Escolar Documentos
Profissional Documentos
Cultura Documentos
Assessment
Daryl Rosales
Jane Bernadette Balili
Lyra Marie Padernal
Manual on Nursing Health Assessment
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Manual on Nursing Health Assessment
ACKNOWLEDGMENT
The researchers would like to express their gratitude to the following persons who have
To our parents who never fail to continually support us financially, morally and
emotionally. You serve as one of our inspirations to drive us to strive hard to continue this
To Bro. Manny De Leon, FMS, president of Notre Dame of Dadiangas University, we are
much grateful for promoting research in the university. Through this, we are able to conduct the
study to produce this manual. It is indeed very helpful to us and to everyone in the society as it
develops not just our skills but also it gives us a deeper knowledge on our profession and
To the Notre Dame of Dadiangas University Library personnel, thank you for the kind
accommodation and recommendation for the books that you rendered to us. We also would like
to thank for the patience and understanding when we use the libarary and for the enthusiasm
and kindness that you showed us—it empowered us to make every effort in formulating and
To the people who generously lend us their resources (i.e.,books, laptop), thank you for
entrusting us your things. Thank you for being a part of our endeavor in making this manual
possible.
To our Clinical instructors for the guidance and knowledge imparted to us and for the
patience every time we seek help. Most especially to Mr. Jose Dagoc, Jr, RN, MAN, our
research adviser who had made helpful suggestions for the study’s improvement and who also
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constantly reminded us about our manual. Sir, your unending support, supervision and
To Ms. Helen R. Sestina, RN, MAN, Dean of College of Nursing, for the support and
To the Sauveur de Bien 2011, for your cooperation and eagerness in being a part of our
study as our respondents—we thank you for honestly giving your remarks and suggestions for
our manual. We would like to offer this manual to all of you in order to guide you in your field.
To our batchmates, the Mein Benennen 2010 for their love, support, encouragement and
sincere friendship. Thank you for being with us all throughout this time.
And above all, to our Almighty God for all blessings and graces showered upon us – for giving
us the gifts of life, family, friends, education and most of all our talents. We offer to you
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Manual on Nursing Health Assessment
PREFACE
In this manual, we address the nurse-to-be in a clinical care setting that will equip them
with the basic knowledge of conducting a comprehensive health assessment. This manual is
written primarily for the BSN students of Notre Dame of Dadaingas University especially the
Level 3 who will be developing their assessment skills in their Related Learning Exposure.
Apart from the essential knowledge and basic concepts that this manual imparts, it also
teaches the techniques, principles, theories and the skills of health assessment that are
appropriate for use for both the nursing students and the clinical instructors.
Manual in Nursing Health Assessment is has the following contents for learning. Part I:
Assessment Precaution which discusses the different types of contact precaution and its
guidelines prior to conducting assessment to clients. Part II: Nursing Health History discusses
strategies for effective health assessment, functions of Interview and health history, types of
health history, and the components of health history. Part III: Nursing Physical Assessment
discusses the concepts, techniques, principles, alterations, sequence and guidelines for
physical examination. It also includes Maternal and Child Assessment and Pain Assessment.
Part IV: Gordon’s Functional Assessment presents the guide questions in each functional
Part I of this manual provides the reader an overview of the contact precautions as this
will remind them that conducting nursing health assessment not only requires consent and
privacy but also protection to both the nurse and the patient.
Parts II, III, and IV of this manual provides the guidelines, techniques, strategies, and
practical questions to be used upon conducting their nursing health assessment. The aim of its
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contents is to guide and impart knowledge to the readers about the proper and ideal way of
In summary, this manual is aimed towards the improvement of each nursing students in
good assessment that we fully understand and indentify the real needs of the client thereby
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Table of Contents
Page
Assessment 8
Types of Data
Assessment precautions 15
Biographical data
Family history
Review of Systems
Psychosocial profile
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Pain Assessment
Gordon’s Functional Health Patterns 132
Bibliography 192
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- Interview
- Observation
- Examining
Types of Data
- Subjective Data
- Objective Data
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The NURSING Process is the way one thinks like a nurse. This process is the
foundation, the essential, enduring skill that has characterized nursing from the
beginning of the profession. Through the years the nursing process has changed and
evolved, growing in clarity and understanding.
The nursing process is simply one variation of scientific reasoning that allows nurses to
organize, systematize, and conceptualize nursing practice. (Bandman and
Bandman.1995) It is an approach that allows nurses to differentiate their practice from
that of the physicians and other health care professionals. (Perry and Potter.2007)
1. ASSESSMENT
What brought you to the hospital?
2. DIAGNOSIS
What is the problem?
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3. PLANNING
What can I do about it?
client.
STANDARD IV. The nurse develops a plan of care that prescribes intervention to
4. IMPLEMENTATION
Move into action.
care.
5. EVALUATION
Did it work?
STANDARD VI. The nurse evaluates the client’s progress towards attainment of
outcomes.
This Manual will focus on the first step of nursing process: THE ASSESSMENT,
specifically on how to collect clients Health data: Health History, Cues on Gordon’s
Functional Health Pattern and Physical Assessment.
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-is both the initial step in the nursing process and an ongoing component of every other
step in the process.
-is a systematic, dynamic process by which the nurse, through interaction with the
client, significant others and health care providers, collects and analyzes data about the
client (ANA, 1991).
-is part of each activity the nurse does for and with the client. The initial nursing
assessment is the basis of the client care and later assessments contribute to revisions
and updates in the plan as the client’s condition changes.
*All individuals are constantly using their five senses to assess changes in their
environment to make necessary changes and adapt to it.
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Phases:
Orientation Phase- the nurse reviews the purpose for the interview, the
types of data to be obtained, and the methods most appropriate for
conducting the interview.
Establishing the Nurse- Client relationship- the nurse consciously
communicates a sense of trust and confidentiality to clients.
Working Phase- the nurse asks questions to form a database from which
the nursing care plan will be developed.
Termination Phase- the nurse give the client a clue that the interview is
coming to an end. ( Perry and Potter.2007)
Listen attentively using all your senses and speak slowly and clearly.
Use language the client understands, and clarifies points that are not
understood.
Plan questions to follow a logical sequence.
Ask only one question at a time.
Allow the client the opportunity to look at things the way they appear to
him or her and not the way they appear to the nurse or someone else.
Do not impose your own values on the client.
Avoid using personal examples such as saying “If I were you…”
Use and accept silence to help the client search for more thoughts or to
organize them.
Use eye contact and be calm, unhurried and sympathetic. (Kozier.2004)
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The nurse does not make judgments or conclusions but focuses on establishing
a comprehensive database that reflects the health status of the client. Similarly,
the nurse seeks to gather data, not judgments and conclusions.
Objective Data- are factual data that are observed by the nurse and could be noted by
any other skilled observer; are measurable and verifiable, such as test results and
physical examinations.
Subjective Data- are information given verbally by the client; they are so called
because they reflect the patient’s perception and recall of his current health need(s) and
past health.
Both types of data are subject to error, and both are critical to the care giving
process.
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Avoid arguing and facilitate personal space so the client does not feel threatened
or cornered.
Set limits on overt sexual client behavior and avoid responding to subtle
seductive behaviors.
Encourage client to use more appropriate methods of coping in relating to others.
First be aware of your own thoughts and feelings regarding dying, spirituality and
sexuality; then recognize that these factors may affect the client’s health and may
need to be discussed with someone.
Ask simple questions in a nonjudgmental manner.
Allow time for ventilation of client’s feelings as needed.
If you do not feel comfortable or competent discussing personal, sensitive topics,
you may make referrals as appropriate, for example, to a pastoral counselor for
spiritual concerns or other specialists as needed. (Weber and Kelley.2007)
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Airborne Precautions
Droplet Precaution
Contact Precaution
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Standard Precautions
Use standard precautions for the care of all patients
Key Components:
Handwashing (or using an antiseptic handrub)
After touching blood, body fluids, secretions, excretions and contaminated items
Immediately after removing gloves
Between patient contact
Gloves
For contact with blood, body fluids, secretions and contaminated items
For contact with mucous membranes and nonintact skin
Masks, goggles, face masks
Protect mucous membranes of eyes, nose and mouth when contact with blood
and body fluids is likely
Gowns
Protect skin from blood or body fluid contact
Prevent soiling of clothing during procedures that may involve contact with blood
or body fluids
Linen
Handle soiled linen to prevent touching skin or mucous membranes
Do not pre-rinse soiled linens in patient care areas
Patient care equipment
Handle soiled equipment in a manner to prevent contact with skin or mucous
Membranes and to prevent contamination of clothing or the environment
Clean reusable equipment prior to reuse
Environmental cleaning
Routinely care, clean and disinfect equipment and furnishings in patient care
areas
Airborne Precautions
1. Measles
2. Varicella (including disseminated zoster)
3. Tuberculosis
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Droplet Precautions
Contact Precautions
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o Biographical data
o Family history
o Review of Systems
o Psychosocial profile
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HEALTH HISTORY
The health history is your first major interaction with your patient.
It consists of what the patient tells you, what the patient perceives, and
what the patient thinks is important.
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PURPOSE:
*Identify supports
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Reason for seeking Health Care Reason for seeking Health Care
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o Be sure to let your patient know why you are asking these questions and that
it will take time. If you do not have enough time to complete the history, do
not rush. Instead, perform a focused history first, and then complete the
history at later sessions. ( Dillon.2007)
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A. BIOGRAPHICAL DATA
The biographical data provide you with direct information related to a current health
problem, alert you to risk factors for health problem, and point out the need for referrals.
Your patient’s ability to provide biographical data accurately reflects his or her mental
status.
BIOGRAPHICAL DATA
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The reason for seeking health care, also called the chief complaint (CC), is a brief
statement of the client’s purpose for requesting the services of a health care provider.
The client’s reason for seeking health care is recorded in direct quotes. When clients
have multiple reasons, list them all and ask clients to indicate the priority complaints. No
more than three should be stated in this portion of the history, and the client’s stated
priorities should be noted first.
The CC of an ill patient may be a statement of an acute or chronic problem(s) that is his
priority of treatment. In case of a well client, the CC statement may be a statement of
the client’s request for a health screening, health promotion, or disease case-finding
purposes.
Reminders: Use the patient’s own words to describe the reason for his/her visit. Ask
the patient to tell you why she has sought care. Record the patient’s response using her
actual words; do NOT rephrase the stated reason using medical
terminology.(Rhoads.2006)
Example:
Correct: I’ve had a runny nose and sore throat for three days.
Incorrect: Patient states that she has experienced coryza and pharyngitis for 3 days.
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These data represent an amplification of the patient’s reason for seeking care. The
thoroughness and quality of the data in the history of present illness are the driving
force in determining which systems the clinician will focus on in the interview of systems
as subsequent physical examination. This judgment requires that the clinician think
critically in analyzing the data and apply evidence-based research
findings.(Rhoads.2006)
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To what degree does this problem affect your ability to perform your usual
daily activities?
R: region/radiation/related symptoms
most severe.
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I: impact of the symptoms/illness on the patient’s activities of daily living (ADL) and
quality of life.
N: neglect or abuse, including any signs that physical and emotional neglect or abuse
play a role in the patient’s condition.
O: other symptoms that occur in association with the major presenting symptom
T: treatment (medications and other therapies that the patient has used to try to
alleviate the symptoms/condition)
O: options for care that are important to the patient (e.g. advance directives)
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-Prescribed by whom
This section of the health history collects information about all of the patient’s past
health and illnesses, with particular emphasis on disease processes, surgical
procedures and hospitalizations.(Rhoads.2006) The purpose is to identify any health
factors from the past that may have a direct relationship to your patient’s current
health status.
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Patient’s definition of
health and perception
Ask the patient to fully describe his/her health.
of current health
status.
Childhood illnesses Record the date, treatment and any long term adverse
sequelae, especially any that affect the patient’s
functional abilities (e.g. post polio syndrome) or current
health status (e.g. past history of untreated
streptococcal infection, which may contribute to mitral
valve disease of the heart).
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Injuries Record the nature of the injury; date; cause (e.g. motor
vehicle accident); treatment; outcome, including any
long-term sequelae, especially if they affect the patient’s
functional ability or activities of daily living (ADL).
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reaction.
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E. FAMILY HISTORY
-This provides clues to genetically linked or familial diseases that may be risk factors for
your patient.
Ask about the health status and ages of your patient’s family members.
Family members include the patient’s spouse, children, parents, siblings, aunts
and uncles, and grandparents.
Ask about genetically linked or common diseases such as heart disease, high
blood pressure, stroke, diabetes, cancer, obesity, bleeding disorders,
tuberculosis, renal disease, seizures or mental disease.
If the patient’s family members are deceased, record the cause of
death.(Dillon.2007)
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F. REVIEW OF SYSTEMS
Head and Neck Headaches; lumps; scars; recent head trauma, injury or
surgery; history of concussion or loss of consciousness;
dizzy spells; fainting; stiff neck; pain with movement of
head and neck; swollen nodes or masses.
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Mouth and Throat Sore throats, streptococcal infections, mouth sores, oral
herpes, bleeding gums, hoarseness, changes in voice
quality, difficulty chewing or swallowing, changes in sense
of taste.
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G. PSYCHOSOCIAL PROFILE
-This section focuses on health promotion, protective patterns and roles and
relationships. It includes questions about healthcare practices and beliefs, a description
of a typical day, a nutritional assessment, activity and exercise patterns, recreational
activities, sleep/rest patterns, personal habits, occupational risks, environmental risks,
and family roles and relationships and stress and coping mechanism.(Dillon.2007)
DATA SIGNIFICANCE/CONSIDERATIONS
Activity and Exercise Ask about the type and amount of activity of exercise.
Patterns If your patient participates in contact sports, assess
use of protective equipments and provide instruction
as needed.
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Sleep/ Rest patterns Ask patient how many hours of sleep she/he gets, if
sleep is interrupted, how many hours she/he needs to
feel rested, any medication taken to aid sleep, or if
patient has any sleeping disorders.
Socioeconomic Status Ask your patient if he/she has health insurance, dental
insurance or a prescription plan. Limited financial
resources may limit available healthcare services.
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Family Roles and Ask the patient about his/her relationship within the
Relationship family and other social group.
Stress and Coping The amount of stress in your patient’s life and how she
Patterns or he copes with it can affect her or his health. Illness
only adds stress and anxiety. Ask your patient how
she or he deals with everyday stress, what she or he
does when feeling upset.(Dillon.2007)
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The Barthel Index consists of 10 items that measure a person’s daily performance and
functioning specifically in the activities of daily living and mobility. Items include feeding,
grooming, bathing, dressing, transferring to and from the toilet, moving from a wheelchair, going
up and down stairs, walking on level surface, moving from wheelchair to bed and return, and
The assessment can be used to determine a baseline level of functioning and can be
To use the Barthel Index, the items are weighted according to a scheme developed by
the authors. The person receives a score based on whether they have received help while doing
the task. The scores for each of the items are summed to create a total score. The higher the
score the more ―independent: the person and is also associated with a likelihood of being able
to live at home with a degree of independence following discharge from hospital. Independence
means that the person needs no assistance at any part of the task. If a person does about 50%
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The Katz Index of Independence in Activities of Daily Living, commonly referred to as the
Katz ADL, is the most appropriate instrument to assess functional status as a measurement of
the client’s ability to perform activities of daily living independently. This tool is used to detect
problems in performing activities of daily living and to plan care accordingly. The index ranks
continence, and feeding. Clients are scored yes/no for independence in each of the 6 functions.
A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates
The instrument is most effectively used among older adults in a variety of care settings,
when baseline measurements, taken when the client is well, are compared to periodic or
subsequent measures.
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*Pain Assessment
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Inspection
Know ―normals‖
Observe ―normals/abnormals‖
Palpation
Detects texture, shape, temperature, movement, pain, moisture
Short fingernails, warm hands
Gentle approach
Light palpation first, if pain - STOP!
Palpate tender areas last
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Three types:
Light palpation (1/2 inch)
Deep palpation (1 inch)
Bimanual deep palpation (2 hands)
Percussion
Auscultation
Stethoscope is used:
bell for low pitch sounds (cardiac sounds)
Diaphragm for high pitch sounds (bowel, breath, normal cardiac)
Note four characteristics of sounds:
Frequency/pitch: number of vibrations per second
Loudness: soft, medium, loud
Quality: types; gurgling, blowing
Duration: short, medium, long (specify)
Maintain a quiet environment
Know landmarks
Know ―normals‖
Requires concentration, practice, and application of knowledge
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Assess:
coping ability
previous knowledge
readiness
Encourage questions
Explain at developmental level
Use concrete terms
Small amounts of info at a time
Simple & clear explanations
Only offer choices that are available
Honest praise/rewards
Do not stereotype
Assess and accommodate:
sensory & physical functioning
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I. General Appearance
i. Appears at stated age
ii. Level of consciousness
iii. Skin color
iv. Nutritional status
v. Posture and position
vi. Obvious physical deformities
vii. Mobility
1. Gait
2. Use of assistive devices
3. Range of motion of joints
4. Involuntary movement
viii. Facial expression
ix. Mood and affect
x. Speech: articulation, pattern, content, native language
xi. Hearing
xii. Personal hygiene
II. Measurement
a. Weight
b. Height
c. Skinfold thickness
d. Vision using Snellen’s eye chart
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i. Apical
ii. Radial
iii. Brachial
iv. Femoral
v. Popliteal
vi. Dorsalis pedis
c. Respiration
d. Blood pressure (if indicated)
i. General pigmentation
Observe the skin tone. Normally it is consistent with genetic
background and varies from pinkish tan to ruddy dark tan or from
light to dark brown. Dark-skinned people normally have areas of
lighter pigmentation on the palms, nail beds, and lips. General
pigmentation is darker in sun-exposed areas.
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1. Pallor
Jaundice
When the red-pink tones from the oxygenated hemoglobin
in the blood are lost, the skin takes on the color of
connective tissue (collagen), which is mostly white. Pallor is
common in acute high-stress states, such as anxiety or fear
due to the powerful peripheral vasoconstriction from
Cyanosis
sympathetic nervous system stimulation. The skin also looks
pale with vasoconstriction from exposure to cold and
cigarette smoking and in the presence of edema.
Ashen gray color in dark skin or marked pallor in whites
occurs with anemia, shock, and arterial insufficiency.
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2. Erythema
This is an intense redness of the skin due to excess blood
(hyperemia) in the dilated superficial capillaries. This sign is
expected with fever, local inflammation, or with emotional
reactions such as blushing in vascular flush areas (cheeks,
neck and upper chest).
Erythema occurs with polycythemia, venous stasis, carbon
monoxide poisoning and the extravascular presence of red
blood cells (petechiae, ecchymosis, and hematoma).
3. Cyanosis
This is a bluish mottled color that signifies decreased
perfusion; the tissues are not adequately perfused with
oxygenated blood. Be aware that cyanosis can be a
nonspecific sign. A person who is anemic could have
hypoxemia without ever looking blue because not enough
hemoglobin is present (either oxygenated or reduced) to
color the skin. On the other hand, a person with
polycythemia (an increase in the number of red blood cells)
looks ruddy blue at all times and may not necessarily be
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4. Jaundice
Jaundice is exhibited by a yellow color, indicating rising
amounts of bilirubin in the blood. Except for physiological
jaundice in the newborn, jaundice does not occur normally.
Jaundice is first noted in the junction of the hard and soft
palate in the mouth and in the sclera. But do not confuse
sclera jaundice with the normal yellow subconjunctival fatty
deposits that are common in the outer sclera of dark-skinned
persons. The sclera yellow of jaundice extends up to the
edge of the iris. Jaundice is best assessed in direct natural
daylight. Common calluses on palms and soles often look
yellow – do not interpret these as jaundice.
Jaundice occurs with hepatitis, cirrhosis, sickle-cell
disease, transfusion reaction, and hemolytic disease of the
newborn.
Light or clay-colored stools and dark golden urine often
accompany jaundice in both light- and dark-skinned people.
b. Temperature
Note the temperature of your own hands. Then use the backs (dorsa) of
your hands to palpate the client and check bilaterally. The skin should be
warm, and the temperature should be equal bilaterally; warmth suggests
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normal circulatory status. Hands and feet may be slightly cooler in a cool
environment. A thermometer is used in taking the core temperature.
Place the end of the thermometer under the patient’s dry armpit to
take what's known as an axillary temperature.
Hold the thermometer in place by gently pressing the patient’s
elbow against the side of his/her chest.
Remove the thermometer after 5 minutes. To ensure accuracy,
check the temperature of the opposite armpit.
Read under a bright light.
i. Hypothermia
A digital axillary
thermometer Generalized coolness may be induced, such as in hypothermia
used for surgery or high fever. Localized coolness is expected with
an immobilized extremity, as when a limb in a cast or with an
intravenous infusion.
General hypothermia accompanies central circulatory
disturbance, such as in shock.
Localized hypothermia occurs in peripheral arterial insufficiency
and Raynaud’s disease.
ii. Hyperthermia
Generalized hyperthermia occurs with an increased metabolic
rate, such as in fever, or after heavy exercise. A localized area
feels hyperthermic with trauma, infection or sunburn.
Hyperthyroidism has an increased metabolic rate, causing warm,
moist skin.
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c. Moisture
Perspiration appears normally on the face, hands, axilla, and skinfolds
in response to activity, a warm environment, or anxiety.
i. Thickness
The epidermis is uniformly thin over most of the body, although
the thickened callus areas are normal on palms and soles. A callus
is a circumscribed overgrowth of epidermis and is an adaptation to
excessive pressure from the friction of work and weight bearing.
Very thin, shiny skin (atrophic) occurs with arterial insufficiency.
ii. Edema
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f. Vascularity or bruising
Cherry (senle) angiomas are small (1 to 5 mm), smooth, slightly raised
bright red dots that commonly appear on the trunk in all adults over 30.
They normally increase in size and number with aging and are not
significant. Any bruising (ecchymosis) should be consistent with the
expected trauma of life. There are normally no venous dilatations or
varicosities.
Multiple bruises at different stages of healing and excessive bruises
above knees or elbows should raise concern about physical abuse.
Document the presence of any tattoos (a permanent skin design from
indelible pigment) on the person’s chart. Advise the person that the use of
tattoo needles and tattoo parlor equipment of doubtful sterility increases
the risk of hepatitis C and other communicable diseases that can be
transmitted through the needles.
Needle marks or tracks from intravenous injection of street drugs may
be visible on the antecubital fossae, forearms or any available vein.
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g. Lesions
If any lesions are present, note the:
i. Color
ii. Elevation: flat, raised or pendunculated.
iii. Shape:
1. Discoid – Round or oval.
2. Annular – Circular with central clearing.
3. Target (bull’s eye) – Annular with central internal activity.
iv. Pattern
The grouping or distinctness of each lesion:
1. Discrete – individual lesions. Are separate and distinct.
2. Grouped – lesions are clustered together.
3. Confluent – lesions merge so that discrete lesions are not
visible or palpable.
4. Dermatoral – lesions form a line or an arch and follow a
dermatome.
v. Size (in centimeters): use a ruler to measure. Avoid household
descriptions such as ―quarter size‖ or ―pea size.‖
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vii. Type:
1. Pustule – a small, pus-filled lesion (called follicular pustule if
it contains a hair).
2. Cyst – a closed sac in or under the skin that contains fluid or
semisolid material.
3. Nodule – a raised lesion detectable by touch that’s usually 1
cm or more in diameter.
4. Wheal – a raised, reddish area that’s commonly itchy and
lasts 24 hours or less.
5. Fissure – a painful crack like lesion of the skin that extends
at least into the dermis.
6. Macule – a small, discolored spot or patch on the skin.
7. Vesicle – a small, fluid-filled blister that’s usually 1 cm or
less in diameter.
8. Papule – a solid, raised lesion that’s usually less than 1 cm
in diameter.
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B. Hair
a. Color
Hair color comes from melanin production and is black. Graying begins
as early as the third decade of life because of reduced melanin production
in the follicles. Genetic factors affect the age of onset of graying.
b. Texture
Scalp hair may be fine or thick and may look straight, curly, or kinky. It
should look shiny, although this characteristic may be lost with the use of
some beauty products such as dyes, rinses, or permanents.
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Note dull, coarse or brittle scalp hair. Gray, scaly, well-defined areas
with broken hairs accompany tinea capitis, a ringworm infection found
mostly in school-aged children.
c. Distribution
Fine vellus hair coats the body, whereas coarser terminal hairs grow at
the eyebrows, eyelashes and scalp. During puberty, distribution conforms
to normal male and female patterns. At first, coarse curly hairs develop in
the pubic area, then in the axillae, and last in the facial area in boys. In the
genital area the female pattern is an inverted triangle; the male pattern is
an upright triangle with pubis hair extending up to the umbilicus. In Asians,
body hair may be diminished.
Genital hair absent or with abnormal configuration suggests endocrine
abnormalities.
Hisrutism – excess body hair. In females, this forms a male pattern of
the hair distribution on the face and chest and indicates endocrine
abnormalities.
d. Lesions
Separate the hair into sections and lift it, observing the scalp. With a
history of itching, inspect the hair behind the ears and in the occipital area
as well. All areas should be clean and free of any lesions or pest
inhabitants. Many people normally have seborrhea (dandruff), which is
indicated by loose white flakes.
Distinguish dandruff from nits (eggs) of lice, which are oval, adherent to
hair shaft, and cause intense itching.
C. Nails
a. Shape and contour
The nail surface is normally slightly curved or flat, and the posterior and
lateral nail folds are smooth and rounder. Nail edges are smooth, rounded,
and clean, suggesting adequate self-care.
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Jagged nails, bitten to the quick or traumatized nail folds from chronic
nervous picking suggest nervous habits.
Chronically dirty nails suggest poor self-care or some occupations in
which it is impossible to keep them clean.
b. Consistency
The surface is smooth and regular, not brittle or splitting. Pits,
transverse grooves, or lines may indicate a nutrient deficiency or may
accompany acute illness in which nail growth is disturbed.
Nail thickness is uniform. Nails are thickened and ridged in clients with
arterial insufficiency.
The nail is firmly adherent to the nail bed, and the nail base is firm to
palpation. A spongy nail base accompanies clubbing.
c. Color
The translucent nail plate is a window to the even, pink nail bed
underneath. Cyanosis or marked pallor is abnormal.
Dark-skinned people may have brown-black pigmented areas or linear
bands or streaks along the nail edge. All people normally may have white
hairline linear markings from trauma or picking at the cuticle. Note any
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i. Capillary refill
Depress the nail edge to blanch and the release, noting the return of
color. Normally, color return is instant, or at least within a few seconds
in a cold environment. This indicates the status of the peripheral
circulation. A sluggish color return takes longer than 1 or 2 seconds.
Cyanotic nail beds or sluggish color return may indicate cardiovascular
or respiratory dysfunction.
Inspect the toenails. Separate the toes and note the smooth skin in
between.
V. The Head
A. Skull
a. Size and shape
Note the general size and shape. Normocephalic is the term that
denoted a round symmetric skull that is appropriately related to body size.
Be aware that ―normal‖ includes a wide range of sizes.
Deformities of the skull include: microcephaly, an abnormally small head;
macrocephaly, an abnormally large head which is seen in hydrocephaly,
acromegaly, and Paget’s disease.
To assess shape, place your fingers in the person’s hair and palpate the
scalp. The skull normally feels symmetric and smooth. The cranial bones
that have normal protrutions are the forehead, the lateral edge of each
parietal bone, the occipital bone and the mastoid process behind each ear.
Normally, there is no tendeness to palpation. Note lumps, depressions or
abnormal protrutions.
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b. Temporal area
Palpate the temporal artery above the zygomatic (cheek) bone between
the eye and top of the ear. The artery looks more tortuous and feels
hardened and tender with temporal arteritis.
The temporomandibular joint is just below the temporal artery and
anterior to the tragus. Palpate the joint as the person opens the mouth, and
note normally smooth movement with no limitation or tenderness.
Crepitation, limited range of motion, or tenderness is abnormal.
B. Face
a. Facial structures
Inspect the face, noting the facial expression and its appropriateness to
behavior or reported mood. Anxiety is common in the hospitalized or ill
person. Hostility or embarrassment is abnormal. Tense, rigid muscles may
indicate anxiety or pain; a flat affect may indicate depression; excessive
smiling may be inappropriate.
Although the shape of facial structures may vary somewhat among races,
they always should be symmetric. Note symmetry of eyebrows, palpebral
fissures, nasolabial folds, and sides of the mouth. Marked asymmetry
appears with central brain lesion (e.g., brain attack) or with peripheral cranial
nerve VII damage (Bell’s palsy).
Note any abnormal facial structures (coarse facial features, exophthalmos,
changes in skin color or pigmentation), or any abnormal swelling. Also note
any involuntary movements (tics) in the facial muscles. Normally none occur.
Edema in the face occurs first around the eyes (periorbital) and the cheeks
where the subcutaneous tissue is relatively loose. Note grinding of jaws,
fasciculations, or excessive blinking.
C. Eyes
a. Central visual acuity
i. Snellen’s eye chart
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Record the result using the numeric fraction at the end of the last
successful line read. Indicate whether or not the person missed any
letters or if corrective lenses were worn – for example, ―O.D. *20/30
– 1, with glasses.‖
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light in from the side and note the response. Normally, you will see
constriction of the same-sided pupil (a direct light reflex), and
simultaneous constriction of the other pupil (a consensual light
reflex).
Test for accommodation by asking the person to focus on a
distant object. This process dilates the pupils. Then have the
person shift gaze to a near object, such as your finger held about 7
to 8 cm (3 inches) from the nose. A normal response includes
papillary constriction and convergence of the axes of the eyes.
Absence of constriction or convergence and asymmetric
response is abnormal.
Record the normal response to all these maneuvers as PERRLA,
or Pupils Equal, Round, React to Light and Accommodation.
D. Ears
Examination of the external ear in infants and children is similar to that
described for the adult, with the addition of examination of position and alignment
on head. Note the ear position. The top of the pinna should match an imaginary
line extending from the corner of the eye to the occiput.
Low-set ears or deviation in alignment may indicate mental retardation or a
genitourinary malformation.
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iii. Tenderness
Move the pinna and push on the tragus. They should feel firm,
and movement should produce no pain. Palpating the mastoid
process should also produce no pain.
Pain with movement occurs with otitis externa and furuncle. Pain
at the mastoid process may indicate mastoiditis or lymphadenitis of
the posterior auricular node.
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b. Position
The eardrum is flat, slightly pulled in at the center,
and flutters when the person performs the Valsalva
maneuver or holds the nose and swallows
(insufflations). You may elicit these maneuvers to
assess drum mobility. Avoid them with an aging
person because they may disrupt equilibrium. Also
avoid middle ear insufflations in a person with upper
respiratory infection because it could propel infectious
matter into the middle ear.
Abnormal findings include retracted ear drum due
to vacuum in middle ear with obstructed eustachean
tube and bulging drum from increased pressure in
otitis media.
Drum hypomobility is an early sign of otitis media.
c. Integrity of membrane
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i. Voice test
Test one ear at a time while masking hearing in the other ear to
prevent sound transmission around the head. This is done by
placing one finger on the tragus and rapidly pushing it in and out of
the auditory meatus. Shield your lips so the person cannot
compensate for a hearing loss (consciously or unconsciously) by lip
reading or using the ―good‖ ear. With your head 30 to 60 cm (1 to 2
ft) from the person’s ear, exhale and whisper slowly some two-
syllable words, such as Tuesday, armchair, baseball and fourteen.
Normally, the person repeats each word correctly after you say it.
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1. Weber test
The Weber test is valuable when a person reports hearing
better with one ear than the other. Place a vibrating tuning
fork in the midline of a person’s skull and ask if the tone
sounds the same in both ears or better in one. The person
should hear the tone by bone conduction through the skull,
and it should sound equally loud in both ears.
It is abnormal when sound lateralizes to one ear. It is
commonly found in a conductive or sensorineural loss.
2. Rinne test
The Rinne test compares air conduction and bone
Rinne test
conduction sound. Place the stem of the vibrating tuning fork
on the person’s mastoid process and ask him or her to signal
when the sound goes away. Quickly invert the fork so the
vibrating end is near the ear canal; the person should still
hear a sound. Normally the sound is heard twice as long by
air conduction (next to ear canal) as by bone conduction
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E. Nose
a. External nose
Normally, the nose is symmetric, in the midline, and in proportion to
other facial features. Inspect for any deformity, asymmetry, inflammation,
or skin lesions. if any injury is reported or suspected, palpate gently for
any pain or break in contour.
Test the patency of the nostrils by pushing each nasal wing shut with
your finger while asking the person to sniff inward through the other naris.
This reveals any obstruction which can be explored by using a nasal
speculum. The sense of smell, mediated by cranial nerve I, is usually not
tested in a routine examination. Absence of sniff indicates obstruction
(e.g., nasal polyps, rhinitis).
The newborn may have milia across the nose. The nasal bridge may be
flat in black and Asian children. There should be no nasal flaring or
narrowing with breathing. Nasal flaring in the infant indicates respiratory
distress.
A transverse ridge across the nose occurs in a child with chronic allergy
from wiping the nose upward with palm, nasal narrowing on inhalation is
seen with chronic nasal obstruction and mouth-breathing.
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b. Nasal cavity
View each nasal cavity with the person’s head erect, then with the head
tilted back. Inspect the nasal mucosa, noting its normal red color and
smooth moist surface. Note any swelling, discharge, bleeding, or foreign
body.
In rhinitis, nasal mucosa is swollen and bright red with an upper
respiratory infection.
Discharge is common with rhinitis and sinusitis, varying from watery and
copious to thick, purulent, and green-yellow.
With chronic allergy, mucosa looks swollen, boggy, pale and gray.
Observe the nasal septum for deviation. A deviated septum is common
and is not significant unless airflow is obstructed. Also note any
perforation or bleeding in the septum.
A deviated septum looks like a hump or shelf in one nasal cavity.
Perforation is seen as a spot from penlight shining in other naris. Epistaxis
commonly comes from anterior septum.
Inspect the turbinates, the bony ridges curving down from the lateral
walls. The superior turbinate will not be in your view, but the middle and
inferior turbinates appear the same light red color as the nasal mucosa.
Note any swelling. Turbinates are quite vascular and tender if touched.
Note any polyps, which are benign growths that accompany chronic
allergy, and distinguish them from the normal turbinates. Polyps are
smooth, pale gray, avascular, mobile and nontender.
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2. Epistaxis
Nose bleeding.
3. Foreign body
Children particularly are apt to put an object up the nose,
producing unilateral mucopurulent drainage and foul odor.
4. Perforated septum
A hole in the septum, usually in the cartilaginous part, may
be caused by trauma from continual picking of crusts,
chronic infection, sniffing cocaine, or nasal surgery.
5. Furuncle
A small boil located in the skin or mucous membrane;
appears red and swollen and is quite painful. Avoid
manipulation or trauma that may spread the infection.
6. Acute rhinitis
The first sign is clear, watery discharge, rhinorrhea, which
later becomes purulent. This is accompanied by sneezing
and swollen mucosa, which causes nasal obstruction.
Turbinates are dark red and swollen.
7. Allergic rhinitis
Rhinorrhea, itching of nose and eyes, lacrimation, nasal
congestion, and sneezing are present. Note serous edema
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8. Sinusitis
Facial pain, following upper respiratory infection; signs
include red swollen nasal mucosa, swollen turbinates, and
purulent discharge. Person also experiences fever, chills,
malaise.
9. Nasal polyps
Smooth, pale gray nodules, which are overgrowths of
mucosa, most commonly caused by chronic allergic rhinitis.
May be stalked.
10. Carcinoma
This appears gray-white and nontender. It may produce
slow bloody unilateral discharge. It is not a common lesion.
F. Mouth
Begin with anterior structures and move posteriorly. Use a tongue blade to
retract structures and a bright light for optimal visualization.
Since the oral examination is intrusive for the infant or young child, the timing
is best toward the end of the complete examination, along with the ear
examination. But if any crying episodes occur earlier, seize the opportunity to
examine the open mouth and oropharynx.
Use a game to help prepare the young child. Encourage the preschool child to
use a tongue blade to look into a puppet’s mouth. Or place a mirror so that the
child can look into the mouth while you do. The school-age child is usually
cooperative and loves to show off missing or new teeth.
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i. Lips
Inspect the lips for color, moisture, cracking or lesions. retracts
the lips and note their inner surface as well. Black persons normally
may have bluish lips.
In light skinned people: circumoral pallor occurs with shock and
anemia; cyanosis with hypoxemia and chilling; cherry red lips with
carbon monoxide poisoning, or ketoacidosis.
Abnormal findings include Cheilitis or perlèche, cracking of the
lips’ corners, and herpes simplex and other lesions.
A normal finding in infants is the sucking tubercle, a small pad in
the middle of the upper lip from friction of breast or bottle feeding.
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iii. Tongue
Check the tongue for color, surface characteristics, and moisture.
The color is pink and even. The dorsal surface is normally
roughened from the papillae. A thin white coating may be present.
Ask the person to touch the tongue to the roof of the mouth. Its
ventral surface looks smooth, glistening, and shows veins. Saliva is
present. Beefy red swollen tongue and smooth glossy areas is
abnormal.
Enlarged tongue occurs with mental retardation, hypothyroidism,
and acromegaly; a small tongue accompanies malnutrition.
Dry mouth occurs with dehydration, fever; tongue has deep
vertical fissures.
Saliva is decreased while the person is taking anticholinergic and
other medication and excess saliva and drooling occur with
gingivostomatitis and neurologic dysfunction.
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v. Palate
Shine your light up to the roof of mouth. The more anterior hard
palate is white with irregular transverse rugae. The posterior soft
palate is pinker, smooth and upwardly movable. A normal variation
is a nodular bony ridge down the middle of the hard palate, a torus
palatinus. This benign growth arises after puberty. It is a more
common finding in Native Americans, Inuits and Asians. Oral
kaposi’s sarcoma is the most common early lesion in people with
AIDS.
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b. Range of Motion
Note any limitations of movement during active motion. Ask the person to
touch the chin to the chest, turn the head to the right and left, try to touch
each ear to the shoulder (without elevating shoulders), and to extend the
head backward. When the neck is supple, motion is smooth and controlled.
Note pain at any particular movement. Note ratchet or limited movement due
to cervical arthritis ot inflammation of the neck muscles. With arthritis, the
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neck is rigid and the person turns at the shoulders rather than the neck.
Nuchal rigidity occurs with meningitis.
Test muscle strength and the status of cranial nerve XI by trying to resist
the person’s movements with your hands as the person shrugs the shoulders
and turns the head to each side.
As the person moves the head, note enlargement of the salivary glands.
Normally, no enlargement is present. Note a swollen parotid gland when the
head is extended; look for swelling below the angle of the jaw. Normally, there
are no other pulsations while the person is in sitting position. Thyroid
enlargement may be a unilateral lump, or it may diffuse and look like a
doughnut lying across the lower neck.
c. Lymph Nodes
Using a gentle circular motion of your fingerpads, palpate the lymph nodes.
Normally, the salivary glands are not palpable. When symptoms warrant,
check for parotid tenderness by palpating in a line from the outer corner of the
eye to the lobule of the ear. Beginning with the preauricular lymph nodes in
front of the ear, palpate the 10 groups of lymph nodes in a routine order.
Many nodes are closely packed, so you must be systematic and thorough in
your examination. Once you establish your sequence, do not vary or you may
miss some small nodes. The parotid is swollen with mumps and parotid
enlargement has been found with AIDS.
The following criteria are common clues but are not definitive in all
circumstances:
1. Acute infection – nodes are bilateral, enlarged, warm, tender and firm but
freely movable.
2. Chronic inflammation – the nodes are clumped.
3. Cancerous nodes – are hard, unilateral, nontender and fixed.
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4. HIV infection – are enlarged, firm, nontender and mobile. Occipital node
enlargement is common with HIV infection.
5. Neoplasm in thorax or abdomen – a single enlarged, nontender, hard,
left supraclavicular (Virchow’s node).
6. Hodgkin’s lymphoma – painless, rubbery, discrete nodes that gradually
appear.
d. Trachea
Normally, the trachea is midline; palpable for any tracheal shift. Place your
index finger on the trachea in the sterna notch, and slip it off to each side. The
space should be symmetric on both sides. Note any deviation from the
midline.
e. Thyroid gland
The thyroid gland is difficult to palpate; arrange your setting to maximize
you likelihood of success. Position a standing lamp to shine tangentially
across the neck to highlight any possible swelling. Supply the person with a
glass of water, and first inspect the neck as the person takes a sip and
swallows. Thyroid tissue moves up with a swallow. Look for a diffuse
enlargement or a nodular lump.
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i. Anterior approach
This is a method of palpating the thyroid but it is awkward to
perform, especially for a beginning examiner. Stand facing the
person. Ask him or her to tip the head forward and to the right. Use
your right thumb to displace the trachea slightly to the person’s
right. Hook your left humb and fingers around the sternomastoid
muscle. Feel for lobe enlargement as the person wallows.
Abnormal findings are enlarged lobes that are easily palpated
before swallowing, or are tender to palpation; or the presence of
nodules and lumps.
VII. Breasts
In assessing the breasts, secure consent of the client first and do not force
him/her to submit for breast examination. If client isn’t comfortable with you
examining his/her breasts, let him/her do it or ask him or her about its
appearance.
The normal male breast has a flat disk of undeveloped breast tissue
beneath the nipple. Gynecomastia is an enlargement of this breast tissue,
making it clinically distinguishable from the other tissues in the shest wall. It
feels like a smooth, firm, movable disk. This occurs normally during puberty. It
usually affects only one breast and is temporary. The adolescent male is
acutely aware of his body image. Reassure him that this change is normal,
common and temporary.
Gynecomastia also occurs with the use of anabolic steroids, some
medications, and some disease states. An obese male has an increase of
fatty, not glandular tissue.
a. General appearance
Note symmetry of size and shape. It is common to have slight
asymmetry in size; often the left breast is slightly larger than the right.
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b. Skin
Skin is normally smooth and of even color. note any localized areas of
redness, bulging, or dimpling. Also note skin lesions or focal vascular
pattern. A fine blue vascular network is visible normally during pregnancy.
Pale linear striae, or stretch marks, often follow pregnancy.
d. Nipple
The nipples should be symmetrically placed on the same plane on the
two breasts. Nipples usually protrude, although some are flat and some
are inverted. Note any dry scaling, any fissure or ulceration, and bleeding
or other discharge.
If the woman mentions a breast lump that she has discovered herself, examine
the unaffected breast first to learn a baseline of normal consistency for this
individual. Observe the lump for these characteristics:
1. Location – using the breast as a clock face, describe the distance
in centimeters from the nipple (e.g., ―7:00, 2 cm from the nipple‖).
2. Size – judge in centimeters in three dimentions: width x length x
thickness.
3. Shape – state if the lump is oval, round lobulated, or indistinct.
4. Consistency – state if the lump is soft, firm or hard.
5. Movable – is the lump freely movable, or is it fixed when you try to
slide it over the chest wall?
6. Distinctness – is the lump solitary or multiple
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4. Pectus carinatum
A forward protrusion of the sternum, with ribs sloping back at either
side and vertical depressions along costochondral junctions (pigeon
breast).
5. Scoliosis
A lateral S-shaped curvature of the thoracic and lumbar spine,
usually with involved vertebrae rotation. Note unequal shoulder and
scapular height and unequal hip levels, rib interspaces flared on
convex side.
6. Kyphosis
An exaggerated posterior curvature of the thoracic spine
(humpback) that causes significant back pain and limited mobility.
b. Symmetric expansion
Confirm symmetric chest expansion by placing your warmed hands on
the posterolateral chest wall with thumbs at the level of T9 or T10. Slide
your hands medially to pinch up a small fold of skin between your thumbs.
Ask the person to take a deep breath. Your hands serve as mechanical
amplifiers; as the person inhales deeply, your thumbs should move apart
symmetrically. Note any lag in expansion.
Unequal chest expansion occurs with marked atelectasis or pneumonia;
with thoracic trauma, such as fractured ribs; or with pneumothorax. Pain
accompanies deep breathing when the plurae are inflamed.
Asses for tactile (or vocal) fremitus. Fremitus is a palpable vibration.
Sound generated from the larynx are transmitted through patent bronchi
and through the lung parenchyma to the chest wall, where you feel them
as vibrations.
Use either the palmar base of the fingers or the ulnar edge of one hand,
and touch the person’s chest while he or she repeats the words ―ninety-
nie‖ or ―blue moon.‖ These are resonant phrases that generate strong
vibrations. Start over the lung apices and palpate from one side o another.
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c. Breath sounds
Evaluate the presence and quality of normal breath sounds. The person
is sitting, leaning forward slightly, with arms resting comfortably across the
lap. Instruct the person to breathe through the mouth, a little bit deeper
than the usual, but to stop if he or she begins to feel dizzy. Be careful to
monitor the breathing throughout the examination, and offer times for the
person to rest and breathe normally. Watch that he or she does not
hyperventilate to the point of fainting.
Use the flat diaphragm endpiece of the stethoscope and hold it firmly on
the person’s chest wall. Listen to at least one full respiration in each
location. Side-to-side comparison is most important.
Do not confuse background noise with lung sounds. Become familiar
with these extraneous noises that may be confused with lung pathology if
not recognized:
a. Adventitious sounds
Note the presence of any adventitious sounds. These are
added sounds that are not normally heard in the lungs. If
present, they are heard as being superimposed on the breath
sounds. They are caused by moving air colliding with secretions
in the tracheobronchial passageways, or by the popping open of
previously deflated airways.
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than the abdomen. Determine the profile from the rib margin to the public
bone. The contour describes the nutritional state and normally ranges
from flat rounded. Abnormal findings include Scaphoid abdomen,
protuberant abdomen and abdominal distention.
b. Symmetry
Shine a light across the abdomen toward you, or shine it lengthwise
across the person. The abdomen should be symmetric bilaterally. Note
any localized bulging, visible mass or asymmetric shape. Even small
bulges are highlighted by shadow. Step the foot of the examination table
to recheck symmetry. Abnormal findings include Bulges, masses, Hernia,
protrusion of the abdominal viscera abnormal opening in muscle wall.
c. Umbilicus
Normally it is midline and inverted, with no sign of discoloration,
inflammation or hernia. It becomes everted and pushed upward with
pregnancy. Umbilicus is everted with acites or underlying mass, deep
sunken with obesity, enlarged and everted with umbilical hernia. Bluish
periumbilical color occurs with intraabdominal bleeding (Cullen’s sign).
d. Skin
The surface is smooth and even, with homogeneous color. This is good
area to judge pigment because it is often protected from sun. Moles,
circumscribed brown macular or popular areas, are common on the
abdomen.
Abnormal findings include redness with localized inflammation, Jaundice
(shows best in natural daylight), skin glistering and taut that occurs with
ascites.
Normally, no lesions are present, although you may not well-healed
surgical scars. If a scar is present, draw its location in the person’s record,
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Veins usually are not seen, but a fine venous network may be visible in
thin persons. Abnormal findings include Prominent, dilated veins occur
with portal hypertension, cirrhosis, ascites or vena caval obstruction. Veins
are more visible with malnutrition due to thinned adipose tissue.
Good skin turgor reflects healthy nutrition. Gently pinch up a fold of
skin; then release to note the skin’s immediate return to original position.
Poor turgor occurs with dehydration, which often accompanies
gastrointestinal disease.
e. Pulsation or movement
Normally, you may see the pulsation from the aorta beneath the skin in
the epigastric area, particularly in thin persons with good muscle wall
relaxation. Respiratory movement also shows in the abdomen, particularly
in males. Finally, waves of peristalsis sometimes are visible in very thin
persons. They ripple slowly and obliquely across the abdomen. Marked
pulsation of the aorta occurs with widened pulse pressure and with aortic
aneurysm. Marked visible persitalsis, together with a distended abdomen,
indicates intestinal obstruction.
f. Hair distribution
The pattern of pubic hair growth normally has a diamond shape in adult
males and an inverted triangle shape in adult females. Patterns alter with
endocrine or hormone abnormalities and with chronic liver disease.
g. Demeanor
A comfortable person is relaxed quietly on the examining table and has
a benign facial expression and slow, even respirations.
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h. Bowel sounds
Note the character and frequency of bowel sounds. Bowel sounds originate from the
movement of air and fluid through the small intestine. Depending on the time elapsed
since eating, a wide range of normal sounds can occur. Bowel sounds are high-pitched,
gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per
minute. Judge if they are normal, hypoactive or hyperactive.
HYPERACTIVE SOUNDS
Are loud, high pitched, rushing, tinkling sounds that signal
increased motility.
HYPOACTIVE SOUNDS
Follow abdominal surgery or with inflammation of the
peritoneum.
i. Vascular sounds
As you listen to the abdomen, note the presence of any vascular
sounds or bruits. Using firmer pressure, check over the aorta, renal
arteries, iliac, and femoral arteries, especially in people with hypertension.
Usually, no such sound present. Note location, pitch, and timing of a
vascular sound. A systolic bruit is a pulsatile blowing sound and occurs
with stenosis or occlusion of an artery.
j. General tympany
First, percuss lightly in all four quadrants to determine the prevailing
amount of tympany and dullness. Tympany should predominate because
air in the intestines rises to the surface when the person is supine.
Dullness occurs over a distended bladder, adipose tissue, fluid or a mass.
Hyperresonance is present with gaseous distention.
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ABDOMINAL DISTENSIONS
OBESITY OVARIAN CYST
ASCITES PREGNANCY
Inspection: Single curve. Everted umbilicus. Inspection: Single curve. Umbilicus protruding.
Bulging flanks when supine. Taut, Auscultation: Fetal heart tones. Bowel sounds
glistening skin, recent weight gain, diminished.
increases in abdominal girth. Percussion: Tympany over intestines. Dull over
Auscultation: Normal bowel sounds over enlarging uterus.
intestines. Diminished over ascetic fluid. Palpation: Fetal parts. Fetal movements.
Percussion: Tympany at top where
intestines float. Dull over fluid. Produces
fluid wave and shifting dullness.
Palpation: Taut skin and increased
intraabdominal pressure limit palpation.
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Percussion: Tympany over large area. Percussion: Dull over mass if reaches up to
Palpation: May have muscle spasm of skin surface.
abdominal wall. Palpation: Define borders. Distinguish from
enlarged organ or normally palpable structure.
FECES
Inspection: Localized distention
Auscultation: Normal Bowel sounds
Percussion: Tympany predominates. Scatterd dullness over fecal mass.
Palpation: Plastic-or ropelike mass with feces in intestines.
DUODENUM COLON
Duodenal ulcer typically has dull, Large bowel obstruction has moderate,
aching, gnawing pain, does not radiate, colicky pain of gradual onset in lower
may be relieved by food and may abdomen, bloating. Irritable bowel
awaken the person from sleep. syndrome has sharp or burning,
cramping pain over a wide area; does
not radiate. Brought on by meals,
relieved by bowel movement.
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X. The extremities
a. Upper extremities
Lift both the person’s hands in your hands. Inspect, then turn the
person’s hands over, noting color of skin and nailbeds; temperature,
texture and turgor of skin; and the presence of any lesions, edema or
clubbing. Use the profile sign to detect clubbing.
With the person’s hands near the level of his or her heart, check
capillary refill. This is an index of peripheral perfusion and cardiac output.
Depress and blanch the nail beds; release and note the time for color
return. Usually, the vessels refill within a fraction of a second. Consider it
normal if the color returns in less than 1 or 2 seconds. The two arms
should be symmetric in size.
Note the presence of any scars on hands and arms. Needle tracks in
antecubital fossae occur with intravenous drug use; linear scars in wrist
may signify past self-inflicted injury.
Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall,
and equal force. Grade the force on a four-point scale:
4+, bounding
3+, increased
2+, normal
1+, weak
0, absent
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LEVEL OF CONSCIOUSNESS
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DETERMINATION OF PREGNANCY
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G. Skin changes
H. Vaginal changes including leukorrhea
I. Quickening
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LEOPOLD’s MANEUVER
- the systematic abdominal palpation usually done by a health care provider at
about 32 weeks or over for the following purposes:
1. To determine fetal position and presentation
2. To determine the degree of flexion and station of the fetal head.
3. To locate site where fetal heart beat can be auscultated.
STEPS
a. Explain the procedure to the mother
b. Instruct the mother to void or empty the bladder: the bladder lies
anterior to the uterus. A full bladder causes discomfort to the mother.
It will also aid in gaining more accurate results for maneuvers 3 and 4.
c. Position the mother in dorsal recumbent (back flat, knee flex): this
position relaxes abdominal muscles.
d. Drape the mother to provide privacy.
e. Warm two hands by rubbing one against the other briskly before
placing them flat on the mother’s abdomen: the use of warm hands
during palpation prevents tension and hardening of abdominal
muscles favoring good results.
f. Palpate gently
The first three maneuvers are conducted at the side of the bed
facing the client.
1st Maneuver- Place both hands in the Upper abdomen/fundus. Feel for the
presence of mass and distinguish if it’s the head or buttocks.
Head- Hard, Round and ballottable.
Buttocks- Soft, globular and non-ballottable
2nd maneuver- Place the palmar surfaces of both hands on either side of the
abdomen and applies gentle one hand remains still on one side, the other hand
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gradually palpates the opposite side from the top of the lower segment of the
uterus in a slightly circular motion using the flat surface of the fingers.
Back- hard, smooth resistance plane
Small parts- irregular, nodular, with bony prominences.
3rd Maneuver- Gently but firmly grasps the lower abdomen just above the
symphysis pubis, between the thumb and the finges one hand and then pressing
together. If the presenting part is not engaged a movable body which is the head
is felt.
Buttocks- soft globular, non-ballotable
4th Maneuver- using the tip of the first 3 Fingers placed on both sides of ther
midline about 2 inches above Poupart’s ligament. Pressure is now made
downward and in the direction of the birth canal, the movable skin of the
abdomen being carried downward along with the fingers. The fingers of one hand
meet no obstruction and can be carried downward well under poupart’s ligament:
the fingers glides over the nape of the baby’s neck if it well flexed.
The other hand however, usually meets an obstruction an inch or so above the
poupart’s ligament: the fingers is palpating the brow of the baby.0
* Place stethoscope at the side of the abdomen where fetal back is located.
(Refer to maneuver 2) : fetal heartbeat is best heard at the fetal back.
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3. The degree of fetal flexion and how far the head has descended
into the pelvis.
4. Fetal heartbeat.
DURING LABOR
Fetal Assessment:
Auscultation- auscultate FHT at least every 15-30 minutes during first stage and
every 5-15 minutes during second stage.
A. Normal range 120-160 beats/minute
B. Best recorded during the 30 seconds immediately following a contraction
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Maternal Assessment
Premonitory assessment
Physiologic changes preceding labor
a. Lightening (engagement); occurs up to two weeks before labor in primipara;
at beginning of labor for multipara
b. Braxton hicks’ contractions; may become more noticeable; may play a part in
ripening of cervix.
c. Easier respirations from decreased pressure on diaphragm
d. Frequent urination, from increased pressure on bladder
e. Restlessness/poor sleeping patterns, ―nesting‖ behaviors
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a. Progress of labor
b. Cervical changes
c. Maternal mood changes: if irritable or aggressive may be tiring or unable to cope
d. Signs of nausea, vomiting, trembling, crying, irritability
e. Maternal/fetal vital signs
f. Breathing patterns, may be hyperventilating
g. Urge to bear down with contractions.
SECOND STAGE OF LABOR
-from dilation of cervix to birth of baby
Assessments:
a. Signs of imminent delivery
b. Progress of descent
c. Maternal/fetal vital signs
d. Maternal pushing efforts
e. Vaginal distension
f. Bulging of perineum
g. Crowning
h. Birth of baby
THIRD STAGE OF LABOR
- from birth of the baby to the expulsion of placenta.
Assessments:
a. Signs of placental separation
1. Gushing of blood
2. Lengthening of cord
3. Change in shape of uterus (discoid to globular)
b. Completeness of placents
c. Status of mother/baby contact for first critical 1-2 hours
1. Baby’s apgar scores
2. Blood pressure, pulse, respirations, lochia, fundal status of
mother.
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NEWBORN ASSESSMENT
APGAR SCORING
Was developed by Dr. Virginia APGAR as a method of assessing the
newborn’s adjustment to extrauterine life.
Was taken at one minute and five minutes after birth. (Evangelista-
Sia.2004)
The composite score at 5 minutes provide the best direction for the
planning of newborn care. (Stein.2007)
Assess O 1 2
Below100 (signifies Above100 (signifies
Heart Rate Absent
asphyxiated) distress)
Respiration Absent Slow Good crying
Muscle tone Flaccid Some Flexion Active Motion
Reflex irritability NO response Grimace Vigorous cry
Body pink,
Color Blue all over Pink all over
extremities blue
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Score:
7-10 Good adjustment, vigorous
Moderate depressed infant, needs airway clearance, repeat scoring every five
minutes as needed.
Severely depressed infant, in need of resuscitation. (Evangelista-Sia.2004)
Assess O 1 2
Chest movement Synchronized Lag on respiration See-saw respiration
Intercostal
None Just visible Marked
Retraction
Xiphoid retraction None Just visible Marked
Nares Dilatation None Minimal Marked
Audible by
Respiratory Grunt None Audible by ear
stethoscope
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B Physical Examination
1. SKIN: thickens with gestational age; may be dry/peeling if postmature.
2. LANUGO: disappears as pregnancy progresses.
3. SOLE(plantar) creases: increase with gestational age.
4. AREOLA OF BREAST: at term, 5-10mm in diameter.
5. EAR: cartilage stiffens, recoil increases, and curvature of pinna increases with
advancing gestational age.
6. GENITALIA: in the male, check for descended testicles and scrotal rugae, in the
female, look for the labia majora to cover the labia minora and clitoris.(Stein2007)
B Neuromuscular Assessment (best done after 24 hours)
1. Resting posture: relaxed posture (extension seen in the premature; flexion
increases with maturity.
2. Square window angle: flex hand onto underside of forearm, identify abgle at
which you fell resistance. Angle decreases with increasing Gestational age.
3. Arm recoil: flex infant’s arms, extend for 5 seconds, then release. Note angle
formed as arms recoil. Decreases with increasing gestational age.
4. Popliteal angle: place infant on back, extend leg, and measure angle at point of
resistance. Angle becomes more acute as gestation progresses.
5. Scarf sign: draw one arm across chest until resistance is felt: note relation of
elbow to midline of chest. Resistance increases with advancing gestational age.
6. Heel to ear: attempt to raise foot to ear, noting point at which foot slips from your
grasp. Resistance increases with gestational age. (Stein.2007)
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A. Weight
1. Average between 2750 and 3629g (6-8lb) at term
2. Initial loss of 5-8% of body weight normal during first few days; should be
regained in 1-2 weeks.
Variations:
- Under 2500g: small for gestational age (SGA)
- Over 4100g(9 lbs): large for gestational age (LGA)
B Length: average 45.7-55.9 cm (18-22 in)
Variations:
- Under 45.7cm (18in): SGA
-Over 55.9 cm (22 in): LGA
C. Head Circumference: average 33-35.5cm (13-14in); remeasure after several
days if significant molding or caput succedaneum present.
Variations:
- Under 31.7 cm: microcephaly/SGA
-Over 36.8cm: hydrocephaly/LGA
D. Chest circumference: average 1.9 cm less than head
E. Abdominal girth may be measured if indicated. Consistent placement of tape is
important for comparison, identification of abnormalities. Measurement is best done
before feeding, as abdomen relaxes after a feeding.
F. Skin
1. Color in Caucasian infants usually pink; varies with other ethnic backgrounds.
2. Pigmentation increases after birth
3. Skin may be dry.
4. Acrocyanosis of hands and feet normal for 24 hours; may develop ―newborn
rash‖ (erythema toxicum neonatorum)
5. Small amounts of lanugo and vernix caseosa still seen.
6. Cappillary hemangiomas above eyebrows and at base of neck under hairline
are essentially normal.
7. Mongolian spot (darkened areas of pigmentation over sacral area and
buttocks) are normal and fade in early childhood.
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Variations:
-raised capillary hemangiomas on areas other than face or neck are not normal.
- Excess Lanugo: possible prematurity
-Excess vernix: prematurity
G. Fontanels
1. Anterior: diamond shape
2. Posterior: triangular
3. Should be flat and open
Variations:
- Depressed: dehydration
-Bulging: increased intracranial pressure
* HEAD
- Hair: coarse or brittle, possible endocrine disorder
-Scalp: edema present at birth from pressure of cervix against presenting part.
-Skull: Collection of blood between a skull bone and its periosteum from pressure during
delivery.
H. Ears
1. Should be even with canthi of eyes
2. Cartilage should be present and firm.
Variations:
- Lack of cartilage: possible prematurity
- Low placement: possible kidney disorder or Down’s syndrome
I. Eyes
1. May be irritated by medications instillation, some edema/discharge present.
2. Color is slate blue.
Variations:
-Wide space between eyes is seen in fetal alcohol syndrome.
J. Nose: copious drainage associated with syphilis
K. Mouth
1. Trush: appears as white patches in mouth; candida infection passed from
mother during passage through birth canal.
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Variations:
Misplaced urinary meatus:
- Epispadias: on upper surface of penis
- Hypospadias: on under surface of Penis
R. Upper Extremities
Variations:
- Extra fingers
- Webbed fingers
- Asymmetric movement: possible trauma or fracture.
S. Legs
1. Bowed
2. No click or displacement of head of femur observed when hips flexed and
abducted.
T. Feet
1. Flat
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BLOOD PRESSURE
- variation with activity: normal
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PULSE
- persistently under 120: possible heart block
- persistently over 170: possible respiratory distress syndrome.
TEMPERATURE
- Elevated: possible dehydration or infection
- Temperature falls with low environmental temperature, late in cold stress, sepsi,
cardiac disease.
RESPIRATIONS
- Under 25/minute: possibly result of maternal analgesia
- Over 60/minute: possible respiratory distress.(Stein.2007)
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Pain Assessment
associated with actual or potential damage. Persons have individualized responses to pain
because it is physiologic, behavioral, and emotional phenomena; same with pain tolerance and
threshold—it varies among patients and it may fluctuate in the same patient as circumstances
change. Pain threshold refers to the intensity if the stimulus a person needs to sense pain while
pain tolerance is the duration and intensity of pain that a person tolerates before openly
expressing pain.
Pain is considered as the fifth vital sign because it serves as a distress signal in the
body. Pain, however, should have status beyond temperature, pulse, respiration, and blood
pressure. It should always be a concern and it is the patient who should decide whether the pain
When a patient complains of pain, the location and related symptoms may assist in the
diagnosis of the patient’s condition. If the pain is related to a diagnosed condition (e.g., trauma,
surgery, or cancer), assessment of its character and intensity is necessary for pain control.
The patient’s self-report of the presence and severity of pain is the most accurate,
reliable means of pain assessment. If the patient reports pain, respect what he says and act
promptly to assess and control it. The patient knows best and the first principle to be considered
in assessing pain is: Pain is whatever the patient says it is occurring whenever he says it does.
responses to various scales that evaluate pain intensity and quality. The success of pain
management plan hinges on having the patient chooses an appropriate goal—a pain intensity
rating that will reduce their discomfort to a tolerable level and will let them engage comfortably
to a tolerable level.
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A review of related history provides a thorough history of the past and present
experiences of pain the patient felt and it also includes the management, its effects to the
patient’s whole being, its factors and the attitude towards the experience of pain.
PRESENT PROBLEM:
Onset: date of onset, sudden or slow, time of day, duration, variation. Rhythm (constant
or intermittent)
Quality: throbbing, shooting, stabbing, sharp, cramping, gnawing, hot or burning, aching,
heavy, tender, splitting, tiring or exhausting, sickening, fear producing, punishing or cruel
Intensity: Ranges from slight to severe using one of the pain scales
Location: Where is the pain? Can the patient point a finger to it? Does it travel or
radiate?
Effect of pain on psyche: change in mood or social interactions, poor concentration, can
Previous experiences with pain and its effect; typical coping strategies for pain control
Family’s concerns and cultural beliefs about pain; expect or tolerate pain in certain
situations
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Attitude toward the use of opioids, anxiolytics, and other pain medications for pain
Throughout the examination of the patient, be alert to signs of pain, which may include
any combinations of the following list. When communication is a problem, as with cognitively
impaired, young children, and older adults, have a family member describe known cues to the
patient’s expression of pain. It is often likely that an individual patient will repeat a behavior
Guarding, protective behavior, hands over painful area, distorted posture, irritability
Facial mask of pain: lackluster eyes, ―beaten look,‖ wrinkled forehead, tightly closed or
opened eyes, fixed or scattered movement , grimace or other distorted expression, a sad
or frightened look
Body movements such as head rocking, pacing, or rubbing; an inability to keep the
hands still
Change in vital signs : blood pressure, pulse, respiratory rate and depth, with acute
exacerbations of pain; fewer changes in vital signs found in cases of chronic pain
Pupil dilatation
Dry mouth
There are a number of classic pain patterns that provide valuable clues to underlying conditions:
Bone and soft tissue pain may be tender, deep, and aching
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Heavy, throbbing and aching pain may be associated with a tumor pressing on a cavity
A clenched fist over the chest with diaphoresis and grimacing is the classic picture of
myocardial infarction. Even a mild pain can require immediate attention in this regard.
A variety of scales and instrument have been developed to obtain and measure a patient’s
Introducing the patient to the appropriate use of any scale requires a patient a clear explanation
of the purposes of the scale and the meanings of the numbers or figures on the scale.
The numerical pain intensity scale is the most commonly used pain rating scale. Simply
ask the patient to rate his pain on a scale from 0 to 10, with 0 representing no pain and 10
Pain can be evaluated in a nonverbal manner for pediatric patients ages 3 and older or
for adult patients with language difficulties. One common pain rating scale consists of 6 faces
with expressions ranging from happy and smiling to sad and teary.
To use a pain intensity rating scale, tell the patient that each face represents a person
with progressively worse pain. Ask the patient to choose the face that best represents how he
feels. Explain that although the last face has tears, he can choose this face even if he isn’t
crying.
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Examples of commonly used pain intensity rating scale for children are the Wong/Baker
Faces Rating Scale (Fig. 1-1) and the Oucher scale (Fig. 1-2). These pain rating scales are
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The visual analog scale is a horizontal line, 10 cm long with word descriptors at each
end—―no pain‖ on one end, ―pain as bad as it can be‖ on the other. The scale also may be used
vertically.
In using the visual analog scale, ask the patient to put a mark along the line to indicate
the intensity of pain felt. Then measure the line in millimeters up to his mark. The mark
represents the patient’s pain rating. This scale may be too abstract for some patients to use.
To use the visual analog scale, ask the patient to put a mark on the line across the scale
to indicate his current pain intensity then measure the distance in millimeters, from ―no
pain‖ to his marking.
No pain Pain as
bad as it can be
With the verbal descriptor scale, the patient chooses a description of his pain from a list
―annoying‖.
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Pain scales can also be used for neonates and infants. The Premature Infant Profile (PIPP)
(Figure 1-5) which was developed by Stevens and colleagues validates premature infants, but
the observations are also appropriate for judging pain in full-term neonates and young infants.
Similarly, the Neonatal Infant Pain Scale (NIPS) (Figure 1-6) developed by Lawrence
requires careful observation of the infant. You can readily assess the cry (often high-pitched and
shrill, sleep patterns (disturbed, fussy, even trashing), facial expressions (tightly closed eyes,
wide open mouth, and wrinkled brow), feeding and sucking, overall tone, and consolability. A
crying, hypertonic, sleepless baby who is unable to suck and unable to be consoled is hurting.
The Individualized Numeric Rating Scale (INRS) (Figure 1-7) developed by Solodiuk and
Curley is used with nonverbal children. It recognizes the necessary observations and present
presents them in a manner that makes recording and follow-up easy. The INRS is a good guide
to assessing pain in the nonverbal or otherwise compromised patient at any age and in a variety
injury.
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GUIDE QUESTIONS:
Prior to Admission:
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During Hospitalization:
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During Hospitalization:
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During Hospitalization
D. Activity-Exercise Pattern
This pattern refers to activity and routine exercise, activity, leisure, and recreation
that help maintain both physical and mental health. It also includes: (a) activities of daily
living that requires energy expenditure like eating, cooking, hygiene and other usual
home activities, and (b) the type, amount, quality and quantity of exercises done
including sports. In collecting the data in this pattern, ask about the exercise done and if
engaging in sports, assess if patient uses protective equipments.
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During Hospitalization:
E. Sleep-Rest Pattern
Rest and Sleep are essential for health as it restores a person’s energy, allowing
the individual to resume optimal function. This pattern focuses on rest, and relaxation
practices, the amount of sleep of the client, use of medication and other drugs, sleep
environment, recent changes in sleep patterns and difficulties in sleeping
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Number of awakenings during sleep period and any perceived cause of waking
up?
Do you use any sleeping aids?
Any medications taken before sleeping?
Describe usual bedroom surroundings
During Hospitalization:
F. Cognitive-Perceptual Pattern
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During Hospitalization:
Assess for the level of consciousness, vision, hearing, taste, touch, smell
Check if oriented to time, place and people
Are you in pain? When did pain begin? Rate pain from 1-10, 10 being the highest
During hospitalization:
Verbalization of the client with regards to current status and body image
Is there anything alteration in the person's appearance?
Changes in way you feel about yourself or your body? Difficulty accepting
changes?
How do you feel about the events and situations happening to you now?
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Objective data such as body posture, eye contact, voice tone, interactions with
other people especially to roommates
Are you anxious about something?
H. Role-Relationship Pattern
This pattern describes the client’s pattern of role participation and relationships
with others, support systems, and the effect of changes of the client’s role with regards
to the present condition.
I. Sexuality-Reproductive Pattern
Sexuality is important in developing self-identity, interpersonal relationships,
intimacy and love. This pattern may include information about client’s sexual satisfaction
and dissatisfaction with sexuality patterns, the knowledge about sexual behavior, ability
to express one’s full sexual potential, ability to make autonomous decisions, and
experiences of sexual pleasure and its practices. Problems regarding reproductive
functions are also included in the assessment.
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J. Coping-Stress Tolerance
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During Hospitalization:
K. Value-Belief Pattern
This pattern includes the health beliefs, the religious practices, traditions and
expressions which affect the spiritual and physical well-being of the client. It also
includes the values and goals that influence their decisions and choices in health care.
Religious affiliation
Do you have any special religious practices concerning health?
What principals did this person learn as a child that is still important to her/ him?
What support systems does this person currently have?
Have your religious beliefs helped you to deal with problems in the past?
Any religious restrictions to care (diet, blood transfusions)
Will this admission interfere with your spiritual or religious practices?
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BIOGRAPHICAL DATA
Name: ______________________________________________________________
Address: ____________________________________________________________
Sex: _______________________________________________________________
Age: _______________________________________________________________
Race: ______________________________________________________________
Nationality: _________________________________________________________
Culture: ____________________________________________________________
Dependents: ________________________________________________________
Religion: ___________________________________________________________
Occupation: ________________________________________________________
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Referral: ___________________________________________________________
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Childhood illnesses:
Serious injuries:
Serious/Chronic Illness:
Immunizations:
Allergies:
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Medications:
Travel:
Military Service:
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FAMILY HISTORY
Patient:
Spouse:
Daughter:
Son:
Brother:
Sister:
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Father:
Mother:
Paternal Aunt:
Paternal Uncle:
Maternal Aunt:
Maternal Uncle:
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Paternal Grandfather:
Paternal Grandmother:
Maternal Grandfather:
Maternal Grandmother:
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REVIEW OF SYSTEMS
General Hx Survey:
Integumentary:
Eyes:
Ears:
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Respiratory:
Cardiovascular:
Breasts:
Gastrointestinal:
Female Reproductive:
Male Reproductive:
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Musculoskeletal:
Neurological:
Endocrine:
Immune/Hematological:
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PSYCHOSOCIAL PROFILE
Typical Day:
Nutritional Patterns:
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Personal Habits:
Occupational Hx Patterns:
Socioeconomic Status:
Environmental Hx Pattern:
Cultural Influences:
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Sexuality Pattern:
Social Supports:
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General Appearance
Measurement
Weight __________
Height __________
Skinfold thickness ___________
Vision using Snellen’s eye chart __________
Vital signs
Temperature ________
Hypothermia __________
Hyperthermia _________
Pulse ______________
Respiration ___________
Blood pressure __________
Others: __________
C.Widespread color change
Pallor ____
Erythema ___
Cyanosis ____
Jaundice ____
Others: ______
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D.Moisture
Diaphoresis _________
Dehydration __________
Others: __________
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Any exudates____________
II. Hair
Color ________
Texture_________
Distribution _________
Lesions ___________
III. Nails
Shape and contour _____________
Consistency _______________
Color _____________
Capillary refill ____________
IV.The Head
Skull
Size and shape
Temporal area _____________
.
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V. Face
Facial structures
A. Eyes
Central visual acuity
Lacrimal apparatus
Anterior eyeball structures.
Cornea and lens
B. Ears
External ear
Size and shape
Microtia ______
Macrotia ______
Skin condition
Tenderness
Position
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Integrity of membrane
Hearing Acuity
C. Nose
External nose
Nasal cavity
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F. Breasts
General appearance
Skin
Nipple
Breath sounds
H. Abdomen
a. Contour
b. Symmetry
c. Umbilicus
d. Skin
e. Pulsation or movement
f. Hair distribution
g. Demeanor
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h. Bowel sounds
i. Vascular sounds
j. General tympany
I .EXTREMITIES
Upper Extremities:
Lower Extremities:
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Prior to Admission:
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During Hospitalization:
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Prior to Admission:
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During Hospitalization:
________________________________________________________________
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Prior to Admission:
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During Hospitalization:
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Prior to Admission:
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During Hospitalization:
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V. Sleep-Rest Pattern
Prior to Admission:
______________________________________________________________________
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During Hospitalization:
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Prior to Admission:
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During Hospitalization:
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Prior to Admission:
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During Hospitalization:
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Prior to Admission:
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During Hospitalization:
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IX.Sexuality-Reproductive Pattern
Prior to Admission:
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During Hospitalization:
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X. Coping-Stress Tolerance
Prior to Admission:
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During Hospitalization:
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XI.Value-Belief Pattern
Prior to Admission:
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During Hospitalization:
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ADMISSION ASSESSMENT
Name: _______________________________________________________
VITAL SIGNS:
Review admission CBC, urinalyses and chest-xray. Note any abnormalitites here:
________________________________________________________
_____________________________________________________________
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OBJECTIVE
b. Sensorium
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__
c. Memory
Recent: Yes__ No__; Remote: Yes__ No__
2. Vision
a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not assessed___
b. Pupil size: Right: Normal__ Abnormal__;
Left: Normal__ Abnormal__
3. Hearing
a. Not assessed__
b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__ Deaf__
c. Hearing aid: Yes__ No__
4. Taste
a. Sweet: Normal__ Abnormal__ Describe:______________________
b. Sour: Normal__ Abnormal__ Describe:_______________________
c. Tongue movement: Normal__ Abnormal__ Describe:____________
d. Tongue appearance: Normal__ Abnormal__ Describe:___________
5. Touch
a. Blunt: Normal__ Abnormal__ Describe:_______________________
b. Sharp: Normal__ Abnormal__ Describe:______________________
c. Light touch sensation: Normal__ Abnormal__ Describe:__________
d. Proprioception: Normal__ Abnormal__ Describe:________________
e. Heat: Normal__ Abnormal__ Describe:_______________________
f. Cold: Normal__ Abnormal__ Describe:________________________
g. Any numbness? No__ Yes__ Describe:_______________________
h. Any tingling? No__ Yes__ Describe:_________________________
6. Smell
a. Right nostril: Normal__ Abnormal__ Describe:__________________
b. Left nostril: Normal__ Abnormal__ Describe:___________________
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_________________________________________________________
10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
_________________________________________________________
_________________________________________________________
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11. Do you have any difficulty securing any of the following services?
Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care Facility: Yes:__
No:__; Transporation: Yes:__ No:__; Telephone (for police, fire, ambulance): Yes:__
No:__; If any difficulties, note referral here:
______________________________________________________
__________________________________________________________
Yes__ No__
14. Did you think this prescribed routine was best for you?
Yes__ No__ What would be better? ____________________________
18. Have you experienced any ringing in the ears: Right ear: Yes__ No___
Left ear: Yes__ No__
19. Have you experienced any vertigo: Yes__ No__ How often and when?
_________________________________________________________
20. Do you regularly use seat belts? Yes__ No__
21. For infants and children: Are car seats used regularly? Yes__ No__
22. Do you have any suggestions or requests for improving your health?
Yes__ No__ Describe: ______________________________________
_________________________________________________________
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NUTRITIONAL-METABOLIC PATTERN
OBJECTIVE
1. Skin examination
a. Warm__ Cool__ Moist__ Dry__
b. Lesions: No__ Yes__ Describe: _______________________________
c. Rash: No__ Yes__ Describe: _________________________________
d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__
Other____________________________________________________
2. Mucous Membranes
a. Mouth
i. Moist__ Dry__
ii. Lesions: No__ Yes__ Describe: __________________________
iii. Color: Pale__ Pink__
iv. Teeth: Normal__ Abnormal__ Describe:____________________
v. Dentures: No__ Yes__ Upper__ Lower__ Partial__
vi. Gums: Normal__ Abnormal__ Describe:____________________
vii. Tongue: Normal__ Abnormal__ Describe:___________________
b. Eyes
i. Moist__ Dry__
ii. Color of conjunctiva: Pale__ Pink__ Jaundiced__
iii. Lesions: No__ Yes__ Describe:___________________________
3. Edema
a. General: No__ Yes__ Describe:_______________________________
Abdominal girth: ___inches
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10. If mother is breastfeeding, have infant weighed. Is infant’s weight within normal
limits? Yes__ No__
SUBJECTIVE:
1. Any weight gain in the last 6 months? No__ Yes__ Amount: ___________
2. Any weight loss in the last 6 months? No__ Yes__ Amount:____________
3. How would you describe your appetite? Good__ Fair__ Poor__
4. Do you have any food intolerance? No__ Yes__ Describe: ____________
5. Do you have any dietary restrictions? (Check for those that are a part of a
prescribed regimen as well as those that patient restricts voluntarily, for example, to
prevent flatus) No__ Yes__ Describe: ___________________
___________________________________________________________
6. Describe an average day’s food intake for you (meals and snacks): _____
___________________________________________________________
___________________________________________________________
12. Do you have any concerns about breast feeding? No__ Yes__ Describe:
___________________________________________________
13. Are you having any problems with breastfeeding? No__ Yes__ Describe:
___________________________________________________
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ELIMINATION PATTERN
OBJECTIVE
1. Auscultate abdomen:
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2. Palpate abdomen:
a. Tender: No__ Yes__ Where?_________________________________
b. Soft: No__ Yes__; Firm: No__ Yes__
c. Masses: No__ Yes__ Describe: _______________________________
d. Distention (include distended bladder): No__ Yes__ Describe: _______
_________________________________________________________
3. Rectal Exam:
a. Sphincter tone: Describe: ____________________________________
b. Hemorrhoids: No__ Yes__ Describe: ___________________________
c. Stool in rectum: No__ Yes__ Describe: _________________________
d. Impaction: No_- Yes__ Describe:______________________________
e. Occult blood: No__ Yes__ Location: ___________________________
3. Character of stool
a. Consistency: Hard__ Soft__ Liquid__
b. Color: Brown__ Black__ Yellow__ Clay-colored__
c. Bleeding with bowel movements: No__ Yes__
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Have time to get to bathroom: Yes__ No__ How often does problem reaching
bathroom occur? ___________________________________
ACTIVITY-EXERCISE PATTERN
OBJECTIVE
1. Cardiovascular
a. Cyanosis: No__ Yes__ Where? _______________________________
c. Extremities:
i. Temperature: Cold__ Cool__ Warm__ Hot__
ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
____________________________________________________
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2. Respiratory
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________
_________________________________________________________
3. Musculoskeletal
a. Range of motion: Normal__ Limited__ Describe: __________________
b. Gait: Normal__ Abnormal__ Describe: __________________________
c. Balance: Normal__ Abnormal__ Describe: ______________________
d. Muscle mass/strength: Normal__ Increased__ Decreased__
Describe: ________________________________________________
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SUBJECTIVE
1. Have patient rate each area of self-care on a scale of 0 to 4. (Scale has been
adapted by NANDA from E. Jones, et. Al., Patient Classification for Long Term Care;
User’s Manual. HEW Publication No. HRA-74-3107, November 1974.)
0 – Completely independent
5. How many stairs can you climb without experiencing any difficulty (can be
individual number or number of flights)? ___________________________
6. How far can you walk without experiencing any difficulty? _____________
7. Has assistance at home for self-care and maintenance of home:
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No__ Yes__ Who? __________ If no, would you like to have or believes needs
assistance: No__ Yes__ With what activities? _________________
OBJECTIVE
SUBJECTIVE
1. Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ Feel
rested? Yes__ No__ Describe: ________________________
2. Any problems:
a. Difficulty going to sleep? No__ Yes__
b. Awakening during night? No__ Yes__
c. Early awakening? No__ Yes__
d. Insomnia? No__ Yes__ Describe: _____________________________
3. Methods used to promote sleep: Medication: No__ Yes__ Name: _______
Warm fluids: No__ Yes__ What? __________________; Relaxation techniques: No__
Yes__ Describe: _______________________________
COGNITIVE=PERCEPTUAL PATTERN
OBJECTIVE
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SUBJECTIVE
1. Pain
a. Location (have patient point to area) : __________________________
b. Intensity (have patient rank on scale of 0 to 10): __________________
c. Radiation: No__ Yes__ To where? _____________________________
d. Timing (how often: related to any specific events): ________________
_________________________________________________________
e. Duration: _________________________________________________
f. What done relieve at home? __________________________________
g. When did pain begin? _______________________________________
2. Decision-making
a. Decision making is: Easy__ Moderately easy__ Moderately difficult__ Difficult__
b. Inclined to make decisions: Rapidly__ Slowly__ Delay__
3. Knowledge level
a. Can define what current problems is: Yes__ No__
b. Can restate current therapeutic regimen: Yes__ No__
OBJECTIVE
SUBJECTIVE
2. Do you think this admission will cause any lifestyle changes for you?
No__ Yes__ What? ___________________________________________
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3. Do you think this admission will result in any body changes for you?
No__ Yes__ What? ___________________________________________
ROLE-RELATIONSHIP PATTERN
OBJECTIVE
1. Speech Pattern
a. Is English the patient’s native language? Yes__ No__ Native language is:
__________________ Interpreter needed? No__ Yes__
b. During interview have you noted any speech problems? No__ Yes__ Describe:
________________________________________________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No__
Yes__ Describe: ___________________________
b. If patient is a child, is there any physical or emotional evidence of physical or
psychosocial abuse? No__ Yes__ Describe: ____________
_________________________________________________________
SUBJECTIVE
4. Any losses (physical, psychologic, social) in past year? No__ Yes__ Describe:
___________________________________________________
5. How is patient handling this loss at this time? ______________________
___________________________________________________________
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6. Do you believe this admission will result in any type of loss? No__ Yes__
Describe: ___________________________________________________
7. Ask both patient and family: Do you think this admission will cause any significant
changes in the patient’s usual family role? No__ Yes__ Describe:
___________________________________________________
8. How would you rate your usual social activities? Very active__ Active__
Limited__ None__
9. How would you rate your comfort in social situations? Comfortable__
Uncomfortable__
10. What activities or jobs do you like to do? Describe: ___________
___________________________________________________________
SEXUALITY-REPRODUCTIVE PATTERN
OBJECTIVE
Review admission physical exam for results of pelvic and rectal exams. If results not
documented, nurse should perform exams. Check history to see if admission resulted
from a rape.
SUBJECTIVE
Female
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9. What has been your primary coping mechanism in handling this rape episode?
___________________________________________________
10. Have you talked to persons from the rape crisis center? Yes__ No__ If no, want
you to contact them for her? Yes__ No__ If yes, was this contact of assistance? No__
Yes__
Male
Both
OBJECTIVE
1. Observe behavior: Are there any overt signs of stress (crying, wringing of hands,
clenched fists, etc)? Describe: ____________________________
SUBJECTIVE
1. Have you experienced any stressful or traumatic events in the past year in
addition to this admission? No__ Yes__ Describe:___________________
___________________________________________________________
2. How would you rate your usual handling of stress? Good__ Average__ Poor__
3. What is the primary way you deal with stress or problems? ____________
___________________________________________________________
4. Have you or your family used any support or counseling groups in the past year?
No__ Yes__ Group name: ________________________________
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Was the support group helpful? Yes__ No__ Additional comments: _____
___________________________________________________________
5. What do you believe is the primary reason behind a need for this admission?
_________________________________________________
6. How soon, after first noting the symptoms, did you seek health care assistance?
_________________________________________________
7. Are you satisfied with the care you have been receiving at home? No__ Yes __
Comments: ___________________________________________
8. Ask primary caregiver: What is your understanding of the care that will be
needed when the patient goes home? ____________________________
___________________________________________________________
VALUE-BELIEF PATTERN
OBJECTIVE
SUBJECTIVE
1. Satisfied with the way your life has been developing? Yes__ No__ Comments:
_________________________________________________
2. Will this admission interfere with your plans for the future? No__ Yes__ How?
______________________________________________________
3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__ Other:
_____________________________________________________
4. Will this admission interfere with your spiritual or religious practices? No__ Yes__
How? ________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__
Describe: ___________________________________________________
6. Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to
visit you? No__ Yes__ Who? _________________________
7. Have your religious beliefs helped you to deal with problems in the past?
No__ Yes__ How?____________________________________________
GENERAL
1. Is there any information we need to have that I have not covered in this
interview? No__ Yes__ Comments? ______________________________
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2. Do you have any questions you need to ask me concerning your health, plan of
care or this agency? No__ Yes__ Questions: _________________
___________________________________________________________
3. What is the first problem you would like to have help with? ____________
___________________________________________________________
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BIBLIOGRAPHY
Published:
Barrientos-Tan, Crestita; A Research Guide in Nursing Education 3rd Edition. Makati
City-Visual Enterprises, 2006
Kozier, Barbara, et.al. Funadamentals of Nursing 7th edition. Singapore: Pearson
Education Inc. 2004
Patricia, Dillon. Nursing Health Assessment: A Crtitical Thinking Case Studies Approach
2nd Edition. F.A Davis Company, 2007.
Basavanthappa, BT. Fundamentals of Nursing. Jaypee brothers Medical Publishers (p)
Ltd. New Delhi, India. 2002
Daniels, Rick. Nursing Fundamentals: Caring and Clinical Decision Making. Delmar
Learning, Thomson Learning Inc. United States of America. 2004
Altman, Gaylene Bouska. Delmar’s Fundamental and Advanced Nursing Skills—
Second Edition. Delmar Learning, Thomson Learning Inc. United States of
America. 2004
Weber, J. and Kelley, J. Health Assessment in Nursing 3 rd ed. Lippincott Williams and
Wilkins United States of America. 2007
Evangelista-Sia, Maria Loreto; Infant Care and Feeding 2004 edition by RMSIA
Publishing
Unpublished:
Garcia, Leila G. ―A Proposed Related Learning Experience Handbook of Nursing for
Notre Dame of Dadiangas College .‖ Masters thesis. San Pedro College, Davao
City 2003.
Laveme et. al. An Assessment of Related Learning Experience in Psychiatric Nursing of
Notre Dame of Dadiangas University; Undergraduate Thesis General Santos
City, 2007.
E-sources:
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