Download Acknowledgement

The Islamic university of Gaza
Faculty of Nursing
"NURSING HEALTH ASSESSMENT"
NURS 2214
Prepared by:
Dr. Abdalkarim Radwan
Faculty of nursing
4th edition
©2010
Acknowledgement
**A special and high acknowledgement to the God who helps
me to search and write this course.
**Another acknowledgement to the deanship of faculty of
nursing of the Islamic university in Gaza which provoked the
awareness and importance of nursing health assessment, as a
basic branch for high quality nursing care.
**To our colleagues in (NANDA) who continue to formulate
and refine nursing diagnoses to provide nursing with tools to
enhance and promote the growth of the profession.
**To our colleagues in faculty of nursing who are promoting
the need for health assessment for our students in clinical
training areas.
Dr. Abdalkarim Radwan
Faculty of Nursing
2010
2
Preface
The course "nursing health assessment" is designed for nursing
students in the second year; it contains the theory and skills
necessary to collect a comprehensive health history and to perform a
complete physical examination.
This course introduces the learner to the knowledge necessary to
assess the physical, psychological sociocultural and spiritual
experiences of an individual. The learner will use skills of
observation, interviewing, inspection, auscultation, and palpation to
collect data. The focus will be on individuals throughout their
lifespan.
This subject is not intended to contain detailed anatomy and
physiology.
This course is a divided into multiple chapters in a well organized
manner to be learned in 14 – 15 weeks by two hours weekly.
The students must know perfectly the steps of health assessment and
can identify specific nursing diagnosis, which must based on the
functional health patterns of North American Nursing Diagnoses
Association's (NANDA).
These functional health patterns format focuses the health history
with the independent domain of professional nursing.
The course contains multiple references for students further
information's related to nursing health assessment including some
websites on the internet.
Dr. Abdalkarim Radwan
faculty of nursing
©2010
3
(Chapter – 1)
The Nursing Process
4
The Nursing Process :
"An organizational framework for the practice of nursing
Orderly, systematic"
* Central to all nursing care
Encompasses all steps taken by the nurse in caring for a patient
Definition of the Nursing Process: (An organized sequence of
problem-solving steps used to identify and to manage the health
problems of clients)
* It is accepted for clinical practice established by the American
Nurses Association
Benefits of Nursing Process:
1. Provides an orderly & systematic method for planning &
providing care
2. Enhances nursing efficiency by standardizing nursing practice
3. Facilitates documentation of care
4. Provides a unity of language for the nursing profession
Is economical
1. Stresses the independent function of nurses
2. Increases care quality through the use of deliberate actions
The Nursing Process Utilizes The Following:
I.
Assessment
II. Nursing Diagnosis
III. Planning
IV. Implementation
V. Evaluation
* Characteristics of the Nursing Process:
a) Within the legal scope of nursing
b) Based on knowledge-requiring critical thinking
c) Planned-organized and systematic
d) Client-centered
e) Goal-directed
f) Prioritized
g) Dynamic
h) Benefits of using the nursing process
i) Continuity of care
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j) Prevention of duplication
k) Individualized care
l) Standards of care
m) Increased client participation
Collaboration of care:
 Being Accountable
 Using critical thinking before taking actions
 Being responsible for your actions
 Entering the professional role
 Working at the level of your peers
 Using the nursing process
Something to think about:
Nurses are responsible for a unique dimension of healthcare – “ the
diagnosis and treatment of human responses to actual or potential
health problems”
“When an apple is cut, others see seeds in the apple. We, as
nurses, see apples in the seeds.”
* What Are Your Responsibilities?
a) Recognize health problems.
b) Anticipate complications.
c) Initiate actions to ensure appropriate and timely treatment.
Begin to think CRITICALLY !!
** Critical Thinking : MENTAL OPERATIONS –decision making
& reasoning. Critical thinking in nursing is an essential component
of professional accountability and quality nursing care.
- Critical thinking is careful, deliberate, and goal directed.
** KNOWLEDGE-having the facts & understanding the reason
behind the knowledge
** ATTITUDES- curious/open-minded/non-judgmental….
Assessment of Well-Being
According to the World Health Organization is well-being in these
domains:
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- Emotional
- Physical
- Social
- Spiritual
Lets Get Started :
a) Nurse collects background info from previous charts
b) Ensure environment is conducive
c) Arrange seating
d) Allow adequate time
e) Nurse introduces self
f) Identifies purpose of interview
g) Ensure confidentiality of information
h) Provide for patient needs before starting
ASSESSMENT:
1. Observation
2. Interview:
– Types of questions
– Environment (physical
considerations
3. Examination
and
emotional)
Spiritual
Types of Data To Collect:
- Objective data-observable and measurable facts (Signs)
- Subjective data-information that only the client feels and can
describe (Symptoms)
* Data collected in nursing process HELPS in multiple aspects e.g. :
- Resources
- Client himself
- Other individuals
- Previous records
- Consultations
- Diagnostics studies
- Relevant literature
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* Assessment:
Data base assessment – comprehensive information you gather
on initial contact with the person to assess all aspects of health
status.
Focus assessment – the data you gather to determine the status of a
specific condition.
Sources of Data:
– Primary source: Client
– Secondary source: Client’s family, reports, test results,
information in current and past medical records, and
discussions with other health care workers
Disease Prevention:
– Primary prevention – protection from a disease while still in
a healthy state.
– Secondary prevention – early detection and treatment of
disease.
– Tertiary prevention – prevent complications and to maintain
health once the disease process has occurred.
Verifying Data:
 Essential in critical thinking!!!!!
 Measurable data
 Double check personal observations
 Double check equipment
 Check with experts and team members
 Recheck out-liers
 Compare objective and subjective data
 Clarify statements
* Planning:
Establish the goals, interventions and outcomes
General Guidelines for Setting Priorities:
 Take care of immediate life-threatening issues.
 Safety issues.
 Patient-identified issues.
 Nurse-identified priorities based on the overall picture, the
patient as a whole person, and availability of time and
resources.
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Nurse Identified Priorities
 Composite of all patient’s strengths and health concerns.
 Moral and ethical issues.
 Time, resources, and setting.
 Hierarchy of needs.
 Interdisciplinary planning.
 Identifying Client-centered Outcomes
 State what the patient will do
or experience at the
completion
of care.
 Give direction to the patient’s
overall care.
 Patient behaviors not nurse behaviors!!
* Diagnosis:
 Sort, cluster, analyze information
 Identify potential problems and strengths
 Write statement of problem or strength
 Risk of infection related to compromised nutrition
 Nursing Diagnosis (cont.)
 Potential for effective breastfeeding related to knowledge level
and support system
 Prioritize the problems
 Not a medical diagnosis
Steps for deriving outcomes from Nursing Diagnosis:
Look at the first clause of the nursing dx and restate in a
statement that describes improvement, control or absence of the
problem.
Risk for infection r/t surgical procedure.
The client will demonstrate no signs or symptoms of infection.
Components of Outcomes
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the
actions?
Performance criteria: how well is the person to perform the
actions?
Target time: by when is the person expected to be able to perform
the actions?
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Nursing Interventions:
- Monitor health status.
- Minimize risks.
- Resolve or control a problem.
- Assist with ADLs.
- Promote optimum health and independence.
* Interventions:
Direct interventions: actions
with clients.
Indirect interventions: actions
on behalf of a client or group of
performed through interaction
performed away from the client,
clients.
* Nursing Diagnosis:
Health issue that can be prevented, reduced, resolved, or
enhanced through independent nursing measures
Documenting the Plan of Care: To ensure continuity of care, the plan
must be written and shared with all health care personnel caring for
the client.
Consists of: Prioritized nursing diagnostic statements, Outcomes&
Interventions.
Documentation
 Clear and concise
 Appropriate terminology: Usually on a designated form
 Physical assessment: Usually by Review of Systems
(Overview of symptoms, Diet &Each body system)
 Use patient’s own words in subjective data – enclose in “ ___”
(quotation marks)
 Avoid generalizations – be specific
 Don’t make summative statements – describe - e.g. patient is
being ornery should be patient resists instruction or patient
states “Don’t talk to me, I don’t care about that”
Evaluation:
1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify, or terminate the
plan
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Determining Outcome Achievement:
 Must be aware of outcomes set for the client.
 Must be sure patient is ready for evaluation.
 Is patient able to meet outcome criteria?
 Is it: (Completely met? ,Partially met?, Not met at all?)
 Record in progress in notes.
 Update care plan.
Identifying Variable Affecting Outcome Achievement
Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?
Predict, Prevent, and Manage:
 Focus on early intervention
 Based on research
 Predict and anticipate problems
 Look for risk factors
Diagnostic Statements:
 Name of the health-related issue or problem as identified in the
NANDA list
 Etiology (its cause)
 Signs and Symptoms
 The name of the nursing diagnosis is linked to the etiology
with the phrase “related to,” and the signs and symptoms are
identified with the phrase “as manifested (or evidenced) by”
Collaborative Problems-Nurse’s Responsibility
 Correlating medical diagnoses or medical treatment measures
with the risk for unique complications
 Documenting the complications for which clients are at risk
 Making pertinent assessments to detect complications
 Reporting trends that suggest development of complications
 Managing the emerging problem with nurse- and physicianprescribed measures
 Evaluating the outcomes
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Nursing Diagnosis: Judgment or conclusion about the risk for—or
actual—need/problem of the patient (NANDA format)
NANDA – North American Nursing Diagnosis Association
 Identifies nursing functions
 Creates classification system
 Establishes diagnostic labels
 Risk of infection related to compromised nutritional state
 Potential complication of seizure disorder related
medication compliance
to
Planning:
- The process of prioritizing nursing diagnoses and collaborative
problems, identifying measurable goals or outcomes, selecting
appropriate interventions, and documenting the plan of care.
- The nurse consults with the client while developing and revising
the plan.
Setting Priorities:
- Determine problems that require immediate action
- Maslow’s Hierarchy of Human Needs
Short-Term Goals:
– Outcomes achievable in a few days or 1 week
– Developed form the problem portion of the diagnostic
statement
– Client-centered
– Measurable
– Realistic
– Accompanied by a target date
Long-Term Goals:
Desirable outcomes that take weeks or months to accomplish for
client’s with chronic health problems
Planning: Identification of goals and outcome criteria, Prioritization
&Time frame
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Selecting Nursing Interventions:
– Planning the measures that the client and nurse will use to
accomplish identified goals involves critical thinking.
– Nursing interventions are directed at eliminating the
etiologies.
Selecting an intervention:
– The nurse selects strategies based on the knowledge that
certain nursing actions produce desired effects.
– Nursing interventions must be safe, within the legal scope
of nursing practice, and compatible with medical orders.
Communicating The Plan:
– The nurse shares the plan of care with nursing team
members, the client, and client’s family.
– The plan is a permanent part of the record.
Evaluation:
– The way nurses determine whether a client has reached a
goal.
– It is the analysis of the client’s response, evaluation helps to
determine the effectiveness of nursing care.
– Ongoing part of the nursing process
– Determining
the
status
of
the
goals
and
outcomes of care
– Monitoring the patient’s response to drug therapy
Documentation:
– Clear and concise
– Appropriate terminology, Usually on a designated form
– Physical assessment: Usually by Review of Systems:
* Overview of symptoms
* Diet
* Each body system
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(Chapter – 2)
Health assessment
Introduction
As long ago as the beginning of the civil war an article was
published recommending periodic health examinations in the interest
of early detection of diseases. This concept was depoted by
American medical association in (1992) in the form of a resolution
advocating periodic health assessment.
In (1995) the declaration that health care is a basic human right was
made at a white house conference on aging. The general public has
expressed with increasing frequency the expectation that preventive
health care constitutes a fundamental part of this care. Preventive
health care is defined in three categories, primary, secondary and
tertiary prevention. Each level of prevention is based on a thorough
assessment of the client's health as status.
The health assessment is frequently the mechanism of entry into the
health care system. Since accessibility has been shown to be an
important factor in determining whether a client will seek health
care, alternates mode of providing health care to greater numbers of
people has been explored.
*recent studies have indicated that although periodic health
assessment have proved beneficial , they may not necessarily need to
be performed by a physician, but also performed by nurses.
**controlled studies comparing physician's and nurses problem lists
after they have examined the same clients show no appreciable
differences . The examinations are certainly less costly to the client
when they done by nurse other than physicians.
** Objectives and types of assessment:
 The purposes of health assessment include surveillance of
health status, the identification of latent or occult disease,
screening for specific type of disease, and follow-up care.
 The periodic assessment, on other hand, is regarded as
occurring at regular intervals.
A return or follow up visit is one that is scheduled to assess the
progress or an abatement of diagnosed dysfunction.
 Increasing client participation in health care.
 The health assessment should accurately define the health and
risk care needs for individual at that specific point in time.
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 The information obtained in the interview and health
assessment is used to formulate the exchanges of responsibility
in defining the contract.
 The findings of the health assessment are shared with the
client in a clearly and understandable manner. In many cases
this may mean educating him to the anatomy and physiology
of his diseased tissues, so that he can fully understand the
meaning and level of his dysfunction.
 Only with clear definition of his problem is the client capable
off assuming active involvement in decision making for his
own care.
** the world health organization (W.H.O) has defined health
education as" the active mechanism of facilitating an optimal
state of social, emotional, & physical functioning that should be
available to all people . Client education is implicit in preventive
care.
** Frequency of assessment:
There is considerable controversy surrounding the issue of how
often the periodic health assessment should be performed on the
ostensibly healthy client.
Early recommendations suggested that the health assessment
should be done each year .but one recommendation suggested that
the health assessment for the persons under (35) years of age
must be every (4 – 5) years, and persons from (35 – 45) years of
age must be every (2 – 3) years. And that any person over (45)
years of age undergo a thorough health assessment every year.
**Importance of nursing health assessment:
Assessment is "the systematic and continuous collection
validation and communication of client data".
** The collection of client data is a vital step in the nursing
process, because the remaining steps depend on complete,
accurate, relevant, and factual data which obtained from the
client.
 When nurses make health assessment they don’t duplicate
medical assessments. The primary purpose of the nursing
assessment is not to gather data that define underlying
15
pathology & medical problems but it focus on client responses
to health problems.
 Through health assessment the nurse carefully examine the
client’s body parts to review their integrity & to determine if
abnormalities exist.
 The nurse relies on data from a variety of sources to reveal
patterns of abnormalities which when validated with health
assessment findings can indicate significant clinical problems.
 Health assessment provides abase line, measurement of the
client’s existing function abilities, successive examinations
used to plan the clients care.
 Health assessment helps the nurse to diagnose client’s
problem & determine the best nursing measures & their
management.
 A complete health assessment involves a more detailed review
of client’s condition.
 Accuracy of health assessment influence, the choice of
therapies a client receives & the determination of response to
those therapies.
Purposes of health assessment:1. To gather base line data about the client's health.
2. To supplement, confirm, or refute data obtained in the health
history.
3. To confirm identify nursing diagnoses.
4. to make clinical judgments about client's changing health
status and management
5. To evaluate the bio-psycho-social and spiritual outcomes of
care.
Difference between medical diagnosis and nursing diagnosis:
**Nursing diagnosis and medical diagnosis
Nursing diagnosis represent the independent role of the nurse.
The nurse can use this model to decide whether the identified
problem can be treated independent by as a nursing diagnosis, or
whether the nurse will monitor and use both medical and nursing
16
interventions to treat or prevent the problem, if medical and
nursing interventions are not needed, the problem is discharged
from nursing care referred to medicine and /or dentistry.
** The medical diagnoses depend on clinical picture and laboratory
findings, but the nursing diagnoses depend on the client's problems
associated with specific disorder. And any problem must notice from
a holistic view e.g. bio-psycho-social and spiritual relations which
play major roles in disease process of the client.
*the difference between medical diagnosis, a collaborative
problem, and nursing diagnosis is explained with the following
examples:Medical
diagnosis
-fractured jaw
Diabetes
mellitus
Collaborative
problem
Potential
Complication:
Aspiration
Potential
Complication:
Hyperglycemia
Hypoglycemia
Nursing diagnosis
*altered oral mucous
membrane related to difficultly with
hygienic secondary to fixation devices
*chronic pain related to tissue trauma.
*impaired skin integrity related to poor
circulation to lower extremities.
*know ledge deficit: effects of exercise
on need for insulin.
Pneumonia
Potential
Complication
Hypoxemia
*ineffective airway clearance related to
presence of excessive mucus.
*fluid volume deficit related to poor fluid
intake.
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Health history
Health history "a holistic approach" done by:I. The interview
II. Psychosocial assessment
III. Nutritional assessment
IV. Assessment of sleep-wakefulness patterns
V. The health history.
Interview
The major purpose of interview conducted before physical
examination is to obtain health history and to elicit symptoms and
the time course of their development.
The interview is defined as "a communication process that
focuses on the client's development, psychological, physiological,
socio cultural , and spiritual responses , that can be treated with
nursing & collaborative interventions ,"
Components of nursing interview:The nursing interview has three basic phases, introductory phase,
working phase and termination phase.
A- Introductory phase:
The nurse introduces self and explains the purpose of the
interview to the client. An Explanation, of note taking,
confidentiality, and type of question, to be asked should be given.
Comfort, Privacy and confidentiality are provided.
B- working phase:
The nurse facilitates the client's comments about major
biographical data, reason for seeking health care and function
health pattern responses.
The nurse must listen and observe cues in addition to using
critical thinking skills to interpret and validate information
received from the client.
The nurse and the client collaborate to identify client's problems
and goals.
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C- Termination phase:
The nurse summarizes information obtained during the
working phase and validates problems and goals with the client.
Possible plans to resolve the problem "nursing diagnosis
collaborative problems" are identified and discussed with the
client.
 communications techniques during interview:1. Types of questions to use:
 Use open ended questions to assess client's feelings and
perceptions "begin with , what, how , which"
 Use closed ended question to obtain facts, you can use
"when, did…etc.
 Use list to obtain specific answers e.g. "is pain sever,
dull sharp"
 Explore all data that deviate from normal e.g. "what
alleviates or aggravates the problem".
2. Types of statements to use:Repeat your perception of client's response to clarify
information, and encourage verbalization.
3. Accept the client use silence to recognize thoughts.
4. avoid some communication styles e.g.
- Excessive or not enough eye contact.
- Doing other things during getting history.
- Biased or leading questions e.g. "you don't feel bad"
- Relying on memory to recall information.
5. specific age variations :- Pediatric clients: validate information from parents.
- Geriatric clients: use simple words, maintain privacy, and
assess hearing acuity.
6. Emotional variations:
- Be calm with angry clients, and simply with anxious ones
and express interest with depressed client,
* Sensitive issues "e.g. sexuality, dying, spirituality" you
must be aware of your own thought, regarding these things.
7. Be aware of possible cultural variations, in the
communication styles of self and clients.
8. You can use culture broker if your client not speak your
language. Use pictures for non reading clients.
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(Chapter – 3)
Psychosocial assessment
Psychosocial assessment involves, taking into account that
person's life developmental processes and the phases of growth
maturation through which that individual progresses.
It is useful to help client's review their past, and compare it with
the present , look at progressive phases intervals, plan for future
in whatever ways are appropriate and necessary.
Discussing development stages or crises with the clients can
provide both nurse client with a perspective of greater depth on
the client's life situation, and its relationship to health or illness.
 The assessment here depends on developmental theories of
human life e.g. Erickson, Piaget, and Freud…. etc.
Nutritional assessment
Nutrition plays a major role in the way an individual looks,
feels, behaves.
The body ability to fight disease and the effectiveness of any type
of therapy in illness greatly depends on the individual's nutritional
status.
Major goals of nutritional assessment:
1- Identification of malnutrition, and its effects, on an individual
health status.
2- Identification of patterns of over consumption and their link
the development of obesity, Diabetes, Hypertension
cardiovascular disease and cancer.
3- Identification of nutritional parameters for optimal health and
fitness.
Components of nutritional assessment:
a. Anthropometric measurement.
b. Biochemical measurement.
c. Clinical examination.
d. Dietary analysis.
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A- anthropometric measurement:
"Defined as The measurement of size, weight, and proportions
of human body".
* Most common measurements taken include height, weight, skin
fold thickness, and circumference of various body parts, including
the head chest, and arm. Measurements taken are compared with
appropriate reference standards based on the individual or
population being assessed.
 Assess body mass index (BMI) to shows a direct and
continuous relationship to morbidity mortality in studies of
large populations. High ratios of waist to hip circumference
are associated with higher risk for illness decreased life span.
BMI
=
(wt. in kilograms)
(High in meters) 2
 Measure "skin fold thickness (TSF) by skin fold calipers) to
determine body fat, and to indicate subcutaneous fat and
caloric status.
 Skin fold thickness can be measured at variety of body sites,
but the non dominant arm is preferred for measurement.
The "TSF is measured on the midpoint of the back of the arm,
during relaxation, and repeat measurement several times to take the
most accurate measurement"
B. Biochemical Measurement:
Biochemical Measures are useful in indicating malnutrition or
the development of diseases as a result of over consumption of
nutrients. Serum and urine are commonly used for biochemical
assessment.
* In assessment of malnutrition, commonly used values include:
total lymphocyte count, albumin, serum transferrin, hemoglobin, and
hematocrit… etc. These values taken with anthropometric
measurements, give a good overall picture of an individual's skeletal
and visceral protein status as well as fat reserves and immunologic
response.
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C. Clinical examination:
Clinical examinations of client involve, close physical
evaluation and may reveal signs suggesting malnutrition or over
consumption of nutrients. Although clinical examination alone
doesn't permit definitive diagnosis of nutritional problem, it should
not be overlooked in nutritional assessment.
*Nutritional assessment technique:
*Types of information needed:
1. Appetite: described by client "Good, fair, poor, too good".
2. Weight: Has it been stable??How has it changed?
3. Diet: Describe the type: regular, special, if not regular why not
"e.g. teeth problem, sensitive mouth.
4. Usual mealtimes: How many meals a day: when? Which are
heavy meals?
5. Food preferences: e.g." prefers beef to other meats"
6. Food dislike: What & Why? Culture related?
7. Usual eating places: Home, snack shops, restaurants.
8. Ability to eat: describe inabilities, dental problems: "ill fitting
dentures, difficulties with chewing or swallowing.
9. Elimination" urine & stool: nature, frequency problems.
10.
Exercise & physical activity: how extensive or deficient.
11.
Psycho social - cultural factors: Review any having a
bearing on proper nutrition.
12.
Taking Medications which affect the eating habits.
13.
Laboratory determinations e.g.: "Hemoglobin, protein,
a1bumin, cholesterol, urinalyses".
14.
Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and determine
the nutritional diagnosis and nutritional plan of care.
** There are multiple signs suggesting malnutrition e.g.:
 Lack of natural shine hair or dry and thin hair.
 Small yellowish lump around eye, white rings around both
eyes, and pale conjunctiva.
 Redness and swelling of lips especially corners of mouth.
 Teeth caries & abnormal missing of it
 Dryness of skin (xerosis) sandpaper feels of skin "follicular
hyperkeratosis).
22
 Nails spoon shaped "koilonychial"
 Tachycardia, elevated blood pressure due to excessive sodium
intake and excessive cholesterol, fat, or caloric intake.
 Muscle weakness and growth retardation.
D. Dietary analysis:
Assessment of dietary intake and patterns involves eliciting
information regarding usual foods consumed and habits of food
purchasing, preparation and consumption.
Individuals rely on food for much more than physical
nourishment.
Food may represent cultural and ethnic background and socioeconomic status and have many emotional and psychological
meaning.
It is important to gain full information about daily food habits
to aid in client assessment and identification of any nutritional
problems, therapy and education.
In assessment of actual food intake, a 24 hour recall method
may be used .This done by asking the client to recall every thing
consumed within the past 24 hour including all foods, fluid,
vitamins, minerals or other supplements.
The nurse should not bias the client's response to question
based on the interviewer's personal habits or knowledge of
recommended food consumption.
*chronic diseases affected by nutritional problems:
1- Obesity: excess of body fat.
2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.
*Assessment of sleep-wakefulness patterns
Normal human beings are characterized as organism that
adapts bodily function in such away to have different
physiochemical & psychological functions for each hour of the day.
The ability to maintain a relative internal constancy has been
termed homeostasis.
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Clients may complain of sleep-pattern disturbance as a primary
problem or one due to another condition. It has been recorder that
1/4 of clients who seek health care complain of a difficulty related to
sleep.
*Factors affecting length and quality of sleep:
1. Anxiety related to the need to meat a task, such as waking at
an early hour for work.
2. The promise of pleasurable activity such as starting a vacation.
3. The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as disease.
*Whether the individual had a "good night's sleep" has been found to
depend on the umber of awakenings and on the total number of
sleeping hours.
*The nurse must evaluate the client with sleep-pattern disturbance,
and be a ware of the individual's unique rest and sleep needs.
*The nurse can assess sleep pattern by doing interview with the
client or using special charts or by EEG.
* Disorders related to sleep:
There are multiple disorders some of them are:
1) Disruption in sleep affects family life ,employment, and
general social adjustment
2) Feelings of fatigue, irritability difficulty in concentrating.
3) Difficulty in maintaining orientation.
4) Illusions, hallucination (visual & tactile )
5) Decreased psychomotor ability with decreased incentive to
work.
6) Mild nystagmus.
7) Tremor of hands.
8) Increase in gluco-corticoid and adrenergic hormone secretion.
9) Increase anxiety with sense of tiredness.
10)
Insomnia "short end sleeping periods"
11)
Sleep apnea "periodic cessation of breathing that occurs
during sleep.
24
12)
Hypersomnia: "sleeping for excessive periods"
in
some clients the sleep period may be extended to 16-18 hours
a day.
13)
Perihypersomnia. "Condition that is described as an
increased used for sleep "18-20 hours a day" lasts for only few
days.
14)
Narcolepsy "excessive day time drowsiness or
uncontrolled onset of sleep."
15)
Cataplexy: abrupt weakness or paralysis of voluntary
muscles e.g. arms, legs & face this attack last from half second
to 10 minutes, one or twice a year.
16)
Hypnagogic hallucinations: " Disturbing or frightening
dream that occur as client is a falling a sleep "
*Assessment of sleep habits:
Have the client record the times of going to sleep and
awakening for sleep periods, including naps for a week or take
information about 24 hours sleep wakefulness pattern. in most cases
it is more productive to allow client to described their sleep habits in
their own words.
During assessment you can ask the following questions:
"How have you been sleeping?"
"Can you tell me about your sleeping habits?"
"Are you getting enough rest?"
"Tell me about your sleep problem"
 An adequate history includes a general sleep history,
psychological history, and a drug history.
25
(Chapter – 4)
Nursing Health History
A nursing health history can be defined as "the systematic
collection of subjective data which stated by the client and objective
data which observed by the nurse " used to determine a client
functional health pattern status.
The nurse collects
physiological,
socio
cultural,
developmental, and spiritual client data .These data assist the nurse
in identifying nursing diagnosis and collaborative problems.
*The North American Nursing Diagnosis Association
(NANDA.1994) defines a nursing diagnosis as a clinical judgments
about individual, family or community responses to actual &
potential health problems &life processes.
**The taking of nursing health history is implemented in two
phases:
1. The client interview phase, which elicits the information
"discussed before"
2. The recording of data phase.
The nursing health history usually occurs in the examiner's office, or
the client's home, or hospital room.
Guidelines for taking the nursing health history:
1. Establish private, comfortable, and quiet environment.
2. Allow the client to state problems and expectations for the
interview.
3. Provide the client with an orientation to the structure,
purposes, and expectations of the history.
4. Communicate and negotiate priorities with the client.
5. Listen more than you talk.
6. Observe non verbal communications e.g. "body language,
voice tone, and appearance".
7. If the client encountered past health history with any health
member, review information before starting interview.
8. Make a judgment about the balance between allowing a client
to talk in an unstructured manner and the need to structure
requested information.
26
9. Clarify the client’s definitions of all key terms and
descriptors.
10.
Avoid questions that can be answered as yes or no if
detailed information is desired.
11.
Keep notes adequate enough for future recording?
12.
Record the nursing health history as soon as possible
after the interview.
** Types of nursing health history:
1A complete health history: This is taken on initial visits to
health care facilities.
2An interval health history: used to collect information in visits
following the one in which an initial data base is collected.
3A problem – focused health history: used to collect data about
a specific problem system or region.
* Clients must be able to provide information they consider
relevant, however the nurse must probe, clarify and quantify in
structured ways.
* The nurse should take notes during data collection; however, it
is usually not possible to write the entire health history during the
interview.
* The nurse should record as much of the health history during
interview as possible and the remainder soon after the interview.
1-
Components of health history
Biographical data : This includes :
Full name
Address and telephone numbers (client’s permanent, contact of
client)
Birth date and birth place.
Sex and race.
Religion.
Marital status.
Social security number.
Occupation (usual and present)
Source of referral.
Usual source of health care.
Source and reliability of information.
Date of interview.
27
2-
Chief complaint: "reason for hospitalization.
The chief complaint statement is a short statement. In the
client’s own words, indicates the client’s purpose for requesting
health care at this time.
** The following are examples of adequately stated chief
complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Pap smear needed.
Physical examination needed for camp.
3-
History of present illness:
Gathering information relevant to the chief complaint, and the
onset of client’s problem, including essential and relevant data, and
self medical treatment.
** Components of present illness:
1Introduction: “client’s summary and usual health”.
2Investigation of symptoms: “onset, date, gradual or sudden,
duration, precipitating factors, frequency, location, quality, and
alleviating or aggravating factors”.
3Negative information.
4Relevant family information.
5Disability system "affected the client’s total life".
4-
-
-
Past health history:
The purpose of the past history is to identify all major past
health problems of the client. This includes.
Child hood illness e.g. history of rheumatic fever.
History of accidents and disabling injuries regardless he was
hospitalized or not.
History of hospitalization includes time of admission and date
of it with admitting complaint and discharge diagnosis and the
follow up care.
History of operations “how and why this done”
History of immunizations and allergies.
Physical examinations and diagnostic tests.
28
5-
-
Family history :
The purpose of the family history is to learn about the general
health of the client's blood relatives, spouse, and children ant to
identify any illness of environmental, genetic, or familiar nature that
might have implications for the client’s current or future health
problems and needs or to their solution:
Family history of communicable diseases.
Heredity factors associated with the causes of many diseases.
Strong family history of certain problems.
Health of family members “maternal, parents, siblings, aunts,
uncles, spouse and children”.
Cause of death of the family members “immediate and
extended family”.
6-
Environmental history:
The purpose of environmental history is "to gather information
about surroundings of the client", including physical, psychological,
social environment, and presence of hazards, pollutants and safety
measures.”
7-
Current health information:
The purpose of the current health information is to record
major, current, health related information.
* recommended out line for the information:
Allergies: environmental, ingestion, drug, other.
Habits “alcohol, tobacco, drug, caffeine”
Medications taken regularly "by doctor or self prescription
Exercise patterns.
Sleep patterns.
12345-
* The pattern of sedentary and active activities in the client's
usual routine is explored. A weekly pattern of activity is recorded.
The client’s sleep pattern is explored and usual daily routine is
recorded.
8-
Psychosocial history:
Which includes: how client and his family cope with disease or
stress, and how they responses to illness and health.
The nurse can assess if there is psychological or social
problem and if it affects general health of the client.
29
9-
Review of systems : (ROS)
This includes a collection of data about the past and present
health of each of the client’s systems. This review of the client’s
physical, sociologic, and psychological health status may identify
hidden problems and provides an opportunity to indicate client
strengths and liabilities.
** Physical systems: which includes assessment of?
a) General review, skin, hair, head and face, eyes, ears, nose and
sinuses, month and throat, neck nodes, and breasts.
b) Assessment respiratory and cardiovascular systems.
c) Assessment of gastrointestinal system.
d) Assessment of urinary system.
e) Assessment of genital system.
f) Assessment of extremities and musculoskeletal system.
g) Assessment of endocrine system.
h) Assessment of hematopoietic system.
i) Assessment of social system.
j) Assessment of psychological system.
10-
Nutritional health history “discussed before”.
11- Assessment of interpersonal factors: This includes
Ethnic and cultural back ground, spoken language, values,
health habits, family relationships.
Life styles e.g. rest and sleep patterns, activities of daily living.
Self concept: perception of strength, desired changes.
Sexuality: developmental level and concerns.
Stress responses: coping patterns, support system, perceptions
of current and anticipated stressors.
30
Functional health pattern
(NANDA)
1. Health Perception-Health Management Pattern
2. Nutritional—Metabolic Pattern
3. Elimination Pattern
4. Activity—Exercise Pattern
5. Sexuality—Reproduction Pattern
6. Sleep—Rest Pattern
7. Sensory—Perceptual Pattern
8. Cognitive Pattern
9. Role—Relationship Pattern
10. Self-Perception-Self-Concept Pattern
11. Coping-Stress Tolerance Pattern
12. Value—Belief Pattern
The purpose of each nursing health history component will be
explained, followed by guideline statements and questions to elicit
subjective data from the client. Guideline questions should be preceded by open-ended statements to encourage the client to verbalize
freely. Then specific questions are asked to obtain specific information. It is important to remember that not every question will apply
to every client. Common sense and professional judgment must be
used to determine which questions are priorities and are appropriate
for each individual client.
Certain factors such as comfort level, level of anxiety, age, and
current health status influence the client's ability to participate fully
in the interview and must be considered. When appropriate, an
objective data outline follows the subjective data questions and
refers the examiner to the section where the specific examination
technique, normal findings, and deviations from normal are located.
At the end of each section is a list of corresponding nursing
diagnostic categories for that specific nursing health history
component. This list is divided into wellness, nursing diagnoses, risk
nursing diagnoses, and actual (problem) nursing diagnoses.
Although clients can be at risk for most problem diagnoses, only
NANDA-approved and a few selected other risk diagnoses are listed.
31
I. Health Perception-Health Management Pattern
*Purpose: The purpose of assessing the client's health
perception health maintenance pattern is to determine how the client
perceives and manages his or her health. Compliance with current
and past nursing and, medical recommendations is assessed. The
client's ability to perceive the relationship between activities of daily
living and health is also determined.
Subjective Data: Guideline Questions
Client's Perception of Health:
- Describe your health.
-How would you rate your health on a scale of 1 to 10 (10 is
excellent) now, 5 years ago, and 5 years ahead?
Client's Perception of Illness
-Describe your illness or current health problem.
-How has this affected your normal daily activities?
-How do you feel your current daily activities have affected
your Health?
-What do you feel caused your illness?
-What course do you predict your illness will take?
-How do you feel your illness should be treated?
-Do you have or anticipate any difficulties in caring for
Yourself or others at home? If yes, explain.
Health Management and Habits
-Tell me what you do when you have a health problem.
-When do you seek nursing or medical advice?
-How often do you go for professional exams (dental, Pap
Smears, breast, BP)?
-What activities do you feel keep you healthy? Contribute to
illness?
-Do you perform self-exams (blood pressure, breast,
testicular)?
-When were your last immunizations? Are they up to date?
-Do you use alcohol, tobacco, drugs? Describe the amount and
Length of time used
- Are you exposed to pollutants or toxins?
Compliance with Prescribed Medications and Treatments
-Have you been able to take your prescribed medications? If
not, what caused your inability to do so?
32
-Have you been able to follow through with your prescribed
nursing and medical treatment (e.g., diet, exercise)? It not, what
caused your inability to do so?
Objective Data: Refer to General Physical Survey.
Associated Nursing Diagnoses Categories to Consider
Wellness Diagnoses
-Health Seeking Behaviors
-Effective Management of Therapeutic Regimen
-Risk Diagnoses
-Risk for Injury
- Risk for Suffocation
- Risk for Poisoning
-Risk for Trauma
-Risk for Peri-operative Positioning Injury
Actual Diagnoses:
- Energy Field Disturbance
- Altered Growth and Development
- Altered Health Maintenance
-Ineffective Management of Therapeutic Regimen: Individual
-Ineffective Management of Therapeutic Regimen: Family
- Ineffective Management of Therapeutic Regime: Community
Noncompliance.
II. Nutritional-Metabolic Pattern
Purpose: The purpose of assessing the client's nutritionalmetabolic pattern is to determine the client's dietary habits and
metabolic needs. The conditions of hair, skin, nails, teeth and
mucous membranes are assessed
Subjective Data: Guideline Questions
*Dietary and Fluid Intake
-Describe the type and amount of food you eat at breakfast,
lunch, and supper on an average day
-Do you attempt to follow any certain type of diet? Explain.
-What time do you usually eat your meals?
-Do you find it difficult to eat meals on time? Explain.
-What types of snacks do you eat? How often?
-Do-you take any vitamin supplements? Describe.
-Do you consider your diet high in fat? Sugar? Salt?
-Do you find it difficult to tolerate certain foods? Specify.
33
-What kind of fluids do you usually drink? How much per
day?
-Do you have difficulty chewing or swallowing food?
-When was your last dental exam? What were the results?
-Do you ever experience sore throats, sore tongue, or sore
gums? Describe.
-Do you ever experience nausea and vomiting? Describe.
-Do you ever experience abdominal pains? Describe.
- Do you use antacids? How often? What kind?
Condition of Skin
-Describe the condition of your skin.
-How well and how quickly does your skin heal?
-Do you have any skin lesions? Describe-Do you have excessively oily or dry skin?
-Do you have any itching? What do you do for relief?
Condition of Hair and Nails:
- Describe the condition of your hair and nails.
- Do you have excessively oily or dry hair?
- Have you had difficulty with scalp itching or sores?
- Do you use any special hair or scalp care products?
- Have you noticed any changes in your nails? Color
Cracking? Shape? Lines?
Metabolism:
-What would you consider to be your "ideal weight"?
-Have you had any recent weight gains or losses?
-Have you used any measures to gain or lose weight?
Describe.
-Do you have any intolerance to heat or cold?
-Have you noted any changes in your eating or drinking
habits? Explain.
-Have you noticed any voice changes?
- Have you had difficulty with nervousness?
Objective Data: Assess the client's temperature, pulse,
respirations, and height and weight.
Wellness Diagnoses
-0pportunity to enhance nutritional metabolic pattern
- Opportunity to enhance effective breastfeeding
-Opportunity to enhance skin integrity
Risk Diagnoses:
34
- Risk for Altered Body Temperature
-Hypothermia
-Hyperthermia
-Risk for Infection
-Risk for altered nutrition: more than body requirements
-Risk for altered nutrition less than body requirements .
-Risk for Aspiration
Actual Diagnoses
-Decreased Adaptive Capacity: Intracranial.
- Ineffective Thermo regulation.
-Fluid Volume Deficit
-Fluid Volume Excess
-Altered Nutrition: Less than body requirements
-Altered Nutrition: More than body requirements
-Ineffective Breastfeeding
-Interrupted Breastfeeding
-Ineffective Infant Feeding Pattern Impaired Swallowing
-Altered Protection
-Impaired Tissue Integrity
-Altered Oral Mucous Membrane
-Impaired Skin Integrity.
III. Elimination Pattern
Purpose: The purpose of assessing the client's elimination
pattern is to determine the adequacy of function of the client's bowel
and bladder for elimination. The client's bowel and urinary routines
and habits are assessed. In addition, any bowel or urinary problems
and use of urinary or bowel elimination devices are examined.
Subjective Data! Guidelines Questions
-Bowel Habits
-Describe your bowel pattern. Have there been any recent
changes?
-How frequent are your bowel movements?
-What is the color and consistency of your stools?
-Do you use laxatives? What kind and how often do you use
them?
-Do you use enemas? How often and what kind?
-Do you use suppositories? How often and what kind?
35
-Do you have any discomfort with your bowel movements?
Describe.
-Have you ever had bowel surgery? What type? Ileostomy?
Colostomy?
Bladder Habits:
-Describe your urinary habits.
-How frequently do you urinate?
-What is the amount and color of your urine?
-Do you have any of the following problems with urinating:
Pain? Blood in urine? Difficulty starting a stream?
Incontinence? Voiding frequently at night? Voiding frequently
during day? Bladder infections?
-Have you ever had bladder surgery? Describe.
- Have you ever had a urinary catheter? Describe. When? How
long?
Objective Data: refer to Abdominal Assessment, and the rectal
assessment.
Associated nursing-Diagnoses Categories to Consider
Wellness Diagnoses
-Opportunity to enhance adequate bowel elimination pattern
-Opportunity to enhance adequate urinary elimination pattern
Risk Diagnoses
-Risk for constipation
-Risk for altered urinary elimination
Actual Diagnoses:
-Altered Bowel Elimination Constipation
-Colonic constipation
-Perceived constipation
-Diarrhea
-Bowel Incontinence
- Altered Urinary Elimination Patterns of Urinary Retention
Total Incontinence
-Functional Incontinence
-Reflex Incontinence
-Urge Incontinence
-Stress Incontinence
IV. Activity-Exercise Pattern
Purpose: The purpose of assessing the client's activityexercise pattern is to determine the client's activities of daily living,
36
including routines of exercise, leisure, and recreation. This includes
activities necessary for personal hygiene, cooking, shopping^ eating,
maintaining the home, and working. An assessment is made of any
factors that affect or interfere with the client's routine activities of
daily living. Activities are evaluated in reference to the client's
perception of their significance in his or her life.
Subjective Data: Guideline Questions
-Activities of Daily Lining
-Describe your activities on a normal day. (Including hygiene
activities, cooking activities, shopping activities, eating activities,
house and yard activities, other self-care activities.)
- How satisfied are you with these activities?
- Do you have difficulty with any of these self-care activities?
Explain.
-Does anyone help you with these activities? How?
- Do you use any special devices to help you with your
activities?
- Does your current physical health affect any of these
activities e.g. dyspnea, shortness of breath, palpations, chest pain.
pain, stiffness, weakness)? Explain.
Leisure Activities
-Describe the leisure activities you enjoy.
-Has your health affected your ability to enjoy your leisure?
Explain.
-Do you have time for leisure activities?
-Describe any hobbies you have.
Exercise Routine: Describe those activities that you feel give
you exercise. How often are you able to do this type of exercise?
Has your health interfered with your exercise routine?
Occupational Activities:
-Describe what you do to make a living.
-How satisfied are you with this job?
-Do you feel it has affected your health?
-How has your health affected your ability to work?
Objective Data Refer to Thoracic and Lung Assessment;
Cardiac Assessment; Peripheral Vascular Assessment; and
Musculoskeletal Assessment.
Associated Nursing Diagnoses Categories to Consider
Wellness Diagnoses:
-Potential for enhanced organized infant behavior
37
- Opportunity to enhance effective cardiac output
-Opportunity to enhance effective diversional activity pattern
-opportunity to enhance effective activity-exercise pattern
-Opportunity to enhance effective home maintenance
management
-opportunity to enhance effective self-care activities
opportunity to enhance adequate tissue perfusion opportunity to
enhance effective breathing pattern
Risk Diagnoses
-Risk for Disorganized Infant Behavior
-Risk for Peripheral Neurovascular Dysfunction
-Risk for altered respiratory function
Actual Diagnoses'
- Activity Intolerance
- Impaired Gas Exchange
- Ineffective Airway Clearance
-Ineffective Breathing Pattern
- Decreased Adaptive Intracranial Capacity
-Decreased Cardiac Output
-Disuse syndrome
-Diversional Activity Deficit
-Impaired Home Maintenance Management
-Impaired Physical Mobility
-Dysfunctional Ventilatory Weaning Response
-Inability to Sustain Spontaneous Ventilation
-Self-Care
Deficit:
(Feeding,
Bathing/Hygiene,
Dressing/Grooming,
Toileting)
-Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral,
and Cardio Pulmonary. Renal, Gastro intestinal, Peripheral)
-Disorganized Infant Behavior
V. Sexuality-Reproduction Pattern
Purpose: The purpose of assessing the client's sexualityreproduction pattern is to determine the client's fulfillment of sexual
needs and perceived level of satisfaction. The reproductive pattern
and developmental level of the client is determined, and perceived
problems related to sexual activities, relationships, or self-concept
are elicited. The physical and psychological effects of the client's
38
current health status ,on his or her sexuality or sexual expression are
examined.
Subjective Data: Guideline Questions
1. Female
a. Menstrual history:
*How old were you when you began menstruating? On what
date did your last cycle begin? How many days does your cycle
normally last? How many days elapse from the beginning of one
cycle until the beginning of another?
* Have you noticed any change in your menstrual cycle? Have
you noticed any bleeding between your menstrual cycles? Do
you experience episodes of flushing, chilling, or intolerance to
temperature change? Describe any mood changes or
discomfort before, during, or after your cycle.
b. Obstetric history:
*How many times have you been pregnant? Describe the
outcome of each of your pregnancies. If you have children, what are
the ages and sex of each? Describe your feelings with each
pregnancy. Explain any health problems or concerns you had with
each pregnancy. If pregnant now,
Was this a planned or unexpected pregnancy?
Describe your feelings about this pregnancy.
What changes in your life-style do you anticipate with this
Pregnancy?
Describe any difficulties or discomfort you have had with this
Pregnancy.
How can I help you meet your needs during this pregnancy?
2. Male/female
a. Contraception
What do you or your partner do to prevent pregnancy? How
acceptable is this method to both of you? Do this means of birth
control affect your enjoyment of sexual relations?
*Describe any discomfort or undesirable effects this method
produces.
Have you had any difficulty with fertility? Explain. Has
infertility affected your relationship with your partner? Explain.
b. Perception of sexual activities
Describe you sexual feelings.
How comfortable are you with your feelings of
femininity/masculinity?
39
Describe your level of satisfaction from your sexual
relationship(s) on scale of 1 to 10 (with 10 being very satisfying).
Explain any changes in your sexual relationship(s) that you
Would like to make.
Describe any pain or discomfort you have during intercourse
Have you (has your partner) experienced any difficulty achieving an orgasm or maintaining an erection? If so, how has this affected your relationship?
c. Concerns related to illness
How has your illness affected your sexual relationships)? How
comfortable are you discussing sexual problems with your partner?
Who would you seek help from for sexual concerns?
d. Special problems
Do you have or have you ever had a sexually transmitted disease? Describe.
What method do you use to prevent contracting a sexually
transmitted disease?
Describe any pain, burning, or discomfort you have while
voiding.
Describe any discharge or unusual odor you have from your
penis/vagina. What is the date of your last Pap smear?
e. History of sexual abuse
Describe the time and place the incident occurred. Explain the
type of sexual contact that occurred. Describe the person who
assaulted you. Identify any witnesses present. Describe your feelings
about this incident. Have you had any difficulty sleeping, eating, or
working since the incident occurred?
Objective Data
Refer to Breast Assessment, d Abdominal Assessment, and
urinary-Reproductive Assessment
Associated nursing Diagnoses Categories to Consider
Wellness Diagnosis: opportunity to enhance sexuality patterns
Risk-Diagnosis
*Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
40
VI. Sleep-Rest Pattern
Purpose:
The purpose of assessing the client's sleep-rest pattern is to
determine the client's perception of the quality of his or her sleep,
relaxation, and energy levels. Methods used to promote relaxation
and sleep is also assessed.
Subjective data, Guideline Questions:
Sleep Habits:
*Describe your usual sleeping time at home.
*How would you rate the quality of your sleep?
Special Problems
*Do you ever experience difficulty with falling asleep?
Remaining asleep? Do you ever feel fatigued after a sleep period?
Has your current health altered your normal sleep habits?
Explain.
Do you feel your sleep habits have contributed to your current
Illness? Explain.
Sleep Aids
What helps you to fall asleep? medications? reading?
relaxation technique? Watching TV? Listening to music?
Objective Data
1. Observe appearance
a. Pale b. Puffy eyes with dark circles
2. Observe behavior
a. Yawning
b. Dozing during day
c. Irritability
d. Short attention span
Associated nursing Diagnoses Category to Consider
Wellness Diagnosis:
Opportunity to enhance sleep
Risk Diagnosis
*Risk for sleep pattern disturbance
Actual Diagnosis: sleeps Pattern Disturbance.
VII. Sensory-Perceptual Pattern
Purpose
The purpose of assessing the client's sensory-perceptual
pattern is to determine the functioning status of the five senses:
vision, hearing, touch (including pain perception), taste, and smell.
41
Devices and methods used to assist the client with deficits in any of
these five senses are assessed
Subjective Data Guideline Questions
Perception of Senses, describe your ability to see, hear, feel,
taste, and smell.
Describe any difficulty you have with your vision, hearing,
and ability to feel (e.g., touch, pain, heat, cold), taste (salty, sweet,
bitter, sour), or smell.
Pain Assessment
*Describe any pain you have now.
*What brings it on? What relieves it?
*When does it occur? How often? How long does it last?
*What else do you feel when you have this pain?
*Show me where on this drawing [of a figure] you have pain.
*Rate your pain on a scale of 1 to 10, with 10 being the most
severe
Pain.
* How has your pain affected your activities of daily living?
Special Aids:
What devices (e.g., glasses, contact lenses, hearing aids) or
methods do you use to help you with any of the above problems?
Describe any medications you take to help you with these
problems.
Objective Data
Refer to the section on Nose and Sinus Assessment, Eye
Assessment, and Ear Assessment.
Associated Nursing Diagnoses Categories to Consider
Wellness Diagnosis: Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain, Risk for Aspiration
Actual Diagnoses
Pain, Chronic Pain and Dysreflexia.
VIII. Cognitive Pattern
Purpose
The purpose of assessing the client's cognitive pattern is to
determine the client's ability to understand, communicate, remember,
and make decisions.
42
Subjective Data! Guideline Questions
*Ability to Understand:
Explain what your doctor has told you about your health. Do
you feel you understand your illness and prescribed care? What is
the best way for you to learn something new (read, watch TV, etc.)?
*Ability to Communicate:
Can you tell me how you feel about your current state of
health? Are you able to ask questions about your treatments,
medications, and so forth? Do you ever have difficulty expressing
yourself or explaining things to others?
*Ability to Remember: Are you able to remember recent events
and events of long ago? Explain.
*Ability to Make Decisions:
*Describe how you feel when faced with a decision.
*What assists you in making decisions?
*Do you find decision making difficult, fairly easy, or
variable?
Objective Data
Refer to the Mental Status Assessment
Associated nursing Diagnoses Categories to Consider
Wellness Diagnosis: Opportunity to enhance cognition
Risk Diagnosis: Risk for altered thought processes
Actual Diagnoses:
*Acute confusion
*Chronic Confusion
*Decisional Conflict
*Impaired Environmental Interpretation Syndrome
* Knowledge Deficit (Specify)
* Altered Thought Processes
*Impaired Memory
IX. Role-Relationship Pattern
Purpose
The purpose of assessing the client's role-relationship pattern
is to determine the client's perceptions of responsibilities and roles in
the family, at work, and in social life. The client's level of
satisfaction with these is assessed. In addition, any difficulties in the
client's relationships and interactions with others are examined.
Subjective Data! Guideline Questions
Perception of Major Roles and Responsibilities in Family
43
*Describe your family.
*Do you live with your family? alone?
*How does your family get along?
*Who makes the major decisions in your family?
*Who is the main financial supporter of your family?
*How do you feel about your family?
*What is your role in your family? Is this an important role?
*What is your major responsibility in your family? How do
you feel
about this responsibility?
* How does your family deal with problems?
*Are there any major problems now?
* Who is the person you feel closest to in your family?
Explain.
* How is your family coping with your current state of health?
Perception of Major Roles and Responsibilities at Work
Describe your occupation.
What is your major responsibility at work?
How do you feel about those you work with?
What would you change if you could about your work?
Are there any major problems you have at work?
Perception of Major Social Roles and Responsibilities
*Who is the most important person in your life? Explain.
*Describe your neighborhood and the community in which
you live.
*How do you feel about the people in your community?
*Do you participate in any social groups or neighborhood
activities?
*What do you see as your contribution to society?
*'What about your community would you change if you
could?
Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.
a. How do they communicate with each other?
b. How do they respond to the client?
c. Do they visit, and how long do they stay with the client?
Associated Nursing Diagnoses Categories to Consider
Wellness Diagnoses:
*0pportunity to enhance effective relationships
44
*opportunity to enhance effective parenting
*Opportunity to enhance effective role performance
*opportunity to enhance effective communication
*opportunity to enhance effective social interaction .
*opportunity to enhance effective caregiver role
*opportunity to enhance effective grieving
Risk Diagnoses:
- *Risk for dysfunctional grieving, High risk for Loneliness
and Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
*Impaired Verbal Communication
*Altered Family Processes: Alcoholism
*Anticipatory Grieving
*Dysfunctional Grieving?
*Altered Parenting
*parental Role Conflict
Altered Role Performance
*Impaired Social Interaction: Social Isolation
X. Self-Perception-Self-Concept Pattern
Purpose
The purpose of assessing the client's self-perception-selfconcept pattern is to determine the client's perception of his or her
identity, abilities, body image, and self-worth. The client's behavior,
attitude, and emotional patterns are also assessed.
Subjective Data: Guideline Questions
Perception of Identity:
Describe yourself.
Has your illness affected how you describe yourself?
Perception of Abilities and Self-Worth:
What do you consider to be your strengths? Weaknesses?
How do you feel about yourself?
How does your family feel about you and your illness?
Body Image:
How do you feel about your appearance?
Has this changed since your illness? Explain.
How would you change your appearance if you could?
How do you feel about other people with disabilities?
45
Objective Data
Refer to the procedures for observing appearance, mood under
the Mental Status Assessment.
Associated Nursing Diagnoses Categories to Consider
Wellness Diagnoses
*0pportunity to enhance self-perception
*Opportunity to enhance self-concept
Risk diagnoses
*Risk for hopelessness
*Risk for body image disturbance
*Risk for low self esteem
Actual Diagnoses
Anxiety - Fatigue - Fear – Hopelessness- PowerlessnessPersonal Identity Disturbance - Body Image Disturbance- self
Esteem Disturbance.
XI. Coping-Stress Tolerance Pattern
Purpose
The purpose of assessing the client's coping-stress tolerance
pattern is to determine the areas and amount of stress in a client's life
and the effectiveness of coping methods used to deal with it.
Availability and use of support systems such as family, friends, and
religious beliefs are assessed.
Subjective Data: Guideline Questions
Perception of Stress and Problems in Life
* Describe what you believe to be the most stressful situation
in your
Life. How has your illness affected the stress you feel? Or how
do you feel stress has affected your illness? Has there been a
personal loss or major change in your life over the last year?
Explain. What has helped you to cope with this change or loss?
Coping Methods and Support Systems:
*What do you usually do first when faced with a problem?
What helps you to relieve stress and tension? To whom do you
usually turn when you have a problem or feel under pressure? How
do you usually deal with problems? Do you use medication, drugs,
or alcohol to help relieve stress? Explain.
Objective Data
Refer to the Mental Status Assessment.
46
Associated nursing Diagnoses Categories to Consider
Wellness Diagnoses
*Opportunity to enhance effective individual coping.
*opportunity to enhance family coping
*Potential for Enhanced Spiritual Well Being
*Potential for Enhanced Community coping
Risk Diagnoses:
*Risk for ineffective coping (individual, family, or
community)
*Risk for self-harm
*Risk for self-abuse
*Risk for Self-Mutilation
*Risk for suicide
*Risk for Violence; Self-directed or directed at others
Actual Diagnoses:
*Impaired Adjustment
*Ineffective Individual Coping
*Ineffective Family Coping: Disabling
*Ineffective Family Coping: Compromised
*Ineffective Community Coping: Post-Trauma Response,
Rape-Trauma Syndrome Relocation and Stress Syndrome.
XII. Value-Belief Pattern
Purpose
The purpose of assessing the client's value-belief pattern is to
determine the client's life values and goals, philosophical beliefs,
religious beliefs, and spiritual beliefs that influence his or her
choices and decisions. Conflicts between these values, goals, beliefs,
and expectations that are related to health are assessed
Subjective Data! Guideline Questions
Values, Goals, and Philosophical Beliefs
What is most important to you in life?
What do you hope to accomplish in your life?
What is the major influencing factor that helps you make
decisions?
What is your major source of hope and strength in life?
Religious and Spiritual Beliefs:
*Do you have a religious affiliation? Is this important to you?
47
*Are there certain health practices or restrictions that are
important for you to follow while you are ill or hospitalized?
Explain.
*Is there a significant person (e.g., minister, priest) from your
religious denomination whom you want to be contacted?
*Would you like the hospital chaplain to visit?
*Are there certain practices (e.g., prayer, reading scripture)
that are important to you?
*Is a relationship with God an important part of your life?
Explain.
*Do you have another source of strength that is important to
you?
*How can I help you continue with this source of spiritual
strength while you are ill in the hospital?
Objective Data
1. Observe religious practices
a. Presence of religious articles in room (e.g., Bible, cards,
medals,
Statues)
b- Visits from clergy
c. Religious actions of client: prayer, visit to chapel, request
for clergy, watching of religious TV programs or listening to
religious radio stations
2. Observe client's behavior for signs of spiritual distress
a. Anxiety
b. Anger
c. Depression
d. Doubt
e- Hopelessness f. Powerlessness
Associated Nursing Diagnoses Category to Consider
Wellness Diagnosis: Potential for Enhanced Spiritual WellBeing
Risk diagnosis:*Risk for spiritual distress
Actual Diagnosis: Spiritual disturbance (distress of the human
spirit).
48
(Chapter – 5)
Physical Assessment
There are four techniques to use in performing physical
assessment: inspection, palpation, percussion, and auscultation with
the addition skill known as olfaction.
1. Inspection :
Inspection is defined as “the use of the senses of vision, smell
and hearing to observe the normal condition or any deviations from
normal of various body parts.”
* The nurse inspects or looks body parts to detect normal
characteristics or significant physical sings.
Inspection helps to know normal characteristics before trying
to distinguish abnormal findings in different ages.
The quality of an inspection depends on the nurse's willingness
to spend time doing a thorough job.
-
Principles of accurate inspection:
Good lightening must be available, either day light or artificial
light is suitable.
Expose body parts being observed while keeping the rest of
the client properly draped.
Always, look before touching.
Provide a warm room for examination of the client “a cold or
hot environment may alter skin color and appearance”.
Observe for color, size, location, texture, symmetry, odors, and
sounds.
Compare each area inspected with the same area on the
opposite side of the body if possible.
Use special light source e.g. pen light to inspect body cavities.
-
2. Palpation:
Definition: “To touch and feel body parts with hands in order to
determine the following characteristics”:
Texture (roughness, smoothness).
Temperature (warm, hot, cold).
Moisture (dry, wet, or moist).
Motion (stillness, vibration).
Consistency of structure (solid, fluid, filled)
-
49
** Principles for accurate palpation:
1Examiners fingernails should be short.
2The most sensitive part of the hand should be used to detect
various sensations.
3Light palpation precedes deep palpation.
4Tender areas are palpated last.
5Palpation is used to examine all accessible parts of body.
6Client must relax in comfortable position before palpation, e.g.
tension of the abdominal muscles: makes palpation of the
underlying organs impassible, and mimic muscle regality.
7Tell client to take slow deep breath to enhance muscle
relaxation.
8Examine condition of the organs such as those in the abdomen.
9Depressed area must be approximately 2cm “1 inch”.
10- Position and consistency and turger of skin measured by
lightly grasping the body part with finger tips.
3. Percussion:
Definition: "to tap a portion of the body to elicit tenderness that
varies with the density of underlying structures.
Percussion denotes location, size and density of underlying
structures, percussion requires dexterity.
** Methods of percussion:
There are two methods of percussion depending on purpose:
1Direct method: involving striking the body surface directly
with one or two fingers.
2Indirect method: performed by placing the middle finger of the
examiner’s non dominant hand “pleximeter hand” firmly against
the body surface with palm and fingers remaining off the skin,
and the tip of the middle finger of the dominant hand “plexor”
strikes the base of the distal joint of the pleximeter.
Use a quick and sharp stroke.
Sounds produced by percussion
Sound
Tympany
Intensity
Loud
Pitch
High
Duration
Moderate
Quality
Drum like
Resonance
Moderate
to loud
Low
Long
hollow
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Percussion
Enclosed
aircontaining
space, gastric
air
bubble,
puffed
out
cheek
Normal lung
Hyperresonance
Very loud
Dullness
Soft
to High
moderate
Soft
High
Flatness
Very
low
Longer
than
resonance
Moderate
Booming
Emphysematou
s lung
Thud like
Liver
Short
Flat
Muscle
4. Auscultation:
Definition “To listen for various breath, heart, and bowel sounds,
using a stethoscope”
* Direct or immediate, auscultation is accomplished by the
unassisted ear that is without amplifying device.
This form of auscultation often involves the application of the ear
directly to a body surface where the sound is most prominent. The
use of sound augmentation device such as a stethoscope in the
detection of body sounds is called mediate auscultation. The three
types of stethoscopes that enjoy clinical popularity today are the
acoustic, magnetic, and electronic stethoscopes.
* Guidelines for using auscultation:
1- Use a good stethoscope that has:- Snug – fitting ear plugs.
- Tubing not longer than "15" inches and internal diameter not
greater than inch.
- Diaphragm and bell.
2- The diaphragm and bell are used differently to detect various
sounds.
5. Olfaction:
Another skill that used during assessment, certain alteration is
body function create characteristic body odors, smelling can detect
abnormalities that unrecognized by other means.
** Assessment of characteristic odors:
 Alcohol odor from oral cavity means ingestion of alcohol.
 Ammonia from urine means urinary tract infection.
 Body odor from skin, particularly in areas where body parts
rub together (e.g. under arms and beneath breasts) means poor
hygiene, excess perspiration (bromidrosis) foal – smelling,
foul smelling perspiration.
51
 Feces odor from wound site means wound abscess, but if this
odor from vomitus this means bowel obstruction, and if the
odor from rectal area this means fecal incontinence.
 Foul – smelling stools in infant from stool means mal
absorption syndrome.
 Halitosis from oral cavity means poor dental and oral hygiene,
gum disease.
 Sweat, fruity ketones from oral cavity may be from diabetic
acidosis.
 Musty odor from casted body part means infection inside cast.
 Fetid odor from tracheostomy or mucous secretions means
infection of bronchial tree (pseudomonas bacteria).
* Basic Guidelines for physical Assessment:1) Obtain a nursing history and survey the client’s general
physical status for an over all impression prior to physical
assessment.
2) Maintain privacy and proper draping.
3) Explain the procedure and purpose of each part of the exam to the
client.
4) Follow a planned order of examination for each body system,
specific history questions related to each body part being
examined may be integrated with the physical examination.
5) Always inspect, palpate, percuss, and then auscultate, except in
abdominal examination. Auscultate bowel sounds and percuss
the abdomen prior to palpation to avoid alterations in bowel
sounds.
6) Use each technique to compare symmetrical sides of the body
and organs.
7) Assess both the structure and function of each body part and
organ (e.g.:- the appearance and condition of the ear as well as
its hearing function )
8) When you identify an abnormality, assess for further data on the
extent of the abnormality and the client’s responses to the
abnormality. Is there radiation of pain to other areas? Is there an
effect on eating? Bowels? Activities of daily living?
9) Integrate client teaching with the physical assessment
(e.g.: self exam of breast, testicular exam, foot care for
the
diabetic)
10) Allow time for client questions.
52
"Remember: the most important guideline for adequate
physical assessment is conscious, continuous practice of
physical assessment skills".
* Variation in physical assessment of the pediatric client.
a) Sequence of physical assessment is dependent upon the
developmental level of the client.
b) Establishment of report with the child and significant others is
the most essential step in obtaining meaningful physical
assessment data.
c) Allowing time for interaction with the child prior to
beginning the examination helps to reduce fears.
d) In certain age groups, portions of assessment will require
physical restraint of the client with the help of another adult.
e) Distraction and play should be intermingled throughout the
examination to assist in maintaining rapport with the pediatric
client.
f) Involving assistance from the child’s significant caregiver
may facilitate a more meaningful examination of the younger
client.
g) The examiner should be prepared to alter the order of the
assessment and approach to the child based on the child’s
response.
h) Protest or an uncooperative attitude toward the examiner is a
normal finding in children from birth to early adolescence,
throughout parts or even all the assessment process.
* Variations for physical assessment of the geriatric client.
a) Remember: normal variation related to aging may be0
observed in all parts of the physical examination.
b) Divide the physical assessment into parts in order to avoid
fatigue in the older client.
c) Provide room with comfortable temperature and no drafts.
d) Allow sufficient time for client to respond to directions.
e) If possible assess the elderly clients in a setting where they
have an opportunity to perform normal activities of daily
living in order to determine the client’s optimum potential.
53
(Chapter – 6)
Vital signs and general assessment
-
 Equipment needed:
Beam balance scale.
Tape measure.
Thermometer.
Sphygmomanometer.
Stethoscope.
 Subjective data:
Reason for seeking health care and major concern about current
health, current age, height, and weight, recent weight changes, fever,
history of hypertension, hypertension, difficulty breathing, changes
impulse or heart rate.
 Objective data:
Observe client from head to toe to note any gross
abnormalities in appearance or behaviors.
Assess vital signs, temperature, pulse, respirations, and blood
pressure to detect any severe deviations and to acquire base line
data.
Weigh the client and measure for height with shoes, and heavy
clashing removed.
-
-
 Procedure:
** Observe the following:
Behavior, if client cooperative or uncooperative.
Mood is there anxiety and which degree of anxiety.
Appearance if the client well dressed or dress bizarre or
inappropriate.
Body movements: if there is coordinated, smooth and steady
or uncoordinated, shaky and unsteady.
** Vital signs (assessment) includes: assessment of Temp, pulse,
respiration and blood pressure are known as life signs.
Vital signs are indicators of the body’s physiologic status and
response to physical, environmental and physiologic stressors.
Vital signs reveal the client’s current ability to maintain body
temperature regulation, to maintain local and systemic blood
flow, and to provide oxygenation of body tissues.
54
 Temperature:
Routinely, where accuracy is not crucial, an oral temp will
sufficient.
Rectal temp is the most accurate.
Unless contraindicated as in a client with a severe cardiac
arrhythmia, a rectal temp is often preferred.
 Pulse:
Palpate the radial pulse and count for at least "30" second.
If the pulse is irregular, count for full minute and note the
number of irregular beats per minute.
Note is the pulse against your finger is strong or weak,
bounding or thready.
N.B pulse rate is "60-80 b/m" regular in rhythm.
 Respiration:
Count the Number of respiration, in full minute.
Note rhythm and depth of breathing.
Respiration: normally "16-20/minut"e (for healthy adult
person).
-
-
 Blood pressure:
Measure Blood Pressure in both arms.
Palpate the systolic pressure before using the stethoscope in
order to detect an auscultatory gap.
Apply cuff firmly, if too loose it will give falsely high reading.
Use cuff in appropriate size.
Note position of client When measuring blood pressure.
Monitor blood pressure after client is seated or supine quietly
for "10" minute.
Repeat after two minutes. Then repeat with client standing.
Instrumentation:
Instruments, or “equipments” used during physical assessment
should be readily accessible, clean, in proper working order.
Ophthalmoscope: "lighted instrument for visualization of the
eye".
Otoscope: for examination of the ear.
Snellen eye chart: used as a screening test for vision.
Nasal speculum, for assessment of the nose.
55
-
Vaginal speculum: examination of the vaginal canal and
cervix.
Tuning fork: for testing auditory function and vibratory
perception.
Percussion hammer: “reflex hammer” to test reflexes and
determine tissue density.
Neuralgic hammer: to test reflexes during the neuralgic
assessment.
Positions for physical Examination
you can make physical assessment with client's different positions
e.g.: (Standing position, Supine position, Sitting position, Dorsal
recumbent position, Sims position, Prone position, Knee chest
position, and Lithotomy position).
** Each position has it's specialty for parts of examination.
NB. :"draping during assessment is used to prevent unnecessary
exposure, to provide privacy and to keep the client warm".
Drapes may be paper, cloth, or bed linens, only parts, being
assessed are exposed.
I. 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.
II. Supine position:*Areas Assessed: Head and neck anterior thorax and lungs, breasts,
axillae, heart, abdomen, extremities, pulses.
* Rationale: This is most normally relaxed position. It prevents
contracture of abdominal muscles and provides easy access to pulse
sites.
* Limitations: If client becomes short of breath easily, examiner
may need to raise head of bed.
56
III. Dorsal position:
* Areas Assessed: Head and neck, anterior thorax and lungs,
Breasts, axillae, heart.
Rationale: Clients with painful disorders are more comfortable with
knees flexed.
Limitations: Position is not used for abdominal assessment because
it promotes contracture of abdominal muscles.
IV. Lithotomy position:
* Areas Assessed: Female genitalia and genital tract.
* Rational: This position provides maximal exposure of genitalia
and facilitates insertion of vaginal speculum.
* Limitations: Lithotomy position is embarrassing and
uncomfortable, so examiner minimizes time that client spends in it.
Client is kept well draped.
* Client with severe arthritis or other joint deformity may be unable
to assume this position.
*V. Sims’ position:
* Areas Assessed: Rectum and vagina.
* Rationale: Flexion of hip and knee improves exposure of rectal
area.
* Limitations: Joint deformities may hinder client’s ability to
Bend hip and knee.
VI. Prone position:
* Areas Assessed: Musculoskeletal system.
* Rationale: This position is used only to assess extension of hip
joint.
* Limitations: This position is intolerable for client with respiratory
difficulties.
VII. Knee-chest position:
Areas Assessed: Rectum.
* Rationale: This position provides maximal exposure of rectal area.
* Limitations: This position is embarrassing and uncomfortable.
Clients with arthritis or other joint deformities may be unable to
assume this position.
57
** When palpation assess for Crepitus which is crackling sensation
& noise caused by rubbing of bone fragments.
* If a joint appears swollen and inflamed, detect warmth in the
tissues.
* Assess muscle strength & tone when doing Range of motion.
* Tone: Is slight muscular resistance felt by examiner as the relaxed
extremity is passively moved through its range of motion.
* Ask client to relax or hang limb, support & move it through Range
of motion. Normal tone causes a mild resistance to movement
through the entire range.
* Assess for increase tone “hyper tonicity” or decrease tone “hypo
tonicity”.
* Assess strength of major muscle group's e.g.:
- Neck “sterno- cleidomastoid”.
- Shoulder “trapezius”.
- Elbow, biceps & triceps.
- Hip major muscle: Quadriceps.
- Gastro-cneumius.
* Remember that strength of dominant side is more than non
dominant, and it is normally for specific ratio.
* Don’t forget to compare each limb with other, Left & Right Side.
-
-
-
-
-
**General Appearance: Includes
Sex and race.
Body builds, posture and gait.
(Note proportion of height weight, erect or slumped posture,
coordination of movements, and pattern of gait).
Hygiene, grooming.
(Note cleanliness, body odors, appropriate dress for age and
environment).
Signs of illness.
(Note posture, skin color, respirations, and nonverbal
communications of pain or distress).
Affect. Attitude, mood.
(Note speech, facial expressions, ability to relax eye contact,
behavior.
Cognitive process.
(Note speech content and patterns, orientation, appropriate verbal
responses).
58
-
Height and weight:
(Determine the client's height and weight).
Weigh client without shoes, and without extra clothing.
Assess ratio between height and weight.
"Weight = height – “100” = ---- +/- 10kg".
Assessment of skin, Hair, and nails
* Subjective data: Skin infection, rashes, lesions, itching.
 Precipitating factors: stress, weather, drugs, exposure to
allergens. Methods of relief (e.g., medications, lotions, soaks)
 Changes in skin color, lesions, and bruising.
 Amount of sun exposure (type of lotions used).
 Scalp lesions, itching, and infections.
 Changes in texture and amount of hair.
 Changes in nails and cuticles Nail breaking, splitting, cuticle
inflammation.
** The examination of skin includes, inspections of skin color
moisture, temperature, and thickness, and turgor.
Vascular changes, edema, and any lesions are noted.
Skin odors are usually noted in the skin fold.
 Color of skin:
Skin color varies from body part to body part and from person
to person.
* Normal changes in skin color my occur with aging
Assessment first involves area, of skin not exposed to the sun
e.g. palms of the hands.
Pallor easily perceived in the buccal “mouth” mucosa
particularly in individuals with dark skin.
Cyanosis readily seen in area, of least pigmentation e.g. lips,
nail beds conjunctiva, and palm.
Jaundice: seen in client’s sclera.
Erythema may indicate circulatory changes.
 Moisture of skin:
Moisture in the skin is directly related to the degree of client’s
hydration and the condition of the outer lipid layer of the skin
surface.
59
-
Skin is normally smooth and dry.
Skin folds e.g. axillae are normally moist.
Assessment of skin done by palpation.
In presence of lesions ooze fluid, nurse must wear gloved to
prevent exposure to infections drainage.
 Temperature:
Temp of skin depends on the amount of blood circulating
through dermis.
Palpation of skin with dorsum of the hand.
Assessment of skin is critical point in some conditions such as:
after cast application, or tight bandage, or after vascular surgery.
 Texture :
Character of skin surface and the feel of deeper portion are its
texture.
Nurse determines, whether the client’s skin is smooth or
rough, thin or thick, tight or supple. Texture of skin normally
smooth, soft and flexible. If any abnormalities in texture found
you must ask the client is he exposed to any recent injury to the
skin?
-
 Turgor:
Turgor: is the skin elasticity which can be diminished by edema
or de hydration.
Assessment of turgor done by pinching skin between the
thumb and forefinger and released.
Normally skin return immediately to its position.
Failure of this process means dehydration.
Decrease in turgor predisposes the client to skin breakdown.
 Vascularity :
Assessment of circulation of skin. E.g. petechiae may indicate
serous blood clotting disorders, drug reactions. Or liver disease.
 Edema:
"Build up of fluid in tissues".
Edematous areas should be inspected for location, color, and
shape.
60
Formation of edema separates the skin’s surface from the
pigmented and vascular layers masking skin color.
The nurse palpates areas of edema to determine mobility,
consistency, and tenderness.
-
 lesions:
Normally skin free of lesions except common freckles.
If lesion present inspection must done for color, location, size,
shape type, grouping, and distribution.
Palpation for lesion’s mobility, contour "flat, raised or
depressed and consistency “soft or indicated”.
N.B: cancerous lesions frequently undergo changes in color and size.
ab-
-
**Hair and Scalp:
If lesions or lice are probable, the nurse wears disposable
gloves to a void infection.
Two parts of hair covering the body.
Terminal hair (long, coarse, thick) and easily visible on the
scalp, axillae, and pubic areas.
Vellus hair” small, soft, tiny” covering the whole body except
palms and soles.
 Assessment done for distribution, thickness, texture, and
lubrication of the hair.
 Some events which affect the distribution of hair over the body
e.g. client with hormone disorders, woman with hersutism.
Normal color of terminal hairs: black, red, yellow, or
variations of these colors.
Older men lose facial hair; but older women may develop hair
on chin and upper lip.
Amount of hair covering extremities may be reduced as a
result of aging and arterial insufficiency especially in lower
limbs.
 Nurse should warn the client that combing or brushing can
cause. Amole which is common on the scalp to bleed.
 Scaliness or dryness of the scalp is frequently caused by
dandruff or psoriasis.
61
-
**Nails Assessment:
Nails reflect an individual's general state of health, state of
nutrition, and occupation.
Vascularity of the nail bed creates the nails underlying color.
Nails are normally transparent, smooth, and convex, with a
nail bed angle of about 160 degrees.
The surrounding cuticles are smooth, intact and without
inflammation.
Nail bed is normally firm on palpation.
Nails normally grow at a constant rate.
The nurse inspects the nail bed for splinter Hemorrhage,
transverse band, and abnormal thickness.
N.B: "vitamins, proteins and electrolytes changes can result in
various lines or band forming on the nail beds".
-
*The color of nails is an indicator of blood oxygenation:
Bluish color means cyanosis.
White or pallor means anemia
Palpation of the nails determines the adequacy of circulation or
capillary refill.
Calluses and corns are commonly found on the toes or fingers.
 Paronychia: inflammation surrounding the nail.
 Anonachia: complete abscenc of nail.
 Platunychia : flatting of the nails.
 Kolilonychia: nails spoon like shape.
 Racketnail: flattened and expanded nails (signs of
secondary syphilis)
 Onycholysis: nails separated from nail bed.
 Leukonychia Totalis: white nails (entire plate).
 Melanonychia: brown color in nails plate.
62
(Chapter – 7)
Head Assessment
-
The nurse inspects the clients head noting size, shape, and
contour.
The skull is generally round with prominences in frontal area
anterior and occipital area posterior.
If infant has large head it may result from hydrocephalus.
In adults enlarged jaws and facial bones resulting from
acromegaly.
The nurse palpates the skull for nodules or masses.
**Assessment of the eye
- Equipment needed:- Eye chart (Snellen chart)
- Near vision chart or newsprint.
- Cover card.
- Penlight, ophthalmoscope & ruler.
* Subjective data: Ask about:
- History of prior eye surgery, trauma, use of corrective glasses or
contact lenses, blurred vision, Diplopia, strabismus.
- Recent changes in vision. Date of previous vision test.
- Allergies, eye redness, frequent watering discharge.
** Client should be seated comfortably in a well Lighted room that
can be darkened for ophthalmic exam.
Assessments of the eyes include external eye structures,
pupils, and iris, visual acuity, ocular movements, Peripheral vision,
and internal eye structures.
** Factors for consideration while doing eye assessment age use of
corrective lens, artificial eye, allergies, pain, visual disturbances, and
health related factors such increase Blood Pressure, or Diabetes
mellitus.
** Assessment of external structures of the eye includes position
and alignment of eyes, eye brow, eye lids, eye lashes, lacrimal
glands, pupils and iris.
** Assessment of pupils done by using penlight which produce
constriction of pupils.
63
** Assessment must do for accommodation and convergence of
pupils.
** Visual Acuity assessment done by placing the client 20 feet
from the snellen eye chart and testing each eye alone.
** Assess extra ocular movements: by asking client to hold his head
and follow movements of your forefinger.
*Assess peripheral vision: “Visual fields”
- Hemianopsia: blindness of 1/2 field in one or both eyes.
- Quadrantanopsia: blindness of 1/4 of visual field in one or both
eyes.
- Ascotoma: Island like blindness in visual field.
N.B: Internal eye structures are examined with ophthalmoscope.
P3
**Assessment of the Ear
* Subjective data: Ask about the following:-History of prior ear surgery, trauma, frequent infection, ear pain,
drainage, hearing loss, tinnitus, vertigo, ototoxic medications, last
hearing examination
- In sitting position of client the nurse inspects the auricle’s
placement, size, symmetry, and color.
- Color of ears must be the same as of the face.
- Redness: sign of inflammation or fever.
- Pallor: indicate frost bite.
- The nurse palpates the auricles for texture, tenderness, and
skin lesion.
- If client complains of pain, nurse gently pull the auricle and
press on the tragus and behind the ear over the mastoid process
if pain increase, means external ear infection, if pain is not
increase, means middle ear infection may be present.
- Inspection of ear canal for size and discharge.
- Assessment of cerumen if it is yellow or green may indicate
infection.
**N.B: deeper structure and middle ear can be observed only by
otodscope.
**Assessment of hearing acuity done simply by identification of
voice tones, with the client repeating testing words spoken by the
nurse.
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**Assessment of the Nose
When inspecting the nose, nurse observes for asymmetry,
inflammation, and deformity.
- In case of swelling or deformities of nose, the nose is palpated
gently for tenderness, swelling and underlying deviations.
* Normally the external nose is symmetrical, strait, non tender,
and without discharge.
Assess mucosa which is normally pink in color.
- Yellowish or greenish discharge – means sinus infection.
- Pale mucosa with clear discharge – means allergy.
N.B: For client with NGT nurse routinely checks for local
breakdown of skin “Excoriation” of the naris characterized by
redness and sloughing of the skin.
**Assessment of the sinuses
Frontal and maxillary sinuses are examined for pain and edema.
- palpate sinuses (both frontal and maxillary for tenderness, which
verbalized by client during exam.
- Percuss sinuses for resonance which is normally hollow tone, and
noting abnormality e.g. flat, dull tone elicited or expresses pain on
percussion.
**Assessment of Mouth and pharynx
- Assessment of oral cavity can be made during administration
of oral hygiene.
 Lips – inspected for color, texture, hydration, contour, and
lesions.
 Inner and buccal mucosa inspected for color, hydration,
texture and lesions e.g. ulcers, abrasions or crusts.
 Gums and teeth can be assessed with assessment of buccal
mucosa which mentioned before.
 Tongue and floor of mouth can carefully inspect.
 Assessment of palate “soft and hard” by extending client’s
backward, assessment for color, shape, texture, and extra bony
prominences or defects.
**Assessment of Pharynx
Assessment for pharynx done: by using tongue depressors.
 Pharyngeal tissues are normally pink and smooth.
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 Edema, ulceration, or inflammation
infections or abnormal lesions.
indicates
**Assessment of Neck:
Client in sitting position: assessment done by inspection and
palpation.
- Assessing of neck include assessing of neck muscles, trachea,
thyroid gland, carotid arteries and jugular veins, cervical
lymph nodes and cervical vertebrae.
- Neck is assessed for size and position of trachea and thyroid,
range of motion, lymph nodes and venous distention.
- Full range of motion is assessed by asking the client to tilt the
head backward and side to side.
- Neck should be symmetrical with full range of motion. No neck
vein distention should be visible.
- Trachea should be centered; the cartilages should be smooth,
non tender and move easily under examiner’s fingers when the
clients swallow.
- On the posterior aspects of the neck the cervical vertebrae are
inspected and palpated for symmetry, tenderness, masses or
swelling.
- Thyroid gland is assessed by palpation, observation and
auscultation.
- Normal thyroid gland not palpable.
- Palpation – for gland itself.
- Observation – includes general observation, e.g. appearance,
skin, eyes, hair and cardiovascular status.
- If enlargement of thyroid gland is detected, the area over the
gland is auscultated for a bruit.
-
N.B: In enlargement of gland, blood flow through arteries is
increased and produces vibrations that heard with the bell of
stethoscope as a soft, rushing sound or bruit.
**Thyroid dysfunction:
1. changes in sleep pattern e.g. fatigue, drowsiness, lethargy,
or insomnia.
2. Emotional disturbances: e.g. mood changes, irritability,
nervousness.
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3. hair loss brittleness of nails.
4. Altered sensitivity to heat or cold.
5. Cardio respiratory changes : dyspnea on exertion , tachy
cardia.
6. changes in appetite: weight loss, abnormal bowel habits...etc.
7. changes in menstruation.
8. hoarseness , difficulty swallowing ….etc.
9. Family history of carcinoma of thyroid gland.
10.
History of radiation for to head or neck.
** Trachea:
Is palpated for alignment and position, which is normally midline
at the supra-sternal notch.
* Palpation done by placing the thump and forefinger on each
side of the trachea.
*Assessment of the lymphatic system:
Functions of lymphatic system:
1. Movement and transportation of lymphocytes .
2. Production of lymphocytes.
3. Production of antibodies.
4. Phagocytosis
5. Absorption of fat and fat soluble substances.
- Examination of lymphatic system for enlargement—
provides early indication of infection or malignancy.
- Lymphatic System consists of a network of collecting ducts,
lymph fluids e.g. spleen, thymus, tonsils, adenoids--- etc.
- Examination of lymphatic System done firstly by inspection
for enlarged lymph nodes, skin lesions, edema, erythematic,
and red streaks on the skin. Second step is palpating gently the
lymph nodes areas using pads of "2, 3, 4" fingers in gentle
circular motion.
- Press lightly and then increasing pressure gradually.
- Move skin lightly over the under lying tissues rather than
moving the examining fingers over the skin.
- When detecting Lymph node you must describe according to
location, size, regularity, and consistency.
- Large, fixed matted, inflamed or tender lymph nodes indicate a
problem.
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N.B enlarged nodes due to malignancy are generally not tender
vary in size, hard, asymmetrical.
abcd-
**Assessment of lymph nodes in head and neck areas:
*Nodal centers which must assessed in head and neck:
1. Pre auricular: in front of the ear.
2. Mastoid or posterior auricular – behind the ear. Above the
mastoid process.
3. Occipital – at the base of skull posterior.
4. Parotid – near the angle of the jaw.
5. Sub mandibular – midway between angle of jaw and the
tip of the mandible.
6. Sub mental – in the midline posterior to the tip of the
mandible.
* Sternocleidomastoid muscle divides the neck into anterior and
posterior triangles – so you can assess:
Anterior superficial nodes – in the anterior triangle of the neck.
Posterior cervical nodes – in the posterior triangle of the neck.
Deep cervical nodes – very deep and difficult to be examine.
Supra clavicular or scalene nodes – In the angle formed by
clavicle and Sternocleidomastoid muscle.
N.B To enhance accurate palpation has client bend head forward or
toward the side of neck to be examined.
**Upper extremity: The epitrochlear node is palpated above and
post to the medical condyle of the humorous.
** Axilla: Palpation of lymph nodes here done by gently rolling
the soft tissue against the chest wall and muscles.
** Breast will be discussed later.
** Lower extremity: Palpation of inguinal and popliteal nodes
while client is lying down with knee slightly flexed.
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(Chapter – 8)
Assessment of respiratory system
* Subjective data: you must ask about:- Coughing (productive, non productive)
- Sputum (type & amount, allergies, dyspnea or shortness of breath
(at rest or on exertion).
- Chest pain, history of asthma, bronchitis, emphysema, tuberculosis.
- Cyanosis, pallor, medication, exposure to environmental inhalants
(chemicals, fumes).
- History of smoking (amount and length of time)
** Assessment of respiratory system includes:
- Inspection for Measurement and assessment of respiration
patterns.
- Assess the skin and overall symmetry and integrity of the
thorax.
- Assess thoracic configuration.
** Client must be uncovered to the waist, and in sitting position
without support.
* Observation of skin may give you knowledge about, nutritional
status of the client.
* Anterior- posterior diameter of thorax in normal person less
than the transverse diameter = (1 – 2).
* Assess for abnormality of configuration, e.g. pigeon chest,
funnel chest, spinal deformities.
* Assess ribs and inter spaces on respiration – may give you in
formation about obstruction in air flow e.g. bulging of inter
spaces on expiration may be from obstruction to air out flow
“tumor, aneurysm, cardiac enlargement”
* Assess pattern of respiration:
Normally: men and children – breathe diaphragmatically and
Women breathe thoracically or costally.
* Respiratory rate average between: (12 – 20/m) in adult.
- Tachypnea respiratory rate over than 20/m.
- Bradypnea respiratory rate less than 10/m.
* Palpation: palpate areas of chest especially areas of
abnormalities if clients complains – all chest areas must palpated
carefully for tenderness, bulges, or al movements.
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* Assess thoracic expansion:
aAnterior – put your hands over anterior-lateral chest and
thumbs extended along costal margin pointing to xiphoid process.
bPosterior—thumbs placed at level of 10th rib with palms
placed on posterior-lateral chest.
** By two ways – you feel amount of thoracic expansion during
quiet and deep breathing, and symmetry of respiration between
left and right hemi thoraces.
* Assessment of fremitus: "fremitus is vibration perceptible on
palpation".
* In case of subcutaneous emphysema: you must palpate the
tissue, audible cracking sounds are heard – these sounds are
termed “Crepitations”.
* Percussion of chest, to determine relative amounts of air,
liquid, or solid material in the underlying lung, and to determine
positions and boundaries of organs.
* Percussion done for posterior and anterior and lateral aspects of
chest with all directions, and with about “5”cms intervals.
1234-
* Auscultation:
To obtains information about the functioning of respiratory
system and to detect any obstruction in the passages.
* Instruct the client to breathe through the mouth more deeply
and slowly than in usual respiration before beginning.
* Auscultate all areas of chest for at least one complete
respiration.
* Breathe sounds: are analyzed according to pitch, intensity,
quality, and relative duration of inspiratory and expiratory phases.
* Bronchial breathe sounds: are normally heard over the trachea,
if heard over lung tissue – indicate pathologic condition, these
sounds “high- pitched, loud sounds with decrease inspiratory and
lengthened increase expiratory phases.
* Absent or decreased breath sounds can occur in:
Foreign body – in pleural space.
Bronchial obstruction.
Shallow breathing.
Emphysema.
* Rale: is short, discrete, interrupted, crackling or bubbling
sound that most commonly heard during inspiration “similar to
70
sounds, produced by hairs being rolled between the fingers close
to ear.”
* Important points when Auscultate rales:
1low pitched, coarse rales, occurring early in inspiration means
bronchitis “originate from bronchi”
2Medium pitched rales in mid-inspiration means disease in
small bronchi e.g. bronchiectasis.
3High pitched, fine rales means disease affecting bronchioles
and alveoli this occurs in late inspiration.
* Rhonchi: are continuous sounds produced by movements of air
through narrowed passages in the tracheal- bronchial tree
"musical sounds heard in expiration".
aLow pitched rhonchi “Sonorous rhonchi usually heard in early
expiration originate in larger bronchi”
bHigh pitched: “Sibilant rhonchi or wheezes” – in late
expiration, this originates in small bronchioles.
* Pleural friction rub: is aloud dry, cracking or grating sound
indicating of pleural irritation.(heard over lateral and anterior
lung in sitting position &not clear with coughing )
(Chapter – 9)
Assessment of cardio vascular system
* Subjective data: you must do the following before assessment:
a- Assessment of chief complaints:
- Chest pain: location, quality, duration & associated symptoms.
- Irregular heart beat: pound too fast, jump….. Etc.
b- Assessment of risk factors:- Do you have a history of hypertension, diabetes, rheumatic
fever?
- Is there a history in your family of heart attack, hypertension,
stroke, and diabetes?
- Describe your nutritional intake: have you ever been told you
have high cholesterol, triglyceride level.
- Do you smoke? How much? And for how long?
- How do you view yourself? What do you do to relax?
71
- How many hours a day do you work? How do cope with stress.
- Exercise: what do you do for exercise? How often?
- Pain in calves, feet, buttocks or legs? What aggravates the pain
(walking, sitting long periods, standing long periods, sleep) what
relieves the pain “elevating legs, rest, lying down”.
- Is there fitting shoes? Does client wear constricting garments or
hosiery?
- In what type of chair does client usually sit?
- Does he/she cross legs frequently?
- What is the amount and toes of exercise the client does? Is client
taking drugs that may mimic arterial insufficiency?
** During assessment the client must is in supine or sitting
positing according to his health.
** Inspection: "Don’t use stethoscope here", Inspection and
palpation done to determine normal and abnormal pulsations
over the pericardium.
* By inspection and palpation you may detect ventricular
hypertrophy; "thickness of chest wall may interfere with that"
* Source y light may help you to inspect subtle movements in
chest e.g.: pulsation, retraction… Etc.
* Apical impulse in left fifth intercostal space, if deviation in site
observed may indicate cardiac enlargement 6th intercostal space.
* Retractions may be seen around site of apical pulse, marked
retraction may indicate pericardial disease.
* Heaves or lifts: when right Ventricle work increase.
** Palpation: Palpate from apex, moving to external border to
base:
* Detect abnormalities in site of palpation and abnormal sounds
especially for thrill “abnormal flow of blood”
* Remember that your client must be in supine position.
* It is important to describe pulsations in relation to there timing
in the cardiac cycle.
* Describe in terms, locations of pulsation in relation to midsternal, mid-clavicular or axillary lines.
* Palpation of apical pulse done at the site mentioned in case of
inspection, strength differs from thin person to obese.
72
* Conditions such as anxiety, anemia, fever, and hyperthyroidism
may increase in force and duration of apical pulse.
* When force and duration of apical pulse increase you feel
lifting sensation under your fingers.
* Palpation of pulse at base of the heart by putting your hand at
second left and right intercostal spaces at sternal borders.
** Percussion: “Limited value in cardiac assessment”
** Auscultaiong: All heart sounds are generally low pitched
“low frequency” and difficult for the human ear to hear.
* Auscultation done by stethoscope which consists of two parts
bell and diaphragm.
* You may start auscultation from base to apex or starting from
apex of heart to the base.
* Firstly examiner notes rate and rhythm of the beat, and then
concentrates initially on sound "1", noting its intensity and
variations therein, possible duplication and effects of respiration.
And then listen to Sound "2" for same characteristics. Finally
listen for extra sounds and for murmers.
N.B: Sound "1": caused by the closing of the tricuspid and mitral
valves. “Systole begins with Sound "1" and extends to Sound "2".
Sound "2": results from the closing of the aortic and
pulmonary valves.
“Diastole begins with Sound "2" and extends to next Sound "1"
** Sound "2" louder than Sound "1" at the base of heart, and is
quieter than Sound "1" at the apex.
N.B:
* Sound "3": During diastole, rapid distention of ventricles occur
causes vibrations of ventricular walls to occur," and this known
as sound "3" ".
** Sound "3" best heard at the apex with bell of stethoscope.
** Sound "4": occur after Sound "3" (late diastolic filling), occur
from vibrations of ventricular wall or vibrations of the valves.
* Summation gallop: three cardiac sounds heard S1, S2 and
summation of S3 and S4.
* Neck vessels:
Jugular veins assessed for venous pulse waves and pressure.
 Assess for distention, which may result from right Sided
heart failure.
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 The client must be in supine position or if it is tired for
him, may be in fowler position "45" degree.
 Assess jugular pulse “venous”which is wave of blood
retrograde after ejecting blood into the right ventricle
 Assess carotid arteries firstly by inspection, and then
palpate below and just medial to the angle of the jaw,
then Auscultate by the bell of the stethoscope.
 When you assess carotid arteries for pulsation note
whether the force is strong or weak, the rise and
collapse, rapid or slow, double or single.
 Listen for heart murmurs which are abnormal sounds
produced by vibrations within the heart or in the walls of
large vessels “during systole of diastole”.
 Murmurs occurrence result from valve defects, changes
in the blood vessels or by defects in the myocardium.
 Special maneuvers for vascular assessment :
 Check for deep phlebitis by quickly squeezing calf
muscles against tibia (normally no pain)
 Check Homan's sign by extending leg and dorsi-flexing
foot (normally no pain).
 check for arterial insufficiency if leg pulses are
decreased by instructing client to lie down and back,
while you support the client's legs 12 inches above heart
level and.
a) Have client move feet up and down at ankles for (60)
seconds (normally feet become pink without exercise
paleness).
b) Ask client to sit up and dangle legs in dependent position
(normally pink color returns to tips of toes in "10" seconds,
and veins on top of feet fill in (15) seconds, if delayed it is
abnormal).
 check for competency of valves (Trendelen-burg test) if
client has varicose veins: feel dilated veins with one
hand while using the other hand to compress veins
firmly above level of the first hand, then palpate for
impulse of blood flow which is normally no pulsation
palpated.
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Arterial and Venous insufficiency of lower extremities
Item
Arterial insufficiency
Pulses
Color
Decreased or absent
Pale on elevation and
cold
Temperatu
re
Edema
Skin
Cool, cold
Sensation
Non
Shiny skin, thick nails,
absent of hair, ulcers
on toes, gangrene may
develop
Leg pain aggravated by
standing & relieved
with rest.
Pressure on buttocks or
calves
or
cramps
during
walking,
parasthesia
Venous
insufficiency
Present
Pink
to
cyanotic,
brown pigment at
ankles
Warm
Present
Ulcers
on
ankles
discolored, scaly
Leg pain aggravated by
standing or sitting &
relieved by elevation of
legs, lying down, or
walking. Also relieved
with use of support
hose.
(Chapter – 10)
Assessment of the abdomen
"Abdomen is the largest body cavity"
** Subjective data: ask the client about the following:
 Nutritional history: appetite, weight loss or gain.
 Gastro intestinal symptoms: dysphagia, nausea, vomiting,
and indigestion.
 Bowel habits: pattern, and stool characteristics.
 Pain: location, quality, pattern, and relationship to ingestion
of food.
 Use of medications: Aspirin, Anti inflammatory drugs, and
steroids.
 Gastro intestinal diagnostic tests and surgeries.
** start assessment with inspection, auscultation, then percussion
and palpation. This allows accurate assessment of bowel sounds
and delays more uncomfortable maneuvers until last.
75
** The client is placed in the supine position, with small pillows
under the head and knees. The abdomen is exposed from the
breast to the symphysis pubis.
* stand the client right side and carry out assessment
systematically, beginning with the left upper quadrant, and
progressing clockwise through the four abdominal quadrants. The
bladder should be empty.
* N.B: nurses do not usually repeat the internal rectal
examination that is done as a part of the medical examination
unless there is a specific reason to do so, because it is
uncomfortable and embarrassing for the client.
 Inspection:
* When the client is under source of light you see exactly changes
in contours.
* Describe accurately the presence or absence of symmetry,
distention, masses, visible peristaltic waves and respiratory
movement, “done in sitting position”.
 Inspect the abdominal skin for pigmentation e.g. jaundice,
lesions, striae scars, dehydration, general nutritional status
and condition of umbilicus, this give information about
general state health.
 Contour of the normal abdomen is described as: flat,
rounded, or scaphoid.
N.B: contour is description of the profile line from the rib from the
rib margin to the pubic bone.
 Flat contour seen in the muscularly competent and well
nourished individual.
 Rounded abdomen: Normally in infant and toddler, but in the
adult caused by poor muscle tone and excessive Subcutaneous
fat deposition.
 Scaphoid contour “Concave in horizontal line” seen in thin
clients of all ages.
 Inspect for respiratory movements especially for retraction of
the abdominal wall on inspiration which is called "Czerny's
sign “associated with some Central Nervous System diseases
such as chorea”
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 Auscultation :
 Auscultate peristaltic sounds which are normally high
pitched.
* Listen for at least "5" minutes before concluding that
no bowel sounds are present. "Peristaltic sounds may be
quite irregular".
* Duration of single sound may be less than a second or
more than it.
* Stimulation of peristalsis may be achieved by flicking the
abdominal wall with a finger “direct percussion”
 Auscultate vascular sounds:
* Loud bruits detected over the aorta may indicate presence
of an aneurysm; the aorta is auscultated superior to the umbilicus.
* Peritoneal friction rub: rough grating sound like sound of
two pieces of leather being rubbed together.
* Listen over the area of liver and spleen e.g. spleen
infection, abscess or tumor: best heard over the lower rib cage in
the anterior axillary line.
* Metastasis disease of the liver and abscess are the usual
causes of peritoneal friction rubs located over the lower right rib
cage.
 Percussion:
* To detecting fluid or gaseous distention and masses and assessing
solid structures within the abdomen.
* Percussion of one for each quadrant to assess areas of tympany
and dullness.
* Potentially painful areas are always Percuss last
* Percussion allows you to identity borders of the liver to detect
organ enlargement.
* To detect liver size, start percussion at the right iliac crest and
proceeds up ward on the right mid-clavicular line, when dullness
occur this is the lower border of the liver.
* To detect upper border of the liver percuss, down from the
nipple along mid-clavicular line, then dullness occur “upper
border” may be found in (5,6,7) intercostals space, distance
between points lower and upper is (6-12cm).
N.B: Diseases e.g. cirrhosis, cancer, and hepatitis cause liver
enlargement.
77
* Stomach position:
With percussion you can locate the tympanic air bubble of the
stomach by percussing over the left lower anterior rib cage.
* Kidney Tenderness:
- In sitting or erect position, use direct or indirect percussion to
assess for kidney inflammation.
- Use ulnar surface of the partially closed fist and percuss the
costo-vertebral angle at the scapular line.
- If the kidneys are inflamed, client feels tenderness during
percussion.
 Palpation:
* Detect abdominal tenderness and noting the quality of abnormal
distensions or masses.
* Palpate “after rubbing hands together” lightly each quadrant.
* Avoid quick jabs if the client is ticklish, place your hand under
client until touch is tolerated.
* During palpation assess for muscular resistance, distention,
tenderness and superficial organs or masses.
* Assess for distended bladder if client has in ability to void,
bladder lies normally below the umbilicus and above symphysis
pubis.
* Start with light palpation then use deep palpation.
* In deep palpation depress hands (2.5-7.5 cm), "1-3 inch"
N.B:
Deep palpation never used over a surgical incision or tender
organs, or masses.
- If tenderness present, check for rebound tenderness, if it was
positive indicated peritoneal irritation e.g. appendicitis
* Liver:
"Right upper quadrant under the rib cage":
* Place your left hand under client’s posterior thorax at the 11th
and 12th ribs and by your right hand palpate in and up to feel the
liver’s edge as the client inhales.
* G.B normally not felt and if distended it felt under liver and
may indicate cholecystitis.
78
* Spleen:
Generally not palpable in normal adult person, but in case
of spleen enlargement you can palpate it below costal margin.
* Aortic pulsation: Assessed in the upper abdomen just left to the
mid line by depressing with thumb and forefinger deeply.
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* Assessment of the anus and recto sigmoid region, rectal exam is
an important component of every comprehensive physical
examination.
* Events required rectal examination:
- Abdominal pain.
- Alternation in bowel habits.
- Anal pain, anal spasm.
- Anal itching or burning.
- Black tary stool.
- Rectal bleeding.
* Positions for rectal examinations:
Left lateral or SEM's position.
Knee- chest position
Standing position, most common use for prostate gland
examination.
Lithotomy position
Squatting position.
N.B.: in all positions, before examination wear two gloves.
 Inspection:
Spread buttocks carefully with both hands to examine the anus
and skin around it which is more pigmented, moist, and hairless.
* Assess lesions, scars, or inflammation, peri-rectal abscess,
fissures, piles, fistula opening, tumor and rectal prolapsed.
* Ask the client to strain down ward as in defecation.
* Inspect for pilonidal sinus or cyst at the sacro- coccygeal area,
and give description.
* Palpation:
* Spread the buttocks apart with your non dominant hand. Gloved
index gently placed against the anal verge, and with firm pressure
in direction of umbilicus as the rectal sphincter relaxes. Ask client
to lighten the sphincter around your finger to examine muscle
strength.
79
* Mucosa of the anal canal is palpated fro tumor or polyps.
* Palpate through mucosa of anterior wall of rectum to assess
prostate gland. "Normal prostate is (4 cm) diameter and (2.5cm)
long".
* Assess normal cervix in female which felt as small round mass
during P.R examination.
* Variations from health which can be detected during rectal
examination:
1Pilonidal cyst or sinus.
2Pruritus anus “excoriated, thickened, pigmented skin”
3Rectal tenesmus: painful straining at stool associated with
spasm of anal and rectal muscle.
4Fecal impaction “Accumulation and dehydration of fecal
material in the rectum”
5Anal fissure: "thin tear of the superficial anal mucosa and seen
when client doing valsalva’s maneuver.
6Fistula in anus: "chronically inflamed tube made up of fibrous
tissue".
7Hemorrhoids: “Dilated congested veins of the hemorrhoid
group”:
aExternal hemorrhoids, painful.
bInternal hemorrhoids, painless unless complicated.
8Rectal polyps: like soft nodules feeling.
9Rectal prolapse: e.g. in case of internal hemorrhoids.
10- Anal incontinence.
11- Abscesses or masses e.g. Ischio rectal abscess, peri rectal
obstruction.
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(Chapter – 11)
Assessment of musculo-skeletal system
** Subjective data: before assessment ask about:
 Pain: at rest, with exercise, changes in shape or size of an
extremity, changes in mobility to carry out activities of daily
living, sports, and works.
 Stiffness: time of day, relation to weight," bearing or
exercise".
 Decreased or altered or absent sensations.
 Redness or swelling of joints.
 History of fractures and orthopedic surgery.
 Occupational and recreational history.
*Assessment of musculo-skeletal system done firstly when the
client walks, moves in bed or performs any type of physical
activity.
- Determine Range of motion, muscle strength and tone, and joint
and muscle condition.
N.B: muscle problems commonly are manifestations of neurological
disease, so you must do neurological assessment simultaneously.
* Joints vary in their degree of mobility, range from freely
movable e.g. knee, to slightly movable joints e.g. the spinal
vertebra.
* Use inspection and palpation skills in assessing this system.
And this done while client in standing, sitting, supine, and prone
position.
** During assessment of muscle groups: assess muscle
weakness, or swelling, and size, then compare bilaterally by
measuring circumference with a tape measure. Joints should not
be forced into painful positions.
* Observer gait and posture as client walks into room.
* Normally the client walks with arms swinging freely at sides
and the head and the face leading the body.
* Normal standing posture is an upright stance with parallel
alignment of the hip, and shoulder.
* Common postural abnormalities include lordosis, kyphosis, &
scoliosis.
81
* Loss of height is frequently the first clinical sign of osteoporosis.
- Small amount of height loss expected with aging.
** Ask client to put each joint through its full range of motion, if
there is weakness, gently supporting & moving extremities through
their Range of motion, to assess abnormalities.
* When assessing Range of motion, compare the same body parts for
equality in movement.
* Don’t force a joint into a painful position.
* Ideally, the normal range is assessed to determine a baseline for
assessing later change.
* Normal joints are non tender, without swelling and move freely.
N.B: “You must assess these points”: In elderly joints often become
swollen & stiff, with reduced Range of motion, resulting from
cartilage erosion and fibrosis of synovial membranes.
(Chapter – 12)
Assessment of Neurological system
You can assess this system when doing physical examination
e.g. cranial nerve function can be testing during the survey of the
head and neck.
* The neurological assessment consists of six parts: (mental status,
cranial nerves, sensory functions, motor function, cerebellar
function, reflexes).
** Subjective data: ask about:
 Loss of consciousness, dizziness, and fainting.
 Headache: precipitating factors and duration.
 Numbness and tingling or paralysis or neuralgia.
 Loss of memory, confusion, visual loss, blurring, and pain.
 Facial pain, weakness, twitching, speech problems e.g.
aphasia.
 Swallowing problems and drooling.
 Neck weakness or spasm.
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* Mental and emotional status is observed as the nursing history is
collected, and by simply interacting with client, e.g. “Nursing care
plan”
* Level of consciousness, which ranges from full a wakening,
“alertness” to unresponsiveness to any form of external stimuli.
* Alert client responds to questions spontaneously.
* You can assess Level of consciousness by using Glasgow coma
scale.
Glasgow coma scale.
Action
Open eyes
Response
Spontaneous
To speech
To pain
None
Score
4
3
2
1
Best verbal response
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor response
Obeys commands
Localized pain
Flexion withdrawal
Abnormal flexion
Abnormal extension
Flaccid
6
5
4
3
2
1
15
Total score
* If client not response to your wards applies firm pressure with the
thumb over the root of the finger nail “he must withdraw the hand”
- Flaccid response to pain indicates absence of muscle tone.
Assessment of behavior and Appearance
* Behavior, mood, hygiene, grooming and choice of dress reveal
pertinent information about client’s mental status.
* Appearance reflects how a client feels about the self.
* Personal hygiene such as unkempt hair, a dirty body, or broken,
dirty fingernails should be noted.
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* Language: Assess ability of individual to understand spoken or
written words & how he speak or writes.
* Assess intellectual function, which includes: memory “recent,
immediate, past”, knowledge, abstract thinking, association and
judgment.
* Assess for sensory function:
- Assess sensitivity to light touch “cotton”
- Assess sensitivity to pain “pinprick”
- Assess sensitivity to vibrations “tuning fork”
- Assess sensitivity to positions.
Don’t forget comparing both sides of body.
(Chapter – 13)
Assessment of the breast





Subjective data: ask about:
Tenderness, pain, swelling, or change in size of breasts.
Change in position of nipple or nipple discharge.
Presence of cysts, lumps, and lesions.
History of prior breast surgery.
**Female breast:
Inspection: with the client sitting, arms relaxed at sides. Inspect
Arcola and nipples for position, pigmentation, inversion, discharge,
crusting & masses.
* Examine the breast tissue for size, shape, color, symmetry, surface,
contour, skin characteristics,
* Assess level of breasts, notes any retractions or dimpling of the
skin.
* Ask client to elevate her hands over her head, repeat the
observation.
* Ask client to press her hands to her hips and repeat observation.
*Palpation: Best done in recumbent position: if the client with
pendulous breasts put a pillow under ipsilateral, scapula of breast
being palpated.
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* Raise the arm of client on the side of the breast being palpated
above clients head.
* palpate the breast from less painful or less diseased area "in client's
suffering from something in her breast"
* Use on palpation palmer aspects of the fingers in a rotating motion,
compressing the breast tissue against the chest wall, this is done
quadrant by until the entire breast has been palpated.
*Note skin texture, moisture, temperature, or masses.
*Gently squeeze the nipple and note any expressible discharge.
"Normally not present in non lactating women".
*Repeat examination on the opposite breast & compare findings.
N.B: If mass is palpated, its location, size, shape, consistency,
mobility and associated tenderness are reported.
*Male Breast:
* Examination of male breast can be brief and should never be
omitted.
*observe nipple & Arcola for ulceration, nodules, swelling or
discharge "normally not present"
*Palpate the Areola for nodules or tenderness.
Genitourinary and reproductive Assessment
* Subjective data: you must focus you’re your questions on the
following:
 Any bulges or pain when straining or lifting heavy objects.
 Unusual drainage.
 Pain with urination or incontinence.
 Lower abdominal pain.
* Assessment of the male genitalia
* Client must be in standing position with exposed groin and genital
area.
*Inspection:
-Inspect pubic hair distribution & skin of the penis.
-retract the foreskin if present.
-Observe the glans penis and the urethral meatus; note any ulcers,
masses or scars.
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-note the location of urethral meat us and any discharge.
-Observe skin of the scrotum for ulcers, masses, redness, or
swelling, and note size, contour, and symmetry.
* Lift the scrotum to inspect posterior surface.
N.B: Left testicle is often larger than the right one.
*inspect the inguinal areas and groin for bulges.
** Palpation: "use gloves"
* palpate any lesions, nodules, or masses, noting tenderness contour,
size; palpate shaft of penis for indurations.
* Use thumb and first two fingers to palpate each testis separately,
noting size, shape, consistency and undue tenderness a pressure on
testis normally produces pain"
*palpate for presence of inguinal hernias." By insertion index finger
laterally, invaginating the scrotal sac to the external inguinal ring"
*palpate the anterior thigh for a hernia ting mass in the femoral
canal.
*Assessment Female Genitalia:
* ask about:
- Pain or burning with intercourse or urination.
- Itching, purulent or foul smelling discharge.
- Amenorrhea or mid cycle bleeding.
- Difficulty starting or stopping urinary steam or stress incontinence.
- Have client empty her bladder; assume Lithotomy position, and
you must wear gloves.
*Inspection & palpation:
-Inspect labia majora for size and color and skin texture; observe
also the mons pubis and perineum.
*with gloved hand , separate labia majora and inspect clitoris,
urethral meats, hymen & vaginal opening , note skin color,
ulcerations, nodules , discharge or swelling.
The end
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References
 Nettina, Sandra M. (2010) Lippincott Manual of Nursing
Practice, 9th Edition, New York: Lippincott Company.
 Penelope Ann Hilton. (2005). Fundamental nursing skills,
1st edition ,Whurr Publishers Ltd, London .
 Williams & Wilkins. (2005) Assessment: A 2-in-1
Reference for Nurses, 1st Edition, Lippincott company,
Philadelphia.
 http://www.umanitoba.ca/nursing/courses/128,(2005)
 Corbourg,H. &others (2004). Health assessment/nursing
skill
labs,
Sir
Stanford
Fleming
College(www.flemingc.on.ca)
 Philadelphia Weber,J. (1997). Nurses hand book of health
assessment, 3ed edition, New York: Lippincott Company.
 Tucker C, MODULE A INTRODUCTION TO NURSING
Process, August 21, 2002 .
 Doeges,M.(1993) nursing diagnoses with interventions –
including (NANDA) , 4th edition, Philadelphia: Davis
company.
 Malasanos,L.(1990). Health
Toronto: Mosby Company.
assessment,
With best wishes for all success
Dr. Abdalkarim Radwan
87
4th
edition,