akram mohammad abusalah bns, msn, ph. d. islamic university of gaza strip nursing health assessment...

Akram Mohammad AbuSalah

BNS, MSN, Ph. D.

Islamic University of Gaza Strip

Nursing Health Assessment

1


Chapter (1)The Interview

The first assessment begin in (1992) by American medical association

In (1995) health assessment considered as basic

human right

Preventive health care divided in three categories,

primary, secondary and tertiary prevention. Each

level of prevention is based on a thorough

assessment of the client's health as status.

Periodic health assessment needed to be

performed by a physician, or a nurse 3

Objectives of health assessment

Surveillance of health status, identification of occult

disease, screening, and follow-up care

The periodic assessment, at regular intervals

Increasing client participation in health care

Accurately define the health and risk care needs for

individuals

Health assessment is shared with the client in a clearly

and understandable manner

The client must share in decision making for his own

care. 4

Types of Assessment

Comprehensive assessment: is usually

the initial assessment it very thorough and

includes detailed health history and

physical examination and examine the

client's overall health status

Focused assessment : is problem

oriented and may be the initial

assessment or an ongoing assessment 5

Frequency of assessment

The persons under (35) years every (4 – 5)

years

The persons from (35 – 45) every (2 – 3) years.

Persons from (45-55) years of age undergo a

thorough health assessment every year.

Persons over (55) years may needs

assessment every 6 months or less

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1. Systematic and continuous collection of client

data

2. It focus on client responses to health problems

3. The nurse carefully examine the client’s body

parts to determine any abnormalities

4. The nurse relies on data from different sources

which can indicate significant clinical problems

5. Health assessment provides a base line used

to plan the clients care

Importance of nursing health assessment F

7

6. Health assessment helps the nurse to

diagnose client’s problem & the

intervention

7. Complete health assessment involves a

more detailed review of client’s condition

8. Health assessment influence the choice

of therapies & client's responses

8

Purposes of health assessment

1. Gather data

2. Confirm or refuse data obtained in the

health history

3. To identify nursing diagnoses

4. To make clinical judgments about client's

changing health status

5.To evaluate bio-psycho-social and spiritual

outcomes of care9

Nursing and medical diagnosis

There is a big Difference between both because:

Nursing diagnose is independent role of the

nurse

Nursing diagnoses depends on the client's

problems/response associated with specific

disorder

Any problem in nursing diagnosis must notice

from a holistic view e.g. bio-psycho-social and

spiritual relations10

Medical diagnoses

Depends on clinical picture and laboratory findings

The specialist doctor has a right to diagnose not else

Example:

- DM is medical diagnoses (hypo or hyperglycemia)

- Nursing diagnoses in this case e.g. Impaired skin

integrity R/T poor circulation, Knowledge deficit

about the effects of exercise on needs of insulin.

The difference between medical diagnosis, a

collaborative problem, and nursing diagnosis

is explained with the next table:- 11

Health Assessment

Holistic approach:

1. The interview

2. Psychosocial assessment

3. Nutritional assessment

4. Assessment of sleep-wakefulness patterns

5. The health history.13

1. Interview

Definition: communication process focuses

on the client's development of

psychological, physiological, sociocultural,

and spiritual responses, that can be treated

with nursing & collaborative interventions

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Major purpose:

To obtain health history and to elicit symptoms

and the time course of their development. The

interview conducted before physical

examination is done.

Components of nursing interview

1. Introductory phase

2. Working phase

3. Termination phase15

1. Introductory phase:

Introduce yourself and explains the

purpose of the interview to the client.

Before asking questions, Let client to feel

Comfort, Privacy and Confidentiality

16

Working phase:

The nurse must listen and observe cues in addition to

using critical thinking skills to validate information

received from the client. The nurse identify client's

problems and goals.

Termination phase:

1.The nurse summarizes information obtained during

the working phase

2. Validates problems and goals with the client.

3.Making plans to resolve the problems (nursing

diagnosis and collaborative problems are identified

and discussed with the client)17

Communications techniques during interview

1. Types of questions :

Begin with open ended questions to assess

client's feelings e.g. what, how, which“

Use closed ended question to obtain facts

e.g." when, did…etc

Use list to obtain specific answers e.g. "is

pain sever, dull sharp

Explore all data that deviate from normal

e.g. “increase or decrease the problem

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2. Types of statements to be use:

Repeat your perception of client's response to

clarify information and encourage verbalization

3. Accept the client silence to recognize

thoughts

4. Avoid some communication styles e.g.

Excessive or not enough eye contact.

Doing other things during getting history.

Biased or leading questions e.g. "you don't feel

bad"

Relying on memory to recall information 19

5. Specific age variations :-

Pediatric clients: validate information from parents.

Geriatric clients: use simple words and assess hearing

acuity

6. Emotional variations:

Be calm with angry clients and simply with anxious and

express interest with depressed client

Sensitive issues "e.g. sexuality, dying, spirituality" you

must be aware of your own thought regarding these

things.

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7. Cultural variations:

Be aware of possible cultural variations in

the communication styles of self and clients

8. Use culture broker:

Use culture broker as middleman if your

client not speak your language.

Use pictures for non reading clients.

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Chapter (2)Psychosocial assessment

Psychosocial assessment

Psychological assessment involves person's

growth and development throughout his life.

Discuss crises with the clients to assess

relationship between health & illness. “It

depends on multiple G&D theories e.g.

Erickson, Piaget, and Freud …. etc.23

Stages of AgeInfancy period: birth to 12 months Neonatal Stage: birth-28 days Infancy Stage: 1-12 monthsEarly childhood Stage: It’s refers to two integrated

stages of development Toddler: 1 - 3years. Preschool: 3 - 6 years. Middle childhood 6-12 yearsMiddle childhood 6-12 yearsLate childhood: Pre pubertal: 10 – 13 years. Adolescence: 13 - 19 yearsYoung adulthood 20-40 yearsYoung adulthood 20-40 yearsMiddle adulthood 40-65yearsMiddle adulthood 40-65yearsLate adulthood 65 and moreLate adulthood 65 and more


Chapter (3)Nutritional assessment

Nutritional assessment

Nutrition plays a major role in the way

an individual looks, feels,& behaves.

The body ability to fight disease

greatly depends on the individual's

nutritional status

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Major goals of nutritional assessment

1. Identification of malnutrition. 2. Identification of over consumption 3. Identification of optimal nutritional status.

Components of Nutritional

Assessment 1. Anthropometric measurement. 2. Biochemical measurement. 3. Clinical examination. 4. Dietary analysis

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1. Anthropometric measurement

Measurement of size, weight, and proportions of human body.

Measurement includes: height, weight, skin fold

thickness, and circumference of various body parts,

including the head, chest, and arm.Assess body mass index (BMI) to shows a direct and

continuous relationship to morbidity and mortality in studies of large populations. High ratios of waist to hip circumference are associated with higher risk for illness & decreased life span.

BMI = (Wt. in kilograms) = 60 = 60 =

23.4 (High in meters) 2 (1.6)2 2.5628

BMI RANGEBMI RANGE

Rang kg/m2 Condition

less than 16.0 Very thin

16.0 - 18.4 Thin

18.5- 24.9 Average

25–29.9 Overweight

30-34.9 Obese

≥ 35 Highly obese

2. Biochemical Measurement

Useful in indicating malnutrition or the development of

diseases as a result of over consumption of nutrients.

Serum and urine are commonly used for biochemical

assessment.

In assessment of malnutrition, commonly tests include:

total lymphocyte count, albumin, serum transferrin,

hemoglobin, and hematocrit …etc. These values taken

with anthropometric measurements, give a good

overall picture of an individual's skeletal and visceral

protein status as well as fat reserves and immunologic

response.

3. Clinical examination

Involves, close physical evaluation and

may reveal signs suggesting malnutrition

or over consumption of nutrients.

Although examination alone doesn't

permit definitive diagnosis of nutritional

problem, it should not be overlooked in

nutritional assessment31

Nutritional assessment technique for clinical examination

A. Types of information needed

Diet: Describe the type: regular or not,

special, "e.g. teeth problem, sensitive

mouth.

Usual mealtimes: How many meals a day:

when? Which are heavy meals?

Appetite: "Good, fair, poor, too good".

Weight: stable? How has it changed? 32

Food preferences: e.g." prefers beef to other meats"

Food dislike: What & Why? Culture related?

Usual eating places: Home, snack shops,

restaurants.

Ability to eat: describe inabilities, dental problems:

"ill fitting dentures, difficulties with chewing or

swallowing

Elimination" urine & stool: nature, frequency

problems

Exercise & physical activity: how extensive or

deficient 33

Psycho social - cultural factors: Review any thing which can

affect on proper nutrition

Taking Medications which affect the eating habits

Laboratory determinations e.g.: “Hemoglobin, protein, albumin,

cholesterol, urinalyses"

Height, weight, body type "small, medium, large"

After obtaining information, summarize your findings and determine the nutritional diagnosis and nutritional plan of care.

Imbalanced nutrition: Less than body requirements, related to lack of knowledge and inadequate food intake

Risk for infection, related to protein-calorie malnutrition

B. Signs & symptoms of malnutritionDry and thin hair Yellowish lump around eye, white rings around

both eyes, and pale conjunctiva Redness and swelling of lips especially corners

of mouth Teeth caries & abnormal missing of it Dryness of skin (xerosis): sandpaper feels of

skinSpoon shaped Nails " Koilonychia “ anemiaTachycardia, elevated blood pressure due to

excessive sodium intake and excessive cholesterol, fat, or caloric intake

Muscle weakness and growth retardation 35

4. Dietary analysis Food represent cultural and ethnic background

and socio- economic status and have many emotional and psychological meaning

Assessment includes usual foods consumed &

habits of foodThe nurse ask the client to recall every thing

consumed within the past 24 hour including all foods, fluid, vitamins, minerals or other supplements to identify the optimal meals

Should not bias the client's response to question based on the interviewer's personal habits or knowledge of recommended food consumption

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Diseases affected by nutritional problems

1- Obesity: excess of body fat.

2- Diabetes mellitus.

3- Hypertension.

4- Coronary heart disease.

5- Cancer.

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Chapter (4)Sleep-wakefulness patterns

Assessment of sleep-wakefulness patterns

Normal human has “homeostasis” (ability to maintain a relative internal constancy)

Any person may complain of sleep-pattern

disturbance as a primary problem or

secondary due to another condition

1/4 of clients who seek health care

complain of a difficulty related to sleep

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Factors affecting length and quality of sleep

1. Anxiety related to the need for meeting a tasks,

such as waking at an early hour for work.

2. The promise of pleasurable activity such as

starting a vacation.

3. The conditioned patterns of sleeping.

4. Physiologic wake up.

5. Age differences.

6. Physiologic alteration, such as diseases

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Good sleep depends on the number of awakenings

and the total number of sleeping hours

The nurse can assess sleep pattern by doing

interview with the client or using special charts or

by EEG

Disorders related to sleep

1.Sleep disturbances affects family life, employment, and

general social adjustment

2. Feelings of fatigue, irritability and difficulty in

concentrating

3. Difficulty in maintaining orientation 42

4. Illusions, hallucination (visual & tactile ) 5. Decreased psychomotor ability with decreased

incentive to work

6. Mild Nystagmus

7. Tremor of hands

Increase in gluco-corticoid and adrenergic

hormone secretion

9. Increase anxiety with sense of tiredness

10. Insomnia "short end sleeping periods“

11. Sleep apnea "periodic cessation of breathing

that occurs during sleep

12. Hypersomnia: "sleeping for excessive periods” the sleep period may be extended to 16-18 hours a day

13. Peri-hypersomnia. "Condition that is described as an increased used for sleep "18-20 hours a day" lasts for only few days

14. Narcolepsy "excessive day time drowsiness or uncontrolled onset of sleep.

15. Cataplexy: abrupt weakness or paralysis of voluntary muscles e.g. arms, legs & face last from half second to 10 minutes, one or twice a year

16. Hypnagogic hallucinations: " Disturbing or frightening dream that occur as client is a falling a sleep

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Assessment of sleep habits Let the client record the times of going to sleep and

awakening periods, including naps.

Allow client to described their sleep habits in their own

words

You can ask the following questions: How have you been sleeping?‖ Can you tell me about your sleeping habits?" Are you getting enough rest?" Tell me about your sleep problem"

Good History includes: a general sleep history,

psychological history, and a drug history45


Chapter (5)Nursing Health History

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Definition of Health History

Systematic collection of subjective data which stated by the client, and objective data which observed by the nurse

That using to determine a client functional health pattern status.

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Phases of taking health history

Two phases:-

The interview phase which elicits the

information (primary sources)

The recording phase (secondary sources).

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Guidelines for Taking Nursing History

Private, comfortable, and quiet environment.

Allow the client to state problems and expectations for the interview.

Orient the client the structure, purposes, and expectations of the history.

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Guidelines for Taking Nursing History cont..

Communicate and negotiate priorities with the client

Listen more than talk.

Observe non verbal communications e.g. "body language, voice tone, and appearance".

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Review information about past health history

before starting interview.

Balance between allowing a client to talk in an

unstructured manner and the need to structure

requested information.

Clarify the client's definitions (terms &

descriptors)

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Avoid yes or no question (when detailed

information is desired).

Write adequate notes for recording?

Record nursing health history soon after

interview.

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Types of Nursing Health History

Complete health history: taken on initial visits

to health care facilities.

Interval health history: collect information in

visits following the initial data base is collected.Problem- focused health history: collect data about a specific problem

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Components of Health History

1-Biographical Data: This includesFull nameAddress and telephone numbers (client's permanent contact of client) Birth date and birth place. Sex Religion and race.Marital status.Social security number.Occupation (usual and present)Source of referral. Usual source of healthcareSource and reliability of information.Date of interview.

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2- Chief Complaint: “Reason For Hospitalization

Examples of chief complaints:

Chest pain for 3 days.

Swollen ankles for 2 weeks.

Fever and headache for 24 hours.

Pap smear needed.

Physical examination needed for camp.

SYMPTOM ANALYSIS

P Q R S Ta. Provocative or Palliativea. Provocative or Palliative

First occurrence :First occurrence : What were you doing when you first

experienced or noticed the symptom? What to trigger it ? stress? Position?, activity?What seems to cause it or make it worse? For

a psychological symptom .What relieves the symptom : change diet?

Change position ? Take medication ? Being active?

Aggravation:Aggravation: what makes the symptom worse?

SYMPTOM ANALYSIS

P Q R S Tb. Quality Or Quantity b. Quality Or Quantity

QUALITY:

How would you describe the symptom- how it

feels, looks, or sounds?QUANTITY:

How much are you experiencing now?

Is it so much that it prevents you from

performing any activity?

SYMPTOM ANALYSIS P Q R S T

C. Region Or RadiationC. Region Or Radiation

RegionRegion : : Where does the symptom occur?Where does the symptom occur?

Radiation : Radiation : Does it travel down your back or arm, up Does it travel down your back or arm, up

your neck or down your legs?your neck or down your legs?

SYMPTOM ANALYSIS

P Q R S T

d. Severity scale

Severity

How bad is symptom at its worst?

CourseDoes the symptom seem to be getting

better, getting worse?

SYMPTOM ANALYSIS P Q R S Te. Timinge. Timing Onset :Onset : On what date did the symptom first occur

Type of onset :Type of onset : How did the symptom start sudden? Gradually?Frequency :Frequency : How often do you experience the symptom ;

hourly ? Daily ? Weekly? monthly Duration :Duration : How long does an episode of the symptom last

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3-History of present illness

Gathering information relevant to the

chief complaint, and the client's

problem, including essential and

relevant data, and self medical

treatment.

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Component of Present Illness

Introduction: "client's summary and usual health".Investigation of symptoms: "onset, date, gradual or sudden, duration, frequency, location, quality, and alleviating or aggravating factors".Negative information.Relevant family information.Disability "affected the client's total life".

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4- Past Health History:

The purpose: (to identify all major past health problems of the client)

This includes:

Childhood illness e.g. history of rheumatic

fever.

History of accidents and disabling injuries

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Past Health History. Cont…

History of hospitalization (time of admission, date, admitting complaint, discharge diagnosis and follow up care.History of operations "how and why this done"History of immunizations and allergies.Physical examinations and diagnostic tests.

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5-Family History

The purpose: to learn about the general health of

the client's blood relatives, spouse, and

children and to identify any illness of

environmental genetic, or familiar nature that

might have implications for the client's health

problems.

66

Family History. Cont…

Family history of communicable diseases.

Heredity factors associated with causes of some diseases.

Strong family history of certain problems.

Health of family members "maternal, parents, siblings,

aunts, uncles…etc.".

Cause of death of the family members "immediate and

extended family".

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6-Environmental History:

Purpose

“To gather information about surroundings

of the client", including physical,

psychological, social environment, and

presence of hazards, pollutants and safety

measures."

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7- Current Health Information

The purpose is to record major current health related

information.

Allergies: environmental, ingestion, drug, other.

Habits "alcohol, tobacco, drug, caffeine"

Medications taken regularly "by doctor or self prescription

Exercise patterns.

Sleep patterns (daily routine).

The pattern life (sedentary or active)

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8- Psychosocial History:

Includes:How client and his family cope with disease or stress, and how they responses to illness and health.You can assess if there is psychological or social problem and if it affects general health of the client.

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9- Review of Systems (ROS)

Collection of data about the past and the

present of each of the client systems.

(Review of the client’s physical, sociologic,

and psychological health status may identify

hidden problems and provides an opportunity

to indicate client strength and disabilities

Physical Systems

Which includes assessment of:-

General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes and breasts.Assessment of respiratory and cardiovascular system.Assessment of gastrointestinal system.Assessment of urinary system.Assessment of genital system.Assessment of extremities and musculoskeletal system.Assessment of endocrine system.Assessment of heamatoboitic system.

Assessment of social system.

Assessment of psychological system.

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10- Nutritional Health History

“Discussed Before”

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11- Assessment of Interpersonal Factors.

This includes :-

Ethnic and cultural background, spoken language, values,

health habits, and family relationship.

Life style e.g. rest and sleep pattern

Self concept perception of strength, desired changes

Sexuality developmental level and concerns

Stress response coping pattern, support system,

perceptions of current anticipated stressors.


Chapter (6)Functional Health Pattern

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Definition of (NANDA)

The North American Nursing Diagnosis

Association (NANAD 1994) defines a nursing

diagnosis as “A clinical judgments about

individual, family or community response to

actual and potential health problems and life

responses”

Functional health pattern (NANDA)

1- Health Perception-Health Management Pattern2- Nutritional—Metabolic Pattern3- Elimination Pattern4- Activity—Exercise Pattern5- Sexuality—Reproduction Pattern6- Sleep—Rest Pattern7- Sensory—Perceptual Pattern8- Cognitive Pattern9- Role—Relationship Pattern10- Self-Perception-Self-Concept Pattern11- Coping-Stress Tolerance Pattern12- Value—Belief Pattern

Health Perception-Health Management Pattern

1- Determine how the client perceives and manages his or her health.

2- Compliance with current and past nursing and, medical recommendations.

3- The client's ability to perceive the relationship between activities of daily living and health.

Subjective DataClient's Perception of Health:Client's Perception of Health: Describe your health.

Client's Perception of IllnessClient's Perception of Illness Describe your illness or current health problem.

Health Management and HabitsHealth Management and Habits Tell me what you do when you have a health

problem.

Compliance with Prescribed Medications and TreatmentsCompliance with Prescribed Medications and Treatments Have you been able to take your prescribed

medications? If not, what caused your inability to do so?

Objective Data Refer to General Physical Survey

Associated Nursing Diagnoses

Wellness DiagnosesWellness DiagnosesEffective Management of Therapeutic Regimen

Risk Risk DiagnosesDiagnoses Risk for Injury Risk for Suffocation Risk for Trauma

Actual Diagnoses Actual Diagnoses Altered Growth and Development Ineffective Management of Therapeutic Regimen:

Individual Ineffective Management of Therapeutic Regimen:

Family Ineffective Management of Therapeutic Regimen:

Community Noncompliance.

Nutritional-Metabolic Pattern

Assessing the client's nutritional-metabolic pattern is to determine the client's dietary habits and metabolic needs. The conditions of hair, skin, nails, teeth and mucous membranes are assessed.

Subjective DataDietary and Fluid IntakeDietary and Fluid IntakeDescribe the type and amount of food you eat at

breakfast, lunch, and supper on an average dayDo-you take any vitamin supplements? Describe.Do you find it difficult to tolerate certain foods? Specify.Do you ever experience nausea and vomiting? Describe. Do you ever experience abdominal pains? Describe

Condition of SkinCondition of SkinDescribe the condition of your skin.How well and how quickly does your skin heal?Do you have any skin lesions? Describe-Do you have any itching? What do you do for relief?

Condition of Hair and NailsCondition of Hair and NailsHave you had difficulty with scalp itching or sores?Do you use any special hair or scalp care products?Have you noticed any changes in your nails? Color

Cracking? Shape? Lines?

MetabolismWhat would you consider to be your "ideal

weight"?Have you had any recent weight gains or losses?Do you have any intolerance to heat or cold?Have you noted any changes in your eating or

drinking habits? Explain.Have you noticed any voice changes?

Objective Data

Assess the client's temperature, pulse, respirations, and height and weight.

Wellness Diagnoses

0pportunity to enhance nutritional metabolic pattern

Opportunity to enhance effective breastfeeding Opportunity to enhance skin integrity

Risk Diagnoses Risk for Altered Body Temperature

Hypothermia

Risk for Infection

Risk for altered nutrition less than body requirements .Risk for Aspiration

Actual Diagnoses

Fluid Volume Deficit

Fluid Volume Excess

Altered Nutrition: Less than body requirements

Altered Nutrition: More than body requirements

Ineffective Breastfeeding

Altered Oral Mucous MembraneImpaired Skin Integrity.

Elimination Pattern

Adequacy of the client's bowel and bladder.

The client's bowel and urinary habits.

Bowel or urinary problems

Use of urinary or bowel elimination devices.

Subjective Data

Bowel HabitsBowel HabitsHow frequent are your bowel movements?

Do you use laxatives? What kind and how often do

you use them?

Do you use enemas or suppositories? How often and

what kind?

Do you have any discomfort with your bowel

movements? Describe.

Bladder HabitsBladder HabitsHow frequently do you urinate?What is the amount and color of your urine?Do you have any of the following problems with

urinating: Pain? Blood in urine? Difficulty starting a

stream? Incontinence? Voiding frequently at night? Voiding frequently during day? Bladder infections?

Have you ever had a urinary catheter? Describe. When? How long?

Objective DataObjective DataRefer to abdominal assessment, and the rectal

assessment.

Associated nursing-Diagnoses

Wellness DiagnosesWellness Diagnoses

Opportunity to enhance adequate bowel

elimination pattern

Opportunity to enhance adequate urinary

elimination pattern

Risk DiagnosesRisk Diagnoses

Risk for constipation

Risk for altered urinary elimination

Actual DiagnosesActual Diagnoses

Altered Bowel Elimination Constipation

Diarrhea

Bowel Incontinence

Altered Urinary Elimination Patterns of Urinary

Retention

Total Incontinence

Stress Incontinence

Activity-Exercise Pattern

Activities of daily living, including routines of

exercise, leisure, and recreation.

Activities necessary for personal hygiene,

cooking, shopping, eating, maintaining the

home, and working.

An assessment is made of any factors that affect

or interfere with the client's routine activities of

daily living.

Subjective DataDescribe your activities on a normal day. (Including

hygiene activities, eating activities.)Do you have difficulty with any of these self-care

activities? Explain. Does anyone help you with these activities? How?Do you use any special devices to help you with your

activities?Does your current physical health affect any of these

activities e.g. dyspnea, shortness of breath, palpations, chest pain. pain, stiffness, weakness)? Explain.

Occupational ActivitiesDescribe what you do to make a living.Do you feel it has affected your health?How has your health affected your ability to work?

Objective DataRefer to Thoracic and Lung Assessment Cardiac AssessmentPeripheral Vascular Assessment Musculoskeletal Assessment.


Wellness Diagnoses Wellness Diagnoses Opportunity to enhance effective cardiac output Opportunity to enhance effective self-care activities Opportunity to enhance adequate tissue perfusion

Opportunity to enhance effective breathing pattern

Risk Diagnoses

Risk for Disorganized Infant BehaviorRisk for Peripheral Neurovascular DysfunctionRisk for altered respiratory function

Actual DiagnosesActivity IntoleranceImpaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Disuse syndromeImpaired Physical MobilityInability to Sustain Spontaneous VentilationAltered Tissue Perfusion

Sexuality-Reproduction Pattern

Subjective DataSubjective Data

1- Female1- Female

Menstrual history:Menstrual history:

Last cycle begin?

Duration ?

Any change or abnormality ?

Describe any mood changes or discomfort before,

during, or after your cycle

Obstetric history

How many times have you been pregnant?

Describe the outcome of each of your pregnancies.

If you have children, what are the ages and sex of each?

Explain any health problems or concerns you had with

each pregnancy. If pregnant now .

ContraceptionWhat do you or your partner do to prevent pregnancy?

Describe any discomfort or undesirable effects this method

produces.

Have you had any difficulty with fertility? Explain

Do you have or have you ever had a sexually transmitted disease? Describe.

Describe any pain, burning, or discomfort you have while voiding.

Objective DataObjective DataRefer to Breast Assessment, d Abdominal

Assessment, and urinary-Reproductive Assessment

Special problems

Associated nursing Diagnoses

Wellness Diagnosis:Wellness Diagnosis:

Opportunity to enhance sexuality patterns

Risk-Diagnosis Risk-Diagnosis

Risk for altered sexuality pattern

Actual Diagnoses Actual Diagnoses

Sexual Dysfunction, Altered Sexuality

Patterns

Sleep-Rest PatternSubjective dataSubjective data

Sleep Habits:Sleep Habits:

How would you rate the quality of your sleep?

Special ProblemsSpecial ProblemsDo you ever experience difficulty with falling

asleep? Remaining asleep? Do you ever feel fatigued after a sleep period?

Sleep AidsSleep AidsWhat helps you to fall asleep? medications?

reading? relaxation technique? Watching TV? Listening to music?

Objective DataObjective Data

1. Observe appearance

a. Pale b. Puffy eyes with dark circles

2. Observe behavior

a. Yawning

b. Dozing during day

c. Irritability

d. Short attention span

Associated nursing Diagnoses


Opportunity to enhance sleep

Risk DiagnosisRisk Diagnosis

Risk for sleep pattern disturbance

Actual DiagnosisActual Diagnosis::

Sleep Pattern Disturbance.

Sensory-Perceptual PatternSubjective DataSubjective Data

Describe your ability to see, hear, feel, taste, and smell.Describe any difficulty you have with your vision, hearing,

and ability to feel (e.g., touch, pain, heat, cold), taste (salty, sweet, bitter, sour), or smell.

Pain AssessmentPain Assessment Complete Symptom Analysis

Special Aids:Special Aids: What devices (e.g., glasses, contact lenses, hearing

aids) Describe any medications you take to help you with

these problems.

Objective DataObjective DataRefer to the section on Nose and Sinus Assessment, Eye

Assessment, and Ear Assessment.


Wellness Diagnosis:Wellness Diagnosis: Opportunity to enhance comfort level

Risk DiagnosesRisk Diagnoses Risk for pain

Actual DiagnosesActual Diagnoses Pain

Cognitive Pattern


Ability to Understand:Ability to Understand: Explain what your doctor has told you about your

health.

Ability to Communicate:Ability to Communicate: Can you tell me how you feel about your current

state of health?

Ability to Remember:Ability to Remember: Are you able to remember recent events and

events of long ago? Explain.

Ability to Make Decisions:Ability to Make Decisions: Describe how you feel when faced with a decision.

Objective DataObjective Data Refer to the Mental Status Assessment

Associated nursing DiagnosesAssociated nursing Diagnoses

Wellness Diagnosis:Wellness Diagnosis: Opportunity to enhance

cognition

Risk DiagnosisRisk Diagnosis:: Risk for altered thought

processes

Actual Diagnoses:Actual Diagnoses: Acute confusion Chronic Confusion Knowledge Deficit (Specify) Impaired Memory

Role-Relationship Pattern


Perception of Major Roles and Responsibilities in Perception of Major Roles and Responsibilities in

FamilyFamily Describe your family. Are there any major problems now?

Perception of Major Roles and Responsibilities at WorkPerception of Major Roles and Responsibilities at Work Describe your occupation. What is your major responsibility at work?

Perception of Major Social Roles and ResponsibilitiesPerception of Major Social Roles and Responsibilities Describe your neighborhood and the community in which

you live.

Objective DataObjective Data1. Outline a family genogram for your client.2. Observe your client's family members.

Associated Nursing DiagnosesWellness Diagnoses:Wellness Diagnoses: Opportunity to enhance effective relationships Opportunity to enhance effective communication

Risk Diagnoses: Risk Diagnoses: High risk for Loneliness Risk for Altered Parent/Infant/Child Attachment

Actual Diagnoses: Actual Diagnoses: Impaired Verbal Communication Impaired Social Interaction: Social Isolation

Coping-Stress Tolerance Pattern

Subjective DataSubjective DataPerception of Stress and Problems in LifePerception of Stress and Problems in Life Describe what you believe to be the most

stressful situation in your Life. How has your illness affected the stress you feel?

Coping Methods and Support SystemsCoping Methods and Support Systems:: What do you usually do first when faced with a

problem? What helps you to relieve stress and tension? Do you use medication, drugs, or alcohol to help

relieve stress? Explain.

Objective DataObjective Data Refer to the Mental Status Assessment.

Associated nursing DiagnosesAssociated nursing Diagnoses

Wellness DiagnosesWellness Diagnoses Opportunity to enhance effective individual

coping. Opportunity to enhance family coping

Risk Diagnoses:Risk Diagnoses: Risk for self-harm Risk for suicide

Actual DiagnosesActual Diagnoses:: Ineffective Individual Coping Ineffective Family Coping: Disabling

Value-Belief Pattern

Subjective DataSubjective Data Values, Goals, and Philosophical Beliefs

Religious and Spiritual Beliefs:Religious and Spiritual Beliefs: Are there certain health practices or restrictions

that are important for you to follow while you are ill or hospitalized? Explain.

Objective DataObjective Data Observe religious practices Bible , clergy Observe client's behavior for signs of spiritual distress Anxiety, Anger , Depression , Doubt, Hopelessness

and Powerlessness



Potential for Enhanced Spiritual Well-Being

Risk diagnosis:Risk diagnosis:

Risk for spiritual distress

Actual Diagnosis:Actual Diagnosis:

Spiritual disturbance (distress of the

human spirit).


Chapter (7)Physical Assessment Techniques

112

Indications for the Physical Exam

Routine screeningRoutine screening

Eligibility prerequisite for health insurance, military Eligibility prerequisite for health insurance, military

service, job, sports, schoolservice, job, sports, school

Admission to a hospital or long term care facilityAdmission to a hospital or long term care facility

113

STEPS OF ASSESSMENTThinkThink

OrganizeOrganize

Don’t forget…Nutrition / Height & WeightDon’t forget…Nutrition / Height & Weight

Environment:Environment:

Accommodate special needs (cultural sensitivity)Accommodate special needs (cultural sensitivity)

Equipment - clean surface & clean equipment Room - quiet, Equipment - clean surface & clean equipment Room - quiet,

warm & well litwarm & well lit

Maintain privacyMaintain privacy

Observe & ListenObserve & Listen

114

DON’T FORGET

REVIEWING GENERAL INFORMATIONREVIEWING GENERAL INFORMATION

INTRODUCTION TO CLIENTINTRODUCTION TO CLIENT

OBTAINING THE HEALTH HISTORYOBTAINING THE HEALTH HISTORY

PAIN ASSESSMENTPAIN ASSESSMENT

THIS IS KEY TO THIS IS KEY TO HOLISTICHOLISTIC APPROACH APPROACH

Physical Assessment

There are four techniques to use in performing

physical assessment: 1.Inspection

2. Palpation

3. Percussion

4. Auscultation

Note: there are five addition skill known as

olfaction

115

1. Inspection: Inspection is defined as “the use of the senses of

vision, smell and hearing to observe the normal condition or any deviations from normal of various body parts.”

The nurse inspects or looks body parts to detect

normal characteristics or significant physical sings.

Inspection helps to know normal characteristics

before trying to distinguish abnormal findings in

different ages.

The quality of an inspection depends on the nurse's

willingness to spend time doing a thorough job.117

118

Inspection

Use vision, hearing & smellUse vision, hearing & smell

Always firstAlways first

Look for symmetryLook for symmetry

Use good lightingUse good lighting

Use good exposureUse good exposure

119

Principles of Accurate Inspection

Good lightening either day light or artificial light is suitable.Good lightening either day light or artificial light is suitable.

Expose body parts being observed only.Expose body parts being observed only.

look before touching.look before touching.

warm room for examination of the client “not cold not hot". warm room for examination of the client “not cold not hot".

Observe for color, size, location, texture, symmetry, odors, and Observe for color, size, location, texture, symmetry, odors, and

sounds.sounds.

Compare each area inspected with the opposite side of body if Compare each area inspected with the opposite side of body if

possible.possible.

Use pen light to inspect body cavitiesUse pen light to inspect body cavities..

PalpationTouch & feel with hands to determine:Touch & feel with hands to determine:

Texture – use fingertipsTexture – use fingertips (roughness, smoothness). Temperature – use back of handTemperature – use back of hand (warm, hot, cold). MoistureMoisture (dry, wet, or moist). Organ location and sizeOrgan location and size Consistency of structureConsistency of structure (solid, fluid, filled)

Slow and systematicSlow and systematic

Light to deepLight to deepLight palpation (tenderness)Light palpation (tenderness)Deep palpation (abdominal organs/masses)Deep palpation (abdominal organs/masses)

121

Principles for Accurate Palpation Examiner finger nails should be short.Examiner finger nails should be short.

Use sensitive part of the hand.Use sensitive part of the hand.

Light Palpation precedes deep palpation.Light Palpation precedes deep palpation.

Start with light then deep palpationStart with light then deep palpation

Tender area are palpated lastTender area are palpated last

Tell client to take slow deep breath to enhance muscle relaxation.Tell client to take slow deep breath to enhance muscle relaxation.

Examine condition of the abdominal organsExamine condition of the abdominal organs Depressed areas must be approximately “2cm” Depressed areas must be approximately “2cm”

Assess turger of skin measured by lightly grasping the body part Assess turger of skin measured by lightly grasping the body part

with finger tips.with finger tips.

122

Light palpation

123

Deep palpation

PercussionTap a portion of the body to elicit tenderness that varies

with the density of underlying structures.

Percussion denotes location, size and density of

underlying structures, percussion requires dexterity. Methods of percussion: Methods of percussion:

Direct method:Direct method: involving striking the body surface directly with one or two fingers.

Indirect method:Indirect method: performed by placing the middle finger of the examiner’s non dominant hand “pleximeter hand” firmly against the body surface with palm and fingers remaining off the skin, and the tip of the middle finger of the dominant hand “plexor” strikes the base of the distal joint of the pleximeter. Use a quick & sharp stroke

125

Percussion

Description of sounds Sound produced by the body is characterized by

intensity, frequency, duration and quality. Intensity, or loudness, associated with physiologic

sound is low; thus, the use of the stethoscope is needed.

Frequency, or pitch, of physiologic sound is in reality “noise” in that most sounds consist of a frequency spectrum as opposed to the single-frequency sounds that we associate with music or the tuning fork.

Duration relates to the time elapsed from the beginning of the sound till the end of the sound.

Quality of sound relates to overtones that allow one to distinguish between different sounds.

126

127

Sound Intensity Pitch Duration Quality Example

Tympany Loud High Moderate Drum like Large

pneumothorax

Resonance Moderate

to loud

Low Long hollow Normal lung

Hyper-

resonance

Very loud Very

low

Longer

than

resonance

Booming Emphysematous

lung

Dullness Soft to

moderate

High Moderate Thud like Liver

Flatness Soft High Short Flat Muscle

Sounds produced by percussion

Five percussion sounds produced in different body regions

1. Resonant – normal lung1. Resonant – normal lung

2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally 2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally

heard in children and very thin adults , and abnormally in emphysema heard in children and very thin adults , and abnormally in emphysema

3. Tympany : A hollow drum-like sound produced when a gas-containing cavity 3. Tympany : A hollow drum-like sound produced when a gas-containing cavity

is tapped sharply. Tympany is heard if the chest contains free air is tapped sharply. Tympany is heard if the chest contains free air

(pneumothorax) (pneumothorax) or the abdomen is distended with gas air filled (stomach)air filled (stomach)

4. Dull or thud like sounds are normally heard over dense areas such as the heart 4. Dull or thud like sounds are normally heard over dense areas such as the heart

or liver. Dullness replaces resonance when fluid replaces air-containing lung or liver. Dullness replaces resonance when fluid replaces air-containing lung

tissues, such as occurs with pneumonia, pleural effusions, or tumorstissues, such as occurs with pneumonia, pleural effusions, or tumors

5. Flat: shown in no air areas such as thigh muscle, bone and tumor5. Flat: shown in no air areas such as thigh muscle, bone and tumor

Auscultation“To listen for various breath, heart, and bowel

sounds”

Direct or immediate Direct or immediate auscultation is accomplished by the unassisted ear that is without amplifying device. This form of auscultation often involves the application of the ear directly to a body surface where the sound is most prominent.

Mediate auscultation: Mediate auscultation: the use of sound the use of sound augmentation device such as a stethoscope augmentation device such as a stethoscope in the detection of body sounds. in the detection of body sounds.

130

AuscultationListening to body soundsListening to body sounds

Movement of air (lungs)Movement of air (lungs)

Blood flow (heart)Blood flow (heart)

Fluid & gas movement (bowels)Fluid & gas movement (bowels)

Remember the sound changes in Remember the sound changes in

the abdomen…the abdomen…

131

HOW TO BEGIN…Positions for physical exam Positions for physical exam

Using a stethoscope:Using a stethoscope:

Longer the tube – more sound has to travelLonger the tube – more sound has to travel

Hold diaphragm firmly against client’s skin (NOT Hold diaphragm firmly against client’s skin (NOT

THROUGH CLOTHING)THROUGH CLOTHING)

If using bell – less pressureIf using bell – less pressure

Warm in your hands first! Warm in your hands first!

Listen / Concentrate on the soundsListen / Concentrate on the sounds

132

Olfaction

Another skill that used during assessment, certain alteration is body

function create characteristic body odors, smelling can detect

abnormalities that unrecognized by other means.

Assessment of characteristic odors: Alcohol odor from oral cavity means ingestion of

alcohol. Ammonia from urine means urinary tract

infection. Body odor from skin, particularly in areas where

body parts rub together means poor hygiene, excess perspiration (bromidrosis).

Feces odor from wound site means wound abscess, but if this odor from vomitus this means bowel obstruction, and if the odor from rectal area this means fecal incontinence.

Foul–smelling stools in infant from stool means mal absorption syndrome.

Halitosis from oral cavity means poor dental and oral hygiene, gum disease.

Sweet, fruity ketones from oral cavity may be from diabetic acidosis.

Musty odor from casted body part means infection

inside cast. Fetid odor from tracheostomy or mucous secretions

means infection of bronchial tree (pseudomonas bacteria).

Basic Guidelines for physical Assessment

1. Obtain a nursing history and survey2. Maintain privacy.3. Explain the procedure4. Always inspect, palpate, percuss, and then

auscultate except abdominal start with auscultate

5. Compare symmetrical sides6. If abnormality (Symptom analysis )7. Client teaching 8. Allow time for client’s questions.

"RememberRemember: the most important guideline for

adequate physical assessment is conscious,

continuous practice of physical assessment skills".

Variation in physical assessment of the pediatric client.

Sequence of physical assessment is dependent

upon the developmental level of the client.

Allowing time for interaction with the child

prior to beginning the examination helps to

reduce fears.

In certain age groups, portions of assessment

will require physical restraint of the client with

the help of another adult.

Distraction and play should be intermingled throughout the examination to assist in maintaining rapport with the pediatric client.

Involving assistance from the child’s significant caregiver may facilitate a more meaningful examination of the younger client.

The examiner should be prepared to alter the order of the assessment and approach to the child based on the child’s response.

Protest or an uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence, throughout parts or even all the assessment process.

Variations for physical assessment of the geriatric client. Remember: normal variation related to aging may be

observed in all parts of the physical examination.

Dividing the physical assessment into parts in order to

avoid fatigue in the older client.

Provide room with comfortable temperature and no

drafts.Allow sufficient time for client to respond to directions.

If possible assess the elderly clients in a setting where

they have an opportunity to perform normal activities of

daily living in order to determine the client’s optimum

potential.


Chapter (8)Vital Signs and General Assessment

Vital signs and general assessment

Equipment needed: Balance scale. Tape measure. Thermometer. Sphygmomanometer. Stethoscope.

Subjective Data: Reason for seeking health care and major

concern about current health, current age, height, and weight, recent weight changes, fever, history of hypertension, hypertension, difficulty breathing, changes impulse or heart rate.

139

Objective Data:

Observe client from head to toe to note any gross

abnormalities in appearance or behaviors.

Assess vital signs, temperature, pulse, respirations,

and blood pressure to detect any severe deviations

and to acquire base line data.

Weight the client and measure for height with

shoes, and heavy clothing removed.

140

Vital signs (assessment) include:Assessment of temperature, pulse, respiration and blood

pressure are known as life signs. Vital signs are indicators of the body’s physiologic status

and response to physical, environmental and physiologic stressors.

Vital signs reveal the client’s current ability to maintain body temperature regulation, to maintain local and systemic blood flow, and to provide oxygenation of body tissues.

A. TemperatureBody temperature is difference between heat produced

and heat lost. The hypothalamus acts as the body's thermostat to maintain between the body's heat-producing function (metabolism, shivering, muscle contraction, exercise and thyroid activity) and heat losing methods (radiation, convection)141

Method of measurement a. Oral b. Rectal c. Axillary d. Forehead

e.Tympanic Remember Routinely, where accuracy is not crucial, an oral temp will

sufficient. Rectal temperature is the most accurate. Unless contraindicated a rectal temperature is often

preferred.

Factors influencing of temperature Biologic rhythms Gender: women has greater fluctuations in body temperature

than men because change of hormones Environmental effect (hot, cold), Physiologic change(exercise)Drugs and Age (child have slightly higher normal

temperature, elderly people have decrease body temperature).

B. PulseThe pulse reflects the force of the heart contracting. Also

reflects stroke volume, the mount of blood ejected with each contraction.

A pulse deficit (a difference between the apical and radial pulse rate)

Factors influencing of pulse 1. Pain 2. Emotion 3. Exercise 4. Prolong heat application 5. Decrease BP, and increase temperature. 6. Poor oxygen in the blood.Remember Palpate the radial pulse and count for at least "30" second. If the pulse is irregular, count for full minute and note the

number of irregular beats per minute. Note is the pulse against your finger strong or weak

(Amplitude of rhythm)

Rhythm: regular or irregularAmplitude of rhythm Absent 0 Thready 1 Weak 2 Normal 3 Bound 4

Site of pulse Temporal, Carotid, Brachial, Radial, Femoral,

Dorsalis Pedis , Popliteal, Posterior Tibia and Apical. N.B pulse rate is "60-100 b/m" regular in rhythm.

The normal pulse rate varies from a low of 50 bpm in healthy, athletic young adults to rates well in excess of 100 bpm after exercise or during times of excitement144

C. Respiration:Count the number of respiration (rate), in full minute

Respiration: normally "16-20 breath/minute" (for healthy adult person).

Note rhythm (regular or irregular) and depth of breathing (reflects the tidal volume, described as shallow or deep breathing).

Factors influencing of reparation 1. Age Newborn 35 breath / minute , 1 year 30 breath / minute , 6 year 21 breath / minute, 10 year 19 breath / minute , 18 year 16-18 breath / minute 2. Any disease 3. Exercise 4. Emotion

D. Blood pressure: Measure Blood Pressure in both arms. Pulse pressure: the difference between the systolic

and the diastolic pressures (normally is 30 to 40 mm Hg)

Palpate the systolic pressure before using the stethoscope in order to detect an auscultatory gap.

Apply cuff firmly, if too tight (small) it will give falsely high reading.

Use cuff in appropriate size. Note position of client when measuring blood

pressure. Monitor blood pressure after client is seated or

supine quietly for "10" minute. Repeat after two minutes. Then repeat with client

standing.

Factors influencing the BP 1. Age Newborn 40 mmHg/systolic / 20 diastole 1 month 84/54 mmHg 1 year 95 /65 mmHg 6 year 105 / 65 mmHg 10 – 13 year 120 / 80 mmHg 14- 17 year 120/80 mmHg 18 year 120/80 mmHgNormal range 100 – 140mmHg (systolic) and

from 60-90 mmHg/( diastolic)2. Sex 3. Emotion 4. Position:

Laying down 4. After meal 5. Exercise148

Instrumentation used in assessmentInstruments, or “equipments” used during physical

assessment should be readily accessible, clean, in proper working order.

Ophthalmoscope: "lighted instrument for visualization of the eye".

Otoscope: for examination of the ear. Snellen eye chart: used as a screening test for

vision. Nasal speculum: used for assessment of the nose.

Vaginal speculum: examination of the vaginal canal

and cervix. Tuning fork: for testing auditory function and

vibratory perception. Percussion hammer: “reflex hammer” used to test

reflexes and determine tissue density. 149

Positions Each position has it's specialty for parts of examination.

Draping during assessment is used to prevent unnecessary exposure. Drapes may be paper, cloth, or bed linens

I. Sitting positionAreas Assessed: Head and neck, back, posterior thorax and lungs, anterior

thorax and lungs, breasts, axially, heart, vital signs, and upper extremities

Rationale: Sitting upright provides full expansion of lungs and

provides better visualization of symmetry of upper body parts.

Limitations: Physically weakened client may be unable to sit.

Examiner should use supine position with head of bed elevated instead.

II. Supine positionAreas Assessed: Head and neck anterior thorax and

lungs, breasts, axillae, heart, abdomen, extremities, and pulses

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

Limitations: If client becomes short of breath easily, examiner may need to raise head of bed.

III. Dorsal position:Areas Assessed: Head and neck, anterior thorax and

lungs, Breasts, axillae and heart. Rationale: Clients with painful disorders are more

comfortable with knees flexed. Limitations: Position is not used for abdominal

assessment because it promotes contracture of abdominal muscles

IV. Lithotomy position:Areas Assessed: Female genitalia and genital tractRational: This position provides maximal exposure of

genitalia and facilitates insertion of vaginal speculum.Limitations: Lithotomy position is embarrassing and uncomfortable, so

examiner minimizes time that client spends in it. Client is kept well draped.

Client with severe arthritis or other joint deformity may be unable to assume this position.

V. Sims’ position:Areas Assessed: Rectum and vaginaRationale: Flexion of hip and knee improves exposure of

rectal area. Limitations: Joint deformities may hinder client’s ability to bend hip

and knee.

VI. Prone position: Areas Assessed: Musculoskeletal system Rationale: This position is used only to assess extension of

hip joint. Limitations: This position is intolerable for client with

respiratory difficulties.

VII. Knee-chest position:Areas Assessed: Rectum.Rationale: This position provides maximal exposure

of rectal area. Limitations: This position is embarrassing and uncomfortable. Clients with arthritis or other joint deformities may be

unable to assume this position.


Chapter (9)Assessment of Skin, Hair and Nails

Structure of the Integument The skin is the largest organ of the body comprising 15

percent of total body weight. Layers of the skin A. Epidermis B. Dermis C.

Subcutaneous tissueEpidermal appendagesHairNailsGlands: two types of skin glands: 1. Sweat Gland Eccrine sweat glands: are widely distributed and

open directly onto the skin surface Apocrine sweat glands: open into hair follicle in

axillary and genital areas2. Sebaceous glands: Produce sebum(oily secretion)

Functions of skin and epidermal appendages

Barrier to water and electrolyte loss

Regulation of body heat

Sensory organ for touch, temperature, and Pain

Production of protective skin film by eccrine and

sebaceous glands

Participation in production of vitamin

Wound repair

159

Assessing the Integument

1. Subjective data

Skin infection, rashes, lesions, itching.

Precipitating factors: stress, weather, drugs

Changes in skin color, lesions

Amount of sun exposure

Scalp lesions, itching, and infections.

Changes in texture and amount of hair.

Changes in nails and cuticles nail breaking 160

2. History of current symptom Are you having experience of skin problem, such as

rashes, lesionDescribe any birthmarks, tattoos, or molesHave you noticed any changed in your ability to feel

pain, pressure, light touch, or temperature changed? Have you had any hair loss or change in the

condition of your hair?Have you had any change in the condition or

appearance of your nails? Describe any previous problem within the skin, hair

or nails ( past history)Have you ever had any allergic skin reaction to food,

medication, plants? Has anyone in your family had a recent illness, rash,

or other skin problem? (Family history)

3. Physical Assessment

Equipment Penlight Tongue depressor Centimeter rule

Gloves Magnifying glass Flashlight Wood’s lamp

Technique to examination of skin Inspection Palpation Inspections and palpation of skin Color Moisture Temperature

Thickness Turgor Vascular changes Edema

Lesions Skin odors are usually noted in the skin fold. 162

Inspection color of skin

Skin color varies from body part to body part and

from person to person. Assessment first involves area of skin not

exposed to the sun e.g. palms of the hands. Pallor easily perceived in the buccal “mouth”

mucosa particularly in individuals with dark skin. Cyanosis readily seen in area of least

pigmentation e.g. lips, nail beds conjunctiva and palm.

Jaundice or Yellow seen in client’s sclera.

Erythema may indicate circulatory changes164

Palpation moisture of skin

Skin is normally smooth and dry. Skin folds e.g. axillae are normally moist. In presence of lesions or ooze fluid, nurse must

wear gloves to prevent exposure to infections drainage

Moisture indicates: 1- Degree of client’s hydration 2- Condition of the outer lipid layer of the skin

surface

Dry (xerosis): Vitamin A def. and Myxedema

Oily: Acne166

Palpation of TemperatureTemperature of skin depends on the amount of

blood circulating through dermis.

Generalized warmth: (Fever, Hyperthyroidism)

Local warmth: (Inflammation)

Coolness: (Hypothyroidism, Frost bite,

Hypothermia, Shock, Low cardiac output)

Palpation of skin with dorsum of the hand.

Assessment of skin is critical point in some

conditions such as: after cast application, or after

vascular surgery. 167

Palpation of TextureTexture of skin normally smooth, soft and flexible

If any abnormalities in texture found you must ask

the client is he exposed to any recent injury to the

skin?

Nurse determines whether the client’s skin is smooth

or rough, thin or thick, tight or supple (flexible).

Very Soft: (Thyrotoxicosis)

Tight: (Scleroderma = hard skin)

Rough: (Hypothyroidism)

168

Palpation of Turgor

Turgor: is the skin elasticity diminished by edema or dehydration.

Assessment of turgor done by pinching skin between the thumb and forefinger and released.

Normally skin return immediately to its position.

Failure of this process means dehydration.

Decrease in turgor predisposes the client to skin breakdown.

Palpation of Vascularity Vascularity: Assessment of circulation of skin E.g.

petechiae may indicate serous blood clotting disorders, drug reactions or liver disease.

Inspection and Palpation of EdemaEdema : "Build up of fluid in tissues“Inspected for location, color, and shape. Palpates areas of edema to determine mobility,

consistency, and tenderness

Inspection and Palpation of LesionsNormally skin free of lesions except common freckles. If lesion present, inspection must done for distribution,

arrangement, morphology, color and sizePalpation for lesion’s mobility, contour (flat, raised or

depressed) and consistency (soft or hard are indicated). Cancerous lesions frequently undergo changes in color and

size.

Hair and Scalp

Assessment done for distribution, thickness, texture,

and lubrication of the hair.

Some events which affect the distribution of hair over

the body e.g. client with hormone disorders, woman

with hirsutism

Amount of hair covering extremities may be reduced

as a result of aging and arterial insufficiency especially

in lower limbs.

Scaliness or dryness of the scalp is frequently caused

by dandruff or psoriasis. 171

Nails Assessment

Nails reflect an individual's general state of health, state of nutrition, and occupation.

Nails are normally transparent, smooth, and convex, with a nail bed angle of about 160 degrees.

The surrounding cuticles are smooth, intact and without inflammation.

Nail bed is normally firm on palpation.

Nails normally grow at a constant rate.

Abnormal condition of nailAnonychia: complete absence of nails

Platunychia: flatting nails

Koilonychia : nails like spoon shape (iron deficiencies

anemia)

Racket nail: fattened and expanded nails

Onycholysis: separation of nail form nail bed

(thyrotoxicosis)

Melanoychia: presence of brown color in nails plate

Paronychia: inflammation of tissue surrounding the nail

173


Chapter (10)Assessment of respiratory system

Anatomy of Respiratory System

The lung is a two cone-shaped, elastic structure suspended

within the thoracic cavity.

Lung are paired, they are not complete symmetric, the

right lung contain three lobe, whereas the left lung contain

only two lobes.

The apex of each lung extended slightly above the clavicle,

where the base is at the level of diaphragm

The thoracic cavity contains the nasopharynx, larynx,

trachea, bronchi, bronchioles, alveoli.

The thoracic cavity is lined by a thin, double- layered

serous membrane collectively called the pleural membrane176

Assessment of respiratory system

Subjective data: the nurse must ask the client about:-

Coughing (productive, non productive)

Sputum (type & amount)

Allergies, dyspnea or SOB (at rest or on exertion).

Chest pain, history of asthma, bronchitis, emphysema,

tuberculosis.

Cyanosis, pallor.

Exposure to environmental inhalants (chemicals,

fumes).

History of smoking (amount and length of time) 179

Technique for Respiratory Exam

Before beginning, if possible:

Quiet environment

Proper positioning (patient sitting for posterior thorax exam,

supine for anterior thorax exam)

Expose skin for auscultation

Patient comfort, warm hands and diaphragm of

stethoscope, be considerate of women (drape sheet to

cover chest)

After that the nurse should apply the four

techniques; Inspection, Palpation, Percussion and

Auscultation180

Initial Respiratory Survey (Inspection)Observe the patient’s breathing pattern

Rate (normal vs. increased/decreased) Depth (shallow vs. deep)Effort (any sign of accessory muscle use, inspect

neck)Assess the patient’s color

Cyanosis Normal Respiratory Rates

Infant 30-60Toddler 24-40Preschooler 22-34School-age child 18-30Adolescent 12-16Adult 16-20 181

Inspection and assessment of respiration patterns

Assess the skin and overall symmetry and integrity of the thorax.

Assess thoracic configuration. Client must be uncovered to the waist, and in sitting

position without support. Observation of skin may give you knowledge about

nutritional status of the client. Anterior- posterior diameter of thorax in normal person

less than the transverse diameter = (1:2).Assess for abnormality of configuration, e.g. pigeon

chest, funnel chest, spinal deformities. Assess ribs and inter spaces on respiration – may give

information about obstruction in air flow e.g. bulging of inter spaces on expiration may be from obstruction to air out flow “tumor, aneurysm, cardiac enlargement”

Assess pattern of respiration

Normally: men and children – breathe

diaphragmatically and Women breathe thoracically

or costally.

Tachypnea: respiratory rate over than 20/m for adult.

Bradypnea: respiratory rate less than 10/m.

Palpation: palpate areas of chest especially areas of

abnormalities.

If clients complains: all chest areas must palpated

carefully for tenderness, bulges, or any movements

183

Assess thoracic expansion: Anterior: put your hands over anterior-lateral

chest and thumbs extended along costal margin pointing to xiphoid process.

Posterior: thumbs placed at level of T 10 with palms placed on posterior-lateral chest.

By two ways you feel amount of thoracic expansion during quiet and deep breathing, and symmetry of respiration between left and right hemi thoraces.

Assessment of fremitus: which is vibration perceptible on palpation"

In subcutaneous emphysema: you must palpate the tissue, audible cracking sounds are heard – these sounds are termed Crepitation184

Percussion of chest: Done to determine relative amounts of air, liquid, or solid

material in the underlying lung, and to determine positions and boundaries of organs.

Percussion done for posterior and anterior and lateral aspects of chest with all directions, and with about “5”cms intervals.

Auscultation: To obtains information about the function of respiratory

system & to detect any obstruction in the passages. Instruct the client to breathe through the mouth more

deeply and slowly than in usual respiration and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli.

Auscultate all areas of chest for at least one complete respiration: 12 anterior locations and 14 posterior locations

Auscultate symmetrically: Should listen to at least 6 locations anteriorly and posteriorly

Breathe sounds: are analyzed according to pitch, intensity, quality, and relative duration of inspiratory and expiratory phases.

Bronchial breathe sounds: are normally heard over manubrium of sternum

If heard over lung tissue – indicate pathologic condition, these sounds “high-pitched loud sounds with decrease inspiratory and lengthened increase expiratory phases.

Absent or decreased breath sounds can occur in: Foreign body. Bronchial obstruction. Shallow breathing. Emphysema

188

Breath SoundsNormal breath sounds are distinguished by their

location over a specific area of the lung and are identified as tracheal, vesicular, bronchovesicular, and bronchial (tubular) breath sounds as the next:

1. TrachealVery loud, high pitched soundInspiratory = Expiratory sound durationHeard over trachea in the neck2. BronchialLoud, high pitched soundExpiratory sounds > Inspiratory soundsHeard over manubrium of sternumIf heard in any other location suggestive of

consolidation189

3. Bronchovesicular Intermediate intensity, intermediate pitchInspiratory = Expiratory sound durationHeard best 1st and 2nd ICS anteriorly, and

between scapula posteriorlyIf heard in any other location suggestive of

consolidation

4. VesicularSoft, low pitched soundInspiratory > Expiratory soundsMajor normal breath sound, heard over most of

lungs

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Adventitious Breath SoundsAn abnormal condition that affects the bronchial tree

and alveoli may produce adventitious (abnrmal= addtional) sounds. Adventitious sounds are divided into two categories: discrete, noncontinuous sounds (crackles) and continuous musical sounds (wheezes) as the next:

1. Crackles (Rales)Discontinuous, intermittent, nonmusical, brief

sounds. Heard more commonly with inspirationClassified as fine or coarse Its may associated with Prolonged recumbency Crackles caused by air moving through secretions

and collapsed alveoli and associated with the following conditions: pulmonary edema, early CHF, and pnumonia

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2. WheezeContinuous, high pitched, musical sound, longer than

cracklesWhistle quality, heard during expiration, however,

can be heard on inspirationProduced when air flows through narrowed airwaysAssociated conditions: asthma, chronic bronchitis,

and COPD

3. Rhonchi Similar to wheezes (subtype of wheeze)Low pitched, snoring quality, continuous, musical

soundsImplies obstruction of larger airways by secretionsAssociated condition: acute bronchitis

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4. Stridor Inspiratory musical wheezeLoudest over tracheaSuggests obstructed trachea or larynxMedical emergency requiring immediate attentionAssociated condition inhaled foreign body

5. Pleural Friction RubPleural friction rubs are specific examples of crackles.

Discontinuous or continuous brushing soundsIt is a loud dry, cracking or grating sound indicating of

pleural irritation, heard over lateral and anterior lung in sitting position that heard during both inspiratory and expiratory phases

Occurs when pleural surfaces are inflamed and rub against each other

Associated conditions as pleural effusion, Pneumonothorax

Medical conditions associated with decreased or absent of breath sounds

Asthma COPD Pleural Effusion: fluid accumulating within the

pleural spacePneumothorax: caused by accumulation of air or

gas in the pleural space. ARDS( adult respiratory distress syndrome)Atelectasis : is defined as a state in which the lung,

in whole or in part, is collapsed or without air entery

Five Main Symptoms of Respiratory DiseaseCough Sputum PainBreathlessness Wheeze


Chapter (11)Head Assessment, face and neck

Assessment of the Head Inspects the size, shape, and contour of head. The skull is generally round with anterior & posterior

prominences. Large infant's head may be hydrocephalus. Large adult's head & facial bones resulting of

acromegaly. Palpates the skull for nodules or masses Assessment of the eye Assess external eye structures and pupils, visual acuity,

ocular movements, Peripheral vision.Assessment of external eye structures: position and

alignment of eyes, eye brow, eye lids, eye lashes, lacrimal glands, pupils and iris.

Assessment of pupils done by using penlight which produce constriction of pupils to show accommodation and convergence of pupils.

Assess internal eye structures e.g. iris , retina, macula etc

Consider the following Factors:Age use of corrective lens, artificial eye, allergies, pain,

visual disturbances Health related factors such increase Blood Pressure, or

Diabetes mellitus Using the following equipment to assess the eyes:

Eye chart (Snellen chart), Chart or newsprint.Cover card.Penlight, and ophthalmoscope

Ask the client about history of previous eye surgery, trauma, use of corrective glasses or contact lenses, blurred vision, Diplopia, strabismus, recent changes in vision, date of previous vision test, allergies, eye redness, and frequent watering discharge

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Assess Visual Acuity: Done by placing the client 20

feet from the Snellen eye chart and testing each eye alone.

Assess extra ocular movements by asking client to hold his head and follow movements of your forefinger.

Assess peripheral vision: “Visual fields” Hemianopsia: blindness of 1/2

field in one or both eyes.Quadrantanopsia: blindness of

1/4 of visual field in one or both eyes.

Ascotoma: Island like blindness in visual field

Ear AssessmentTake history of ear surgery, trauma, frequent infection,

ear pain, drainage, hearing loss, tinnitus, vertigo, ototoxic medications, and last hearing examination

Assess client in sitting position & inspects the auricle’s placement, size, symmetry, and color.

Redness: sign of inflammation or fever. Color of ears must be the same as of the face.

Pallor: indicate frost bite. Palpate the auricles for texture, tenderness, and skin

lesion. If client complains of pain: pull the auricle and press

on the tragus and behind the ear over the mastoid process if pain increase, means external ear infection, if pain is not increase, means middle ear infection may be present. 199

Inspection the ear canal for size and discharge. Assessment of cerumen if it is yellow or green

may indicate infection. Assessment of hearing acuity: done simply by

identification of voice tones, with the client repeating testing words spoken by the nurse (whisper test)

N.B: deeper structure and middle ear can be observed only by otoscope.

Whisper Test (patient with normal acuity can correctly repeat what was whispered)

Weber Test (uses bone conduction to test lateralization of sound by a tuning fork)

Rinne Test (useful for distinguishing between conductive and sensorineural hearing losses)200

Weber Test: A tuning fork, set in motion by grasping it firmly by its stem and tapping it on the examiner’s hand, is placed on the patient’s head.

A person with normal hearing will hear the sound equally in both ears or describe the sound as centered in the middle of the head.

In an abnormal patient, the sound is heard louder in one ear (lateralization).

Rinne TestThe examiner shifts the stem of a vibrating tuning fork between

two positions: 2 inches from the opening of the ear canal (for air conduction) and against the mastoid bone (for bone conduction). Patient is asked to indicate which tone is louder or when the tone is no longer audible.

Normally, sound heard by air conduction is audible longer and louder than sound heard by bone conduction.

With a conductive hearing loss, bone-conducted sound is heard longer than air-conducted sound

With a sensorineural hearing loss, air-conducted sound is audible longer than bone conducted sound.

The Otoscope ExaminationUsing the Otoscope :

Otoscope should be held in the examiner’s right hand, in a pencil-hold position, with the bottom of the scope pointing up. This position prevents the examiner from inserting the otoscope too far into the external canal. Choose the largest appropriate speculum

Using the opposite hand, the auricle is grasped and gently pulled upper and back to straighten the canal in the adult, while pulled down and back in infant and child ( <3 age )

The External Canal : Redness / swelling / lesion / foreign body / discharge

Tympanic Membrane : Color / character / perforation The healthy tympanic membrane is shiny, translucent ,

pearl-gray color Cone-shaped light reflex

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Assessment of the noseFunctions of the nose 1. Identify odors (upper 1/3 of septum) 2. Air passageway (obligate in newborns) 3. Air conditioning: humidify, warms/cools air, cleans and filters air of dust and most bacteria and voice resonanceInspect and Palpate External Nose 1) Symmetric, in the midline, skin lesion, pain

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Nostril patency:Inspect & observe symmetry, inflammation &

deformity. In case of swelling or deformities of nose, the nose is

palpated gently for tenderness, swelling and underlying deviations.

Normally the external nose is symmetrical, strait, non tender, and without discharge.

Assess mucosa which is normally pink in color. Yellowish or greenish discharge – means sinus

infection. Pale mucosa with clear discharge – means allergy. For client with NGT, nurse should routinely checks

for local breakdown of skin “Excoriation” of the nostril that characterized by redness and sloughing of the skin 206

Assessment of the sinusesFrontal and maxillary sinuses are examined for pain and

edema.Palpate sinuses both frontal (below the eyebrow) and

maxillary (below cheekbones) for tenderness, which verbalized by client during exam.

Percuss sinuses for resonance which is normally hollow tone, and noting abnormality e.g. flat, dull tone elicited or expresses pain on percussion

Transillumination sinusitis: is the transmission of light through tissues of the body. A common example is the transmission of a flash of light through fingers, producing a red glow. This is because red blood cells absorbed other colors of the beam and transmitted only the red component. Absence of light indicates mucosal thickening or the cavity is likely contain fluid or pus sinuses207

Assessment of Mouth and pharynx1. Assessment of oral cavity can be made during

administration of oral hygiene. Lips – inspected for color, texture, hydration, contour, and

lesions. Inner and buccal mucosa, Gums and teeth inspected for

color, hydration, texture and lesions e.g. ulcers, abrasions or crusts.

Tongue and floor of mouth can carefully inspect. Assessment of palate “soft and hard” by extending client’s

backward, assessment for color, shape, texture, and extra bony prominences or defects

2. Assessment of PharynxAssessment for pharynx done: by using tongue depressors. Pharyngeal tissues are normally pink and smooth. Edema, ulceration, or inflammation indicates infections or

abnormal lesions

Assessment of NeckAssessment done by inspection and palpation that the

client placed in a sitting positionAssess neck muscles, trachea, thyroid gland, carotid

arteries and jugular veins, cervical lymph nodes and cervical vertebrae.

Assess neck size and position of trachea and thyroidAssess range of motion by asking the client to tilt the

head backward and side to sideAssess lymph nodes and venous distention.

Normally:Neck should be symmetrical with full range of motion.No neck vein distention should be visible. Inspect and palpate cervical vertebrae Assess the posterior aspects of the neck for symmetry,

tenderness, masses or swelling.

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Thyroid gland is assessed by palpation, observation and auscultation.

Normal thyroid gland is not palpable. The isthmus is the only portion of the thyroid that is normally palpable

Palpation – for gland itself. If enlargement of thyroid gland is detected, the area over the gland is auscultated for a bruit

Bruit: vibrations sound of blood flow through arteries. In enlarged gland, heard with the diaphragm of stethoscope (This abnormal finding)

TracheaTrachea normally centered; (at the suprasternal notch) The cartilages should be smooth, non tender and move

easily under examiner’s fingers when the client swallowPalpation done by placing the thumb and forefinger on

each side of the trachea

Assessment of the lymphatic systemLymphatic System consists of a network of collecting

ducts, lymph fluids e.g. spleen, thymus, tonsils, adenoids--- etc

Functions of lymphatic system Movement and transportation of lymphocytes Production of lymphocytes.Production of antibodies.Phagocytosis Absorption of fat and fat soluble substances.

Enlargement of lymph node: provides early indication of infection or malignancy.

Examination of lymphatic System : 2 stepsFirstly inspection for enlarged lymph nodes, skin lesions and

edema Secondly palpating gently the lymph nodes areas using

pads of "2, 3, 4" fingers in gentle circular motion. Press lightly and then increasing pressure gradually. Move skin lightly over the under lying tissues & not moving

the examining fingers over the skin. Large nodes due to malignancy are generally not tender

vary in size, hard, asymmetrical

Some Areas of lymph nodes Pre auricular: in front of the ear. Mastoid or posterior auricular – behind the ear. Above the

mastoid process. Occipital – at the base of skull posterior. Parotid – near the angle of the jaw.

Sub-mandibular – midway between angle of jaw and the tip of the mandible.

Submentum – in the midline posterior to the tip of the mandible.

Anterior superficial nodes – in the anterior triangle of the neck.

Posterior cervical nodes – in the posterior triangle of the neck.

Deep cervical nodes – very deep and difficult to be examine.

Supra clavicular or scalene nodes – In the angle formed by clavicle and Sternocleidomastoid muscle.

Axilla, breast & Lower extremity (inguinal and popliteal nodes)

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Chapter (12)Assessment of the breast

Assessment of the breastThe breasts, or mammary glands, are highly

specialized glands, which extend laterally from edges of the sternum to the anterior axillary fold.

They are located between the third and seventh ribs on the anterior chest wall. Each breast is divided into 15 to 20 irregularly shaped lobes separated by fibro elastic and adipose tissues. The areola is a roughened, segmented, circular formation, which surround the nipple.

Subjective data Tenderness, pain, swelling, or change in size of

breasts.Change in position of nipple or nipple discharge.Presence of cysts, lumps, and lesions.History of prior breast surgery 217

Female breast: Inspection: Best done in sitting position with arms relaxed

at sidesCarefully observe the breasts for symmetry. The normal

breasts may be slightly different in size. If necessary, reassure the patient that any difference in size is normal.

Inspect Areola and nipples for position, pigmentation, inversion, discharge, crusting & masses.

Examine the breast tissue for size, shape, color, and contour

Assess level of breasts, notes any retractions or dimpling of the skin.

Ask client to elevate her hands over her head, repeat the observation.

Ask client to press her hands to her hips and repeat observation.

Inspect the axilla for: rashes, signs of infection and unusual pigmentation

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Palpation: Best done in recumbent position: Raise the arm of client on the side of the breast being

palpated above client’s head.Palpate the breast from less painful or less diseased area

(Use on palpation palmer aspects of the fingers in a rotating motion, compressing the breast tissue against the chest wall, this is done quadrant by until the entire breast has been palpated.

Note skin texture, moisture, temperature, or masses.Gently squeeze the nipple and note any expressible

discharge. "Normally not present in non lactating women".

Repeat examination on the opposite breast & compare findings.

If mass is palpated, its location, size, shape, consistency, mobility and associated tenderness are reported

Remember the breast may feel slightly more fibrotic or be somewhat tender just prior to or during the menses.

Male Breast: Examination of male breast can be brief and

should never be omitted.Observe nipple & areola for ulceration,

nodules, swelling or discharge Instruct the patient to raise both arms,

exposing the skin of the axilla. Carefully inspect the axilla for: rashes, signs of infection and unusual pigmentation

Palpate the areola for nodules or tenderness

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Chapter (13)Assessment of Cardiovascular System

Anatomy of the HeartRight Atrium Right VentricleLeft Ventricle Left AtriumSuperior and Inferior Vena

Cava Pulmonary Artery Pulmonary Vein Aorta

TWO PUMPSRight side pumps blood

to lungsLeft side pumps blood

to body

FOUR VALVES Two Atrioventricular Valve (AV)

Tricuspid Valve (right atrioventricular valve) Mitral (left atrioventricular valve)

Two Semilunar Valve (SL) Aortic valve (left semilunar valve) Pulmonary valve (right semilunar valve)

Subjective data: 1. Assessment of chief complaints:

Chest pain: location, quality, duration & associated symptoms.

Irregular heart beat: too fast, jump etc.

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2. Assessment of risk factors:- Ask about history of hypertension, diabetes, and rheumatic

feverAsk about family history of heart attack, hypertension,

stroke, and diabetes Describe your nutritional intake: high cholesterol,

triglyceride level.Do you smoke? How much? And for how long?How do you view yourself? What do you do to relax?How many hours a day do you work? How do cope with

stress. Exercise: what do you do for exercise? How often? Pain in calves, feet, buttocks or legs? What aggravates the

pain (walking, sitting long periods, standing long periods, sleep) what relieves the pain “elevating legs, rest, lying down”.

In what type of chair does client usually sit? Does he/she cross legs frequently?

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Inspection:

Assessment the client must be is in supine or sitting

positing according to his health

By inspection and palpation you may detect ventricular

hypertrophy.

Use source of light to inspect subtle movements in

chest e.g.: pulsation, retraction etc.

Apical pulse in left fifth intercostal space, if deviation in

site observed may indicate cardiac enlargement 6th

intercostal space.

Retractions may be seen around site of apical pulse,

marked retraction may indicate pericardial disease. 225

Palpation (supine position)Palpate from apex, moving to external border to baseDetect abnormalities in site of palpation and abnormal

sounds especially for thrill “abnormal flow of blood”Describe in terms: locations of pulsation in relation to

mid-sternal, mid-clavicular or axillary lines. Palpation of apical pulse, strength differs from thin

person to obese. Conditions such as anxiety, anemia, fever, and

hyperthyroidism may increase in force and duration of apical pulse (you feel lifting sensation under your fingers).

Palpation of pulse at base of the heart (putting your hand at second left intercostal spaces at sternal borders).

Percussion: “not used in cardiac assessment”

Auscultation: All heart sounds are generally low pitched “low frequency”

and difficult for the human ear to hear. Auscultation can be started from base to apex or from apex to

the base. Assess: Rate and rhythm of the heart beat.Concentrates initially on sound "1", noting its intensity and

variations, possible duplication and effects of respiration. Sound 1 caused by the closing of the tricuspid and mitral

valves. Systole begins with Sound "1" & extends to Sound "2"Then listen to Sound "2" for same characteristics.Sound "2": results from closing of the aortic & pulmonary

valvesDiastole begins with Sound "2" and extends to next Sound "1"Sound "2" louder than Sound "1" at the base of heart, and is

lighter than Sound "1" at the apex.

Finally listen for extra sounds and for murmurs Sound "3": During diastole, rapid filling and

distention of ventricles occur causes vibrations of ventricular walls" and this known as sound "3" ". Sound "3" best heard at the apex with bell of stethoscope. Its indicate Pathological alterations in ventricular filling in early diastole. it represents a normal finding in children

Sound "4": occur after Sound "3" (late diastolic filling), occur from vibrations of ventricular wall or vibrations of the valves. It’s usually associated with cardiac disease, often that with altered ventricular compliance

Gallop Sound: a gallop characterized by the superimposition of abnormal third and fourth heart sounds, usually indicative of myocardial disease.

Heart murmurs (abnormal sounds produced by vibrations within the heart or in the walls of large vessels “during systole or diastole”.

Murmurs occurrence result from valve defects, changes in the blood vessels or an increased flow of blood through a normal structure (eg, with fever, pregnancy, hyperthyroidism).

Special maneuvers for vascular

assessment Check for deep phlebitis by quickly squeezing

calf muscles against tibia (normally no pain)Check Homan's sign by extending leg and

dorsi-flexing foot (normally no pain).229

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Arterial and venous insufficiency of lower extremities


Chapter (14)Assessment of the abdomen

Assessment of the abdomen

The abdomen is the largest body cavity that extends from the diaphragm inferiorly to the inlet of the true pelvis. Its contents are partially protected:

Superiorly by the lower ribs. Posterior by the lumbar

vertebra. Laterally by the iliac bones

Abdomen RegionsDivisions of the abdomen Four Quadrants. Nine regions.

Locating Abdominal Structure By Quadrant1. Right Upper Quadrant (RUQ)Ascending and transverse colon Duodenum Gallbladder Liver , head of pancreas Right of

adrenal gland The small intestine or ileum in all quadrant Right kidney (upper pole) and right ureter

2. Right Lower Quadrant (RLQ)Appendix Ascending colon , Cecum Right kidney lower pole Right ovary and tube, right ureter, and right

spermatic cord233

3. Left Upper Quadrant (LUQ) contains of:Left of adrenal glandLeft kidney (upper pole)Left ureter Pancreas (body and

tail)Spleen Stomach Transverse ascending colon

4. Left Lower Quadrant (LLQ) contains of:Left kidney (lower pole)Left ovary and tube Left spermatic cord Sigmoid colon 5. Midline Balder , Uterus , Prostate gland

Assessment Procedures Subjective data: ask the client about:Nutritional history: appetite, weight loss or gain.Gastro intestinal symptoms: dysphagia, nausea, vomiting, and

indigestion.Bowel habits: pattern, and stool characteristics.Pain: location, quality, pattern, and relationship to ingestion of food.Use of medications: Aspirin, Anti inflammatory drugs, and steroids.Gastro intestinal diagnostic tests and surgeries.The client is placed in the supine position, with small pillows under

the head and knees. The abdomen is exposed from the breast to the symphysis pubisStart assessment with inspection, auscultation, then percussion and

palpation. Stand the client right side and carry out assessment systematically,

beginning with the left upper quadrant. The bladder should be empty.

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Inspection: Under source of light you see exactly changes in contours. Assess the presence or absence of symmetry, distention,

masses, visible peristaltic waves and respiratory movement.

Inspect the abdominal skin for pigmentation e.g. jaundice, lesions, striae scars, dehydration, general nutritional status and condition of umbilicus, this give information about general state health

Contour of the normal abdomen is described as: flat, rounded, or scaphoid. Normally contour is description of the profile line from the rib margin to the pubic bone.

Flat contour seen in the muscularly competent and well nourished individual.

Rounded abdomen: Normally in infant and toddler, but in the adult caused by poor muscle tone and excessive Subcutaneous fat deposition.

Scaphoid contour “Concave in horizontal line” seen in thin clients of all ages.

Inspect for respiratory movements especially for retraction of the abdominal wall on inspiration which is called "Czerny's sign “associated with some Central Nervous System diseases such as chorea”

Auscultation: Auscultate peristaltic sounds which are normally high

pitched.Listen for at least "5" minutes before concluding that no

bowel sounds are present. "Peristaltic sounds may be quite irregular".

Duration of single sound may be less than a second or more than it.

Stimulation of peristalsis may be achieved by flicking the abdominal wall with a finger “direct percussion

Auscultate vascular sounds: Loud bruits detected over the aorta may indicate presence of an aneurysm; the aorta is auscultated superior to the umbilicus

Listen for Peritoneal friction rub over the area of liver and spleen e.g. spleen infection, abscess or tumor: best heard over the lower rib cage in the anterior axillary line. (rough grating sound like sound of two pieces of leather being rubbed together). 237

Percussion: To detecting fluid or gaseous distention and masses and

assessing solid structures within the abdomen. Percussion of one for each quadrant to assess areas of

tympany and dullness. Potentially painful areas are always Percuss last

Percussion allows you to identity borders of the liver to detect organ enlargement.

To detect liver size, start percussion at the right iliac crest and proceeds up ward on the right mid-clavicular line, when dullness occur this is the lower border of the liver.

To detect upper border of the liver percuss, down from the nipple along mid-clavicular line, then dullness occur “upper border” may be found in (5,6,7) intercostals space, distance between points lower and upper is (6-12cm). Diseases e.g. cirrhosis, cancer, and hepatitis cause liver enlargement

Stomach position: With percussion you can locate the tympanic air bubble of

the stomach by percussing over the left lower anterior rib cage.

Kidney Tenderness: In sitting or erect position, use direct or indirect percussion

to assess for kidney inflammation. Use ulnar surface of the partially closed fist and percuss

the costo-vertebral angle at the scapular line. If the kidneys are inflamed, client feels tenderness during

percussion

Palpation: Detect abdominal tenderness and noting the quality of

abnormal distensions or masses. During palpation assess for muscular resistance,

distention, tenderness and superficial organs or masses. Assess for distended bladder if client has inability to void

(Bladder lies normally below the umbilicus and above symphysis pubis).

In deep palpation depress hands (2.5-7.5 cm), "1-3 inch" Deep palpation never used over a surgical incision or tender organs, or masses.

If tenderness present, check for rebound tenderness, if it was positive indicated peritoneal irritation e.g. appendicitis 239

Palpation of liver: Right upper quadrant under the rib cagePlace your left hand under client’s posterior

thorax at the 11th and 12th ribs and by your right hand palpate in and up to feel the liver’s edge as the client inhales.

G.B normally not felt and if distended it felt under liver and may indicate cholecystitis.

Palpation of spleen: Generally not palpable in normal adult person,

but in case of spleen enlargement you can palpate it below costal margin.

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Assessment of the anus and recto sigmoid region

Events required rectal examination: Abdominal painAlternation in bowel habits. Anal pain, anal spasm.Anal itching or burning. Black tary stool. Rectal bleeding. Positions for rectal examinations: Left lateral or SEM's position. Knee- chest position Standing position, most common use for prostate gland

examination. Lithotomy position Squatting position. In all positions, before examination wear two gloves

Inspection: Spread buttocks carefully with both hands to examine the

anus and skin around it which is more pigmented, moist, and hairless.

Assess lesions, scars, or inflammation, peri-rectal abscess, fissures, piles, fistula opening, tumor and rectal prolapsed.

Ask the client to strain down ward as in defecation. Inspect for pilonidal sinus or cyst at the sacro- coccygeal

area, and give description

Palpation: (PR examination) Spread the buttocks apart with your non dominant hand.

Gloved index gently placed against the anal verge, and with firm pressure in direction of umbilicus as the rectal sphincter relaxes. Ask client to lighten the sphincter around your finger to examine muscle strength.

Mucosa of the anal canal is palpated for tumor or polyps. Assess normal cervix in female which felt as small round

mass during P.R examination242

Common diseases can be detected during rectal examination:

Pilonidal cyst or sinus. Pruritus anusRectal tenesmus:. Fecal impaction Anal fissureFistula in anusHemorrhoids: External painful & internal painless

unless complicated. Rectal polypsRectal prolapse: e.g. in case of internal hemorrhoids Anal incontinence. Abscesses or masses e.g. Ischio rectal abscess, peri

rectal obstruction 243


Chapter (15)Assessment of musculo-skeletal system

The primary structures of the musculoskeletal system are the bones, muscles, cartilage, ligaments, tendons and joints.

The bony skeleton provides a sturdy framework to support body structures. The bone matrix stores calcium, phosphorus, magnesium and fluoride.

In addition, the red bone marrow located within bone cavities produces red and white blood cells in a process of hematopoiesis.

There are 206 bones in the human body, divided into four categories.

Long bones (eg, femur)Short bones (eg, metacarpals)Flat bones (eg, sternum)Irregular bones (eg, vertebrae)Assessments are made of muscles, bones and joints. When

assessing the musculoskeletal system keep in mind that injury or inflammation of any part of the system can cause pain, stiffness, or an alteration in motor strength or mobility.245

Musculoskeletal assessment is conducted from head to toe with inspection and palpation

Assessment of musculo-skeletal system done firstly when the client walks, moves in bed or performs any type of physical activity.

The nurse usually assesses the musculoskeletal system for:

Muscle – size, contractures, tremors, muscle tonicity, smoothness of movement and muscle strength.

Bones – skeletal structure, tenderness, edemaJoints – swelling, tenderness, smoothness of

movement, crepitation, nodules, range of motion.

246

Terms used to describe joint movement:Flexion – bend that decrease angle between bonesExtension – straightening a limb to increase the angle of

jointAbduction – moving a limb away from the body’s midlineAdduction – moving a limb towards the body or beyond itInternal rotation – turning a body part towards midlineExternal rotation – turning a body part away from midlineCircumduction – circular movement of a body partSupination – turning the palm upwardsPronation – turning the palm downwardsInversion – turning the hand or foot inward Eversion – turning the hand or foot outward

247

Musculoskeletal AssessmentSubjective data: Observer gait and posture as client walks into room.

Normally the client walks with arms swinging freely at sides and the head and the face leading the body.

Pain: assess pain at rest, with exercise, changes in shape or size of an extremity, changes in mobility to carry out activities of daily living, sports, and works.

Stiffness of jointDecreased or altered or absent sensations.Redness or swelling of joints.History of fractures and orthopedic surgery.Occupational history

248

Objective dataDetermine range of motion, muscle strength and tone, joint

and muscle condition. Muscle problems commonly are manifestations of

neurological disease, so you must do neurological assessment simultaneously.

Joints vary in their degree of mobility, range from freely movable e.g. knee, to slightly movable joints e.g. the spinal vertebra.

During assessment of muscle groups: assess muscle weakness, or swelling, and size, then compare between sides. Joints should not be forced into painful positions.

Loss of height is frequently the first clinical sign of osteoporosis. Small amount of height loss expected with aging.

Ask client to put each joint through its full range of motion, if there is weakness, gently supporting & moving extremities through their Range of motion, to assess abnormalities.

Normal joints are non tender, without swelling and move freely.

In elderly joints often become swollen & stiff, with reduced range of motion, resulting from cartilage erosion and fibrosis of synovial membranes

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Chapter (16)Assessment of Neurological system

Assess this system when doing physical examination e.g. cranial nerve function can be testing during the survey of the head and neck.

The neurological assessment consists of six parts: (mental status, cranial nerves, sensory functions, motor function, cerebellar function, reflexes).

Subjective data: Loss of consciousness, dizziness, and fainting.Headache: precipitating factors and duration.Numbness and tingling or paralysis or neuralgia.Loss of memory, confusion, visual loss, blurring, and

pain.Facial pain, weakness, twitching, speech problems e.g.

aphasia.Swallowing problems and drooling.Neck weakness or spasm 251

Mental and emotional Mental and emotional status is observed as the

nursing history is collected, and by simply interacting with client, e.g. “Nursing care plan”

Level of consciousnessLevel of consciousness ranges from full a

wakening, “alertness” to unresponsiveness to any form of external stimuli.

Alert client responds to questions spontaneously.Assess level of consciousness by using Glasgow

coma scale

252

253

Glasgow coma scale

Assessment of behavior and Appearance Behavior, mood, hygiene, grooming and choice of dress

reveal pertinent information about client’s mental status.

Appearance reflects how a client feels about the self.Personal hygiene such as unkempt hair, a dirty body, or

broken, dirty fingernails should be noted. Language: Assess ability of individual to understand

spoken or written words & how he speak or writes.Assess intellectual function, which includes: memory

“recent, immediate, past”, knowledge, abstract thinking, association and judgment.

Assess for sensory function:Assess sensitivity to light touch “cotton”Assess sensitivity to pain “pinprick” Assess sensitivity to vibrations “tuning fork” Assess sensitivity to positions.Don’t forget comparing both sides of body

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Chapter (17)Assessment of Urinary System

The main function of urinary system is regulation of the fluid and electrolytes composition of the body fluids and removal of metabolic end products from the blood

Nursing History: Normal voiding pattern and frequency (oliguria – urinary

urgency – poyluria – anuria - dysuria –hematuria - enuresis)Appearance of the urine, urine culture and any recent

changes (amount – color). Normal colure yellow-strawFamily history of kidney problems (polycystic kidney and all

types of hereditary nephritis are genetically transmitted, kidney and bladder calculi

The present illness such as pain or burning sensation, UTI, an ostomy.

Past history and current problems with urination: (syphilis, gonorrhea, sexual transmitted disease STD) DM and HTN .

Factors influencing the elimination patternMedications: Diuretics, Psychotropic agents , Anti-

hypertensive256

Medical Terms related to urinary systemDysuria: painful or difficult voidingHematuria: red blood cells in the urine Urgency: strong desired to urinate due to

inflammation in bladder , prostate , urethraPolyuria: abnormal large volume of urine

voided in given time = 2500mlOliguria: small volume of urine between 100-

500 ml Anuria: absence of urine in bladder less than 50

ml Enuresis: involuntary voiding during sleeping.

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Physical Assessment of Urinary SystemInspection Inspection including examination of abdomen and

urethral meatus.Auscultation including renal arteriesPercussion includes the kidneys to detect tendernessPalpation to detect any mass, lumps, tendernessPercussion of the kidneyTo detect areas of tenderness by costovertebral test,

normally will feel a thudding sensation or pressure but not tenderness

Palpation of kidney Contour, size, tenderness, and lump.In adult normal the kidneys not be palpable because

of their location deep with abnormal.Elderly the right kidney is slightly lower than the left,

it may be easier to palpate 258

Percussion of the bladderPercuss the area over the bladder (5cm) above the

symphysis pubis.To detect difference in sound, percuss toward the base of

the bladder.Percussion normally produces a tympanic soundPalpation of bladderNormally feel firm and smooth.In adult bladdre may not be palpableInspection of the urethral meatus Look for swelling, discharge and inflammationAssessment of Urine Urine assessment includes: Measure volume of urineInspect colour, clarity, and volumeTest the specific gravity, glucose, ketone bodies and blood

and pHNormal urine volume 1-2 litter per 24 hours (normal adult)259

Color: typically yellow-straw but varies according to recent diet and concentration of the urine. Drinking more water generally tends to reduce the concentration of the urine and therefore cause it to have a lighter color. (The converse is also true.)

Smell: Generally fresh urine has a mild smell but aged urine has a stronger odor, similar to that of ammonia.

The smell urine may provide health information. For example, urine of diabetics may have a sweet or fruity odor due to the presence of ketones.

Acidity: PH is a measure of the acidity ( or alkalinity0 of a solution. PH is a measure of the activity of hydrogen ions (H+) in a solution

95% Water, 5% chemical solutes. Urea from breakdown of amino acids (protein) to give ammonia + C02 giving urea and creatinine from breakdown of creatine phosphate in muscle

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Collection of urine samplesAll urine tests are ideally performed on fresh

specimemens: Urine container has been adequate protection agonist

bacterial contamination and chemical deterioration Identification or labeled should be provided.The patient should then be gowned for the physical

examinationBring it into the dry room Urine specimens should collect from the patient means of

the clean –catch midstream technique. All specimens should be refrigerated as soon as possible

they are obtained . to avoid shifted the PH of urine to alkaline because contamination of urea- splitting bacteria from the environment

Consider the Developmental StagesPediatric: difficulties, crying, change in urinary in

childhood).Pregnant: Pain during urination, normal increase urine in

volume and frequency and decrease urine specific gravityElderly: how much and how type of liquid do you drink in

the evening? do you ever lose of control of your bladder 261

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The End

akram mohammad abusalah bns, msn, ph. d. islamic university of gaza strip nursing health assessment...

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