palpation
• Deep palpation
• Light palpation
It is done more frequently than deep palpation and is always performed before
deep palpation.
• As the name implies, light palpation is superficial, delicate, and gentle.
• In light palpation, the finger pads are used to gain information on the
patient’s skin surface to a depth of approximately 1 centimeter (cm) below the
surface. • Light palpation reveals information on skin texture and moisture;
overt, large, or superficial masses; and fluid, muscle guarding, and superficial
tenderness Light palpation To perform light palpation:
1. Keeping the fingers of your dominant hand together, place the finger pads
lightly on the skin over the area that is to be palpated. The hand and forearm
will be on a plane parallel to the area being assessed.
2. Depress the skin 1 cm in light, gentle, circular motions area.
3. Keeping the finger pads on the skin, let the depressed body surface rebound
to its natural position.
4. If the patient is ticklish, lift the hand off the skin before moving it to another
5. Using a systematic approach, move the fingers to an adjacent area and
repeat the process.
6. Continue to move the finger pads until the entire area being examined has
been palpated.
7. If the patient has complained of tenderness in any area, palpate this area
last

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Deep Palpation
• Deep palpation can reveal information about the position of organs and
masses, as well as their size, shape, mobility, consistency, and areas of
discomfort. Deep palpation uses the hands to explore the body’s internal
structures to a depth of 4 to 5 cm or more. This technique is most often used
for the abdominal and male and female reproductive assessments
[Link]

• Percussion is the technique of striking one object against another to cause

vibrations that produce sound. The density of underlying structures produces
characteristic sounds. These sounds are diagnostic of normal and abnormal
findings.

Percussion Sounds
• Resonance: A hollow sound.
• Hyper resonance: A booming sound.
• Tympany: A musical sound or drum sound like that produced by the
stomach.
• Dullness: Thud sound produced by dense structures such as the liver, and
enlarged spleen, or a full bladder.
• Flatness: An extremely dull sound like that produced by very dense
structures such as muscle or bone.

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Types of Percussion
There are four types of percussion techniques
1. Immediate,
2. Mediate,
3. Direct Fist Percussion
4. Indirect Fist Percussion
[Link]

• Auscultation is the act of active listening to body organs to gather

information on a patient clinical status.
• Auscultation includes listening to sounds that are voluntarily and
involuntarily produced by the body.• A quiet environment is necessary for
auscultation Direct or immediate auscultation
• Direct or immediate auscultation is the process of listening with the unaided
ear. This can include listening to the patient from some distance away or
placing the ear directly on the patient’s skin surface • An example of
immediate auscultation is the wheezing that is audible to
• Indirect auscultation with a stethoscope. Your ability to hear is affected by
the quality of the stethoscope

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ASSESSMENT OF ABDOMEN
Anatomy of abdomen
The abdomen is the largest space (cavity) in the body. It lies between the chest
and the pelvis, holding many organs.
The diaphragm forms the upper surface of the abdomen. At the level of the
pelvic bones, the abdomen ends and the pelvis begins.
Organs within the abdomen
The abdomen contains all the
digestive organs, including
 Stomach
 Spleen
 Small and large intestines
 Pancreas
 Liver
 Gallbladder
 Kidneys
 Aderenal Glands
 Ureters
 Urinary bladder
 Abdominal Aorta
 Inferior vana cava
 Nerves and lymphatic vessels

The abdomen also contains the kidneys and spleen.

Many important blood vessels travel through the abdomen, including the
aorta, inferior vena cava, and dozens of their smaller branches. In the front,
the abdomen is protected by a thin, tough layer of tissue called fascia. In front
of the fascia are the abdominal muscles and skin.

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Regions within the abdomen:
There are nine regions of abdomen within which abdominal organs lie. These
are:
1. Right hypochondriac region
2. Epigastric region
3. Left Hypochondriac region
4. Right lumber region
5. Umblical region
6. Left lumber region
7. Reft iliac region
8. Hypogastric region
9. Left iliac region

QUADRANT WITHIN ABDOMEN:

1. Right upper quadrant
2. Right lower quadrant
3. Left upper quadrant
4. Left lower quadrant

Abdominal Girth
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 Abdominal girth is the measurement of the distance around the
abdomen at a specific point. Measurements most often made at the
level of the belly button (navel).

Physical Examination of the Abdomen: Inspection

Inspect the abdomen
• Look at the skin: scars, striae (stretch marks), vein pattern, hair
distribution, rashes, or lesions
• Look at the umbilicus: observe contour and location and any signs of an
umbilical hernia
• Look at the contour of the abdomen: flat, rounded, protuberant, or
scaphoid
• Symmertry of the abdomen
• Inspect for signs of peristalsis (rhythmic movement of the intestine that
can be seen in thin people) and pulsations (within blood vessels such as
the aorta)

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Palpation of abdomen:
General considerations before palpation of abdomen:
1-Ensure that your hands are warm.
2-Stand on the patient’s right side.
3-Patient should have empty bladder.
4-Help to position the patient.
5-Ask whether the patient feels any pain before you start.
6-Distract the patient with conversation or questions.
7--Begin with superficial examination.
8--Move in a systemic manner through the abdominal quadrants.

LIGHTPALPATION: NORMAL FINDINGS ABNORMAL FINDINGS

Used to identify areas of Abdomen is non tender Involuntary reflex guarding is

tenderness and muscular and soft. There is no serious and reflects
resistance. Using the guarding. peritoneal irritation. The

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fingertips, begin abdomen is rigid and the
palpation in a non tender rectus muscle fails to relax
quadrant, and compress with palpation when the
to a depth of 1 cm in a client exhales. It can involve
dipping motion. Then all or part of the abdomen
gently lift the fingers and but is usually seen on
movetothenextarea. the side (i.e., right vs. left
rather than upper or lower)
because of nerve tract
patterns.
DEEP PALPATION:

Deeply palpate all Normal (mild) Severe tenderness or pain

quadrants to tenderness is possible may be related to trauma,
delineate abdominal over the xiphoid, aorta, peritonitis, infection,
organs and detect cecum, sigmoid colon, tumors, or enlarged or
subtle masses. and ovaries with deep diseased organs
Using the palmar palpation.
surface of the fingers,
compress to
a maximum depth.
Perform bimanual
palpation if you
encounter resistance
or to assess deeper
structures.

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 Light palpation

DEEP PALPATION

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Palpate the liver Normal findings Abnormal findings

Noteconsistencyand A hard, firm liver may indicate cancer.

tenderness. Nodularity may occur with tumors,
To The liver is metastatic cancer, late cirrhosis, or
palpate bimanually, usually not syphilis. Tenderness may be from vascular
stand at the client’s palpable, engorgement (e.g., congestive
rightsideandplaceyour although it may heart failure), acute hepatitis, or
lefthandunderthe be felt in some abscess. A liver more than 1–3 cm
client’sbackatthelevelof thin clients. If the below the costal margin is considered
theeleventhtotwelfth lower edge is felt, enlarged (unless pressed down by the
[Link] it should be firm, diaphragm)
paralleltotherightcostal smooth, and even.
margin(yourfingertips Mild tenderness
shouldpointtowardthe may be normal.
client’shead).Askthe
clienttoinhale,then
compressupwardand
inwardwithyourfingers

To palpate
by hooking,
stand to the right Enlargement may be due to hepatitis,
of the client’s liver tumors, cirrhosis, and vascular
chest. Curl (hook) engorgement.
the fingers of both
hands over the
edge of the right
costal margin. Ask
the client to take a
deep breath and
gently but firmly
pull inward and
upward with your
fingers

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HOOKING METHOD:
■ As you stand facing the patient’s head, place the palm of your left hand
against the patient’s right flank, as shown below.
■ Give the left abdomen a firm tap with your right hand. If ascites is present,
you may see and feel a “fluid wave” ripple across the abdomen.
■ If you detect ascites, use a tape measure to measure the fullest part of the
abdomen. Mark this point on the patient’s abdomen with a felt-tip pen so
you’ll be sure to measure it consistently. This measurement is important,
especially if fluid removal or paracentesis is performed. If the patient is
hospitalized, perform this measurement at the same time each day.

Percussion:
 Direct and indirect percussion is used to detect the size and location of
abdominal organs and to detect air or fluid in the abdomen, stomach, or
bowel.
 Direct percussion (strike your hand or finger directly against the
patient’s abdomen)
 Indirect percussion (use the middle finger of your dominant hand or a
percussion hammer to strike a finger resting on the patient’s abdomen)
 Begin percussion in the RLQ and proceed clockwise, covering all four
quadrants. Sounds change from tympany to dullness.

Percussing and measuring the liver:

 Begin percussing the abdomen along the right midclavicular line, starting
below the level of the umbilicus.

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 Move upward until the percussion notes change from tympany to
dullness, usually at or slightly below the costal margin. This indicates the
lower border of the liver.
 Mark the point of change with a felt- tip pen.

 Percuss downward along the right midclavicular line, starting above the
nipple. Move downward until percussion notes change from normal lung
resonance to dullness, usually at the fifth to seventh intercostals space.
This indicates the upper border of the liver.
 Again, mark the point of change with a felt-tip pen.
 Estimate the liver’s size by measuring the distance between the two
marks.
 In an adult, a normal liver span is 4 to 8cm at the midsternal line and 6
to 12 cm at the right midclavicular line.

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 ASSESSMENT OF MOUTH,
NOSE & PHARYNX

THE NOSE
“Nose is the sensory organ of smell and the first past of respiratory system.”
The lower two- third part of the external nose consists of flexible cartilage, and
the upper one- third part is rigid bone. The two nostrils are separated by nasal
septum.

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Techniques used for nose assessment:
 Inspection
 Palpation

Inspecting the nose

Equipments required for inspection:
 Gloves
 Nasal speculum
 Penlight
 Otoscope with a short, wide tip attachment.

Procedure:
 Observe the patient's nose for position, symmetry and colour.
 Note variations such as discoloration, swelling and deformity.
 Observe for nasal discharge or flaring.
 If discharge is present, note the colour, quantity and consistency.
 If you notice flaring, observe for other signs of respiratory distress.
 Then inspect the nasal cavity. Check patency by occluding one nostril
and asking the patient to breathe in through the other nostril. Repeat on
the other side.

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Inspecting the nasal cavity using otoscope:
 To inspect the nose, ask the patient to tilt his head back slightly, then
Push up the tip of the nose and gently insert the ostoscope.
 Use the light from the ostoscope to illuminate the nasal cavity.
 Check for severe deviation or perforation of the nasal septum.
 Examine the vestibule and turbinates for redness, swelling, and
discharge.
 Document the findings.

Palpating the nose:

Palpate the patient's nose with your thumb and forefinger, assessing for pain,
tenderness, swelling and deformity.

The sinuses
"Sinuses are interconnected hollow cavities in the skull. These cavities are
linked to your nasal passages by small channels. The channels let air flow from
your nose into the sinuses and allow mucus to drain from every sinus into the
nose."
Types of sinuses:
Following are the types of sinuses
• Ethmoid sinus.
•Maxillary sinus.
• Frontal sinus.
• Sphenoid sinus.

Examining the sinuses :

Remember, only the frontal and maxillary sinuses are accessible, you won’t be
able to palpate the ethmoidal and sphenoidal sinuses. if the frontal and
maxillary sinuses are infected, you can assess the other sinuses.

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Palpating the maxillary sinuses:
To palpate the maxillary sinuses, gently press your thumbs on each side of the
nose just below the cheekbones.
The illustration also shows the location of the frontal sinuse
Frontal sinuses:Place the penlight on the supraorbital ring and direct the light
upward to illuminate the frontal sinuses .

Maxillary sinuses :Place the penlight on the patient’s cheekbone just below
her eye and ask her to open her [Link] light should transilluminate easily

and equally.

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 THE MOUTH
The mouth is an oval-shaped cavity inside the skull.
The two main functions of the mouth are eating and speaking.
Parts of the mouth include the
o Lips
o Vestibule
o Mouth cavity
o Gums
o Teeth
o Hard and soft palate
o Tongue
o Salivary glands

The mouth is also known as the oral cavity or the buccal cavity.

Techniques of Examination:
Inspection:
The Lips
Observe their color and moisture, and note any lumps, ulcers, cracking, or
scaliness.
The Oral Mucosa
Look into the patient’s mouth and, with a good light and the help of a tongue
blade. Inspect the oral mucosa for color, ulcers , white patches, and nodules.
The wavy white line on the adjacent buccal mucosa developed where the
upper and lower teeth meet, related to irritation from sucking or chewing.

The Gums and Teeth

Note the color of the gums, which are normally pink. Brown patches may be
present, especially but not exclusively in darkskinned individuals. Inspect the
gum margins and the interdental papillae for swelling or ulceration.

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To assess tooth, jaw, or facial pain, palpate the teeth for looseness and the
gums with your gloved thumb and index finger.
The Roof of the Mouth
Inspect the color and architecture of the hard palate.

LYMPH NODES
Lymph nodes of head and neck can be divided into two groups;
 A superficial group of lymph nodes and
 A vertical group of deep lymph nodes.

SUPERFICIAL LYMPH NODES

They receive lymph from scalp, face and neck and ultimately drain into deep
lymph nodes. It includes:
 Occipital
 Mastoid
 Pre-aur8culer
 Parotid
 Sub-mental
 Submandibular
 Facial
 Superficial cervical

DEEP LYMPH NODES

They receive all the lymph from head and neck either directly or indirectly (via
superficial lymph nodes). It includes superior or inferior deep cervical lymph
nodes.

Techniques of Examinition
Inspect the neck:
 Noting its symmetry and any masses or scars.
 Look for enlargement of the parotid or submandibular glands, and note
any visible lymph nodes.
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Palpate the lymph nodes.
Using the pads of your index and middle fingers, press gently, moving the skin
over the underlying tissues in each area.
You can usually examine both sides at once, noting both the presence of lymph
nodes as well as asymmetry.

1. Preauricular—in front of the ear.

2. Posterior auricular—superficial to the mastoid process.

3. Occipital—at the base of the skull posteriorly.

4. Tonsillar—at the angle of the mandible.

5. Submandibular—midway between the angle and the tip of the mandible. These nodes
are usually smaller and smoother than the lobulated submandibular gland against
which they lie.

6. Sub mental—in the midline a few centimeters behind the tip of the mandible.

7. Superficial cervical—superficial to the sternocleidomastoid.

8. Posterior cervical—along the anterior edge of the trapezius.

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9. Deep cervical chain—deep to the sternocleidomastoid and often inaccessible to
examination. Hook your thumb and fingers around either side of the
sternocleidomastoid muscle to find them.

10. Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid.

FINDINGS:
Note lymph nodes size, shape, delimitation (discrete or matted together),
mobility, consistency, and any tenderness. Small, mobile, discrete, nontender
nodes, sometimes termed “shotty,” are frequently found in normal people.
Describe enlarged nodes in two dimensions, maximal length and width, for
example, 1 cm × 2 cm. Also note any overlying skin changes (erythema,
induration, drainage, or breakdown).

Enlarged or tender nodes, if unexplained, call for

(1) re-examination of the regions they drain and
(2) careful assessment of lymph nodes in other regions to identify regional
from generalized lymphadenopathy.

ASSESMENT OF RESPIRATORY SYSTEM

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INSPECTION
Inspect the following things;
 Nasal flaring
 Configuration of chest wall
 Use of assessory muscles
 Position of client

PALPATION
Palpate for fremitus:
“Tactile fremitus is an assessment of the low-frequency vibration of a patient's
chest, which is used as an indirect measure of the amount of air and density of
tissue present within the lungs.’’
Procedure of tactile fremitus:
 Ask the patient to say
" ninety-nine" in a normal voice
 Palpate using the lateral aspect
of your hand
 You should feel the vibrations equally transmitted from the airway, via
the lung to the chest wall
 Increased tactile vocal fremitus suggests consolidation.
 Reduced tactile vocal fremitus suggests fluid outside the lung (pleural
effusion)
 Vocal resonance (listening with a stethoscope) can be used instead of
tactile vocal fremitus

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Chest expansion
Procedure;
 Place your hands on the front of chest wall with your thumbs touching
each other at the second intercostal space as the patient inhales deeply
watch your thumbs.
 They should separate simultaneously and equally to a distance several
centimeters away from the sternum .repeat the measurements at the
fifth intercostal space.
 The same measurement may be made on the back of the chest near the
tenth rib. The chest of patient may expand asymmetrically if he has
pleural effusion, atelectasis,pneumonia,or pneumothorax.
 Result: Vibrations that feel more intense on one side then the other
indicate tissue consolidation on that side. Less intense vibrate may
indicate emphysema pneumo-thorax, pleural effusion. Faint or no
vibrations in the upper posterior thorax may indicate bronchial
obstructions or a fluid filled pleural space.
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PERCUSSION:
PERCUSS FOR DIAPHRAGMATIC EXCURSION:
 Ask the client to exhale forcefully and hold the breath.
 Beginning at the scapular line(T7),percuss the intercostal spaces of the
right posterior chest wall.
 Percuss downward until the tone changes from resonance to dullness.
 Mark this level and allow the client to breathe.
 Next ask the client to inhale deeply and hold it.
 Percuss the intercostal space from the mark downward until resonance
to dullness.
 Mark the level and allow the client to breathe.
 Measure the distance between the two marks.
 Perform this assessment technique on both sides of the posterior
thorax.
 Percussion for chest tone

Procedure (back side)

Start at the apices of the scapulae and percuss across the top of both
shoulders. Then percuss the intercostal spaces across and down, comparing
sides. Percuss to the lateral aspects at the bases of the lungs, comparing sides.
 Resonance is the percussion tone elicited over normal lung tissue.

 Hyper resonance is elicited in case of trapped air such as in emphysema

and pneumothorax.

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Front side:
Percuss the apices above the clavicles, then percuss the intercostals space
across and down, comparing sides.
 Resonance is the percussion tone elicited over normal lung tissue.
Percussion elicits dullness over breast tissue, the heart, the liver.
Tympany is detected over the stomach, and flatness is detected over the
muscles and bones.

 Hyper resonance is elicited in cases of trapped air such as in

emphysema or pneumothorax. Dullness may characterize areas of
increased density such as consolidation, pleural effusion.

Percussion sounds

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SOUNDS Description Clinical significance

Flat Soft, short, high- pitched, Consolidation, as in

extremely dull, as found over the atelectasis and extensive
thigh pleural effusion.
Dull Medium in intensity and pitch, Solid area, as in lobar
moderate length, thud like as pneumonia
found over the liver.
Resonance Loud, long, low- pitched, hollow. Normal lung tissue,
bronchitis.
Hyperresonance Very loud, lower- pitched, as Hyper inflated lungs, as in
found over the stomach. emphysema or
pneumothorax.
Tympanic Loud, high-pitched, moderate Air collection, as in a large
length, musical, dreamlike, as pneumothorax.
found a puffed-out cheek.

AUSCULTAION:
Auscultation of breath sound
 Adventitious sound and voice sound place diaphragm firmly and directly
on anterior chest wall.
 Auscultate from apices of lungs slightly above from clavicles to the base
of lungs at six ribs.
 Ask patient to take deep breath in avoid to transmission of sound that
occur in nasal breathing.
 Be alert of patient comfort and offer time to rest.
 Then listen at each site for one complete cycle

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 Abnormal Breaths Sounds:
The sounds which are superimposed over normal breaths sounds are called
abnormal breath sounds i.e.
 Discontinuous sounds

• Fine crackles

• Coarse crackles

 Continuous sounds
• Wheezes

• Rhonchi

Discontinuous sounds
Characteristics of Fine crackles
• Intermitted
• Non-musical

• High-pitched

• Cracking ,popping sound

• Heard during inspiration

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 Characteristics of coarse crackles
• Intermittent

• Non-musical

• Loud

• Low-pitched

• Bubbling, gurgling sounds

• Heard during early inspiration and possibly during expiration.

Continuous sounds
Characteristics of wheezes
• Musical

• High-pitched

• Squeaky, whistling

• Predominantly heard during expiration but also during inspiration

Characteristics of Rhonchi
• Musical

• Low-pitched

• Snoring, moaning sounds

• Heard during inspiration and expiration.

NEWBORN REFLEX
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 The involuntary movements that
newborns exhibit when stimulated are called newborn reflexes.
These reflexes aid newborns to survive while they have limited control over
their body. These also provide health clues, which is why assessment of the
neuromuscular function is part of the general newborn examination. Specific
focus should be given to newborns’ alertness, muscle tone and strength, head
control, and response to manipulation and handling.

 Here are simple maneuvers for 11 newborn reflexes

1. Blink Reflex
• Blink reflex is the rapid eye closure exhibited by newborns upon coming
of objects near it. Similar with adults, this reflex serves a protective
function against hurting the eye. It can be elicited by shining a strong
light (e.g. flashlight, otoscope light, etc.) on the eyes. This is important in
assessing newborns’ visual attentiveness.

• 2. Rooting Reflex

• Brushing the cheek or stroking near the mouth of the newborn will
cause the head of the newborn to turn to that direction. This reflex is
called rooting reflex, which helps the baby find the source of food. For
an instance, during breastfeeding, when the mother allows her breast to

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 brush the cheek of the newborn, this allows the newborn to turn to its
direction and begin sucking. However, this reflex on the sixth week
because by that time, the baby is able to steadily focus on a food source.

3. Sucking Reflex
• Touching the newborn’s lips causes the baby to make sucking motions.
Like rooting reflex, sucking reflex helps the baby find food. For an
instance, when the lips of the baby touch the mother’s breast or a
bottle, the baby would begin sucking and so food is taken in. Sucking
reflex disappears at six months of age.

4. Extrusion Reflex

Until four months of age, any food placed on the anterior portion of the
tongue of babies will be expelled by them. This serves a protective function by
preventing the baby from swallowing substances that are toxic or poisonous.
This is also the reason why complementary feeding or introduction of solid
food is done at about six months of age.

5. Palmar Grasp Reflex

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  Objects placed on newborns’ palms will be grasped by newborns. Palmar
grasp reflex disappears between six weeks to three months.

6. Walk-in-Place Reflex
 If newborns are held in a vertical position with their feet touching a hard
solid surface, newborns will take few, alternating steps. This can last
until three months of age, the time where they start to bear a good
portion of their weight without being hindered by this reflex.

7. Tonic Neck Reflex

 Turning a newborn’s head to one side will cause the extremities to on
that side extend s while the opposite extremities contracts or flexes. This
is also called boxer of fencing reflex because of the position of the
newborn. Of all reflexes, this is the one which appears to have no
function. However, it is being linked to eye stimulation and handedness.
This disappears between 8-12 weeks.

8. Moro Reflex

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 • There are many ways to elicit Moro reflex. However, the most common
method used is the “drop method” wherein the nurse lifts the baby
completely off the bed while supporting the head and the neck, and
then the nurse lowers the baby rapidly till there is only 4-8 inches
between the baby and the bed. It is important to note that while doing
this, the baby is kept in supine position.

• Complete Moro reflex involves bilateral abduction of arms, extension of

forearms, and full opening of hands. This is then followed by slow return
of hands towards the midline and then followed by curling of the fingers.
Startle reflex is different from Moro reflex in the sense that it lacks full
extension and hand opening and can be elicited spontaneously by
sudden noise or movement.

9. Babinski Reflex
• When the nurse strokes the sole of the foot in an inverted “J” curve from
the heel upward, the newborn’s toes fan. It is only in newborns that
positive Babinski reflex is considered normal. It normally disappears
after the 3rd month.

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10. Reflexes of spinal cord integrity
There are three reflexes to test spinal cord integrity of newborns. First on
the list is magnet reflex, which can be elicited by applying pressure on the
soles of the foot of newborns lying in supine position. As a response, the
newborns would push back against the pressure.
• The second reflex to test spinal cord integrity is called crossed extension
reflex. This is exhibited by the newborn in supine position by raising his
other leg and extending it when the other leg is extended and, the sole
of that foot is irritated or rubbed by a sharp object (e.g. thumbnail). This
is like the act of the newborn trying to push the hand away that irritates
the other leg.

• Lastly, newborns lying in prone position would flex their trunk and swing
their pelvis towards the direction of the touch when their paravertebral
area is touched by a probing finger. This reflex is called trunk incurvation
reflex.

• 11. Landau Reflex

• Babies will exhibit some degree of muscle tone if they were made to lie
in a prone position with the nurse’s hand supporting the trunk. While
they are not expected to raise their head or arch their back in this
position, babies who will sag into an inverted “U” position show
extremely poor muscle tone. In such cases, further assessment and
management is needed.

APGAR SCORE

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Apgar stands for Appearance, Pulse, Grimace, Activity and Respiration.
“The APGAR score is practical method of systematically assessing newborn
infants immediately after birth to help identify requiring resuscitation and to
predict survival in neonatal period.”
Dr. Virginia apgar developed this score

Apgar testing is typically done at one and five minutes after a baby is born, and
it may be repeated at 10, 15, and 20 minutes if the score is low.

A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health.

A score of 10 is very unusual, since almost all newborns lose 1 point for blue
hands and feet, which is normal for after birth.
An Apgar score of 0 describes a newborn with no signs of life: no heartbeat, no
breathing, no response to stimulation, no muscle tone, and central
cyanosis/pallor. Historically, an Apgar score of 0 at 10 min has been a strong
predictor of morbidity and mortality.

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Glasgow coma scale:-
The Glasgow Coma Scale (GCS) is a clinical scale used to reliably
measure a person's level of consciousness after a brain injury.
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The GCS assesses a person based on their ability to perform eye movements,
speak, and move their body. These three behaviours make up the three
elements of the scale: eye, verbal, and motor.

Faculty Measured Response Score

Eye opening Spontaneous 4

To verbal command 3
To pain 2
No response 1
Motor response To verbal command 6
To localized pain 5
Flexes and withdraws 4
Flexes abnormally 3
Extends abnormally 2
No response 1
Verbal response Oriented, converses 5
Disoriented, converses 4
Uses inappropriate words 3
Makes incomprehensible sounds 2
No response 1

PAIN
Highly unpleasant physical sensation caused by illness or injury.
Pain scale:

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A pain scale measures a patient's pain intensity or other features. Pain scales
are a common communication tool in medical contexts, and are used in a
variety of medical settings.

Mnemonic of Pain Assessment

COLDERRA Method:
C : Characteristics :- dull, achy, sharp, stabbing, pressure

O : Onset:- when did the pain start?

L: Location:- where does it actually start?
D: Duration:- how long does it last?
E :Exacerbation:- what makes the pain worse?
R: Radition:- does it travel? To where?
R: Relief:- what provies relief? To what extent?
A: Associated symptoms:- nausea, vomiting etc.

OLDCARTS Method:
O: onset
L: location
D: duration
C: character
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A: aggravating factor
R: relieving factors
T: timing
S: severity

OPQRSTU Method:
O: Onset
P: Provoking factors
Q: Quality
R: Region and radiation
S: Severity
T: Time and treatment
U: Understand and impact

SOCRATES Method:
S: Site
O: Onset
C: Character
R: Radiation
A: Associated symptoms
T: Time and Duration
E: Exacerbating Factors
S: Severity
LIQOR PPPAAA Method:
L: Location
I: Intensity

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Q: Quality
O: Onset
R: Radiation
P: Precipitating factor
P: Progression
P: Previous similar episodes
A: Alteriating
A: Aggreviating
A: Associating Symptoms

COLDSPA Method:
C: Character
O: Onset
L: Location
D: Duration
S: Severity
P: Palliating factor
A: Associating Symptoms.

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