Specific Instructions in the completion of each Chapter:

1. Set your learning goals. Read and understand the Intended Learning Outcomes of each chapter. This shall serve as your checklist of acquired
knowledge and skills after completing the entire chapter, likewise, the basis of the teacher in the formulation of the summative evaluation given
at the end of each chapter.

2. Lecture notes are provided for you. BE SURE NOT TO SKIP the lecture. Read and understand before answering the activities. You can take
note those concepts that are not clear to you and refer to your subject teacher during the specified consultation hours.

3. Read the teacher’s insight and watch the downloaded videos saved in the flash drive to supplement the lecture notes.

4. As you go on, you will encounter exercises that will test your knowledge and understanding as well as your critical thinking. Read the
instructions carefully, and write your answers to the space provided at the end of Midterm coverage.

5. Compile you outputs in your Learning Portfolio to be submitted on the date set by your teacher.

6. Should you have any queries or clarifications with the topics, please contact your subject teacher during consultation hours (please refer to
the preliminaries of this material).

CHAPTER 1

NURSING PROCESS

This chapter covers concepts in applying nursing process and its components in the delivery of nursing care. At the same time Interview
techniques and guidelines, health history taking and using the Gordon’s 11 functional pattern are discussed in terms of gathering data.

Duration: 12.0 hours

MAJOR TOPICS SUBTOPICS

I. Purpose And Advantages Of Nursing Process
II. Phases Of Nursing Process
Assessment · Purpose

· Process

· Types of Data

· Sources of Data

· Interview Technique

· Health History

· Health History Personal Profile (Chief Complaint of Present

Illness, Past Medical History , Medication History, Family History,
Social History)

· Gordon’s 11 Functional Patterns

Diagnosis · Types of Diagnosis

· Examples
Planning · Purpose

· Characteristics
Interventions · Types of Interventions and Examples

· Guidelines
Evaluation

Activities:

1. Self-Assessment Exercises: MCQ type of questions

2. Critical Thinking Exercises: Short Essay

Before you proceed…

Intended Learning Outcomes:

1. Discuss the steps of the Nursing Process

2. Understand the guidelines in health history taking
3. Appreciate the purpose, structure and guidelines of an effective interview
4. Understand the components of health history
5. Differentiate physical and instrumental activities of daily living
6. Understand functional assessment tests for adults
7. Identify symptoms of each body system

Key Terms:

· Nursing Process
· Assessment
· Health History
· Interview
· Data
· Diagnosis
· Planning
· Implementation
· Interventions
· Evaluation
· Goals

Let’s Begin!

BASIC CONCEPTS OF NURSING PROCESS

Definition of Nursing Process:

Ø Specific to the nursing profession

Ø A framework for critical thinking

Ø It’s purpose is to:“Diagnose and treat human responses to actual or potential health problems”

Ø Organized framework to guide practice

Ø Problem solving method - client focused

Ø Systematic- sequential steps

Ø Goal oriented- outcome criteria

Ø Dynamic-always changing, flexible

Ø Involves looking at the whole patient at all times

It provides a "road map" that ensures good nursing care & improves patient outcomes

Critical Thinking- nurses need to use Nursing process

- Always thinking about your thinking, and your actions, and your decisions

Basis in using Critical Thinking:

· Deal w/ complex problems on a daily basis

· Work w/ patient that are unique

· Provide holistic care

Advantages of Nursing Process:

1. Provides individualized care

2. Provides more effective communication among nurses and healthcare professionals

3. Develops a clear and efficient plan of care

4. Provides personal satisfaction as you see client achieve goals

5. Professional growth as you evaluate effectiveness of your interventions

PHASES OF NURSING PROCESS

A. ASSESSMENT

Ø First step of the Nursing Process

Ø systematic, deliberate process by which the nurse collects and analyzes data about the patient

Ø Gather Information/Collect Data through Nursing Interview (history), Health Assessment -Review of Systems, Physical Exam

Ø Entire plan is based on the data you collect, data needs to be complete and accurate

Ø Make sure information is complete & accurate

· Process of Systematic Assessment

1. Collect data
2. Verify data

3. Organize data

4. Identify Patterns

5. Report & Record data

Comprehensive data collection:

ü Begins before you actually see the patient (Nurse report from ER, Chart reviews)

ü Continues with admission interview and physical assessment once you meet patient.

ü Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing
literature.

ü Consider age, growth & development

· Types of Data:

a) Objective Data – signs; those that can be observed and measured

Ex. Vital signs: BP 130/80, PR 68bpm, RR 19cpm, Temp 37.0 C

b) Subjective Data – symptoms; those that described only by the person experiencing it.

Ex. " I have a headache".

· Sources of Data:

a) Primary – patient/client

b) Secondary – family members, patient’s record, health team members, related literature

· Interview Technique

Ø The interview is a purposeful conversation, generally in a face-to-face meeting. It involves at least two persons; the interviewer, the one who
seeks information, and the interviewee, the person from whom the information is sought.

Ø The interviewer is a verbal and non-verbal exchange that provides for the beginning and development of a relationship. It is the second most
common method of gathering information next to questionnaire.

Categories of Interview:

1. Standardized/ Structured

- The interviewer is not permitted to change the specific wording of the interview question schedule. He must endeavor to conduct each
interview in precisely the same manner and he cannot adapt questions for a specific situation.

2. Non-Standardized

- The interviewer has complete freedom to develop each interview in the most appropriate manner for each situation. He is not held to any
specific questions.

3. Semi-Standardized

- The interviewer maybe required asking a number of specific questions, but beyond these, he is free to probe as he chooses.

4. Focused
- The interviewer approaches the respondent with a series of questions based on previous understanding and knowledge of the problem or
phenomenon being studied. The interviewer is thus able to direct his questioning so as to discover the kinds of backgrounds and experiences
that have influenced the subject.

5. Non-Directive

- The subject is given the opportunity to express his feelings without fear of disapproval. There is freedom to discuss a topic without pressure
from the interviewer.

Interview Instruments

1. Interview Schedule

- A questionnaire is read to the respondent.

2. Interview Guide

- One that provides ideas but allows the interviewer freedom to pursue relevant topics in depth.

Types Of Questions

1. Open-Ended Questions

- One aimed at eliciting response that is more than one or two words in length. This type is effective in stimulating descriptive or comparative
responses.

2. Close-Ended Questions

- A type of inquiry that requires no more than one or two worded answer. This might be an agreement or disagreement. The responses maybe
yes or no and maybe answered non-verbally by a nod of the head.

3. Biased Or Leading Questions

- Those that carry a suggestion of the kind of information that should be included in the response.

4. Neutral Questions

- These are questions wherein a person can answer without direction or pressure. It is often used in non-directive interviews

Guidelines When Conducting An Interview

1. Initiation
a. Greet the respondent by name
b. Introduce self
c. Explain the purpose of the interview
d. Put the respondent at ease (physical comfort)
2. Appropriate Use Of Non-Verbal Communication

a. Maintain good eye contact

b. Observe proper body posture
c. Use silence appropriately
d. Avoid distractions (chewing lips, gums, playing with pen)

3. Questioning

a. Speak clearly
b. Use simple language
c. Ask open-ended questions
d. Ask one question at a time
e. Wait for the respondent to answer
f. Ask appropriate probing questions
g. Control pace of interview
h. Control direction of the interview
 i. Do not be judgmental
4. Focusing

a. Elicit information relevant to the purpose of the interview

b. Have an organized sequence of questions
c. Follow the respondent’s verbal cues
d. Ask for clarification appropriately
e. Make appropriate transitional statements

5. Terminating The Interview

a. Ask the interviewee if he has any questions

b. Summarize what has been said
c. Thank the respondent and say goodbye appropriately

· Health History

Ø Taking a Patient’s history is arguably the most important aspect of patient assessment, and is increasingly being undertaken by HCPs including
midwives. The procedure allows patients to present their account of the problem and provides essential information for the practitioner.

Preparing the environment

Ø The first part of any history-taking process and, indeed, most interactions with patients is preparation of the environment

Ø HCPs can encounter patients in a variety of environments: accident and emergency; general wards; department areas; primary care centres;
health centre clinics and the patient’s home.

Ø Respect for the patient as an individual is an important feature of assessment, and this includes consideration of beliefs and values and the
ability to remain non-judgemental and professional

Ø Respect also involves maintenance of privacy and dignity; the environment should be private, quiet and ideally, there should be no
interruptions.

Communication

Ø The HCP should be able to gather information in a systematic, sensitive and professional manner

Ø Good communication skills are essential.

Ø Introducing yourself to the patient is the first part of this process

Ø It is important to let patients tell their story in their own words while using active listening skills. It is also important not to appear rushed, as
this may interfere with the patient’s desire to disclose information

Ø Practitioners should avoid the use of technical terms or jargon and, whenever possible, use the patient’s own words.

Examples of non-verbal and verbal communication skills

Non-verbal Verbal
Eye contact Interested posture Appropriate language
Nodding of head Hand gestures
Clothing Avoid jargon and technical terms Pitch

Facial gestures Rate and intonation Volume

Consent

Ø Before any healthcare intervention, including history taking, informed consent should be gained from the patient

Ø State that patients can only provide consent if they are able to act under their own free will, have an understanding of what they have agreed
to and have enough information on which to base a decision.

The History Taking Process

1. The Presenting Complaint:

To elicit information about the presenting complaint start by using an open question, for example: ‘What is the problem?’ or ‘Tell me about the
problem?’ This should provide a breadth of valuable information from the patient, but not necessarily in the order that you would like. The
patient should then be asked more specific details about his or her symptoms, starting with the most important first. It is important to
concentrate on symptoms and not on diagnosis to ensure that no information is missed.

When a patient reports symptoms from a specific body system, all of the cardinal symptoms in the system should be explored. For example, if a
patient complains of palpitations, then specific questions should be asked about chest pain, breathlessness, ankle swelling and pain in the lower
legs when walking to ensure that all cardinal questions relating to the cardiovascular system have been covered.

Each symptom should be explored in more detail for clarification because this helps to construct a more accurate description of the patient’s
problems. Direct questions can be used to ask about:

· Onset – was it sudden, or has it developed gradually?

· Duration – how long does it last, minutes, days or weeks?

· Site and radiation – where does it occur? D o e s it occur anywhere else?

· Aggravating and relieving features – is there anything that makes it better or worse?

· Associated symptoms – when this happens, does anything else happen with it, such as nausea, vomiting or headache?

· Fluctuating – is it always the same?

· Frequency – have you had it before?

Direct questioning can be used to ask about the sequence of events, how things are currently and any other symptoms that might be associated
with possible differential diagnoses and risk factors. Negative responses are also important, and it is vital to understand how the symptoms affect
the patient’s day-to-day activities.

2. Past Medical History

· Listing of illness unrelated to the present illness, experienced in the past

· Including childhood diseases

· Serious injuries and surgery not requiring hospitalization

· Mention of each disease with an approximate date, severity, duration, complications and sequel (consequences) is essential

3. Medication History

This is crucially important and should consider not only what medication the patient is currently taking but also what he or she might have been
taking until recently.

Because of the availability of so many medications without prescription, known as over-the-counter drugs, remember to ask specifically about
any medications that have been bought at the pharmacy or supermarket, including homeopathic and herbal remedies. For each medication ask
about: the generic name, if possible; dose; route of administration; and any recent changes, such as increase or decrease in dose or change in the
amount of times the patient takes the medication. Finally, ask about any allergies and sensitivities, especially drug allergies, such as allergy or
sensitivity to penicillin. It is important to find out what the patient experienced, how it presented in terms of symptoms, when it occurred and
whether it was diagnosed.

4. Family history

Some disorders are considered familial; a family history can reveal a strong history of, for example, cerebrovascular disease or a history of
dementia,that might help to guide the management of the patient. Open questioning followed by closed questioning can be used to gather
information about any significance in the patient’s family history. For example, start with an open question such as: ‘Are there any illnesses in the
family?’ Then ask specifically about immediate family – namely parents and siblings. For each individual ask about diagnosis and age of onset
and, if appropriate, age and cause of death.

5. Social History

A patient’s ability to cope with a change in health depends on his or her social wellbeing. A level of daily function should be established
throughout the history taking.
The HCP should be mindful of this level of function and any transient or permanent change in function as a result of past or current illness.

Questions about function should include the ability to work or engage in leisure activities if retired; perform household chores, such as
housework and shopping; perform personal requirements, such as dressing, bathing and cooking. In particular, with deteriorating health a patient
may have needed to give up club or society memberships, which may lead to a sense of isolation or loss.

HCPs should consider the whole of the family when exploring a social history.

Relationships to the patient should be explored, for example, is the patient married, is his or her spouse healthy, do they have children and, if so,
what age are they? The health and residence to the patient should be known to understand actual and potential support networks. Other support
structures include asking about friends and social networks, including any involvement of social services or support from charities.

The social history should also include enquiry into the type of housing in which the patient lives. This should include if the accommodation is
owned, rented or leased, what condition it is in and whether there have been any adaptations.

Alcohol In relation to the social history ask specifically about alcohol intake. The

HCP should ask about past and present patterns of drinking alcohol.

Smoking It is documented that smoking causes early death in the population and no safe maximum or minimum limit, unlike alcohol, has been
identified. HCPs should ask questions that identify the history of the patient’s smoking.

Traditionally questions surrounding smoking include: ‘What age did you start smoking?’, ‘What kind of cigarettes do you smoke?’, ‘How many
cigarettes a day do you smoke?’, ‘Do you use roll ups or filtered?’ and ‘Are they low or high tar content?’.

· Gordon’s 11 Functional Patterns

Marjorie Gordon was a nursing theorist and professor who proposed a nursing assessment theory known as Gordon's 11 Functional Health
Patterns in 1987. FHP's as a guide, used by nurses in the nursing process for establishing a comprehensive nursing data base as a result of
nursing assessment of the patient. Gordon's Functional Health Pattern include 11 categories, which make a systematic and standardized approach
to data collection possible, and enable the nurse to determine the following aspects of health and human function:

1 - Health Perception and Health Management Pattern.

Ø Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining
health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems
related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the
home.

Example of Health Perception and Health Management FHP Assessment Questions:

· What is your opinion about health?

· Are you immunized about seven target diseases?

· Last immunization?

· Do you have any allergy? If yes then type of allergy.

· Any surgery in past? What type of surgery?

· Last physical examination & for what purpose.

· Are you using any medicine recently?

· Do you know about these medicines?

2 - Nutrition and Metabolism Pattern

Ø Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local
nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well
as problems with the gastrointestinal system.

Example of Nutrition and Metabolism FHP Assessment Questions:

· Ask about their skin, scalp and nails?

· What is your diet menu?

· Any food restriction regarding disease point of view?

· Any food restriction regarding religious point of view?

· Any food like or dislike?

· Any food allergy?

3 - Elimination Pattern

Ø Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation,
diarrhea, and urinary retention may be identified.

Example of Elimination FHP Assessment Questions:

· Color of urine, amount, frequency, odor and any discharge.

· Any urinary problem, dysurea, Anurea, Oligourea, , polyuria.

· Are you using any laxative? If yes which?

· Any problem during passing defecation?

4 - Activity and Exercise Pattern

Ø Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and
leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and
musculo-skeletal systems.

Example of Activity and Exercise FHP Assessment Questions:

· Do you any breathing problem? (In which apnea, hypoxia, hypoxemia, hypercapnia.)

· Do you have cough? (Productive or non-productive)

· Any changes in heart beat during exercise?

· Do you feel pale during exercise?

· What type of exercise you do or any problem during exercise?

5 - Cognition and Perception Pattern

Ø Assessment is focused on the ability to comprehend and use information and on the sensory functions.
Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be
identified and further evaluated.

Example of Activity and Exercise FHP Assessment Questions:

· Orientation about time place and person.

· Any difficulty in sentence making?

· Loss of memory.

6 - Sleep and Rest Pattern

Ø Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue,
and responses to sleep deprivation may be identified.

Example of Activity and Exercise FHP Assessment Questions:

· Sleeping hour?

· Are you using nap (evening type sleeping).

· What do you feel after waking? (Fresh, headache, drowsy).

· Are you using any medication for sleeping?

· Do you have any exercise or walking at night?

7 - Self-Perception and Self-Concept Pattern

Ø Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's
level of self-esteem and response to threats to his or her self-concept may be identified.

Example of Self-Perception and Self-Concept FHP Assessment Questions:

· What is your self-perception about yourself?

· Are you satisfied with your self-body image?

· Do you like grooming?

8 - Roles and Relationships Pattern

Ø Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role
strain, or dysfunctional relationships may be further evaluated.

Example of Roles and Relationships FHP Assessment Questions:

· What is your role in family?

· If you are in hospital then who will perform your responsibilities?

· All the family members are cooperative with you?

· Who is decision maker in your family?

9 - Sexuality and Reproduction Pattern

Ø Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and
reproductive functions. Concerns with sexuality may he identified.

Example of Sexuality and Reproduction FHP Assessment Questions:

· When you first notice changes in your menarche (first menses is called menarche)

· Do you have any sexual problem? (Loss of libido)

· Active sex (direct sex with male and female)

· Passive sex (sex without male and female partner)

· Digital sex

· Reproductive: Infertility

10 - Coping and Stress Tolerance Pattern

Ø Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems
are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further
evaluated.

Example of Sexuality and Reproduction FHP Assessment Questions:

· If you have stress then what is your coping mechanism towards stress?

· Crying, angry, violence, (what is your opinion regarding that)

11 - Values and Belief Pattern

Ø Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her
choices or decisions.

Example of Sexuality and Reproduction FHP Assessment Questions:

· What is your religion?

· Do you offer prayer?

B. DIAGNOSIS

Ø Second Step of the Nursing Process

Ø Provide a basis for selection of nursing interventions so that goals and outcomes can be achieved

Ø Interpret & analyze clustered data

Ø Identify client’s problems and strengths

Ø Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an
actual or potential problem that requires nursing intervention

Ø Responsible for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment.

Ø Apply critical thinking to problem identification

Ø Requires knowledge, skill, and experience

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

Within the scope of nursing practice Within the scope of medical practice
Identify responses to health and illness Focuses on curing pathology
Can change from day to day Stays the same as long as the disease is
present

· Formulating a Nursing Diagnosis:

1. Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)

2. Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)

3. Don’t state 2 separate problems in one diagnosis

4. Refer to NANDA list in a nursing text book ( North American Nursing Diagnosis Association it formally identifies, develops, and classifies
nursing diagnoses)

· Parts of Diagnosis Statement:

1. Problem statement ( Diagnostic Label)-based on your assessment of clienT(gathered information),

a. pick a problem from the NANDA listS

b. the client’s response to a problem

2. Etiology- what’s causing/contributing to the client’s problem

a. determine what the problem is caused by or related to (R/T)

3. Defining Characteristics- what’s the evidence of the problem

 i. -then state as evidenced by (AEB) the specific facts the problem is based on…

Example:

Ineffective therapeutic regimen management related to difficulty maintaining lifestyle changes and lack of knowledge as evidenced
by B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t
get it”.

· Types of Nursing Diagnosis:

1. Actual- Patient problem & Causes if known

- Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.

2. Risk- Problem & Risk Factors

- patient is at risk for developing this problem

-Example: Risk for falls RT altered gait and generalized weakness

3. Wellness- (NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for
enhancement
-Example: Family coping: potential for growth RT unexpected birth of twins.

· Sources of Diagnostic Error:

1. Patient response not medical diagnosis

2. NANDA diagnostic statement not symptom
3. Treatable cause or risk factor not a clinical sign or chronic problem that is not treatable
4. Problem caused by the treatment or diagnostic study not the treatment or study itself
5. Patient response to equipment not equipment itself
6. Patient's problems not your problems with nursing care
7. Patient problem not nursing intervention
8. Patient problem not goal of care
9. Professional not prejudicial judgments
10. Avoid illegally inadvisable statements
11. Problem and its cause to avoid a circular statement
12. Identify only one patient problem in the diagnostic statement

* When initiating an original care plan, place the highest-priority nursing diagnosis [Link] ordering of nursing diagnoses or patient problems using
notions of urgency and importance to establish a preferential order for nursing interventions.

C. PLANNING

Ø Third Step of the Nursing Process

Ø This is when the nurse organizes a nursing care plan based on the nursing diagnoses.

Ø Nurse and client formulate goals to help the client with their problems

Ø Expected outcomes are identified

Ø Interventions (nursing orders) are selected to aid the client reach these goals.

Ø Begin by prioritizing client problems

Ø Prioritize list of client’s nursing diagnoses using Maslow

Ø Set your priorities of care, what needs to be done first, what can wait.
Ø Apply Nursing Standards, Nurse Practice Act, National practice guidelines, hospital policy and procedure manuals.

Ø Identify your goals & outcomes, derive them from nursing diagnosis/problem.

Ø Determine interventions, based on goals.

Ø Record the plan (care plan/concept map)

Ø Client specific Priorities can change

· Developing a Goal and Outcome Statement:

1. Goal and outcome statements are client focused.

2. Worded positively

3. Measurable, specific observable, time-limited, and realistic

4. Goal = broad statement

5. Expected outcome = objective criterion for measurement of goal or Measurable change that must be achieved to reach a goal

EXAMPLE:

Goal: Client will achieve therapeutic management of disease process….

Outcome Statement: as evidenced by B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium
restrictions by day of discharge.

· Types of Goals:

1. Short term- goal can be achieved in a reasonable amount of time ( few hours to few days)

2. Long term- goals may take weeks/months to be achieved

3. Cognitive goals

4. Psychomotor goals

5. Affective goals

· Goals are patient-centered and SMART (Specific Measurable Attainable Relevant Time Bound)

· Planning Select Interventions:

Ø Interventions are selected and written.

Ø The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal.

Ø Interventions should be examined for feasibility and acceptability to the client

Ø Interventions should be written clearly and specifically.

*Always partner with patients when setting their individualized goals. Mutual goal setting includes the patient and family (when appropriate) in
prioritizing the goals of care and developing a plan of action. Act as a patient advocate.
D. IMPLEMENTATION

Ø The Fourth Step in the Nursing Process

Ø This is the “Doing” step

Ø Interventions will be collaborative, combining nursing actions and physician orders.

Ø Carrying out nursing interventions (orders) selected during the planning step

Ø This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of
interventions

v Intervention - are treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes.

· 3 Types Of Intervention:

1. Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

2. Dependent ( Physician initiated )-nursing actions requiring MD orders

3. Collaborative- nursing actions performed jointly with other health care team members

EXAMPLE:

1. Monitor Vital Sign q4h

2. Maintain prescribed diet (2 Gm Na)

3. Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes

4. Teach potential complications of hypertension to instill importance of maintaining Na restrictions

5. Assess for cultural factors affecting dietary regime

· Factors to Consider When Selecting Interventions:

ü Desired patient outcomes

ü Characteristics of the nursing diagnosis.

ü Research-based knowledge for the intervention

ü Feasibility of the interventions

ü Acceptability to the patient

ü Nurse's competency

· Tips For Making Decisions During Implementation:

1. Review the set of all possible nursing interventions for a patient's problem

2. Review all possible consequences associated with each possible nursing action

3. Determine the probability of all possible consequences

4. Judge the value of the consequence to the patient

E. EVALUATION

Ø To determine effectiveness of NCP

Ø Final step of the Nursing Process but also done concurrently throughout client care

Ø A comparison of client behavior and/or response to the established outcome criteria

Ø Step of the nursing process that measures the client’s response to nursing actions and the client’s progress toward achieving goals

Ø Data collected on an on-going basis

Ø Supports the basis of the usefulness and effectiveness of nursing practice

Ø Involves measurement of Quality of Care

Ø Evaluation of individual plan of care includes determining outcome achievement

Ø Identify variables/factors affecting outcome achievement

Ø Decide where to continue/modify/terminate plan

Ø Continue/modify/terminate plan based on whether outcome has been met (partially or completely)

· Evaluation of Goal Achievement:

ü Measures and Sources: Assessment skills and techniques

ü As goals are evaluated, adjustments of the care plan are made

ü If the goal was met, that part of the care plan is discontinued

ü Redefines priorities

· Reflection in Action:

ü Once you deliver an intervention, you continuously examine results by gathering subjective and objective data from the patient, family, and
health care team members.

ü At the same time you review knowledge regarding a patient's current condition, the treatment, and the resources available for recovery.

ü By reflecting on previous experiences caring for similar patients, you are in a better position to know how to evaluate your patient.

· Perform the following steps to objectively evaluate the degree of success in achieving outcomes of care:

1. Examine
2. Evaluate
3. Compare
4. Judge
5. What is/are the barriers? why did they not agree?

· When do you discontinue a care plan?

Ø If the patient has met all goals and outcomes

· Modifying A Care Plan

1. Reassessment

2. Redefining diagnoses

3. Goals and expected outcomes

4. Interventions

End of Chapter 1….

Reminders: Before proceeding to the exercises, if you

have other topics not fully clear to you, feel free to
browse again on the topics and you can also do
additional readings from other textbooks and
references. No cheating in the self- assessment
exercises. Answer it on your own without looking at
your notes. Good Luck!

Chapter 2
Let’s Begin!

PHYSICAL EXAMINATION

DEFINITION

· Conducted from head to toe (cephalo-caudal technique).

· Determine the mental status and level of consciousness (LOC) at the beginning of the examination.

PURPOSES

— Gather baseline data about the client’s health

— Supplement, confirm, or refute data obtained in the NURSING history

— Confirm & identify nursing diagnosis

— Make clinical judgments about a client's changing health status and management

— Evaluate the physiological outcomes of care

PREPARATION GUIDELINES

1. Explain the procedure

2. Inform the client of the need to assume a special position
3. Tell the client that appropriate draping will be provided.
4. Control room temperature, and provide warm blanket.
5. Ask the client to empty the bladder.
6. Encourage the client to defecate.
7. Use a relaxed voice tone and facial expressions to put the client at ease.
8. Encourage the client to ask questions and report discomfort felt during the examination.
9. Have a family member or a third person of the client’s gender in the room during assessment of genitalia
10. At the conclusion of the assessment, ask the client if he or she has any concerns or questions

POSITIONS:

Sitting

· Use this position for the assessment of head, neck, back, posterior thorax, and lungs, breasts, axillae, heart,

vital signs, and upper extremities

· It provides full expansion of lungs and provides better visualization of symmetry of upper body part.

Supine
· back lying position with legs extended, without a small pillow under the head

· for the assessment of head, and neck, anterior thorax, and lungs, breasts, axillae, heart, abdomen, extremities,

pulses, vital signs, vagina

· Most normally relaxed position. It provides easy access to the pulse sites.

Dorsal recumbent

· back lying position with knees flexed and hips externally rotated, with small pillow under the head.

· Head, neck, anterior thorax and lungs, breasts, axillae, heart and abdomen, extremities, peripheral pulses,

vital signs, and vagina.

· Position is used for abdominal assessment because it promotes relaxation of abdominal muscles.

Lithotomy

· back lying position with feet supported in stirrups; hips should be in line with the edge of the table

· for the assessment of female genitalia, rectum and female reproductive tract

· Provides maximal exposure of genitalia and facilitates insertion of the vaginal speculum

Prone

● face-lying position with or without a small pillow

● assessment of posterior thorax, hip movement

Knee-chest (Genu-pectoral)

· kneeling position with torso at a chest.

· Assessment of rectum

· Provides maximal exposure to rectal area

Fowler’s

· Semi-fowler’s – head of bed elevated at 15-45 degree angle.

· High Fowler’s – head of bed raised at 80-90 degree angle.

 EQUIPMENTS USED FOR PHYSICAL EXAMINATION

TECHNIQUES OF PHYSICAL ASSESSMENT

1. INSPECTION

visual examination

-Should be deliberate, purposeful, and systematic

-is concentrated watching
-it is close, careful scrutiny, first of the individual and as a whole and on each body system

— begins the moment you first meet your client

— the inspection always comes first

— the health care worker inspects with the naked eye and with a lighted instrument

— in addition to visual observations, olfactory and auditory cues are noted

— inspection is used to assess moisture, color, and texture if body surfaces as well as shape , position ,size, symmetry of the body requires good lighting,
adequate exposure, and occasional use of certain instruments to enlarge your view.

Guidelines:

· Make sure the room has a comfortable temperature.

· Use good lighting, preferably sunlight.

· Look & observe before touching.

Compare the appearance of symmetric body parts or both sides of any individual body part.

2. AUSCULTATION

· requires the use of stethoscope

Auscultation
using
stethoscope

Guidelines:
1. Eliminate distracting noises
2. Expose the body part you are going to auscultate
3. Press the diaphragm firmly

Flipped Classroom: For additional reference, you can click

the actual video for the method of auscultation in the chest:

 Play Video

3. PALPATION

· Factors/ characteristics to assess are:

1. Texture

2. Temperature of skin area

3. Location/position, size, consistency, mobility of organs or masses

4. Distention

5. Pulsation

6. Presence of pain upon pressure

7. Presence of lumps

· Different parts of the hands are best suited for assessing different factors:

1. finger pads

2. grasping action of the fingers and thumb

3. dorsal

4. ulnar or palmar

· Types Of Palpation:

1. Light Palpation

-place dominant hand lightly on the surface of the structure

-there should be very little or no depression

-feel the surface using circular motion

-use this technique to feel for pulse, tenderness, surface, texture, temperature & moisture

2. Moderate Palpation
-depress the skin surface 1-2 cm (.5-.75 in) with your dominant hand
-use circular motion to feel for easily palpable body organs and masses
-note for size, consistency and mobility of structures you palpate

3. Deep Palpation

-place your dominant hand on the skin surface and your non dominant hand on top of your dominant hand to apply pressure

-surface depression should be 2.5 cm and 5 cm (1-2 in)

-allows you to feel very deep organs or structures that are covered by thick muscle

a. Bimanual Palpation

-use two hands, placing one on each side of the body part being palpated
-use one hand to apply pressure and the other hand to feel the structure
-note the size, shape, consistency and mobility of the structures you palpate

Moderate -

Deep Palpation - bimanual -

Light Palpation - bimanual -

4. PERCUSSION

· involves tapping body parts to produce sound waves that enable the examiner to assess underlying structures

· Uses:

● -Eliciting pain: percussion helps detect inflamed underlying structures.

● -Determining location, size and shape
● -Determining density
● -Detecting abnormal masses
● -Eliciting reflexes

Direct Percussion

Indirect Percussion
·

Types:

[Link] Percussion
2. Indirect or mediate Percussion

· Procedure:

● a. place middle finger of non-dominant hand on body part you are going to percuss
● b. use pad of middle finger of the other hand to strike the middle finger of non-dominant hand that is placed on the body part
● [Link] finger immediately
● d. deliver 2 quick taps and listen carefully
● e. use quick, sharp taps by flexing wrist

· Sounds Elicited by Percussion:

1. Resonance
-intensity: LOUD
-pitch: LOW
-length: LONG
-quality: HOLLOW
-origin: NORMAL LUNG

2. Hyper-resonance

-intensity:VERY,LOUD
-pitch:LOW
-length:LONG
-quality:BOOMING
-LUNG W/ EMPHYSEMA

3. Tympany
-intensity: LOUD
-pitch: HIGH
-length: MODERATE
-quality: DRUMLIKE
-PUFFED-OUT CHEEKS

4. Dullness

-intensity: MEDIUM

-pitch: MEDIUM
-length: MODERATE
-quality: THUDLIKE
-DIAPHRAGM, PLEURAL EFFUSION, LIVER

5. Flatness
-intensity: SOFT
-pitch: HIGH
-length: SHORT
-quality: FLAT
-MUSCLE, BONE

Special Considerations:

1. The sequence of methods for physical examination of the abdomen is as follows: Inspection, Auscultation, Percussion and Palpation (IAPePa). No
abdominal palpation among clients with tumor of the liver or the kidneys.

2. During physical examination of the abdomen, it is important to flex the knees to relax the abdominal muscles , thereby facilitating the examination of
abdominal organs.

3. The sequence of examining the abdomen is as follows: right lower quadrant, right upper quadrant, left upper quadrant and left lower quadrant (RLQ, RUQ,
LUQ, LLQ).

4. The best position when examining the chest is sitting/upright position. This permits the examination of both the anterior and posterior chest.

5. The best position when examining the back is standing position. This enables the examiner to assess the posture, and the gait of the client.

6. If instrumental vaginal examination is done, pour warm water over the vaginal speculum before use. To ensure comfort.

7. Is a female client is examined by a male doctor, a female staff must be in attendance. This ensures that the procedure is done in ethical manner.

Organization of The Examination

1. History taking precedes physical examination.

2. The commonly used system is “head to toe” (cephalocaudal).

3. The extent of the examination depends on the purpose.

i. A client returning from surgery for repair of a fractured leg will require assessment of the circulatory and musculoskeletal function rather than a breast
assessment or examination.

4. If client becomes fatigued, offer rest periods between assessments.

5. Record results of the examination in scientific terms so that any health professional can interpret the findings.

The Examination

General Survey - The preliminary examination which includes the following:

A. Height and Weight

B. Vital Signs

1. Temperature

- Taken at what route.

2. Pulse

- Rhythm, volume and tension.

3. Respiration

- Rate, rhythm, symmetry, depth, character, color of the client

4. Blood Pressure

C. General Appearance and Behavior

1. Sex and Race

- A person’s sex affects the type of examination performed.

- Different physical features are related to sex and race.

2. Signs of Distress

- There maybe signs or symptoms indicating a problem such as pain, difficulty of breathing, and anxiety.

3. Body Type

- The body type can reflect the level of health, age and lifestyle

- The HCP observes if the client appears trim, muscular, obese, or excessively thin.
4. Posture

- Normal standing posture is an upright stance with parallel alignment of his shoulders.

- Normal sitting posture involves some degree of rounding of the shoulders. --Observe if the client has an erect, slumped, or a bent posture. Posture may reflect
mood or presence of pain. Many elderly persons assumed a stooped position.

5. Gait

- The manner of walking. Note if the movements are coordinated or uncoordinated.

6. Body Movements

- Note for involuntary movements of body

7. Age

- It influences the normal features or physical characteristics of an individual. The ability to participate n some parts of the examination will also be influenced
by age.

8. Hygiene and Grooming

- Note the client’s level of cleanliness by observing the appearance of the hair, skin, or the fingernails.

9. Dress

- Note if the type of clothing worn is appropriate for the temperature and weather condition.

10. Body Odor

- Assess is it from physical exercise, poor hygiene, or poor oral hygiene.

11. Mood and Affect/ Facial Expression

- At rest and in interaction with others.

12. Speech

- It includes the pace of speech, its pitch and clarity.

13. Level of Consciousness

- Including the speed of response to questions and apparent comprehension.

CULTURAL CONSIDERATIONS OF PHYSICAL ASSESSMENT

What you need to know Why you need to know it

Ethnicity and country • This information can be an indicator of the client’s culture, traditions,
of birth customs, health beliefs and preferred languages.

Remember that:

Ethnicity may be more significant than country of birth. For example,

clients may have been born in a country where their parents lived briefly.
Literacy • May affect the client’s capacity to respond to written information
provided during the assessment.

• May indicate the client’s social status and education level in their
previous country of residence or origin.

Remember that:

• Clients may rely on family members to read and explain written

information.

• Clients and their families may not be literate in the language they
prefer to speak.
Interpreter preferences • Identifying an appropriate interpreter, and ensuring that the client is
comfortable using an interpreter, is essential for clear and appropriate
communication.

Remember that:
 • The client may not be familiar with using an interpreter: you may
need to explain the process.

• Clients may have concerns about the confidentiality of interpreters.

• There is a small chance that the client may know the interpreter,
which may raise privacy concerns.

• Consider client preferences regarding the gender and ethnicity of the

interpreter, and whether an on-site or telephone interpreter is preferred.

• Only qualified interpreters should be used: the client’s family

members should not be used as interpreters.
Migration status and • Stress and trauma resulting from pre-migration, migration or post-
experience migration experiences can greatly affect a client’s health and wellbeing.

• Visa status can affect access to subsidised health services.

Beliefs about health and • Clients’ beliefs and past experience affect the way they view health,
illness causes of illness and treatment.

• Understanding and acknowledging the client’s health beliefs and

practices is an important step in creating a mutually acceptable care plan.
Understanding of the • Clients may not be familiar with the structure of the health service
health system system or how to access various services.

• Clients may not be familiar with health system processes (eg waiting
lists for hospitals, Medicare support, etc)
Dietary practices • There may be religious restrictions on food consumption

• Some foods may have cultural meanings for clients (eg the belief that
certain foods are beneficial or harmful to health)
Family and social • The responsibility for care may not lie only with the client: other
support people, including extended family, may assume responsibility for care

Remember that:

• In some cultures, ‘family’ may include non-related individuals.

• A client’s social support networks may be limited.

• A client may be able to access support through community

organizations.
Religious practices • Clients may wish to access spiritual or religious leaders

• Clients may wish to access spiritual or religious leaders

Religious practices
• Particular times for prayer may be important

• Religious practices may occasionally conflict with treatment plans.

• Particular customs may need to be followed during birth, illness and

death and dying

VITAL SIGNS

TEMPERATURE

1. Body temperature – the balance between the heat produced by the body and the heat lost from the body.
Types of Body Temperature:

1. Core temperature – the temperature of the deep tissues of the body. Measured by taking oral and rectal temperature.

2. Surface temperature – the temperature of the skin, subcutaneous tissue and fat. Measured by taking axillary temperature.

Factors affecting the body’s heat production:

Ø Basal Metabolic Rate(BMR) – the younger the person, the higher the BMR; the older the person, the lower the BMR. Therefore, the older
persons, have lower body temperature than the younger persons.

Ø Muscle Activity – exercise increases body heat production.

Ø Thyroxine Output – increases cellular metabolic rate. Hyperthyroidism is characterized by increased body temperature.
Ø Epinephrine, norepinephrine, and sympathetic stimulation – increase the rate of cellular metabolism. These in turn increase body
temperature.

Ø Fever – increases the rate of cellular metabolism.

Processes Involved in Heat Loss:

a. Radiation-transfer of heat from the surface of one object to surface of another without contact between two objects.

b. Conduction-transfer of heat from one molecule to a molecule of lower temperature.

c. Convection- dispersion of heat by air currents.

d. Evaporation- continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

Factors affecting Body Temperature

1. Age – infant’s body temperature is greatly affected by the temperature of the environment. Elder people are at risk of hypothermia due to decreased
thermoregulatory controls, decrease subcutaneous fat, inadequate diet, and sedentary activity.
2. Diurnal Variations(Circadian Rhythms) – highest temperature is usually reached between 8PM-12MN; and the lowest temperature is reached between 4-6
AM.
3. Exercise – strenuous increases BMR thus, the body temperature.
4. Hormones – e.g. progesterone, thyroxine, epinephrine and norepinephrine increase body temperature; estrogen decreases body temperature.
5. Stress – sympathetic nervous system stimulation increases the production of epinephrine and norepinephrine, thereby increasing the metabolic rate and heat
production.

Alterations in Body Temperature

1. Pyrexia/hyperthermia/fever – temperature above normal range.

2. Hyperpyrexia – very high fever, 41 degrees celcius (105.8 deg. Fahrenheit) and above.

3. Hypothermia – subnormal core body temperature. This may be caused by excessive heat loss, inadequate heat production or impaired hypothalamic
function.

Types of Fever:

1. Intermittent Fever-the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.

2. Remittent Fever-a wide range of temperature fluctuations (more than 2C) occurs over the 24-hour period, all of which are above normal.

3. Relapsing Fever-short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.

4. Constant Fever-the body temperature fluctuates minimally but always remains above normal.
Clinical Signs of Fever
1. Onset

– Increased heart rate

– Increased respiratory rate and depth

– Shivering

– Pallor, cold skin

– Complaints of feeling cold

– Cyanotic nail beds

– “gooseflesh” appearance of the skin

– Cessation of sweating

2. Course

– Absence of Chills

– Glassy-eyed appearance

– Increased pulse and respiratory rate

– Increased thirst

– Mild to severe dehydration

– Drowsiness, restlessness, delirium or convulsions

– Herpetic lesions of the mouth

– Loss of appetite

– Malaise, weakness and aching muscles

4. Defervescence(fever abatement)

– Skin that appears flushed and feels warm

– Sweating

– Decreased shivering

– Possible dehydration

Interventions for Clients with Fever

1. Monitor vital signs.

2. Assess skin color and temperature.

3. Monitor WBC, hematocrit value, and other pertinent laboratory reports

4. Remove excess blankets when the client feels warm, but provide extra warmth when the clients feels chilled.

5. Provide adequate nutrition and fluids

6. Measure I and O

7. Reduce physical activity

8. Provide oral hygiene

9. Provide a tepid sponge bath

10. Provide dry clothing and bed linens.

11. Administer antipyretics

Methods of Temperature Taking:

1. Oral – most accessible and convenient method.

Ø Allow 15 minutes to elapse between a client’s

§ intake of hot or cold food or smoking and the

§ measurement of oral temperature.

Ø Place thermometer under the tongue, directed

§ towards the side.

Ø Wash the thermometer before use, from bulb to

§ the stem, after use, from the stem to the bulb.

§ This practice ensures medical asepsis.

Contraindications:

a. Oral lesion or surgery

b. Cough

c. Nausea and vomiting

d. Very young children

e. Restless, disoriented

f. Seizure prone

1. Rectal – the most accurate method/reliable

Ø Procedure:

a. Provide privacy.

b. Position - Sim’s

c. Apply disposable gloves.

d. Squeeze liberal portion of lubricant.

e. With non-dominant hand, separate client’s

buttocks to expose the anus.

f. Ask client to breathe slowly and relax.

g. Gently insert thermometer into anus.

h. If resistance is felt during insertion, withdraw

thermometer immediately.

i. Once positioned, leave thermometer in place

j. Remove thermometer from anus.

k. Wipe with antiseptic solution.

l. Return thermometer to storage

m. Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue

n. Remove gloves and dispose.

Ø Contraindications:

a. Anal or rectal conditions or surgeries [hemorrhoids, hemorrhoidectomy]

b. Diarrhea

1. Axillary – safest and most non-invasive method of temperature taking.

Ø Procedure:

a. Pat dry the axilla

b. Place the thermometer on the client’s axilla

c. Place the arm tightly across the chest to

d. keep the thermometer in place

e. Remove from axilla.

f. Return thermometer to storage.

g. Perform hand hygiene

Normal body temperature: Axillary: 36.5-37.5 degrees celcius in all age groups.
1. Temporal Artery – safe and non-invasive; very fast

- requires electronic equipment that may be expensive or unavailable.

PULSE

Ø Wave of blood created by contraction of the left ventricle of the heart.

Pulse sites:

1. Temporal - over the temporal bone of the head ; superior and lateral to the eye

2. Carotid - at the lateral aspect of the neck

3. Apical - at the left midclavicular line 5th intercostal space

4. Brachial - at the inner aspect of the upper arm (biceps muscles) or medially at the antecubital space

5. Radial - on the thumb side of the inner aspect of the wrist.

6. Femoral - along side of the inguinal ligament

7. Posterior tibial- at the middle aspect of the ankle, behind the medial malleolus.

8. Pedal(dorsalis pedis)- at the dorsum of the foot.

9. Popliteal- at the back of the knee

Assessment of Pulse
Procedure:

1. Perform hand hygiene

2. Assess
3. Position
4. Place tips of first two fingers of hand over groove along radial or thumb side of client’s inner wrist
5. Lightly compress
6. Determine strength of pulse .
7. After pulse can be palpated regularly, look at the watch’s second hand and begin to count

Rate- The normal PR per min are as follows:

Ø Newborn to 1 mo.: 120-160 beats/min

Ø 1yr: 80- 140 bpm

Ø 2yrs: 80-130 bpm

Ø 6yrs: 75-120 bpm

Ø 10 yrs: 50-90 bpmZ

Ø Adult: 60-100 bpm

Tachycardia – Pulse rate above 100 beats per minute (adult)

Bradycardia – Pulse rate below 60 beats per minute (adult)

Rhythm – pattern and intervals of beats

Ø DYSRHYTHMIA – irregular rhythm

Volume (amplitude) – strength of pulse

Ø Normal – moderate pressure

Ø Full or bounding pulse – can be obliterated only by great pressure

Ø Thready pulse (weak, feeble)– it can easily be obliterated

Factors Affecting Pulse Rate

1. Age – younger persons have higher pulse rate than older persons.
2. Sex/gender – after puberty, female have higher PR than the males.
3. Exercise – increases BMR, thereby increasing the pulse rate.
4. Fever – increases BMR, therefor the PR increases.
5. Medications – digitalis, beta blockers, decrease PR; epinephrine atropine sulfate increase pulse rate.
6. Hemorrhage – increases pulse rate as compensatory mechanism for blood loss.
7. Stress – sympathetic nervous stimulation increases the activity of the heart.
8. Position changes – In sitting or standing position, there is decrease venous return to the heart , decrease BP, therefore, increase in the heart rate.

RESPIRATION – act of breathing

3 Processes

1. Ventilation - movement of gases in and out of the lung

2. Diffusion - exchange of gases from an area of higher pressure to an area of lower pressure

3. Perfusion - the availability and movement of blood for transport of gases, nutrients and metabolic waste products.

Two Types Of Breathing:

1. Costal (thoracic) – involves movement of the chest.

2. Diaphragmatic (Abdominal) – involves movement

Respiratory Centers:

Medulla Oblongata – primary center

- Pneumotaxic center – responsible for the rhythmic quality of breathing.

- Apneustic Center – responsible for deep, prolonged inspiration

Assessing respiration

Ø Procedure

1. Position client.

2. Place client’s arm in relaxed position across abdomen or lower chest, or place hand directly over client’s upper abdomen

3. Observe complete respiratory cycle.

4. After cycle is observed, look at watch’s hand and begin to count

Ø Rate – normal:16-20 cycles/min (adult); 30-60 cycles per min (newborn)

– If BP is elevated – the RR becomes slow

– If BP is decreased – RR becomes rapid

Ø Depth – observe the movement of the chest

- may be normal, deep or shallow

Ø Rhythm – observe for regularity of exhalations and inhalations

Ø Quality or character – refers to respiratory effort and sound of breathing

Major Factors Affecting RR:

a. Exercise – increases RR

b. Stress – increases RR

c. Environment – increase temp. – decreases RR

decreased temperature – increases RR

Increased altitude – increases RR

Eupnea- normal respiration that is quiet, rhythmic, effortless

Tachypnea- rapid respiration marked by quick, shallow breaths.

Bradypnea -slow breathing

Hyperventilation- prolonged and deep breaths . carbon dioxide is excessively exhaled.

Hypoventilation- slow shallow respiration.

Dyspnea- difficult and labored breathing.

Orthopnea- ability to breath only in upright position.

BLOOD PRESSURE

Ø is a measure of the pressure exerted by the blood as it pulsates through the arteries.
 ● Systolic pressure – pressure of blood as a result of contraction of the ventricles
● Diastolic pressure- the pressure when the ventricles are at rest (60-90 mmHg)
● Pulse pressure – the difference between systolic and diastolic pressure (normal: 30-40 mmHg)

Factors affecting BP:

• Age – older people have higher BP due to decreased elasticity of blood vessels.

• Exercise – increases cardiac output, hence the BP.

• Stress – Sympathetic nervous system

• Race – hypertension is one of the 10 leading causes of death among Filipinos.

• Obesity – BP is generally elevated among overweight and obese people.

• Sex/Gender

• Medications – some medications can increase or decrease BP.

• Diurnal variations – BP is lowest in the morning and highest in the late afternoon or early evening.

• Disease Process – DM, renal failure, hyperthyroidism cause increase in BP.

Assessing BP

Procedure:

1. Ensure the client is rested

2. Allow 30 minutes to pass if the client had smoked or ingested caffeine before taking the BP

3. Use appropriate size of BP cuff

4. Position the patient in sitting or supine position

5. Apply BP cuff snugly, 1 inch (2.5 cm) above the antecubital space

6. Use the bell shaped diaphragm of the stethoscope since the BP is a low-frequency sound

7. Inflate deflate the cuff slowly, 2-3 mmHg at a time

8. Wait 1-2 mins before making further determinations

9. Document readings.

Blood Pressure SBP DBP

Classification mmHg mmHg
Hypotension <90 <60
Normal 90- 120 Less than 80
Elevated 120–129 Less than 80
Stage 1 130-139 80-89
Hypertension
Stage 2 ≥140 ≥90
Hypertension
Hypertensive Crisis >180 >120
Recommended by American Heart Association

Flipped Classroom: For additional reference, you can click the actual video for vital signs monitoring. Https://[Link]/Watch?V=Guwj-6nl5-8

Chapter 3
Let’s Begin!

ADULT REVIEW OF SYSTEMS

Overview

Ø The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease. It can be
applied in several ways:

1. As a screening tool asked of every patient that the clinician encounters.

2. Asked only if patients who fall into particular risk categories (e.g. reserving questions designed to uncover occult disease of the prostate to
men over 50).

3. To better define the likely causes of a presenting symptom, as described in the HPI section (e.g. patients w/a chief concern of "chest pain"
would be asked detailed cardiac and pulmonary ROS).

Ø It's important to realize that historical Q&A is just one piece of the clinical puzzle. Patient's responses must be interpreted within the context
of the rest of their profile, including risk factors, past history, and exam findings. For example, a patient whose ROS is positive for chest pain
would then be asked to define the dimensions of this symptom including duration, precipitating events, severity, characterization, radiation,
associated symptoms, etc (or questioning using OLD CARTS mnemonics). In addition, an assessment of cardiac risk factors and an organized
search for exam findings indicative of vascular disease (e.g. elevated BP, diminished peripheral pulses, audible bruits, etc) would be very relevant.
On the basis of the sum of this data, the clinician can come to an informed conclusion about the importance/cause of this patient's chest pain
(e.g. angina, heartburn, pulmonary embolism, etc), and use it to guide their subsequent decision making.

Ø There is no ROS gold standard. The breadth of questions included is somewhat arbitrary, based on the author's sense of the most commonly
occurring illnesses and their symptoms. There is planned redundancy, as the same symptoms often apply to multiple organ systems. In addition,
some sub-specialty areas use an expanded ROS, specific to the conditions that they evaluate and treat.

Ø I would like to highlight several important limitations:

a. The list of possible diagnoses that follow a question are not exhaustive. In addition please realize that no patient responses are
pathognomonic.

b. The symptoms in parentheses represent a partial listing of those most commonly associated w/a particular disorder. They are based on
general experience, not discrete evidence.

c. The disease categorizations reflect rough groupings. There are many exceptions. For example, disorders listed in the "acute" section may
have chronic presentations, those described as "upper abdominal" may present w/thoracic symptoms, etc.

Chapter 4
Let’s Begin!

INTEGUMENTARY SYSTEM

· Skin: The client’s skin is uniform in color, unblemished, and no presence of any foul odor. He has a good skin turgor and the skin’s temperature is within
the normal limit.

· Hair: The hair of the client is thick, silky hair is evenly distributed, and has a variable amount of body hair. There are also no signs of infection and
infestation observed.

· Nails: The client has a light brown nail and has the shape of a convex curve. It is smooth and is intact with the epidermis. When nails pressed between the
fingers (Blanch Test), the nails return to their usual color in less than 4 seconds.

Body Part Technique Findings

Inspection » When skin is pinched it goes to previous state
immediately (2 seconds).
Palpation
Skin
» With fair complexion.

» With dry skin

Inspection » Black, evenly distributed and covers the whole scalp,
thick, shiny, free from split ends.
Inspect for the color,
distribution, » Coarse or fine.
thickness, lubrication
and appearance. *Note:

Terminal Hair
Hair
Palpation - Its is the long, thick, and coarse hair of the body
which is easily visible on the scalp, axilla, and the
Palpate for texture. pubic area.

Vellus Hair

- It is the soft, small, tiny hair that covers the whole

body except for the palms and the soles.
Body Part Technique Findings
Inspection » Smooth and has intact epidermis
With short and clean fingernails and toenails.
Nails
Convex and with good capillary refill time of 2
seconds.

TYPES OF SKIN LESIONS

LESION DESCRIPTION
bulla raised, fluid-filled lesion larger than a vesicle (plural: bullae)
fissure crack or break in the skin
macule flat, colored spot
nodule solid, raised lesion larger than a papule; often indicative of systemic disease
papule small, circular, raised lesion at the surface of the skin
plaque superficial, flat, or slightly raised differentiated patch more than 1 cm in diameter
pustule raised lesion containing pus; often hair follicle or sweat pore
ulcer lesion resulting from destruction of the skin and perhaps subcutaneous tissue
vesicle small, fluid-filled, raised lesion; a blister or bleb
wheal smooth, rounded, slightly raised area often associated with itching; seen in ulticaria (hives),
such as that resulting from allergy
1. Head

· Head: The head of the client is rounded; normocephalic and symmetrical.

· Skull: There are no nodules or masses and depressions when palpated.

· Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.

Eyes and Vision

· Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower
eyebrows.

· Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.

· Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per
minute.

· Eyes

o The Bulbar conjunctiva appeared transparent with few capillaries evident.

o The sclera appeared white.

o The palpebral conjunctiva appeared shiny, smooth and pink.

o There is no edema or tearing of the lacrimal gland.

o Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched.

o The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated
and non-illuminated pupils constrict. Pupils constrict when looking at a near objects and dilate at far objects. Pupils converge when object is moved towards the
nose.

o When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.

o When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.

o The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing

· Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for
the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear
ticking in both ears.

Nose and Sinus

· Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no
tenderness and lesions

· Mouth:

o The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle.

o Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums

o The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.

o The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish coating.

o The smooth palates are light pink and smooth while the hard palate has a more irregular texture.

o The uvula of the client is positioned in the midline of the soft palate.

2. Neck

o The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort.

o The lymph nodes of the client are not palpable.

o The trachea is placed in the midline of the neck.

o The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.

THE HEAD TO TOE EXAMINATION (Head to Neck)

BODY PART TECHNIQUE NORMAL FINDINGS
A. HEAD
» Proportional to the size of the body, round, with prominences in
Palpation the frontal area anteriorly and the occipital area posteriorly,
symmetrical in all planes & gently curved
Skull
Scalp Inspection

Separate the hair strands carefully to reveal the scalp.

Inspect for color, appearance, presence of masses, lice,

nits and dandruff » White, clean, free from masses, lumps, scars, nits, dandruff, and
lesions.

Palpation

Palpate for areas of tenderness.

Face
» Oblong or oval or square or heart shaped, symmetrical, facial
Inspection
expression that is dependent on the mood or true feelings, smooth
and free from wrinkles, no involuntary muscle movements.
Observe for the symmetry, shape, facial expression,
movement, and appearance.
Eyes Inspection

Instruct the client to look straight and refrain from » Parallel and evenly placed, symmetrical, non-protruding, with
turning the head in different directions. Observe for scanty amount of secretions, both eyes black and clear.
placement, symmetry, protrusion, clarity, and
lacrimation.
1. Eyebrows Inspection

Observe for the color, symmetry, quantity of hair,

movement, distribution and placement or parallelism.
» Black, symmetrical, thick can raise lower eyebrows symmetrically
and without difficulty, evenly distributed and parallel with each
other.
*Note: To check for movement, let the client raise and
lower the eyebrows at the same time at the cue of your
command or request.
2. Eyelashes Inspection
» Black, evenly distributed and turned outward
Observe for the color, distribution, and direction of
eyelashes
3. Eyelids » Upper lids cover a small portion of the iris, cornea and the sclera
Inspection (limbus) when the eyes are open.

Observe for position, symmetry, and color. » When the eyes are closed, the lids meet completely.

Palpation. With the client’s eyes closed, palpate for the Symmetrical, color is the same as the surrounding skin.
lacrimal gland if it’s palpable
» No palpable mass
4. Lid Margins Inspection
» Clear, without scalings or secretions, lacrimal duct openings
Observe for scaling, secretions, erythema, and the (puncta) are evident at the nasal ends of the upper and lower lids.
lacrimal duct openings (appearance)
5. Palpebral Fissures Inspection
» Appear equal when the eyes are open.
Inspect for the symmetry (the longitudinal opening
between the eyelids)
6. Lower palpebral conjunctiva Inspection
» Salmon pink, shiny, moist and transparent
Observe for color and appearance
7. Sclera Inspection
» White and clear
Observe for color and appearance.
8. Iris Inspection
» Proportional to the size of the eye, round, black/brown, and
symmetrical
Note for size, shape, color, symmetry
9. Pupils Inspection

Note size, shape, symmetry, reaction to light and

accommodation (PERRLA).
» From pinpoint to almost the size of the iris, round, symmetrical,
constrict with increasing light and accommodation.
***To check for the eye’s reaction to light, there is a
need to control the amount of light that gets into the
eyes.
 Therefore, there is need to use the penlight and while
doing so, the side of the eye opposite the direction of the
penlight should be shielded by the examiner’s hand. Note
the degree of constriction of the pupils if they are
symmetrical.

***Accommodation is the ability of the lens to adjust to

objects of varying distances. To check for
accommodation, the examiner instructs the client to look
straight into a photo shield placed in different distances
from the eyes. Note the reaction of the pupils as the photo
is near and when it is held far.
10. Eye Movement Inspection
» Able to move eyes in full range of motion or able to move in all
Ask client to refrain from moving his head while he
direction.
follows the direction of the examiner’s fingers with his
eyes.
11. Visual Acuity Inspection

Let client read the letters of the Snellen’s chart at a

distance of 20 feet.

Note: If the client has his glasses, he should wear them, » 20- distance from the chart
but not if the glasses are intended only for reading. Test
each eye separately. Determine the smallest line of print » 20- distance at which a normal eye can read.
from which he is able to identify correctly more than half
the figures. Record the visual acuity designated at the
side of this line.
12. Field of Vision Inspection

Let the client look straightforward without moving his » Able to see 60 degrees superiorly, 90 degrees temporally, and 70
eyes. By placing your fingers in different specific degrees inferiorly.
directions, ask the client if he could still see your moving
fingers.
Ears Inspection

Observe for parallelism, symmetry, size, shape, position, » Parallel, symmetrical, proportional to the size of the head, bean-
color, and appearance. shaped, helix is in the line with the outer canthus of the eye, skin is
the same color as the surrounding area, clean.
Palpation. Palpate for the firmness of the cartilage of the
auricles.
1. Ear Canal Inspection

By using a penlight, examine by pulling up and back for

» Pinkish, clean, with scant amount of cerumen and a few cilia.
adults, down and back for children. Inspect for color,
appearance, presence of cerumen, foreign bodies, and
cilia.
2. Hearing Acuity Inspection

Whisper from the client’s ear at a distance of 2 feet (one

ear at a time) and then at the back of the client for both
ears.

Note: Instruct the client not to move his head and to » Able to hear whisper spoken 2 feet away.
repeat the words that you will say. One direction at a
time.

Nose Inspection

Observe for placement, symmetry, patency.

» Midline, symmetrical, and patent
Note: Ask client to close one nostril at a time and ask if
he has any difficulty in breathing while one nostril is
covered.
1. Internal nares Inspection
» Clean, pinkish, with few cilia
Appearance, color of mucus membrane, presence of cilia.
2. Septum Inspection
» Straight
Note for appearance.
Mouth Inspection
» Pinkish, symmetrical, lip margin well defined, smooth and moist
1. Lips Observe for color, shape, symmetry, lip margin,
appearance.
2. Gums Inspection
» Pinkish, smooth, moist, no swelling, no retraction, no discharge
Observe for color, appearance, discharge, and swelling or
retraction.
3. Teeth Inspection
» 32 permanent teeth, well-aligned, free from caries or filling, no
halitosis
Number, color, alignment, general condition, breath.
4. Tongue Inspection
» Large, medium, red or pink, slightly rough on top, smooth along
Inspect for size, color, surface, appearance, and the lateral margins, moist, and freely movable.
movement.
5. Frenulum Inspection
» Midline, straight, and thin.
Note for position and appearance.
6. Cheeks Inspection
» Pinkish, moist, and smooth
(Buccal Mucosa) Note color and appearance
7. Palate
Inspection
Soft Palate » Pinkish, smooth and moist
Inspect for color and appearance.
Hard Palate » Slightly pinkish
8. Uvula
Inspection
» At the center, symmetrical, and freely movable
Note for position, color, size, symmetry, and mobility.

[Link] Inspection
» Pinkish, non-inflamed, no exudates
Note for color, size, inflammation, exudates
10. Voice Inspection
» No hoarseness and well-modulated.
Detect if there is hoarseness of voice

B. NECK Inspection » Proportional to the size of the body and head, symmetrical, and
straight
Note for size, symmetry, and position

Palpation
» No palpable lumps, masses, or areas of tenderness
Palpate for lump, masses, or areas of tenderness.
» Adam’s apple palpable.
Palpate the Adam’s apple.

Range of Motion.
» Freely movable without difficulty.
Chin to chest and ear to shoulder.

Muscular Strength
» Symmetrical and able to resist applied force (both muscles)
Symmetry and strength of the sternocleidomastoid
muscle and the force and strength of the trapezius » Able to resist applied force. Symmetrical in structure of size and
muscles muscular strength.

COMMON EXAMINATIONS BEING USED DURING ASSESSMENT OF HEAD and NECK

A. Snellen’s Chart for Visual Acuity

A Snellen chart is an eye chart that can be used to measure visual acuity. Snellen charts are named after the Dutch ophthalmologist Herman Snellen,
who developed the chart in 1862.

The normal Snellen chart is printed with eleven lines of block letters. The first line consists of one very large letter, which may be one of several letters, for
example E, H, or N. Subsequent rows have increasing numbers of letters that decrease in size. A person taking the test covers one eye from 6 metres or 20 feet
away, and reads aloud the letters of each row, beginning at the top. The smallest row that can be read accurately indicates the visual acuity in that specific eye.
The symbols on an acuity chart are formally known as "optotypes".

In the case of the traditional Snellen chart, the optotypes have the appearance of block letters, and are intended to be seen and read as letters. They are not,
however, letters from any ordinary typographer's font. They have a particular, simple geometry in which:

· the thickness of the lines equals the thickness of the white spaces between lines and the thickness of the gap in the letter "C"

· the height and width of the optotype (letter) is five times the thickness of the line.

Only the nine letters C, D, E, F, L, O, P, T, Z are used in the common Snellen chart. The perception of five out of six letters (or similar ratio) is judged to be the
Snellen fraction. Wall-mounted Snellen charts are inexpensive and are sometimes used for approximate assessment of vision, e.g. in a primary-care physician's
office. Whenever acuity must be assessed carefully (as in an eye doctor's examination), or where there is a possibility that the examinee might attempt to
deceive the examiner (as in a motor vehicle license office), equipment is used that can present the letters in a variety of randomized patterns.

B. Tuning Fork for Hearing Acuity/ Hearing Test (Rinne’s and Weber’s tests)

 The tuning fork tests provide a reliable clinical method for assessing hearing loss
 They are most useful in patients with unilateral hearing loss which is purely conductive or purely sensorineural
 Patients with bilateral loss or mixed losses are better assessed with formal pure tone audiometry
 These tests should be carried out with a full examination of the cranial nerves or the ear
 The Rinne and Weber tests help distinguish between a conductive hearing loss (CHL) and sensorineural Hearing Loss (SHL)

 Other tuning fork tests include the Schwabach and Bing tests, though these are not used in routine practice

A. Introduction (WIIPPPE)
· Wash your hands

· Introduce yourself (name and position)

· Identity of patient (confirm name and date of birth)

· Permission (consent and explain examination: “I’m going to examine your hearing using this tuning fork now, is that OK?”)

· Pain (especially over the mastoid)

· Position (sitting comfortably)

· Exposure

B. Equipment

 A 512 Hz tuning fork

 Note you should ideally be in a completely silent room for Rinne and Weber tests

C. How to do Weber’s Test

 To perform Weber’s test strike the fork against your knee or elbow, then place the base of the fork in the midline, high on the patient’s forehead
o It is important to steady the patient’s head with your other hand so that reasonably firm pressure can be applied
 Then ask the patient: “Do you hear the sound louder in one ear than the other?”
o If so, in which ear is it louder?
o If the patient is unclear, you may ask if they hear it “everywhere.” Be careful not to ask the question in a leading manner

D. Interpretation of Weber’s test

 Weber’s test will ‘lateralise’, i.e. move to one side, with a relatively small amount of hearing loss (5dB)
 If a patient has a unilateral conductive hearing loss, the tuning fork sound will be heard louder in the deaf ear
 If a patient has a unilateral sensorineural hearing loss, the tuning fork sound will be heard louder in the normal ear
 In bilateral and symmetrical hearing loss of either type Weber’s test will be normal
 The various outcomes of Rinne and Weber tests are shown below

E. Interpretation of Rinne’s and Weber’s tests

Test Normal Conductive Hearing Loss Sensorineural Hearing Loss
Rinne's Air louder than Bone Bone louder than Air Air louder than Bone
(Rinne’s Positive) (Rinne’s Negative) (Rinne’s false positive)
Weber's Sound heard in the midline Sound heard in bad ear Sound heard in good ear
F. How to do Rinne’s Test
 This test aims to compare air conduction with bone conduction
o Rinne’s test has a high sensitivity (0.84) though this varies with the skill of the examiner
o Rinne’s test can only detect a conductive hearing loss of at least 30dB
 Explain the test first:
o “I’m going to put this vibrating tuning fork in two positions, one touching the bone near your ear, one a short distance from the ear. I want you to tell me
which position you hear the tuning fork loudest in”
 Begin by striking the tuning fork against your knee or elbow
 Hold the tuning fork in one hand and place the base against the patient’s mastoid process (

[Link]

 )
o Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of the sound
 Then promptly lift the fork off the mastoid process and place the vibrating tips about 1cm from their external auditory meatus
o Leave it there again for a few seconds before taking the tuning fork away from their ear
 Ask the patient in which of the positions they were able to hear the note the loudest in

G. What is a positive and negative Rinne’s Test?

 A patient who hears the tuning fork loudest when held 1cm from the external auditory meatus has a positive Rinne’s test
 A patient who hears the fork loudest when it is held against the mastoid process has a negative Rinne’s test

H. Interpretations of Rinne’s Test

 In a normal ear, the sound is conducted to the cochlear most efficiently via air conduction. Sound can also be transmitted to the
cochlea, less efficiently, via bone
 So…
o 1) If a patient can hear best when the tuning fork is in the air (positive Rinne’s) then air conduction is better than bone
conduction so there is no significant conductive hearing loss
 Therefore in sensorineural hearing loss on the right, for example, Rinne’s test should be positive on the right
o 2) If the patient can hear best when the tuning fork is on the mastoid (negative Rinne’s) bone conduction is better than air
conduction, demonstrating a conductive hearing loss

I. False negative Rinne’s Test

 The difficulty in interpreting Rinne’s test is in total unilateral sensorineural hearing loss (i.e. a ‘dead’ ear)
 For example, imagine the right ear is ‘dead’. On testing bone conduction on the right the sound travels to the good left (i.e. untested) ear
and sounds louder than when the fork is held next to the external auditory meatus on the side being tested
 The patient reports that bone conduction is better than air conduction giving a false negative Rinne’s test

Flipped Classroom: For additional reference, you can click the actual video for Webers and Rines
Test: [Link]

End of Chapter 4….

THORAX AND LUNGS ASSESSMENT

THORAX AND LUNGS ASSESSMENT

· How to measure the chest. Take the measurement at the nipple level with a tape measure; observe for chest size, shape, movement of the
chest with breathing, and any retractions.

· Adolescents. In the older school-age child or adolescent, note evidence of breast development.

· Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any noisy or grunting respirations.

· How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each lobe of the lung, anterior and posterior,
while the patient inhales and exhales; describe, document, and report absent or diminished breath sounds, as well as unusual sounds such as
crackling or wheezing.
BODY PART TECHNIQUE NORMAL FINDINGS
Thorax and Lungs Inspection. » The chest contour is symmetrical and the chest is twice as wide as
deep (anteroposterior diameter in a 1:2 ratio). The spine is straight.
(Anterior and Posterior) Have the client sit comfortably. Inspect for the shape, Posteriorly the ribs tend to slope across and down. The ribs are
position of the spine, the slope of the ribs, retraction of prominent in a thin person. There is no bulging or retraction of the
the intercostal spaces (ICS) on inspiration, and bulging of ICS during breathing. The chest wall moves symmetrically during
the ICS on expiration. respiration.

Observe for symmetry of the chest wall during respiration

» No lumps, masses, areas of tenderness.

Palpation » Sides of the thorax expand symmetrically. The examiner’s thumb

separates approximately 3-5 centimeters during the excursion.
Palpate for lumps, masses, areas of tenderness.

Measure chest excursion (to determine the depth of

breathing). Place hands on the lower portion of the rib
cage with the thumbs 2 inches apart pointing towards the
spine and fingers.

Elicit tactile fremitus (a thrill felt by the hand on the » Vibrations are prominent over the areas near the bronchi. It
chest wall while the client is speaking). Place the palms increases with the intensity of the voice. Vibrations are strongest
of the hand bilaterally symmetrical on the chest. Start between the first and second ribs along the sternum anteriorly and
from the top of the chest wall going down. Each time the between the scapulae posteriorly.
hands move, ask the client to say “ninety-nine” or “one--
one—one” with the same intensity of the voice.

Percussion

For the anterior thorax, the client is preferably in a lying

position. For the posterior thorax, the client is in a sitting
position with the arms folded across the chest. This
position will separate the scapulae to further expose the
lungs for assessment. Using indirect percussion, percuss
in the ICS over symmetrical areas of the chest starting
from the supraclavicular area. Compare one side of the » Percussion note varies with the thickness of the chest wall:
chest to another.

» Resonance- the sound created by air-filled lungs. It is clear, long,

low pitch.

» Dull- short, high pitch, soft and thudding, heard over the heart.

» Flat- absolute dullness; absence of air in the underlying tissue.

» Tympany- moderately loud with music quality with a specific

pitch. Noted in the left upper quadrant of the abdomen.

Location Percussion Note

L R
Supra-

clavicular Flat
1st ICS Resonant
2nd ICS Dull Resonant
3rd ICS Dull Resonant
4th ICS Dull Resonant
5th ICS Dull Resonant
6th ICS Resonant Resonant
7th ICS Tympanic Dull
8th ICS Tympanic Dull
9th ICS Tympanic Dull
 » Normal breath sounds differ in character depending on the area of
the lung being auscultated.

» Bronchovesicular sounds are medium-pitched sound or medium

Auscultation intensity, heard posteriorly between the scapulae. The sounds have a
blowing quality with the inspiratory phase equal to the expiratory
To assess the movement of air through the phase.
tracheobronchial tree, the room must be quiet.

» Vesicular sounds are heard over the lung periphery. The sounds
are created by air moving through the smaller airways. They are soft,
breezy, and low-pitched and the inspiratory phase is about three
times longer than the expiratory phase.

» Bronchial sounds are hollow high pitched; whistling sounds which

are normal if heard over large airways like the trachea.

Flipped Classroom: For additional reference, you can click the actual video for the method of assessing the thorax and the
lungs: [Link]

Overview

1. The thorax and lungs should be assessed anteriorly, posteriorly, and laterally

Nursing Points

General

1. Supplies needed

a. Stethoscope

Assessment

1. Anterior

a. Inspect

i. Size and shape of the thorax

1. Anterior-Posterior diameter should be approximately ½ the lateral diameter

2. Barrel Chest – COPD

ii. Symmetry

1. Expansion should be symmetrical on inspiration

iii. Ribs should slope downward from the sternum outward

iv. Observe for signs of distress

1. Tachypnea

2. Retractions

3. Cyanosis

v. Observe the overall rate and rhythm of respiration

vi. Inspect skin color and condition on the thorax

b. Palpate

i. Using 2 fingers, press lightly on the skin over the anterior chest, feeling for crepitus – feels like “rice crispies” under skin
1. Indicates subcutaneous air

c. Percuss

i. Starting at the Apex, percuss in the intercostal spaces moving left to right and downward

ii. Should hear the resonance

iii. May hear dullness over heart and liver

d. Auscultate

i. Listen for audible cough, wheezing, or stridor

ii. Lung sounds

1. Bronchial

a. Upper areas

b. High pitch

c. Insp < Exp

2. Bronchovesicular

a. Middle areas

b. Moderate pitch

c. Insp = Exp

3. Vesicular

a. Outer areas

b. Low pitch

c. Insp > Exp

iii. Listen from left to right starting at the apex and moving downward, including the lateral areas.

1. The only way to hear the right middle lobe is to listen near the axilla on the right side.

iv. Should listen in 10-12 areas on the front

v. BEST heard with stethoscope directly on skin

vi. Listen to one full respiration in each area

vii. Make note of any adventitious sounds

1. Crackles

2. Rhonchi

3. Wheezes

4. Stridor

5. *See Lung Sounds lesson in Respiratory Course for details

2. Posterior

a. Inspect – same as anterior

b. Palpate – same as anterior, plus:

i. Tactile fremitus

1. Use the palm of your hands to palpate from the apex down in 5 places as the patient says the word “ninety-nine”
2. Should feel vibrations equally bilaterally

1. Decreased vibration = fluid consolidation

ii. Expansion

1. Place hands on lower rib cage with thumbs touching, ask the patient to inhale deeply

2. Should see hands expand and return symmetrically

c. Percuss – same as anterior,

i. Avoid scapula

d. Auscultate – same as anterior

i. Avoid scapula

ii. 8-10 locations

ABDOMINAL ASSESSMENT

· In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees
slightly flexed to relax abdominal muscles.

Inspection of the abdomen

· Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).

· Contour (flat, rounded, scaphoid)

· Distension

· Respiratory movement.

· Visible peristalsis.

· Pulsations

Normal Findings:

· Skin color is uniform, with no lesions.

· Some clients may have striae or scar.

· No venous engorgement.

· The contour may be flat, rounded, or scaphoid

· Thin clients may have visible peristalsis.

· Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

· This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion.

· The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles.

· Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may
be used in exploring arterial murmurs and venous hum.

Peristaltic sounds

· These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues
relevant to the motility of the bowel.

· Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

o Divide the abdomen into four quadrants.

o Listen to overall auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the
abdominal quadrants. This direction ensures that we follow the direction of bowel movement.
o Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listens for at least 5 minutes, especially at the periumbilical
area, before concluding that no bowel sounds are present.

o The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of
bowel sounds may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

o Some factors that affect bowel sound:

§ Presence of food in the GI tract.

§ State of digestion.

§ Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).

§ Bowel surgery

§ Constipation or Diarrhea.

§ Electrolyte imbalances.

§ Bowel obstruction.

Percussion of the abdomen

· Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid
structures within the abdomen.

· The direction of abdominal percussion follows the auscultation site at each abdominal guardant.

· The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.

· Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the
RUQ, spleen at the 6th or 9th rib just posterior to or at the midaxillary line on the left side.

· Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver

· The palms of the left hand are placed over the region of liver dullness.

· The area is struck lightly with a fisted right hand.

· Normally tenderness should not be elicited by this method.

· Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

· Can be done by either indirect or direct method.

· Percussion is done over the costovertebral junction.

· Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

· It is a gentle exploration performed while the client is in a supine position. With the examiner’s hands parallel to the floor.

· The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular
motion.

· This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

· Tensing of abdominal musculature may occur because of:

o The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.

o The client is ticklish or guards involuntarily.

o Presence of subjacent pathologic condition.

Normal Findings:
· No tenderness noted.

· With smooth and consistent tension.

· No muscles guarding.

Deep Palpation

· It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall.

· The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.

· Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or masses may be felt with this method.

· In the absence of disease, the pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the
aorta.

Liver palpation

· There are two types of bimanual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand
over the left hand.

o Ask the patient to take 3 normal breaths.

o Then ask the client to breathe deeply and hold. This would push the liver down to facilitate palpation.

o Press hand deeply over the RUQ

· The second methods:

o The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.

o Place the examiner’s right hands parallel to the costal margin or the RUQ.

o Upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the
abdominal wall.

o Ask the client to breathe deeply.

o As the client inspires, the liver may be felt to slip beneath the examining fingers.

Normal Findings:

· The liver usually cannot be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt the coastal
margins.

· When the normal liver margin is palpated, it must be smooth, regular in contour, firm, and non-tender.

BODY PART TECHNIQUE NORMAL FINDINGS

ABDOMEN Divide the abdomen into 4 imaginary quadrants. Draw a
vertical line from the xiphoid process to the symphysis
pubis and a horizontal line across the umbilicus. These
quadrants are labeled right upper quadrant (RUQ), left
upper quadrant (LUQ), right lower quadrant (RLQ), and
left lower quadrant (LLQ).

Ask the client if he needs to void. Drape the upper chest

and legs. Expose the abdomen from the xiphoid process
to the symphysis pubis. The client lies in a supine
position with arms down at the sides; a small pillow may
be placed under the head.

Inspection

Inspect the abdomen for skin integrity, color, contour,

symmetry, movement or pulsations, and color and
placement of the umbilicus.
 » Skin is unblemished, no scars, color is uniform, flat, rounded
(convex), or scaphoid (concave),

» Symmetrical movements caused by respiration, aortic pulsation at

epigastric area visible in thin persons

» Umbilicus is flat or concave, positioned midway between the

xiphoid process and the symphysis pubis

» Color is the same as the surrounding skin.

Auscultation » There are clicks and gurgles, the frequency of which has been
estimated at from 5-34 per minute. Occasionally, borborygmi (loud
Warm the diaphragm of the stethoscope. A cold prolonged gurgles of hyperperistalsis) the familiar “stomach
stethoscope may cause the client to contract the growling” can be heard.
abdominal muscles and the contractions may be heard
during auscultation. The diaphragm is used because
intestinal sounds are high – pitched sounds. Place the
diaphragm in each of the 4 quadrants' overall auscultation
sounds.

Percussion

Reveals the presence of air in the stomach and abdomen.

To identify the boarders start percussion at the right iliac

rest upward along the midclavicular line. Percuss each
quadrant starting from the right clockwise.
» Tympany predominates because of the presence of air in the
Palpation
stomach and intestines
Perform light palpation first to detect areas of tenderness,
» Percussion is dull at the liver’s lower border.
muscle guarding, (Voluntary tightening of abdominal
muscles), lumps of masses, consistency and
organomegaly.

Depress the abdominal wall lightly, about 1 cm. with the

pads of your fingers. Move the finger pads in a slight
circular motion. Palpate all 4 quadrants.

Palpate the liver using deep palpation. Stand on the

client’s right side. Place your left hand on the posterior
thorax at about the 11th or 12th rib and then apply upward
pressure. With the fingers of the right hand pointing
» Soft abdomen, no tenderness, no muscle guarding, no lumps, or
upward, place the hand on the RUQ well below the
masses, or organomegaly.
liver’s lower border, then press gently until you reach the
depth of 1 ½ - 2 inches. Ask the client to take a deep
breath using the abdominal muscles. As he inhales, tries
to palpate the liver’s edge as it descends.
» Liver’s edge feels firm and not tender.
Flipped Classroom: For additional reference, you can click the actual video for the method of assessing the thorax and the
lungs: [Link]

BREAST EXAMINATION

Inspection of the Breast

· There are 4 major sitting positions of the client used for clinical breast examination. Every client should be examined in each position.

o The client is seated with her arms on her side.

o The client is seated with her arms abducted over the head.

o The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles.

o The client is seated and is learning over while the examiner assists in supporting and balancing her.

· While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging, retraction, and fixation.

· An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion of the suspensory ligaments, to
fix, preventing them from upward movement in position 2 and 4.

· Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligaments.

Normal Findings:

· The overlying the breast should be even.

· May or may not be completely symmetrical at rest.

· The areola is rounded or oval, with the same color, (Color varies from light pink to dark brown depending on race).
· Nipples are rounded, everted, the same size and equal in color.

· No “orange peel” skin is noted which is present in edema.

· The veins may be visible but not engorge and prominent.

· No obvious mass noted.

· Not fixated and moves bilaterally when hands are abducted over the head, or is leaning forward.

· No retractions or dimpling.

Palpation of the Breast

· Palpate the breast along with imaginary concentric circles, following a clockwise rotary motion, from the periphery to the center going to the
nipples. Be sure that the breast is adequately surveyed. Breast examination is best done 1-week post menses.

· Each areolar areas are carefully palpated to determine the presence of underlying masses.

· Each nipple is gently compressed to assess for the presence of masses or discharge.

Normal Findings:

· No lumps or masses are palpable.

· No tenderness upon palpation.

· No discharges from the nipples.

· NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the various sitting position used for the
woman is unnecessary.

BODY PART TECHNIQUE NORMAL FINDINGS

BREASTS Females: variable in size depending on body build.

* obese - large and pendulous.

Inspection

Ask the client to remove the top gown or drape to allow

*Slender - thin and small.
simultaneous visualization of both breasts. Have the
client sit comfortably with arms at the side. Inspect the
breast for size, symmetry, and contour or shape. Inspect
the skin of the breast for color, retraction, or dimpling.
*Young clients - firms, elastic in consistency, cone-shaped
symmetrical, skin surface smooth.

*older women - breasts sag, nipples lower, stringy and nodular.

Palpation

Assist the client in a supine position. This position

allows the breast tissues to flatten evenly against the
Males: flat, symmetrical. If obese maybe slightly rounded.
chest wall facilitating palpation. Ask the client to raise
his/her hand and place it under the head. Palpate the
breasts for lumps or masses, areas of tenderness, and
consistency of breast tissues.

» Color of the skin same with the abdomen, no retraction, no

dimpling.
The palmar surface of the three fingers is used to
compress the breast tissues against the chest wall.

» No mass or lump, no areas of tenderness.

Perform palpation in a clockwise rotary motion from the

» In younger clients, borders of the breasts are clearly delineated. In
boarders going inward.
older clients irregular consistency, glandular/nodular.
 » Lobular feel of glandular tissue is normal.

» The lower edge of each breast may feel firm and hard.

» Premenstrual fullness, nodularity, and tenderness maybe present.

» Warm to touch and smooth.

AREOLA

Inspection

Inspect the size, shape, color, and symmetry.

» Round or oval, color darker than surrounding skin,
symmetrical.

» For dark–skinned clients, color is darker than other skin surfaces.

» No masses and areas of tenderness.

Palpation

Palpate for masses and areas of tenderness.

NIPPLES Inspection

Inspect for size, shape position, discharge, and lesions.

» Round or inverted, equal in size, similar in color, nipples point in
one direction, no discharge, no lesion, no dimpling, and no crusting.

Palpation » No masses, no tenderness, no discharge.

Using the thumb and index finger, compress the nipple to

determine any discharge.

Flipped Classroom: For additional reference, you can click the actual video for the method of assessing the thorax and the
lungs: [Link]

MALE GENITALIA EXAMINATION ( Overview)

Risk Factors for Testicular Cancer

1. Age 20-34 (15-35)

2. History of undescended testes

3. Early puberty

4. Family history

5. White race

6. Higher social class

7. Obesity

8. Never married or late marriage

9. Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy

10. Maternal abdominal/pelvic x-ray during pregnancy

11. Mother or sisters with breast cancer

Warning Signs for Cancer of the Testicle

1. A small, hard, painless lump-about the size of a pea

2. Feeling of heaviness in the testicle

3. Enlargement of the testicle

4. Change in how the testicle feels to the touch

5. Sudden accumulation of fluid/blood in the scrotum

6. Dull ache in the groin

7. Swelling or tenderness in other parts of the body (groin, breast, neck)

Testicular Self-Examination

1. Perform after a warm bath/shower

2. Use both hands and start on the right testicle

3. Place index and middle finger underneath testicle

4. Place thumb on top of testicle

5. GENTLY roll the testicle between thumbs and fingers

6. Check all sides of the right testicle and repeat procedure on left testicle

7. Find the epididymis on the top and back of each testicle.

8. Examine the testes in the mirror while standing. Look for unusual contours and swelling of testes (noting that one usually hangs lower than
the other)

End of Chapter 4 (continuation part 1)….

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

Inspection of the Heart

· The chest wall and epigastrium is inspected while the client is in supine position. Observe for pulsation and heaves or lifts

Normal Findings:

· Pulsation of the apical impulse may be visible. (this can give us some indication of the cardiac size).

· There should be no lift or heaves.

Palpation of the Heart

· The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex, moving to the left sternal border,
and then to the base of the heart.

Normal Findings:

· No, palpable pulsation over the aortic, pulmonic, and mitral valves.

· Apical pulsation can be felt on palpation.

· There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

· The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness.

Auscultation of the Heart

· Anatomic areas for auscultation of the heart:

· Aortic valve – Right 2nd ICS sternal border.

· Pulmonic Valve – Left 2nd ICS sternal border.

· Tricuspid Valve – – Left 5th ICS sternal border.

· Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:

1. If the heart sounds are faint or undetectable, try listening to them with the patient seated and leaning forward, or lying on his left side, which
brings the heart closer to the surface of the chest.

2. Having the client seated and leaning forward is best suited for hearing high-pitched sounds related to semilunar valves problem.

3. The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and extra heart sounds.

Auscultating the heart:

1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral

2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is
best heard over the aortic valve.

3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.

4. Count heart rate at the apical pulse for one full minute.

Auscultation of Heart Sounds

Normal Findings:

· S1 & S2 can be heard at all anatomic site.

· No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).

· Cardiac rate ranges from 60 – 100 bpm.

Flipped Classroom: For additional reference, you can click the actual video for method of assessing the thorax and the
lungs: [Link]
ABDOMINAL ASSESSMENT
ABDOMINAL ASSESSMENT

· In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees
slightly flexed to relax abdominal muscles.

Inspection of the abdomen

· Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).

· Contour (flat, rounded, scaphoid)

· Distension

· Respiratory movement.

· Visible peristalsis.

· Pulsations

Normal Findings:

· Skin color is uniform, no lesions.

· Some clients may have striae or scar.

· No venous engorgement.

· Contour may be flat, rounded or scaphoid

· Thin clients may have visible peristalsis.

· Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

· This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion.

· The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles.

· Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may
be used in exploring arterial murmurs and venous hum.

Peristaltic sounds

· These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues
relevant to the motility of bowel.

· Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

o Divide the abdomen into four quadrants.

o Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the
abdominal quadrants. This direction ensures that we follow the direction of bowel movement.

o Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical
area, before concluding that no bowel sounds are present.

o The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of
bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

o Some factors that affect bowel sound:

§ Presence of food in the GI tract.

§ State of digestion.

§ Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).

§ Bowel surgery

§ Constipation or Diarrhea.

§ Electrolyte imbalances.

§ Bowel obstruction.

Percussion of the abdomen

· Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid
structures within the abdomen.

· The direction of abdominal percussion follows the auscultation site at each abdominal guardant.

· The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.

· Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the
RUQ, spleen at the 6th or 9th rib just posterior to or at the midaxillary line on the left side.

· Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver

· The palms of the left hand are placed over the region of liver dullness.

· The area is strucked lightly with a fisted right hand.

· Normally tenderness should not be elicited by this method.

· Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

· Can be done by either indirect or direct method.

· Percussion is done over the costovertebral junction.

· Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

· It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel to the floor.

· The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular
motion.

· This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

· Tensing of abdominal musculature may occur because of:

o The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.

o The client is ticklish or guards involuntarily.

o Presence of subjacent pathologic condition.

Normal Findings:

· No tenderness noted.

· With smooth and consistent tension.

· No muscles guarding.

Deep Palpation

· It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall.

· The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.

· Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or masses may be felt with this method.

· In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta.

Liver palpation

· There are two types of bimanual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand
over the left hand.

o Ask the patient to take 3 normal breaths.

o Then ask the client to breathe deeply and hold. This would push the liver down to facilitate palpation.

o Press hand deeply over the RUQ

· The second methods:

o The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.

o Place the examiner’s right hands parallel to the costal margin or the RUQ.

o An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the
abdominal wall.

o Ask the client to breathe deeply.

o As the client inspires, the liver may be felt to slip beneath the examining fingers.

Normal Findings:

· The liver usually cannot be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt the coastal
margins.

· When the normal liver margin is palpated, it must be smooth, regular in contour, firm, and non-tender.
 MUSCULOSKELETAL ASSESSMENT

Inspection

· Observe for size, contour, bilateral symmetry, and involuntary movement.

· Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration.

· Always compare both extremities.

Palpation

· Feel for evenness of temperature. Normally it should be even for all the extremities.

· Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting for equality of contraction).

· Perform range of motion.

· Test for muscle strength. (performed against gravity and against resistance)

· Table showing the Lovett scale for grading for muscle strength and functional level

Functional level Lovett Scale Grade Percentage of

normal
No evidence of contractility Zero (Z) 0 0
Evidence of slight contractility Trace (T) 1 10
Complete ROM without gravity Poor (P) 2 25
Complete ROM with gravity Fair (F) 3 50
Complete range of motion against gravity with some Good (G) 4 75
resistance
Complete range of motion against gravity with full Normal (N) 5 100
resistance
Normal Findings

· Both extremities are equal in size.

· Have the same contour with prominences of joints.

· No involuntary movements.

· No edema

· Color is even.

· Temperature is warm and even.

· Has equal contraction and even.

· Can perform complete range of motion.

· No crepitus must be noted on joints.

· Can counteract gravity and resistance on ROM.

BODY PART TECHNIQUE NORMAL FINDINGS

UPPER EXTREMITIES

Arms

Inspection

Support hands at chest level. Note the color of skin, » Skin color varies (pinkish, tan, dark brown), symmetrical, fine hair
length, hair distribution, presence of visible veins. evenly distributed, presence/absence of visible veins.

Palpation

Palpate arms for temperature, moisture, lumps, masses, » Warm, dry and elastic, no areas of tenderness. Muscle appears
and areas of tenderness. Note for muscle size and tone. equal with good muscle tone.
Palms and Dorsal Surfaces Inspection
» Palms pinkish (dorsal surface), warm; males – thick; females –
Note the color, temperature, thickness, moisture, and softer; elastic.
turgor.
Nails
Inspection

Inspect for color, thickness, shape and curvature.

» Nails are transparent, smooth and convex with pink nailbeds and
white translucent tips.

Count the number of fingers. » Five fingers in each hand.

Palpation

Gently grasps the client’s fingers and observe the color » As pressure is applied to the nailbed, appears white or blanched,
of the nailbeds, then gently apply pressure with the and pink color returns immediately as pressure is released.
thumb to the nailbed quickly and release.

Manipulation – the process of moving or attempting to move the part being examined. Limitation of movements can be discovered.
Shoulders Range of motion
 1. Raise both arms to vertical position. » Performs with relative ease.

2. Place head behind the neck.

3. Place hands behind the small of the back.

Arms Range of motion

1. Abduct – away from the body » Performs with relative ease

2. Adduct – towards the body

3. Rotate – internal and external (one arm at a time) » No relative difficulties

Elbows Range of motion

1. Bend and straighten elbow » Performs with relative ease.

Hands and wrists Range of motion

1. Extend and spread the fingers

» Performs with relative ease
2. Make a fist, thumb across the knuckles.
LOWER EXTREMITIES

Legs Inspection

Note the color of skin, hair distribution, and presence of

varicose veins, length, and symmetry of muscle.
» Skin color varies (pinkish, tan, dark brown) skin is smooth, fine
hair evenly distributed, absence of varicose veins, muscles
symmetrical, length symmetrical.

Palpation
» Muscles appear equal, warm and with good muscle tone.
Let the client tiptoe. Palpate the muscles for warmth and
strength.

Toes

Inspection

Inspect for the number of toes, texture of sole and dorsal

» Five toes in each foot; sole and dorsal surface is smooth; with pink
surface, toe nails.
nail beds and white translucent tips.

Palpation
» As pressure is applied, the nailbed appears white or blanched; pink
color returns when pressure is released.
Gently grasps the client’s toenails nailbeds. Gently
apply pressure with the thumb to the nailbed quickly and
release.

Legs (one leg at a time) Range of motion

1. Abduct

2. Adduct
» Performs with relative ease
3. Rotate

4. Hop (both feet)

5. Walk to and from

Knees Range of motion

Let the client sit down on a chair and bend foot at the » Performs with relative ease
knee
 1. Bend and extend
Ankles Range of motion

1. Flexion and extension » Performs with relative ease

2. Rotation (internal and external)

Toes
Range of motion
» Performs with relative ease
1. Spread and wiggles

Overview

1. Musculoskeletal system involves the muscles, bones, and joints

2. This means we must assess structure AND function

Nursing Points

General

1. If patient cannot stand, assessments should be performed in the bed to the best of your ability

2. If they cannot perform Active Range of Motion (ROM), use Passive movements to determine ROM

Assessment

1. For ALL joints:

a. Inspect

i. Muscle size/shape

ii. Skin color at joint

iii. Swelling, masses

iv. Deformity

v. Pain with ROM

b. Palpate

i. Crepitus during ROM

ii. Heat at joint

iii. Strength

2. Strength

a. Grading

i. 0 = no movement

ii. 1 = flicker

iii. 2 = passive movement only

iv. 3 = overcomes gravity

v. 4 = overcomes some resistance

vi. 5 = overcomes strong resistance

b. Upper extremities – perform these tasks against resistance

i. Push hands

ii. Pull hands

iii. Raise arms to front and side

 iv. Lower arms

v. Grip hands

c. Lower extremities – perform these tasks against resistance

i. Raise legs

ii. Lower legs

iii. Push with feet

iv. Pull toes back

3. Spine

a. Inspect and Palpate

i. Spinous processes should be in alignment vertically

ii. Look for any abnormal curvatures

1. Kyphosis – excessive thoracic curvature

2. Lordosis – excessive lumbar curvature

3. Scoliosis – excessive lateral curvature

b. Range of motion

i. Cervical

1. Chin to chest

2. Chin up

3. Head side to side

4. Ears to shoulders

ii. Thoracic

1. Twist side to side

iii. Lumbar

1. Lean backwards

iv. All ROM should be smooth and coordinated without pain

4. Upper extremities

a. Shoulders

i. ROM

1. External and Internal Rotation

2. Abduction

3. Adduction

4. Forward and backward

5. Shrug

b. Elbows

i. ROM

1. Flexion

2. Extension
3. Supination

4. Pronation

c. Wrists

i. ROM

1. Flexion

2. Extension

3. Rotation

4. Supination

5. Pronation

d. Hands/Fingers

i. ROM

1. Flexion

2. Extension

3. Grips

5. Lower extremities

a. Hips

i. ROM

1. Flexion

2. Extension

3. Internal rotation

4. External rotation

5. Abduction

6. Adduction

b. Knees

i. ROM

1. Flexion

2. Extension

c. Ankles

i. ROM

1. Dorsiflexion

2. Plantar flexion

3. Supination

4. Pronation

5. Rotation

d. Feet/Toes

i. ROM

1. Flexion
2. Extension

Nursing Concepts

1. Reflexes usually tested during neurologic assessment, but could be included here as well

2. Could use a goniometer to assess degree of flexion or extension of joints.

PERIPHERAL VASCULAR ASSESSMENT

Assessing the peripheral vascular system includes measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and
tissues to determine perfusion (blood supply to an area) to the extremities. Certain aspects of peripheral vascular assessment are often
incorporated into other parts of the assessment procedure. For example, blood pressure is usually measured at the beginning of the physical
examination.

Peripheral Pulses

 Palpate the peripheral pulses on both sides of the client's body individually, simultaneously (except the carotid pulse), and systematically to determine
the symmetry of the pulse volume. If you have difficulty palpating some of the peripheral pulses, use a Doppler ultrasound probe. There should be
symmetric pulse volumes and full pulsations.

Peripheral Veins

 Inspect the peripheral veins in the arms and legs for the presence and/or appearance of superficial veins when limbs are depe ndent and when limbs
are elevated. In dependent position, there is the presence of distention or nodular bulges at calves. When limbs are elevated, veins collapse (veins may
appear tortuous or distended in older people).
 Assess the peripheral leg veins for signs of phlebitis.
 Inspect the calves for redness and swelling over vein sites.
 Palpate the calves for firmness of tension of the muscles, presence of edema over the dorsum of the foot, and areas of localized warmth.
 Push the calves from side to side to test for tenderness.
 Firmly dorsiflex the client's foot while supporting the entire leg in extension (Homan's test), or have the person stand or walk.
 Limbs should not be tender. The limbs should be symmetric in size.

Peripheral Perfusion

 Inspect the skin of the hands and feet for color, temperature, edema, and skin changes.
 Assess the adequacy of arterial flow if arterial insufficiency is suspected.
 It is normal if the skin color is pink, the temperature is not excessively warm of cold, no edema, and skin texture is resilient and moist.

Buerger's test

(Arterial Adecuacy test)

 Assist the client to a supine position. Ask the client to raise one leg or one arm about 30 cm or 1 ft above heart level, move the foot or hand briskly up
and down for about 1 minute, then sit up and dangle the leg or arm.
 Observe the time elapsed until return of original color and vein filling.
 It is normal if the original color returns in 10 seconds; and about 15 seconds for the vein to fill in the hands or feet.

Capillary Refill Test

 Squeeze the client's fingernail and toenail between your fingers sufficiently to cause blanching (about 5 seconds).
 Release the pressure, and observe how quickly normal color returns. Color normally returns immediately (less than 2 seconds).

Deviations From Normal

 Asymmetric volumes (may indicate impaired circulation).

 Absence of pulsations may indicate arterial spasm or occlusion.
 Decreased, weak, thready pulsations may indicate impaired cardiac output.
 Increased pulse volume may indicate hypertension, high cardiac output, or circulatory overload.
 Distended veins in the thigh and/or lower leg or on posterolateral part of calf from knee to ankle.
 Tenderness on palpation.
 Pain in calf muscles with forceful dorsiflexion of the foot (positive Homan's test).
 Swelling of one calf or leg.
 Cyanotic (venous insufficiency)
 Pallor that increases with limb elevation
 Dependent rubor, a dusky red color when limb is lowered (arterial insufficiency).
 Brown pigmentation around ankles(arterial or chronic venous insufficiency)
 Skin cool (arterial insufficiency)
 Marked edema (venous insufficiency)
 Mild edema (arterial insufficiency)
 Skin thin and shiny or thick, waxy, shiny, and fragile, with reduced hair and ulceration (venous or arterial insufficiency).
  Delayed color return or mottled appearance, delayed venous filling and marked redness of arms and legs after Buerger's test. It indicates arterial
insufficiency.

Overview
1. Peripheral vascular assessment includes portions of a skin assessment as well as pulses and other indicators of perfusion

Nursing Points
General

1. Start with upper extremities, then move to lowers

Assessment

1. Upper extremities

a. Inspect

i. Color of skin and nail beds

ii. Lesions

iii. Edema

iv. Size of arms

1. Any difference bilaterally?

v. Presence of hair

b. Palpate

i. Temperature

ii. Texture

iii. Turgor

iv. Edema (pitting?)

1. See Integumentary assessment

c. Pulses

i. Brachial – medial aspect of elbow

ii. Radial – medial, anterior aspect of wrist, proximal to thumb joint

iii. Rating:

1. 0 = absent

2. +1 = weak

3. +2 = normal

4. +3 = strong

5. +4 = bounding

iv. Compare bilaterally

d. Capillary refill – press nail bed, see how long it takes for color to return

i. Should be less than 3 seconds

e. If patient has an AV graft or fistula

i. Palpate for a thrill

ii. Auscultate for a bruit

2. Lower extremities

a. Inspect
 i. Color of skin and nail beds

ii. Lesions

iii. Edema

iv. Size of legs

1. Any difference bilaterally?

v. Presence or absence of hair

vi. Venous pattern

1. Tortuous or varicose veins

b. Palpate

i. Temperature

ii. Texture

iii. Edema (pitting?)

1. See Integumentary assessment

c. Pulses

i. Popliteal – medial aspect of posterior knee joint

ii. Dorsalis pedis – dorsal aspect of foot between 1st and 2nd metatarsal

iii. Posterior tibial – along the medial malleolus

iv. Rating:

1. 0 = absent

2. +1 = weak

3. +2 = normal

4. +3 = strong

5. +4 = bounding

v. Compare bilaterally

d. Capillary refill on toenails

i. Press nail bed, see how long it takes for color to return

1. Should be less than 3 seconds

3. Abnormal findings

a. Venous insufficiency

i. Dark discoloration of skin

ii. Absence of hair

iii. warm to touch

iv. Edema

v. Varicose veins

vi. “Tiredness” in legs

vii. Flaky skin

b. Arterial insufficiency
 i. Erythematous skin

ii. Bright red ulcerations

iii. Edema

iv. Pain

v. Weakness

vi. Cool to touch

c. Absent pulses

i. Use doppler to confirm if truly absent

ii. Report to provider, especially if NEW finding

Nursing Concepts

1. Common to see peripheral vascular issues in patients with hyperlipidemia, diabetes, and peripheral vascular disease

NEUROLOGICAL ASSESSMENT

SIX MAJOR CATEGORIES

A. Mental and Emotional Status

Mental and emotional status can be learned through interaction with client. The nurse poses the questions throughout the examination to
gather data and observe the client at times to detect the appropriateness of emotions and ideas of thoughts expressed.

1. Level of Consciousness

a. Conscious

– responds to questions quickly

– perceives events occurring around him

– awareness of time, place, and people

b. Stupor

- unable to recall who, where he is or the time of the day

c. Comatose

- unresponsive to verbal and painful stimuli

2. Behavior and Appearance

- The client’s behavior, hygiene and grooming, and choice of dress reveal pertinent information regarding mental status.

- Appearance reflects how a client feels about the self.

3. Language

The ability of an individual to understand spoken or written words and to express the self through writing, words or gestures is a
function of the cerebral cortex. An injury to the cortex my result in a disorder known as aphasia. There are three types of aphasia: [Link] (or
receptive), [Link] (or expressive), and [Link] (mixed sensory and motor).

4. Intellectual Function

a. Memory

– Let the client recall past events such as birthday or an anniversary; previous health history or instructions given earlier

*** Recent memory

– The nurse asks the client to recall events during the same day (but it should be validated for accuracy)

*** Remote memory

– Ask client to recall previous medical history; ask client his birthday or anniversary

*** Immediate memory

– The nurse asks the client to repeat a series of numbers or repeat a series of numbers backward.

b. Knowledge

– Ask him what he knows about his health condition or the reason for seeking health care.

c. Abstract Thinking

– Ask the client to explain a phrase and note whether the explanations are relevant and concrete.

d. Association

– Finding similarities or association of concepts

e. Judgment

– The nurse asks the client to compare and evaluate facts and ideas to understand their relationship to form appropriate conclusions.

B. Sensory Function

The sensory pathways of the central nervous system conduct sensations of pain, temperature, vibrations, and crude and finely localized
touch.

Normally, a client has sensory responses to all stimuli tested. All sensory testing is performed with client’s eyes closed so he is unable to
see when and where stimulus strikes the skin.

C. Cerebellar Function

1. Coordination

– performing rapid, rhythmical, alternating movements. Note for symmetry and speed of movement.

a. Pats hands against thigh as fats as he can

b. Touching each fingers with the thumb of the same hand in rapid succession

c. Point to point test

2. Balance

a. Stand with feet together, eyes closed (Romberg Test)

b. Have the client close eyes and stand on one foot and then the other

c. Ask the client to walk in a straight line by placing the heel of one foot directly in front of the toes of the other foot

d. Heel and toe walking

e. Hop on one foot, then on the other

D. Motor Function

The examiner applies a gradual increase in pressure to a muscle group. The client resists the pressure applied by the examiner by
attempting to move against resistance. The client resists until instructed to stop. The examiner varies the amount of pressure applied, the joint
moves.

1. Biceps – Pull down one forearm as client attempts to flex arms

2. Triceps – As client’s arm is flexed, apply pressure against the forearm.

Ask client to straighten arm

 3. Ask client to squeeze your fingers with both hands

E. Reflexes

Type Procedure Normal Reflex

Biceps · Flex arm at the elbow with the palms down.

· Place the thumb in the antecubital fossa at the base of biceps

Flexion of the arm and elbow
tendon.

· Strike the thumb with the reflex hammer.

Triceps · Flex the client below, holding the upper arm horizontally and allow
the lower arm to go limp.
Extension of elbow
· Strike the lower triceps tendon just above the elbow.
Patellar · Have the client sit with her legs hanging freely over the side of the
bed or chair or have the client be in supine and support his knee in flexed
position. Extension of lower leg

· Briskly tap patellar tendon just below the patella.

Plantar · Have the client lie in supine with legs straight and feet relaxed.

· Take the handle of the hammer and strike the lateral aspect of the Flexion of the toe
sole from the heel to the ball of the foot curving across the ball of the
foot towards the big toe.

F. Cranial Nerves

Cranial Nerve Name Type Function Assessment Method

» Ask client to close eyes and identify different mild
I Olfactory Sensory Smell aromas, such as coffee, tobacco, vanilla, oil of cloves,
peanut butter, orange, lemon, lime, chocolate
» Ask client to read Snellen chart, check visual fields by
II Optic Sensory Vision and visual fields
confrontation and conduct an opthalmoscopic exam
Extraocular eye movement
(EOM); movement of
III Oculomotor Motor sphincter of pupil; » Assess six ocular movement and pupil reaction
movement of ciliary mescles
of lens
EOM, specifically moves
IV Trochlear Motor eyeball downward and » Assess six ocular movement
laterally

Trigeminal

» While client looks upward, lightly touch lateral sclera

Sensation of cornea, skin of
a. Opthalmic Branch of eye to elicit blink reflex; to test light sensation, have
face, and nasal mucosa
client close eyes, wipe a wisp of cotton over the client’s
Sensory forehead and paranasal sinuses; to test deep sensation,
use alternating blunt and sharp ends of a safety pin over
same areas.

V » Assess skin sensation as for ophthalmic branch above

Sensation of skin of face

and anterior oral cavity
» Ask client to clench teeth
(tongue and teeth)
 b. Maxillary Branch

Muscles of mastication,
sensation of skin of face
Sensory

c. Mandibular Branch

Motor and
Sensory
VI Abducens Motor EOM; moves eyeball laterally » Assess direction of gaze
» Ask client to smile, raise the eyebrows, frown, puff out
cheek, close eyes tightly; ask client to identify various
Motor and Facial expressions; taste
VII Facial tastes placed on tip and sides of tongue: sugar (sweet),
Sensory (anterior 2/3 of the tongue)
salt (salty), lemon juice (sour), and quinine (bitter);
identify areas of taste.

Auditory

Sensory Equilibrium » Assessment of same with cerebellar functions

a. Vestibular

VIII Branch

Sensory Hearing » Assess clients ability to hear spoken word and

b. Cochlear Branch vibrations of tuning fork

» Use tongue blade on posterior tongue while client

Glosso- Swallowing ability and gag
Motor and says “ah” to elicit gag reflex; apply tastes on posterior
IX reflex, tongue movement,
Sensory tongue for identification; ask client to move tongue from
phrayngeal taste (posterior tongue)
side and up and down.
Sensation of pharynx and
Motor and » Assessed with cranial nerve IX; Assess client’s speech
X Vagus larynx; swallowing; vocal
Sensory for hoarseness
cord movement
» Ask client to shrug shoulders against resistance from
Head movement; shrugging
XI Accessory Motor your hands and turn head to side against resistance
of shoulders
from your hand (repeat on the other side)
» Ask client to protrude tongue at midline, then move it
XII Hypoglossal Motor Protrusion of tongue
side to side.

Overview
1. Heavily based on interviewing the patient

2. Also involves direct or indirect assessment of cranial nerves

Nursing Points
General

1. Neuro assessment begins when you first walk in the room – during your general assessment

2. To determine alertness:

a. Start by just walking in the room – if they open their eyes, that’s considered “spontaneous” eye opening

b. If they don’t – call their name 2 or 3 times – if they open their eyes, it’s to “voice”

c. If they still haven’t roused – gently shake and progressively increase noxious or painful stimuli until they arouse – “to pain”
3. Supplies needed

a. Pen light

b. Alcohol swab

c. Reflex hammer

d. Cotton-tipped applicator

e. Snellen chart if available

f. Cup of water

Assessment

1. Mental Status

a. Level of Consciousness

i. Normal

ii. Confused

iii. Delirious

iv. Somnolent

v. Obtunded

vi. Stuporous

vii. Comatose

b. Glasgow Coma Scale

i. Eye opening

1. 4 = spontaneous

2. 3 = to voice

3. 2 = to pain

4. 1 = no response

ii. Vocalization

1. 5 = oriented

2. 4 = confused

3. 3 = inappropriate

4. 2 = incomprehensible

5. 1 = no response

iii. Motor response

1. 6 = follows commands

2. 5 = localizes to pain

3. 4 = withdraws from pain

4. 3 = abnormal flexion

5. 2 = abnormal extension

6. 1 = no response

iv. *NOTE*
1. Much of this information is obtained throughout the rest of your assessment, NOT as an individual assessment

c. Orientation

i. Person

1. “Can you tell me your name?”

2. Can be assessed when gathering 2 patient identifiers

ii. Place

i. “Where are we right now?” OR “What city are we in?”

iii. Time

. “Can you tell me what month it is?”

i. Asking the full date may be difficult for anyone

iv. Situation

. “What brings you into the clinic/hospital?”

i. This also helps assess recent memory

d. Thought process / Attention span

i. Are they following your line of questioning?

ii. Are they paying attention?

iii. Are their responses scattered?

iv. Logical thought process questions:

0. Will a stone float on water?

1. Are there fish in the sea?

2. Can you use a hammer to cut wood?

e. Memory/Judgment

i. Ask questions you can easily verify

ii. Common knowledge:

0. What must you do to water to make it boil?

1. When is Memorial Day?

2. What are the four seasons of the year?

iii. Personal remote memory:

0. Kids’ birthdays

1. Their birthday

iv. Judgment

0. Are they making safe/good decisions while hospitalized?

f. Destructive thoughts

i. “Are you having any thoughts of hurting yourself or anyone else?”

2. Cranial Nerve Testing

a. I – rarely tested, can ask patient if they have any difficulty identifyingsmells

i. Have them identify known smells (alcohol rub, coffee)

b. II, IV, and VI

i. Visual Acuity – use a Snellen chart 20 feet away if possible. Otherwise have the patient read a sign on the wall

0. Allow them to use corrective lenses if they have them

ii. PERRLA = Pupils Equal, Round, Reactive to Light and Accommodation

0. Shine pen light in eyes bilaterally to assess constriction

1. Should be equal bilaterally

2. Right pupil should also contract when light shines in left pupil and vice versa (accommodation)

3. Make note of pupil size

iii. Extraocular movements (EOM)

0. Ask pt to follow finger in 6 cardinal positions

c. V – motor and sensory function

i. Palpate masseter muscles while patient clenches jaw

0. Can also assess for TMJ at this point – clicking or pain

ii. Have pt close their eyes, lightly touch cheek, forehead, chin and ask pt to tell you when they feel it and if it’s the same bilaterally

d. VII – facial motor function

i. Have patient smile, frown, close eyes tightly, raise eyebrows, and show teeth

ii. Look for symmetry of movement

e. VIII – hearing

i. Lightly rub fingers about a foot from patient’s ears and move closer until they can hear

ii. Whisper test – whisper a 2-syllable word about 2 feet from the patient and see if they can hear it

f. IX, X, XII – tongue

i. Swallow/gag reflex

0. If patient can swallow safely, nerves are intact

ii. Open mouth and say “Ah”- uvula should rise midline

iii. Stick out tongue – should be midline

g. XI –

i. Shrug shoulders against resistance

ii. Turn head left and right against resistance

3. Sensory / Reflexes

a. Use a cotton-tipped applicator with the wood split to test sharp and dull on 4 extremities

i. Show the patient “sharp” and “dull” first, then ask them to close their eyes and tell you what they feel

ii. Compare side to side

b. Use reflex hammer to test reflexes:

i. Bicep

ii. Tricep

iii. Patellar

iv. Achilles
 v. Graded:

0. 0 = no response

1. 1 = diminished

2. 2 = normal

3. 3 = brisk

4. 4 = hyperactive

c. Babinski reflex – pull the handle of the reflex hammer up and across the foot (like an upside down J)

i. Should see toes curl

ii. If toes flare out, that’s a bad sign (positive babinski)

4. Balance / Coordination

a. Assess gait by having patient walk 5 feet away and back

i. Should be smooth and effortless

b. Romberg test

i. Have the patient stand with feet together, close eyes, and hold for 20 seconds

ii. Should be able to stay balanced without falling

iii. Some sway is normal

c. Finger to nose test

i. Have the patient touch your finger, then their nose, repeatedly as you move your finger – in approximately 5-6 positions.

ii. Should be able to easily bring their hand back to their nose from any position

iii. Have them repeat with both hand

Nursing Concepts

1. There are MANY things that could cause barriers to this assessment

a. Use alternative assessments when needed

b. Document objectively

i. “Unable to assess” is appropriate

Flipped Classroom: For additional reference, you can click the actual video for vital signs
monitoring. [Link]