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Manual on Nursing Health

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

helped them in making this manual for nursing health assessment:

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

manual and this course we are undertaking.

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

improves our attitude.

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

improving our manual.

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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Manual on Nursing Health Assessment

constantly reminded us about our manual. Sir, your unending support, supervision and

encouragement had helped us a lot in fulfilling this manual.

To Ms. Helen R. Sestina, RN, MAN, Dean of College of Nursing, for the support and

time shared and for the approval of our letters.

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

everything for your greater honor, praises and glory!

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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

health patterns and sample formats to be used when conducting an interview.

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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Manual on Nursing Health Assessment

contents is to guide and impart knowledge to the readers about the proper and ideal way of

conducting a thorough and comprehensive assessment for the formulation of an effective

nursing care plan for the improvement of client’s condition.

In summary, this manual is aimed towards the improvement of each nursing students in

rendering quality care to clients through a comprehensive assessment because it is through

good assessment that we fully understand and indentify the real needs of the client thereby

improving their health.

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Manual on Nursing Health Assessment

Table of Contents

Page

Assessment 8

Assessment as Part of Nursing Process

Three Major Methods in Assessing

Types of Data

Assessment precautions 15

Nursing Health History 19

Strategies for Effective Health Assessment

Functions of Interview and Health History

Types of Health History

Components of health History

Biographical data

Reason for seeking Health Care

Current health status and symptom analysis if indicated

Past health history

Family history

Review of Systems

Psychosocial profile

The Barthel Index of Activities of Daily Living

Katz Index of Independence in Activities of Daily Living

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Manual on Nursing Health Assessment

Nursing Physical Assessment 46

Methods used in Assessment

Sequence of Physical Assessment

Alterations in Physical Assessment

Maternal and Child Assessment

Pain Assessment
Gordon’s Functional Health Patterns 132

Sample forms in Nursing Health Assessment 143

Bibliography 192

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Manual on Nursing Health Assessment

Assessment as Part of Nursing Process

Three Major Methods in Assessing

- Interview

- Observation

- Examining

Types of Data

- Subjective Data

- Objective Data

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Manual on Nursing Health Assessment

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 a systematic, rational method of planning and providing


individualized nursing care for individuals, families, groups and communities. Its goal
are to identify a client’s actual or potential health care needs, to establish plans to meet
the identified needs, and to deliver and evaluate specific nursing interventions to meet
those needs. (Kozier.2004)

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)

The NURSING Process is divided into five steps:

1. ASSESSMENT
What brought you to the hospital?

Let me have a look at that.

Describe how you are feeling.

STANDARD I. The nurse collects client health data.

2. DIAGNOSIS
What is the problem?

What is the Cause?

How do I know it?

STTANDARD II. The nurse analyzes the assessment

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Manual on Nursing Health Assessment

3. PLANNING
What can I do about it?

What is most important?

What do I want to happen, by when?

STANDARD III. The nurse identifies expected outcomes individualized to the

client.

STANDARD IV. The nurse develops a plan of care that prescribes intervention to

attain expected outcomes.

4. IMPLEMENTATION
Move into action.

Carry out the plan.

STANDARD V. The nurse implements the interventions identified in the plan of

care.

5. EVALUATION
Did it work?

Why or why not?

Is the problem solved, or do I need to try again?

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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Manual on Nursing Health Assessment

ASSESSMENT (data collection)

-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.

ASSESSING = Observation + Interview + Examination

(Data Collection) (Health History) (Physical Exam)

(Gordon’s Functional Health Pattern)

OBSERVATION, INTERVIEW and EXAMINATION

A. OBSERVATION-To observe is to gather data using the sense. Observation is a


conscious, deliberate skill that is developed through effort and with an organized
approach. (Kozier.2004)

B. INTERVIEW- is a planned communication or a conversation with a purpose,


for example to get or give information, identify problems of mutual
concerns, evaluate change, teach, provide support, or provide
counseling or therapy. (Kozier.2004)

-is a pattern of communication initiated for a specific purpose and focused on a


specific content area.(Perry and Potter.2007)

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Manual on Nursing Health Assessment

Purposes of interview in Nursing:

to obtain Nursing Health History


Identify health needs and risk factors; and
To determine specific changes in the level of wellness and pattern living.

Objectives of Nursing Interview:

Establish a therapeutic relationship with the client.


Establish the nurse’s sense of caring for the client as an individual.
Introduce the client to the facility in a manner that is not threatening.
Gain insights about the client’s concerns.
Determine the client’s expectations of health care providers and the
health care delivery system.
Obtain cues about parts of the data collection phase that require in-
depth investigation.

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)

Guidelines for Communication during an interview

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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Manual on Nursing Health Assessment

C. EXAMINING- the physical examination or physical assessment is a systematic data-


collection method that uses observation to detect health problems. It is carried out
systematically. It may be organized according to the examiner’s preference, in a head-to
–toe approach or a body systems approach. (Kozier.2004)

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.

INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES

When Interacting with an anxious client

Provide the client with simple, organized information in a structural format.


Explain who you are and your role and purpose.
Ask simple, concise questions.
Avoid becoming anxious like the client.
Do not hurry and decrease any external stimuli.

When Interacting with an Angry Client

Approach the client in a calm, reassuring, in-control manner.


Allow him to ventilate feelings. However, if the client is out of control, do not
argue with or touch the client.
Obtain help from other health care professionals as needed.

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Avoid arguing and facilitate personal space so the client does not feel threatened
or cornered.

When Interacting with a Depressed client

Express interest in and understanding of the client and respond in a neutral


manner.
Do not try to communicate in an upbeat, encouraging manner. This will not help
the depressed client.

When Interacting with a Manipulative Client

Provide structure and set limits.


Differentiate between manipulation and reasonable request.
If you are not sure whether you are being manipulated, obtain an objective
opinion from other nursing colleagues.

When Interacting with a seductive client

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.

When Discussing Sensitive Issues ( For example, Sexuality, Dying, Spirituality)

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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Synopsis of types of precautions and patients requiring the precautions

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

In addition to standard precautions, use airborne precautions for patients known or


suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of
such illnesses include:

1. Measles
2. Varicella (including disseminated zoster)
3. Tuberculosis

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Droplet Precautions

In addition to standard precautions, use droplet precautions for patients known or


suspected to have serious illnesses transmitted by large-particle droplets. Examples of
such illnesses include:

1. Invasise Haemophilus influenza type b disease including meningitis, pneumonia,


epiglottitis, and sepsis
2. Invasive Neisseria meningitides disease, including meningitis, pneumonia and
sepsis
3. Other serious bacterial respiratory infections spread by droplet transmission,
including:
a. Diphtheria (pharyngeal)
b. Mycoplasma pneumonia
c. Pertussis
d. Pneumonic plague
e. Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and
young children
4. Serious viral infections spread by droplet transmission, including:
a. Adenovirus
b. Influenza
c. Mumps
d. Parvovirus B19
e. Rubella

Contact Precautions

In addition to standard precautions, use contact precautions for patients known or


suspected to have serious illnesses easily transmitted by direct patient contact or by
contact with items in the patient’s environment. Examples of such illnesses include:

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1. Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-


drug-resistant bacteria judged by the infection control program, based on current
state, regional or national recommendations, to be of special clinical and
epidemiologoic significance.
2. Enteric infections with a low infectious dose or prolonged environmental survival,
including:
a. Clostridium difficile
b. For diapered or incontinent patients: enterohemorrhagic Eschirichia coli
O157, Shigella Hepatitis A, or rotavirus
3. Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants
and young children.
4. Skin infections that are highly contagious or that may occur on dry skin,
including:
a. Diphtheria (cutaneous)
b. Herpes simplex virus (neonatal or mucocutaneous)
c. Impertigo
d. Major (noncontained) abscesses, cellulitis, or decubiti
e. Pediculosis
f. Scabies
g. Staphylococcal furunculosis in infants and young children
h. Zoster (disseminated or in the immunocompromised host)
5. Viral/hemorrhagic conjunctivitis
6. Viral hemorrhagic infections (Ebola, Lassa, or Marburg) (Kozier.2004)

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Strategies for Effective Health Assessment

Functions of Interview and Health History

Types of Health History

-Complete Health History

- Focused Health History

Components of health History

o Biographical data

o Reason for seeking Health Care

o Current health status and symptom analysis if


indicated

o Past health history

o Family history

o Review of Systems

o Psychosocial profile

o The Barthel Index of Activities of Daily Living

o Katz Index of Independence in Activities of Daily


Living

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STRATEGIES FOR EFFECTIVE HEALTH ASSESSMENT

I. Interview and History taking Strategies

FUNCTIONS OF THE INTERVIEW AND HEALTH HISTORY:

Interviewing and taking health Histories serve five major functions:

1. Establishing the initial bond between provider and patient.


2. Laying the foundation for subsequent clinical decision-making.
3. Providing a legal record of the subjective and objective data elicited during the
clinical interview, which drive clinical judgments.
4. Fulfilling a critical component of the documentation required for third-party payer
reimbursement for clinical services.
5. Serving an essential element in the peer review process for evaluation of clinical
practice, such as application of evidence-based practice and identification of
desired patient outcomes. (Rhoads.2006)

HEALTH HISTORY

Provides the subjective database for your assessment.

The health history is your first major interaction with your patient.

The health history is subjective.

It consists of what the patient tells you, what the patient perceives, and
what the patient thinks is important.

Provides a holistic, qualitative picture of your patient.

Helps direct your physical assessment and are essential in developing a


successful plan of care for your patient.

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PURPOSE:

*Provide the subjective database

*Identify patient strengths

*Identify patient health problems, both actual and potential.

*Identify supports

*Identify teaching needs.

*Identify discharge needs.

*Identify referral need. (Dillon.2007)

Types of Health Histories

A. COMPLETE HEALTH HISTORY-


is taken on initial visits to health care facilities when the providers within
the facilities will be providing comprehensive or continuous care.
(Malasanos.1990)
is performed on all nonemergent, (Rhoads.2006)
begins with biographical data, including the patient’s name, age, gender,
birth date, birthplace, marital status, race, religion, address, education,
occupation, contact person and health insurance/ social security
number.(Dillon.2007)

B. PROBLEM-FOCUSED HEALTH HISTORY-


is used to collect data about a specific problem system or region.
(Malasanos.1990)
is performed in emergency situations and/or when the patient is already under
the ongoing care of the clinician and presents with a specific problem-oriented
complaint. (Rhoads.2006)
may be indicated when your patient’s condition is unstable or when time
constraints are an issue.(Dillon.2007)

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COMPONENTS OF HEALTH HISTORIES

Complete Health History Problem-Focused Health History

Biographical data Biographical data

Reason for seeking Health Care Reason for seeking Health Care

Current health status and Current health status and


symptom analysis if indicated symptom analysis if indicated

Past health history Past health history only as it


relates to specific reason of
seeking care.
Family history
Family history only as it relates
to specific reason of seeking care.

Review of Systems Review of Systems only as it


relates to specific reason of
seeking care.
Psychosocial profile

Psychosocial profile only as it


relates to specific reason of
seeking care. (Dillon.2007)

FOCUSED versus COMPREHENSIVE HISTORY

*Deciding which type of health history to do depends on two factors:

1. Patient’s condition: either emergent or nonemergent case.


2. Amount of time: allot at least 30 minutes to an hour to obtain a complete health
history.

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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)

Guidelines for taking the Health History

1. Establish an environment conducive to effective communication; that is private,


comfortable, and quite.
2. Allow the client to state problems and expectations for the encounter.
3. Provide the client with an orientation to the structure, purposes and expectations of
the health history.
4. Make some judgment early in the interview about the priorities for the encounter
given the constraints of the interviewer and the client. Communicate and negotiate
priorities with the client.
5. If the client has already encountered a provider within the health care system, review
pertinent recorded information before the interview.
6. Make a judgment about the balance between allowing a patient to talk in an
unstructured manner and the need to structure requested information.
7. Clarify the client’s definitions of all key terms and descriptors.
8. Avoid questions that can be answered as yes or no if detailed information is desired.
9. Keep notes adequate enough for future recording. Specific quantitative data is
especially subject to faulty recall.
10. Record the health history as soon as possible after the interview. (Malasanos et ol.
1990)

Components of the health history

A complete health history addresses health and illness patterns, health


promotion and protective patterns, and roles and relationships. The parts of the
health history that focus on health and illness patterns includes:

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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

Data Significance/ Consideration

Name Prevents confusion when patients have Similar names.


Formats of name may differ culturally.
(Full & Maiden Name)

May provide socioeconomic information and identify


Address and Phone
environmental health risks (e.g. urban vs. suburban or
Number
rural neighborhoods)

May be a Source for further data and support for


Contact Person
patient. Essential in case of medical emergency.

Allows you to compare stated age with apparent age


(e.g. chronic illness can make a person appear older).
Identifies age-related risk factors for health problems
Age/ Birth date/ Place of
(e.g. children more risk for accidents; incidence of
Birth
cardiovascular disease and cancer increases with age).
Age helps identify patient’s developmental stage. Place
of birth may correlate with environmental risks.

Identifies risk for gender-related health problems (e.g.


Gender women have much higher incidence of breast cancer
than me.)

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Identifies risk for health problems associated with a


Race/Ethnicity/Nationality particular race or ethnic group. Identifies possible
ethnic influences on healthcare practices.

Alerts you to religious beliefs that may influence health


practices (e.g. Judaism and diet, Jehovah’s Witnesses
Religion
and Blood products). May identify sources of support
for your patient.

Identifies possible support people. Present health


status may affect family relationships, patient’s
Marital Status
economic status, and ability to support family. Referral
may be necessary.

Do not assume that unmarried patients live alone. Ask


Number of dependents
if they live with someone.

Helps determine teaching approaches. Do not assume


that educational level correlates with knowledge and
Educational Level
understanding. Do not talk down to patient who has
had little formal education.

Identifies possible occupational risk factors. Provides


clues about socioeconomic status. Current health
Occupation
status also may affect patient’s occupational status.
Referral may be necessary.

Referrals may be needed depending on type of health


Health Insurance
insurance.

Ideally, the patient is source of history. Secondary

Source of History/Reliability source, usually a family member of friend, is necessary


with children or when patient is unable to provide
history. Establish reliability of person providing history

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by noting consistency in responses and willingness to


communicate.

Identifies primary care physician/practitioners. If no


Referral referral source identified, may need to make referral for
follow-up. (Dillon.2007)

B. REASON FOR SEEKING HEALTH CARE

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.

*The following are examples of adequately stated chief complaints.

Chest pain for 3 days

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Manual on Nursing Health Assessment

Swollen ankles for 2 weeks.


Fever and headache for 24hours.
Pap smear needed. Last pap 9/8/ 07
Physical examination needed for camp.

C. HISTORY OF PRESENT ILLNESS (HPI)

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)

*The goal in obtaining the history of present illness is to get a comprehensive


description of the characteristics and progression of symptoms for which the patient
seeks care. The mnemonic device PQRST may be used to ensure that all the
necessary data are gathered regarding the patient’s presenting symptoms:

P: precipitating factors (What provokes the symptoms?)

Ask: What were you doing when the problem started?

Does anything make it better, such as medications or certain positions?

Does anything make it worse, such as movement or breathing?

Q: quality (Describe the character and location of symptoms.)

Ask: Can you describe the symptom?

What does it feel like, look like or sound like?

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How often are you experiencing it?

To what degree does this problem affect your ability to perform your usual

daily activities?

R: region/radiation/related symptoms

(Does the symptom radiate to other area of the body?)

Ask: Can you point to where the problem is?

Does it occur or spread anywhere else?

Do you have any other symptoms? (Ask about related symptoms.)

S: severity (Ask the patient to quantify the symptom[s] on a scale of 0-10)

Ask: Is the symptom mild, moderate or severe?

Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the

most severe.

T: timing (Inquire about the onset, duration, frequency, etc.)

Ask: When did the symptom start?

How long does it last?

* Although PQRST is useful in accurately describing symptoms, it does not capture


many elements of health and illness as experienced by the patient. The following
mnemonic device integrates ethno cultural considerations into the data gathering
process and facilitates the provision of culturally congruent care. The mnemonic device
is CLIENT OUTCOMES.

C: character of the symptoms, including intensity/severity

L: location, including radiation (if present)

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I: impact of the symptoms/illness on the patient’s activities of daily living (ADL) and
quality of life.

E: expectation (client’s) of the care giving process

N: neglect or abuse, including any signs that physical and emotional neglect or abuse
play a role in the patient’s condition.

T: timing, including onset, duration, frequency of symptoms

O: other symptoms that occur in association with the major presenting symptom

U: understanding/beliefs (client’s) about the possible causation of the illness/condition

T: treatment (medications and other therapies that the patient has used to try to
alleviate the symptoms/condition)

C: complementary alternative medicine (CAM) including a description of the patient’s


use of these agents or practices

O: options for care that are important to the patient (e.g. advance directives)

M: modulating factors, meaning factors that precipitate, aggravate, or alleviate the


patient’s symptoms/condition

E: exposure to infectious agents, toxic materials, etc.

S: spirituality, including spiritual beliefs, values, and needs of the


patient.(Rhoads.2006)

*Other data included here are as follows:

Current health promotion activities: diet, exercise, stress management,


meditation, yoga, spiritual or religious groups.
Client’s perceived level of health
Current medications
- Herbal preparations

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- Type of Drugs prescription, OTC, vitamins, illegal)

-Prescribed by whom

- When first prescribed

- Reason for prescription

- Dose of medication and frequency per day

- Client’s perception of the effectiveness of medication

D. PAST HEALTH MEDICAL HISTORY (PMH)

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.

The PAST HEALTH MEDICAL HISTORY: Identifies any chronic preexisting


health problems.
Identifies additional health risks caused by preexisting conditions.(Dillon.2007)

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Key elements of the past medical history include:

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).

Ilnesses to note include measles/rubella, mumps,


pertussis, chickenpox, poliomyelitis, diphtheria,
rheumatic fever, scarlet fever and smallpox.

Major adult Record date of diagnosis, treatment and whether the


illnesses/conditions condition was successfully treated or requires ongoing
care. Assess impact on patient’s functional ability and
quality of life.

Allergies Allergy may explain current problem; food, drug,


environmental factors, and contact substances. Be sure
to specifically ask about substances to which the client
could be exposed in health care setting, such as latex or
iodine. When asking about allergies, be sure that the
client knows what is meant by allergies.

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If the patient has allergy, note type of reaction. Allergic


reactions include hives, pruritis and respiratory
problems.

Medications Medications may be causing current problem. For


example. OTC drugs medication may be interacting with
a prescribed medication, causing adverse effects or
negating desired effects. Ask about prescribed and OTC
medications, including vitamins, supplement, and herbs.
Obtain name of medication, dose, frequency and last
time taken.

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).

Hospitalizations/ Record the reason for the hospitalization, dates and


Surgeries complications, if any. Obtain the name and address of
the facility to obtain the patient’s medical records, if
necessary.

Previous hospitalizations may have a direct link to


current problem or provide clues to preexisting
problems.

Knowing past surgical procedures may rule out certain


problems or explain others. For example, a patient with
right lower quadrant pain cannot have appendicitis if his
or her appendix has been removed, but pain may be
caused by adhesions.

Transfusions Elicit and record the date, type, number of units


administered, and the nature and severity of any

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reaction.

Immunizations Lack of immunization may explain current problem. Elicit


and record date of last immunization by type, such as
diphtheria, pertussis, tetanus, polio, pneomococcal
vaccine, influenza, smallpox, chlorea, typhoid, anthrax,
bacilli Calmette-Guerin (BCG). Also record the date of
the patient’s last purified protein derivative (PPD)
tuberculin skin test, as well as any other skin testing,
such as allergy testing.

Screening exams Record that date of the following exams, as appropriate


to the patient: Pap smear, mammogram, prostate-
specific antigen (PSA), digital rectal exams, cholesterol,
lipid profile, blood glucose, eye exam, glaucoma testing,
hearing test, PPD, Chest X-ray.

Psychiatric/mental Elicit and record any conditions requiring psychological


health or psychiatric intervention. Briefly describe treatment
interventions. (Rhoads.2006)

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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

- This includes the collection of data about the past


and present health of each client’s systems. This
review of the client’s physical, sociological, and
psychological health status, may identify problems
not uncovered previously in the history and
provides an opportunity to indicate client
strengths and liabilities.(Malasanos et ol. 1990)

AREA/SYSTEM ASK ABOUT

General Hx Survey Unusual problems or symptoms, fatigue, exercise


intolerance, unexplained fevers, night sweats, weakness,
difficulty doing activities of daily living, number of colds or
illnesses per year.

Integumentary Skin diseases, such as psoriasis, itching, rashes, scars,


sores, ulcers, warts, and moles; changes in skin lesions;
skin reaction to hot or cold. Changes in hair texture,
baldness, usual patterns of hair care (e.g. shampooing,
coloring, permanents). Changes in nails (e.g color, texture,
splitting, cracking, breaking); usual patterns of nail care
(e.g use of polish, acrylic nails.)

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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Eyes Wearing glasses or contact lenses, visual defects, last eye


examination, last glaucoma check, eye injury, itching,
tearing, drainage, pain, floaters, halos, loss of vision or
parts of fields, blurred vision, colored lights, flashing lights,
light sensitivity, twitching, cataracts or glaucoma, eye
surgery, retinal detachment, strabismus or amblyopia.

Ears Last hearing test, difficulty hearing, sensitivity to sounds,


ear pain, drainage, vertigo,, ear infections, ringing,
fullness, in ears, ear wax problems, use of hearing aids,
ear-care habits, such as use f cotton-tipped swabs.

Nose and Sinuses Nosebleeds, broken nose, deviated septum, snoring,


pastnasal drip, runny nose, sneezing, allergies, use of
recreational drugs, difficulty breathing through nose,
problem with ability to smell, pain over sinuses, sinus
infections.

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.

Respiratory Breathing problems; cough; sputum (color and amount);


bloody sputum; shortness of breath with activity; noisy
respirations such as wheezing; pneumonia, bronchitis;
tuberculosis; last chest x-ray and results; purified protein
derivative and result; history of smoking.

Cardiovascular Chest pain; palpitations; murmurs, skipped beats,


hypertension; awakening at night with SOB; dizzy spells;
cold or numb hands and feet; color changes in hands and
feet; pain in legs while walking; swelling of extremities; hair

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loss on legs; sores that do not heal; results of ECG, if ever


done.

Breasts Breast masses, lumps, pain, discharge, swelling; changes


in breast or nipples, cystic breast disease; breast cancer;
breast surgery; reduction, enhancements; breast self-
examination; date of last clinical breast examination; date
of last mammogram, if ever done.

Gastrointestinal Loss of appetite, indigestion, heart burn, GERD, nausea,


vomiting, vomiting blood, lover or gallbladder disease,
jaundice, abdominal swelling, regular bowel patterns,
changes in bowel patterns, color of stool, diarrhea,
constipation, hemorrhoids use of laxatives.

Female Reproductive Menarche, description of cycle, last menstrual period,


painful menstruation, excessive bleeding, irregular
menses, bleeding between periods, last Pap test and
result, satisfaction with sexual performance, painful
intercourse, use of contraceptives, history of sexually
transmitted disease.

Male Reproductive Lesions, discharge; pain on urination, painful intercourse,


prostate or scrotal problem, history of STDs, infertility
problems, impotence, or sterility; satisfaction with sexual
performance, knowledge of prevention of STDs including
HIV, use of contraceptives.

Musculoskeletal Fractures, sprains, muscle cramps, pain, weakness, joint


swelling, redness, limited range of motion, joint deformity,
noise with movement, spinal deformities, low back pain,
loss oh height, osteoporosis, degenerative joint disease,
impact on ability to do ADLs, use of calcium supplements.

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Neurological Loss of consciousness, fainting, seizures, head injury,


changes in cognition or memory, hallucinations,
disorientation, speech problems, sensory disturbances
such as numbness, tingling, or loss of sensation, motor
problems, problems with gait, balance or coordination and
impact on ability to do ADLs.

Endocrine Endocrine disorders such as thyroid disease or diabetes,


unexplained changes in weight or height, increased thirst,
hunger or urination, heat and cold intolerance; goiter;
weakness, hormone therapy, changes in hair or skin.

Immune/Hematological Anemia, bleeding disorders; recurrent infections, cancers;


HIV; fatigue; blood transfusion; bruising; allergies;
unexplained swollen glands.(Dillon.2007)

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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

Hx Practices and How does the patient perceive her/his role in


Belief maintaining health?

Does she/he get yearly physical examination or seek


healthcare when ill?

Does she/he perform self-examinations and other self-


care measures?

Typical Day Describing a typical day may identify health risk


factors. Or, if the patient has a health problem, it helps
determine what effect this problem has on his/her
everyday life.

Nutritional Patterns Ask about special diets, food preferences, food


allergies, weight changes, happiness with weight, and
history of eating disorders.

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.

Recreation, Hobbies, Recreational activities, hobbies, and pets usually

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Pets enhance health by reducing stress. But they can also


pose health risks.

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.

Personal Habits Ask patient about the use of tobacco/cigarettes;


alcoholic beverages; caffeine or drugs.

Occupational Hx Ask your patient if her/his job requires exposure to


Patterns toxins such as asbestos, pesticides, plastics,
anesthetics, radiation or solvents, protective gear or
heavy physical activity.

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.

Environmental Hx Ask patient about the type of community he’s/she’s in;


Pattern the type of neighborhood.

Roles, Relationship, Your patient’s feelings, attitudes, past experiences and


Self-Concepts relationships contribute to his/her sense of value and
worth and affect his/her overall health.

Cultural Influences Culture can influence communication patterns, health


beliefs and practices, dietary habits, family roles and
life-and-death issues.

Religious/ Spiritual Religion and spirituality influence health beliefs and


Influences practices, dietary preferences, family roles, and life-
and-death issues.

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Family Roles and Ask the patient about his/her relationship within the
Relationship family and other social group.

Sexuality Pattern Illness can have both physical and psychological


effects on your patient’s sexuality. Changes in body
image or self-concept, changes in ability to perform
sexually, prescribed medications and depression can
all have adverse effects on sexuality.

Social Supports Support systems outside the family are important


during illness. Ask your patient if there is anyone aside
from family that he or she can call on for help.

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

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

continence of bowel and bladder.

The assessment can be used to determine a baseline level of functioning and can be

used to monitor improvement in activities of daily living over time.

Using the Barthel Index

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%

independently then the ―middle‖ score would apply.

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Katz Index of Independence Scale

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

adequacy of performance in the 6 functions of bathing, dressing, toileting, transferring,

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

severe functional impairment.

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.

Katz Index of Independence in Activities of Daily Living

Activities Independence Dependence


Points (1 or 0) (1 Point) (0 Points)

NO supervision, direction WITH supervision, direction,


or personal assistance personal assistance or total
care

BATHING (1 POINT) Bathes self (0 POINTS) Need help with


completely or needs help bathing more than one part
in bathing only a single of the body, getting in or out
Points: __________ part of the body such as of the tub or shower.
the back, genital area or Requires total bathing
disabled extremity

DRESSING (1 POINT) Get clothes from (0 POINTS) Needs help with


closets and drawers and dressing self or needs to be
puts on clothes and outer

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Points: __________ garments complete with completely dressed.


fasteners. May have help
tying shoes.

TOILETING (1 POINT) Goes to toilet, (0 POINTS) Needs help


gets on and off, arranges transferring to the toilet,
clothes, cleans genital cleaning self or uses bedpan
Points: __________ area without help. or commode.

TRANSFERRING (1 POINT) Moves in and (0 POINTS)Needs help in


out of bed or chair moving from bed to chair or
unassisted. Mechanical requires a complete transfer.
Points: __________ transfer aids are
acceptable

CONTINENCE (1 POINT) Exercises (0 POINTS) Is partially or


complete self control over totally incontinent of bowel
urination and defecation. or bladder
Points: __________

FEEDING (1 POINT) Gets food from (0 POINTS) Needs partial or


plate into mouth without total help with feeding or
help. Preparation of food requires parenteral feeding.
may be done by another
person.
Points: __________

Total Points: ________

Score of 6 = High, Patient is independent.

Score of 0 = Low, patient is very dependent.

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*Methods used in Assessment

*Sequence of Physical Assessment

*Alterations in Physical Assessment

*Maternal and Child Assessment

*Pain Assessment

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NURSING PHYSICAL ASSESSMENT

Nursing physical assessment is the systematic & continuous collection, validation,


and communication of client data from a physical examination. The principle used is the
cephalo-caudal technique which means from head to toe. This technique aids the
student nurse assess his/her client in an organized and systematic way. Cephalo-
caudal assessment is under complete physical examination. Unlike regional
examination, complete physical examination includes the entire body of the client. This
type of assessment is an effective way in gathering the most number of objective cues
from the client which will lead to a comprehensive nursing health assessment.

Methods used in physical assessment:

 Inspection

 Initial contact and ongoing

 Use olfaction, touch

 General appearance, body language

 Systematic unhurried approach

 Expose part, respect privacy

 Examine: color, size, shape, position, symmetry (compare like areas)

 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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Special considerations in assessing pediatric and geriatric clients:

General Principles in assessing pediatric clients:

 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

General principles in assessing geriatric clients:

 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

III. Vital signs


a. Temperature
i. Axillary
ii. Oral
iii. Tympanic
iv. rectal
b. Pulse

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i. Apical
ii. Radial
iii. Brachial
iv. Femoral
v. Popliteal
vi. Dorsalis pedis
c. Respiration
d. Blood pressure (if indicated)

IV. Skin and accessory body parts


A. Skin
a. Color

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.

Common (benign) pigmented areas also occur:

1. Freckles (ephelides) – small, flat macules of brown melanin


Vitiligo
pigment that occur on sun exposed skin.
2. Moles (nevus) – a proliferation of melanocytes, tan to brown
color, flat or raised. Acquired nevi are characterized by their
symmetry, small size (6mm or less), smooth borders and
single uniform pigmentation.
3. Birthmarks – may be tan to brown in color. An acquired
condition is vitiligo, the complete absence of melanin
pigment in patchy areas of white or light skin on the face,

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neck, hands, feet, body folds, and around orifices. Vitiligo


can occur in all races, although dark-skinned people are
more affected and potentially suffer a greater threat to their
body image.

ii. Widespread color change


Note any color change over the entire body skin such as pallor,
Pallor
erythema, cyanosis, and jaundice. Note whether the color change
is transient and expected or if it is due to pathology. In dark-skinned
people the amount of normal pigment may mask color changes.
Lips and nail beds show some color change, but they vary with the
person’s skin color and may not be accurate signs. The more
Erythema
reliable sites are those with the least pigmentation, such as under
the tongue, the buccal mucosa, the palpebral conjunctiva, and the
sclera.

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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The pallor of impending shock is accompanied by other


subtle manifestations, such as increasing pulse rate, oliguria,
apprehension, and restlessness.
Anemia, particularly chronic iron deficiency anemia, may
show ―spoon nails,‖ with a concave shape. A lemon yellow
tint of the face and slightly yellow sclera accompany
pernicious anemia, also indicated by neurologic deficits and
a red, painful tongue. Fatigue, exertional dyspnea, rapid
pulse, dizziness, and impaired mental function accompany
most severe anemias.

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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hypoxemic. The person just is unable to fully oxygenate the


massive numbers of red blood cells. Lastly, do not confuse
cyanosis with the common and normal bluish tone on the lips
of dark-skinned persons.
Cyanosis indicates hypoxemia and occurs with shock,
heart failure, chronic bronchitis, and congenital heart
disease.

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.

How to use an axillary thermometer:

 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. Diaphoresis, or profuse perspiration, accompanies an increased


metabolic rate, such as occurs in heavy activity or fever.
Diaphoresis occurs with thyrotoxicosis and with stimulation of the
nervous system with anxiety or pain.

ii. Dehydration in the oral mucus membranes should be assessed.


Normally there is none, and the mucous membranes look smooth
and moist. Be aware that dark skin may normally look dry and flaky,
but this does not necessarily indicate systemic dehydration.
With dehydration, mucous membranes look dry and the lips look
parched and cracked. With extreme dryness the skin is fissured,
resembling cracks in a dry lake bed.

d. Texture and turgor


Normal skin feels smooth and firm, with an even surface. In
hyperthyroidism, skin feels smoother and softer, like velvet. In
hypothyroidism, skin feels rough, dry and flaky.

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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Edema is fluid accumulating in the intercellular spaces; it is not


present normally. To check for edema, imprint your thumbs firmly
against the ankle malleolus or the tibia. Normally the skin surface
stays smooth. If your pressure leaves a dent in the skin, ―pitting‖
edema is present.

Its presence is graded on a four-point scale:

1 + mild pitting, slight indentation, no perceptible swelling of the


leg.
2 + moderate pitting, indentation subsides rapidly.
3 + deep pitting, indentation remains for a short time, leg looks
swollen.
4 + very deep pitting, indentation lasts a long time, leg is very
swollen.

This scale is somewhat subjective; outcomes vary among


examiners.

Edema masks normal skin color as well as obscures pathological


conditions such as jaundice or cyanosis because the fluid lies
between the surface and the pigmented and vascular layers. It
makes dark skin look lighter.
Edema is most evident in dependent parts of the body (feet,
ankles, and sacral areas), where the skin looks puffy and tight.
Skin turgor Edema makes the hair follicles more prominent, so you note a pig-
skin or orange-peel look (called peau d’orange).
Unilateral edema may be due to a peripheral or a local cause. In
bilateral edema or in generalized edema (anasarca), a central
problem such as heart failure and kidney failure is considered.

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e. Mobility and turgor


In an adult, pinch up a large fold of skin on the anterior chest under the
clavicle. Mobility is the skin’s ease of rising, and turgor is its ability to
return to place promptly when released. This reflects the elasticity of the
skin.
To assess skin turgor in an infant, grasp a fold of loosely adherent
abdominal skin between the thumb and forefinger and pull the skin taut.
The skin should quickly return to its normal position after releasing. If the
skin remains tented, the infant has poor turgor.
Mobility is decreased when edema is present. Poor turgor is evident in
severe dehydration or exreme weight loss; the pinched skin recedes
slowly or ―tents‖ and stands by itself.
Scleroderma, literally ―hard skin,‖ is a chronic connective tissue disorder
associated with decreased mobility.

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.‖

vi. Location and distribution on body:


1. Generalized – distributed all over the body.
2. Regionalized – limited to one area of the body.
3. Localized – sharply limited to a specific areas.
4. Scattered – dispersed either densely or widely.
5. Exposed areas – limited to areas exposed to the air or sun.
6. Imtertriginous – limited to areas where skin comes in
contact with itself.

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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.

viii. Any exudates. Note its color and/or odor.

Lesions are traumatic or pathological changes in previously normal


structures. When a lesion develops on previously unaltered skin, it is
primary (new). However, when a lesion changes over time or changes
because of a factor such as scratching or infection, it is secondary (a
change in a primary lesion).
When evaluating a lesion, you’ll need to classify it as primary or
secondary. Then determine if it’s solid or fluid-filled and describe its
characteristics, pattern, location and distribution.
Palpate lesions with your hand wearing a glove to prevent contact with
the lesion, blood mucosa and any body fluid. Roll a nodule between the
thumb and index finger to assess depth. Gently scrape a scale to see if it
comes off. Note the nature of its base or if it bleeds when the scale comes

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off. Note the surrounding skin temperature. However, the erythema


associated with rashes is not always accompanied by noticeable
increases in skin temperature.
Does the lesion blanch with pressure or stretch? Stretching the area of
skin between your thumb and index finger decreases the normal
underlying red tones, thus providing more contrast and brightening the
macules. Red macules from dilated blood vessels will blanch momentarily,
whereas those from extravasated blood (petechiae) do not. Blanching also
helps identify a macular rash in dark-skinned people.
Lesions may be benign, such as a benign nevus, or mole. However,
changes in an existing growth on the skin or a new growth that ulcerates
or doesn’t heal could indicate cancer or a precancerous lesion.
If you suspect a lesion may be malignant melanoma, observe for the
ABCDE’s of malignant melanoma:
1. A – Asymmetrical lesion.
2. B – Border irregular.
3. C – Color of lesion varies with shades of tan, brown, or
black and, possibly, red, blue, or white.
4. D – Diameter greater than 6 mm.
5. E – Elevated or enlarging lesion.

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.

i. The profile sign


View the index finger at its profile and note the angle of the nail base; it
should be about 160 degrees. The nail base is firm to palpation. Curved
nails are a variation of normal with a convex profile. They may look like
clubbed nails, but notice that the angle between the nail base and nail is
normal.
Clubbing of nails occurs with congenital chronic cyanotic heart disease
and with emphysema and chronic bronchitis.
In early clubbing, the angle straightens out to 180 degrees and the nail
Nail clubbing base feels spongy to palpation.

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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abnormal marking on the nail beds. Brown, linear streaks (especially


sudden appearance) are abnormal in light-skinned people and may
indicate melanoma.
Splinter hemorrhages, transverse ridges, or beau’s lines are abnormal.

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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The Snellen alphabet chart is the most commonly used and


accurate measure of visual acuity. It has lines of letters arranged in
decreasing size.
Place the Snellen alphabet chart in a well-lit spot at eye level.
Position the person on a mark exactly 20 feet from the chart. Hand
the person an opaque card with which to shield one eye at a time
during the test; inadvertent peeking may result when shielding the
eye with person’s own fingers. If the person wears glasses or
contact lenses, leave them on. Remove only reading glasses
because they will blur distance vision. Ask the person to read
through the chart to the smallest line of letters possible. Encourage
the person to try the next smallest line also.
Abnormal findings would be hesitancy, squinting, leaning
forward, and misreading letters.
Normal visual acuity is 20/20. Contrary to some people’s
impression, the numeric fraction is not a percentage of normal
vision. Instead, the top number (numerator) indicates the distance
the person is standing from the chart, while the denominator gives
the distance at which a normal eye could have read that particular
line. Thus ―20/20‖ means, ―you can read at 20 feet what the normal
eye could have read at 20 feet.‖
The larger the denominator, the poorer the vision. If vision is
poorer than 20/30, refer to an optometrist. Impaired vision may be
due to refractive error, opacity in the media (cornea, lens, vitreous
humor), or disorder in the retina or optic pathway.
If the person is unable to see even the largest letters, shorten the
distance to the chart until it is seen and record the distance (e.g.,
―10/200‖). If visual acuity is even lower, assess whether the person
can count your fingers when they are spread in front of the eyes or
distinguish light perception using penlight.

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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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The Snellen’s Eye Chart

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ii. Lacrimal apparatus


Ask the person to look down. With your thumbs, slide the outer
part of the upper lid up along the bony orbit. Inspect for any
redness or swelling.
Swelling of the lacrimal gland may show as a visible bulge in the
outer part of the upper lid.
Presence of excessive tearing may indicate blockage of the
nasolacrimal duct. Check this by pressing the index finger against
the sac, just inside the lower orbital rim, not against the side of the
nose. Pressure will slightly evert the lower lid, but there should be
no other response to pressure.

b. Inspect anterior eyeball structures.


i. Cornea and lens
Shine a light from the side across the cornea, and check for
smoothness and clarity. This oblique view highlights any abnormal
irregularities in the corneal surface. There should be no opacities
(cloudiness) in the cornea, the anterior chamber, or the lens behind
Marked corneal the pupil. Do not confuse an arcus senilis with opacity. The arcus
opacity
senilis is anormal finding in aging persons.

ii. Iris and pupil


The iris normally appears flat, with a round regular shape and
even coloration. Note the size, shape and equality of the pupils.
Normally the pupils appear round, regular, and of equal size in both
eyes. In the adult, resting size is from 3-5mm. A small number of
people (5%) normally have pupils of two different sizes, which is
termed anisocoria.
To test the papillary light reflex, darken the room and ask the
person to gaze into the distance (this dilates the pupils). Advance a

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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.

a. Inspect and palpate the external ear


Low set ears
i. Size and shape
The ears are of equal size bilaterally with no swelling or
thickening. Ears of unusual size and shape may be a normal
familial trait with no clinical significance. Edema is abnormal.
1. Microtia – ears smaller than 4 cm vertically.
2. Macrotia – ears larger than 10 cm vertically.

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ii. Skin condition


The skin color is consistent with the person’s facial skin color. the
skin is intact, with no lumps or lesions. on some people you may
note Darwin’s tubercle, a small painless nodule at the helix. This is
a congenital variation and is not significant.
Reddened, excessively warm skin indicates inflammation. Crusts
and scaling occur with otitis externa, eczema, contact dermatitis,
and seborrhea. Enlarged tender lymph nodes in the region indicate
inflammation of the pinna or mastoid process. Red-blue
discoloration indicates frostbite and other abnormal findings are
tophi, sebaceous cyst, chondrodermatitis, keloid, and carcinoma.

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.

iv. The external auditory meatus


Note the size of the opening and there should be no swelling,
redness, or discharge. Atresia is the absence or closure of the ear
canal, which is abnormal.
A sticky yellow discharge accompanies otitis externa, or may
indicate otitis media if the drum has ruptured.
Some cerumen is usually present. The color varies from gray-
yellow to light brown and black, and the texture varies from moist
and waxy to dry and desiccated. A lrge amount of cerumen
obscures visualization of the canal and drum.

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Impacted cerumen is a common cause of conductive hearing


loss.

b. Inspect using the otoscope


If an otoscpoe is available, note the size of the auditory meatus as you
inspect the external ear. Then choose the largest speculum that will fit
comfortably in the ear canal, and attach it to the otoscope. Tilt the
person’s head slightly away from you toward the opposite shoulder. This
method brings obliquely sloping eardrum into better view.
Pull the pinna up and back on an adult or older child; this helps
straighten the S-shape of the canal. Pull the pinna down on an infant and
a child under 3 years of age. Hold the pinna gently but firmly. Do not
release traction on the ear until you have finished the examination and the
otoscope is removed.
Hold the otoscope ―upside down‖ along your fingers and have the dorsa
of your hand along the person’s cheek braced to steady the otoscope.
This position feels awkward to you at first it soon will fell natural and you
will find it useful to prevent forceful insertion. Also your stabilizing hand
acts as a protecting lever if the peron suddenly moves the head.

i. The external canal


Note any redness, swelling, lesions, foreign bodies or discharge.
If any discharge is present, note the color and odor. (Also, clean
any discharge from the speculum before examining the other ear to
avoid contamination with possibly infectious material). For a person
with a hearing aid, note any irritation on the canal wall from poorly
fitting earmolds.
Redness and swelling occur with otitis externa; canal may be
completely closed with swelling. Purulent otorrhea suggests otitis
externa or otitis media if the drum has ruptured.

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Frank blood or clear, watery drainage (cerebrospinal fluid)


following trauma suggests basal skull fracture and warrant
immediate referral. CSF feels oily and is positive for glucose on
TesTape.

1. The tympanic membrane


a. Color and characteristics
The normal eardrum is shiny and translucent, with
a pearl-gray color. Yellow-amber drum color occurs
with serous otitis media. Red color occurs with acute
otitis media and air/fluid level or air bubbles behind
drum indicate serous otitis media.

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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Inspect the eardrum and the entire circumference


of the annulus for perforations. The normal tympanic
membrane is intact. Some adults may show scarring,
which is a dense white patch on the drum. This is a
sequel of repeated ear infections.
Peforation shows as a dark oval area or as a larger
opening on the drum. Vesicles on drum are also
abnormal.

c. Test hearing acuity


Your screening for a hearing deficit begins during the history; how well
does the person hear conversational speech? An audiometer gives a
precise quantitative measure of hearing by assessing the person’s ability
to hear sounds of varying frequency. Since this equipment usually is not
available in the clinical setting, you may use alternate screening
measures. These are ―crude‖ tests. They are non-quantitative; they are
useful to document the presence of hearing loss but do not measure the
degree of loss. Refer any abnormal findings for more accurate measures
with pure tone audiometry.

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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If the person is unable to hear whispered words it is abnormal. A


whisper is a high-frequency sound and is used to detect high-tone
loss.

ii. Tuning fork tests


Tuning fork tests measure hearing by air conduction or by bone
conduction, in which the sound vibrates through the cranial bones
to the inner ear. The air conduction route through the ear canal and
middle ear is usually the more sensitive route. To activate the
Weber test
tuning fork, hold it by the stem and strike the tines softly on the
back of your hand. A hard strike makes the tone too loud, and it
takes a long time to fade out.

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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(through the mastoid process). A normal response is a


positive Rinne test or ―AC>BC.‖ Repeat with the other ear.
Ration of AC to BC is altered with hearing loss. Sound is
heard longer by bone conduction with a conductive loss.

d. The vestibular apparatus


The Romberg test assesses the ability of the vestibular apparatus in the
inner ear to help maintain standing balance.

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.

c. Palpate the sinus area


Using your thumbs, press over the frontal sinuses below the eyebrows
and over the maxillary sinuses below the cheekbones. Take care not to
press directly on the eyeballs. The person should feel firm pressure but no
pain.

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Abnormalities of the nose


1. Choanal atresia
A bony or membranous septum between the nasal cavity
and the pharynx of the newborn.

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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and swelling of turbinates to fill the air space. Turbinates are


usually pale (although may appear violet), and their surface
looks smooth and glistening. May be seasonal or perennial,
depending on allergen.

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.

ii. Teeth and gums


The condition of the teeth is an index of the person’s general
health. Your examination should not replace the regular dental
examination, but you should note any diseased, absent, loose or
abnormally positioned teeth. The teeth normally look white, straight,
and evenly spaced, and clean and free of debris or decay.
Discolored teeth appear brown with excessive fluoride use; yellow
with tobacco use.
Compare the number of teeth with the number expected for the
person’s age. Ask the person to bite as if chewing something and
note alignment of upper and lower jaw. Normal occlusion in the
back is the upper teeth resting directly on the lowers; in the front,
the upper incisors slightly override the lower incisors.
Grinding down of tooth surface is abnormal. Plaques or soft
debris, caries or decay, Malocclusion (poor biting relationship), and
protrusion of upper and lower incisors are also abnormal.
Normally, the gums look pink or coral with a stippled (dotted)
surface. The gum margins at the teeth are tight and well defined.

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Check for swelling; retractions of gingival margins; and spongy,


bleeding, or discolored gums. Black people normally may have a
dark melanotic line along the gingival margin.
Note the number of teeth in infants and children, and whether if
it’s not appropriate for the child’s age. Also note pattern of eruption,
position, condition, and hygiene. Saliva is present after 3 months of
age and shows in excess with teething children.

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.

iv. Buccal mucosa


Hold the cheek open with a wooden tongue blade, and check the
buccal mucosa for color, nodules, or lesions. it looks pink, smooth
and moist, although patchy hyperpigmentation is common and
normal in dark-skinned people.
Dappled brown patches are present with Addison’s disease
(chronic adrenal insufficiency).

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An expected finding is Stensen’s duct, the opening of the parotid


salivary gland. It looks like a small dimple opposite the upper
second molar. You also may see raised occlusion line on the
buccal mucosa parallel with the level the teeth meet due to the
teeth closing against the cheek. Orifice of stensen’s duct looks red
with mumps.
Another abnormal finding would be Koplik’s spots, a prodromal
sign of measles.
A larger patch also may be present along the buccal mucosa.
This is leukodema, a benign grayish opaque area, more common in
blacks and East Indians. When it’s mild, the patch disappears as
you stretch the cheeks. The severity of the condition increases with
age, looking grayish white and thickened. The cause of this
condition is unknown. The chalky white raised patch of leukoplakia
is abnormal. Do not mistake leukodema for oral infections such as
candidiasis (thrush).
Fordyce’s granules are small, isolated white or yellow papules on
the mucosa of cheek, tongue, and lips. These little sebaceous cysts
are painless and not significant.
Note any bruising or laceration on the buccal mucosa or gums of
the infant or young child.

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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Observe the uvula; it normally looks like a fleshy pendant


hanging in the midline. Ask the person to say ―ahhh‖ and note the
soft palate and uvula rise in the midline. This tests one function of
cranial nerve X, the vagus nerve.
Epstein pearls are a normal finding in the palate of newborns and
infants. They are small, whitish, glistening, pearly papules along the
median raphe of the hard palate and on the gums, where they look
like teeth. They are small retention cysts and disappear in the first
few weeks.
A high arched palate is usually normal in the newborn, but a very
narrow or high arch also occurs with Tumer’s syndrome, Ehlers-
Danlos syndrome, and Treacher Collins syndrome, or develops in
the mouth-breather in chronic allergies.
Bednar aphthae are traumatic areas or ulcers on the posterior
hard palate on either side of the midline. They result from abrasions
while sucking.
G. Throat
Using your light, observe the oval, rough-surfaced tonsils behind the anterior
tonsillar pillar. The color is the same pink as the oral mucosa, and their surface is
peppered with indentations, or crypts. In some people the crypts collect small
plugs of whitish cellular debris. This does not indicate infection. However, there
should be no exudates on the tonsils. Tonsils are graded in size as follows:
1+ visible
2+ halfway between tonsillar pillars and uvula
3+ touching the uvula
4+ touching each other

You may normally see 1+ or 2+ tonsils in healthy people, especially in children,


because lymphoid tissue is proportionately enlarged until puberty.
With an acute infection, tonsils are bright red, swollen, and may have exudates
or large white spots.

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A white membrane covering the tonsils may accompany infectious


mononucleosis, Leukemia and diphtheria. Tonsils are enlarged to 2+, 3+, or 4+
with an acute infection.
The tonsils are not visible in the newborn. They gradually enlarge during
childhood, remaining proportionately larger until puberty. Tonsils appear still
larger if the infant is crying or gagging. Normally, the newborn can produce a
strung, lust cry.
Although it is not usually done in the screening examination, toughing the
posterior wall with the tongue depressor elicits the gag reflex. This tests cranial
nerves IX and X, the glossopharyngeal and vagus.
Test cranial nerve XII, the hypoglossal berve, by asking the person to stick out
the tongue. It should protrude in the midline. Children enjoy this request! Not any
tremor, loss of movement, or deviation to the side.
With damage to cranial nerve XII, the tongue deviates toward the paralyzed
side. A fine tremor of tongue occurs with hyperthyroidism; a coarse tremor with
cerebral palsy and alcoholism.

VI. The Neck


a. Symmetry
Head position is centered in the midline, and the accessory neck muscles
should be symmetrical. The head should be held erect and still. Head tilt
occurs with muscle spasm, rigid head and neck occur with arthritis.

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.

Conditions of tracheal shift:


1. The trachea is pushed to the unaffected or healthy side with an aortic
aneurysm, a tumor, unilateral thyroid lode enlargement, and
pneumothorax.
2. The trachea is pulled toward the affected or diseased side with large
atelectasis, pleural adhesions, or fibrosis.
3. Tracheal tug is a rhythmic downward pull that is synchronous with systole
and that occurs with aortic arch aneurysm.

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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A sudden increase in the size of one breast signifies inflammation or


new growth.

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.

c. Lymphatic drainage areas


Observe the axillary and superclavicular regions. Note any bulging,
discoloration, or edema.

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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7. Nipple – is it displaced or retracted?


8. Note the skin over the lump – is it erythematous, dimpled or
retracted?
9. Tenderness – is the lump tender to palpation?

Signs of retraction and inflammation of the breast:


1. Dimpling – the shallow dimple is a sign of skin retraction. The dimple may be
apparent at rest, with compression or with lifting of the arms.
2. Edema (Peau d’Orange) – lymphatic obstruction causes edema. This thickens
the skin and exaggerates the hair follicles, giving a pig skin or orange-peeled
look.
3. Fixation – asymmetry, distention, distortion or decreased mobility with the
elevated arm maneuver.
4. Deviation in nipple pointing – an underlying cancer causes fibrosis in the
mammary ducts which pulls the nipple angle toward it.
5. Nipple retraction – the retracted nipple looks flatter and broader, like an
underlying crater.

VIII. Anterior and posterior chest


a. Thoracic cage
Note the shape and configuration of the chest wall. The spinous
process should appear in a straight line. The thorax is symmetric, in an
elliptical shape, with downward sloping ribs, about 45 degrees relative to
the spine. The scapulae are placed symmetrically in each hemithorax.
Skeletal deformities may limit thoracic cage excursion, or the movement
of the ribcage. Skeletal deformities include: scoliosis and kyphosis.
The anteroposterior diameter should be less than the transverse
diameter. The ratio of anteroposterior to tranverse diameter is from 1:2 to
5:7. If anteroposterior diameter is equal to transverse diameter, it is known
as barrel chest. Ribs are horizontal; chest appears as if held in continuos

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inspiration. This occurs in chronic emphysema due to hyperinflation of the


lungs.
The neck muscles and trapezius should be developed normally for age
and occupation. Neck muscles are hypertrophied in chronic obstructive
pulmonary disease from aiding in forced respirations.
Note the position the person takes to breathe. This includes a relaxed
posture and the ability to support one’s own weight with arms comfortably
at the sides or in the lap.
People with COPD often sit in a tripod position, leaning forward with
arms braced against their knees, chair or bed.
Assess the skin color and condition. Color should be consistent with
person’s genetic background, with allowance for sun-exposed areas on
the chest and on the back. No cyanosis or pallor should be present. Not
any lesions. Inquire as to any change in a nevus.
Normally, accessory muscles are not used to augment respiratory
effort. However, with very heavy exercise, the accessory neck muscles
(scalene, sternomastoid, and trapezius) are used momentarily to enhance
inspiration.

Configurations of the thorax:


1. Normal adult
The thorax has an elliptical shape with an anteroposterior-to-
transverse diameter of 1:2 or 5:7
2. Barrel chest
Note equal anteroposterior-to-transverse diameter and that ribs are
horizontal instead of the normal downward slope.
3. Pectus excavatum
A markedly sunken sternum and adjacent cartilages (also called
funnel breast). Depression begins at second intercostals space,
becoming depressed most at junction of xiphoid with body of sternum.
More noticeable on inspiration. Congenital, usually not symptomatic.

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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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Fremitus varies among persons but symmetry is most important; the


vibrations should feel the same in the corresponding area on each side.
However, just between the scapulae, fremitus may feel stronger on the
right side than on the left side because the right side is closer to the
bronchial bifurcation. Avoid palpating over the scapulae because bone
damps out sound transmission.
The following factors affect the normal intensity of tactile fremitus:

1. Relative location of bronchi to the chest wall


Normally, fremitus is most prominent between the scapulae and
around the sternum, sites where the major bronchi are closest to the
chest wall. Fremitus normally decreases as you progress down
because more and more tissue impedes sound transmission.
2. Thickness of the chest wall
Fremitus feels greater over a thin chest wall than over an obese or
heavily muscular one where thick tissue damps the vibration.
3. Pitch and intensity
A loud, low-pitched voice generates more fremitus than a soft, high
pitched one.

Note any areas of abnormal fremitus. Decreased fremitus occurs


when anything obstructs transmission of vibrations, e.g., obstructed
bronchus, pleural effusion or thickening, pneumothorax, or
emphysema. In creased fremitus occurs with compression or
consolidation of lung tissue, e.g., lobar pneumonia. This is present only
when the bronchus is patent and when the consolidation extends to the
lung surface. Rhonchal fremitus is palpable with thick branchial
secretions. Pleural friction fremitus is palpable with inflammation of the
pleura.

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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:

1. Examiner’s breathing on stethoscope tubing


2. Stethoscope tubing bumping together
3. Patient shivering
4. Patient’s hairy chest; movement of hairs under stethoscope sounds
like crackles (rales) – minimize this by pressing harder or by wetting
the hair with a damp cloth.
5. Rustling of paper gown or paper drapes.

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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1. Crackles (or rales) are caused by fluid in the small airways


or atelectasis. Crackles are referred to as discontinuous
sounds; they are intermittent, nonmusical and brief. Crackles
may be heard on inspiration or expiration. The popping
sounds produced are created when air is forced through
respiratory passages that are narrowed by fluid, mucus, or
pus. Crackles are often associated with inflammation or
infection of the small bronchi, bronchioles, and alveoli.
Crackles that don't clear after a cough may indicate
pulmonary edema or fluid in the alveoli due to heart failure or
adult respiratory distress syndrome (ARDS).
Crackles are often described as fine, medium, and
coarse.
Fine crackles are soft, high-pitched, and very brief.
You can simulate this sound by rolling a strand of hair
between your fingers near your ear, or by moistening
your thumb and index finger and separating them
near your ear.
Coarse crackles are somewhat louder, lower in pitch,
and last longer than fine crackles. They have been
described as sounding like opening a Velcro fastener.
2. Wheezes are sounds that are heard continuously during
inspiration or expiration, or during both inspiration and
expiration. They are caused by air moving through airways
narrowed by constriction or swelling of airway or partial
airway obstruction.

Wheezes that are relatively high pitched and have a shrill


or squeaking quality may be referred to as sibilant
rhonchi. They are often heard continuously through both
inspiration and expiration and have a musical quality.

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These wheezes occur when airways are narrowed, such


as may occur during an acute asthmatic attack.
Wheezes that are lower-pitched sounds with a snoring or
moaning quality may be referred to as sonorous rhonchi.
Secretions in large airways, such as occurs with
bronchitis, may produce these sounds; they may clear
somewhat with coughing.

3. Pleural friction rubs are low-pitched, grating, or creaking


sounds that occur when inflamed pleural surfaces rub
together during respiration. More often heard on inspiration
than expiration, the pleural friction rub is easy to confuse
with a pericardial friction rub. To determine whether the
sound is a pleural friction rub or a pericardial friction rub, ask
the patient to hold his breath briefly. If the rubbing sound
continues, it’s a pericardial friction rub because the inflamed
pericardial layers continue rubbing together with each heart
beat - a pleural rub stops when breathing stops.

4. Stridor is a high pitched sound resulting from turbulent air


flow in the upper airway. It may be inspiratory (laryngeal
problem), expiratory (lower airways problem) or present on
both inspiration and expiration (tracheal problem). It can be
indicative of serious airway obstruction from severe
conditions such as epiglottitis, a foreign body lodged in the
airway, or a laryngeal tumor.

IX. The abdomen


a. Contour
Stand on the person’s right side and look down on the abdomen. Then
stoop or sit gaze across the abdomen. Your head should be slightly higher

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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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indicating the length in centimeters. Anmormal findings include cutaneous


angiomas occur with portal hypertension or liver disease, Lesions and
rashes.

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

Inspection: Uniformly rounded.Umbilicus Inspection: Cuve in lower half of abdomen,


sunken midline. Everted umbilicus.
Auscultation: Normal bowel sound Auscultation: Normal bowel sounds over upper
Percussion: Tympany. Scattered dullness abdomen where intestines pushed superiorly.
over adipose tissue. Percussion: Top dull over fluid. Intestines
Palpation: Normal. May be hard to feel pushed superiorly. Large cyst produces fluid
through thivk abdominal wall. wave and shifting dullness.
Palpation: transmit aortic pulsation while
ascites does not.

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.

AIR OR GAS TUMOR

Inspection: Single round curve. Inspection: Localized distention


Auscultation: Depends on cause of gas Auscultation: Normal bowel sounds

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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.

COMMON SITES OF REFERRED ABDOMINAL PAIN


LIVER STOMACH
Hepatitis may have mild-moderate, dull Gastric ulcer pain is dull, aching,
pain in right upper duadrant or gnawing epigastric pain, usually
epigastrium, along with anorexia, brought on by food, radiates to back or
nausea, malaise, low-grade fever. substernal area. Pain of perforated
ulcer is burning epigastric pain of
sudden onset that refers to one or both
shoulders.
ESOPHAGUS APPENDIX
Gatroesophageal reflux disease is a Appendicitis typically starts as dull,
complex of symptoms of esophagitis, diffuse pain in periumbilical region that
including burning pain in mid- later shifts to severe, sharp, persistent
epigastrium or behind lower sternum pain and tenderness localized in RLQ.
that radiates upward, or a ―heartburn:. Pain is aggravated by movement,
coughing, deep breathing, associated
with anorexia, then nausea and
vomiting, fever.
GALLBLADDER KIDNEY
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Cholecystitis is biliary colic, sudden Kidney stones prompt a suddene onset


pain in right upper quadrant that may of severe, colicky flank or lower
radiate to right or left scapula, and abdominal pain.
which builds over time following
ingestion of fatty foods, alcohol or
caffeine.
PANCREAS SMALL INTESTINES
Pancreatitis has acute, boring Gastroenteritis has diffuse, generalized
midepigastric pain radiating to the back abdominal pain, with nausea, diarrhea.
and sometimes to the left scapula or
flank, severe nausea, and vomiting.

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

Palpate the brachial pulses – their force should be equal


bilaterally.

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b. The lower extremities


Uncover the legs while keeping the genitalia draped, inspect both legs
together, noting skin color, hair distribution, venous pattern, size (swelling
or atrophy), and any skin lesions or ulcers.
Normally, hair covers the legs. Even if leg hair is shaved, you will still
notice hair on the dorsa of the toes.
Note pallor with vasoconstriction; erythema with vasodilation and
cyanosis.
In the presence of skin discoloration, skin ulcers, or gangrene, note the
size and exact location.
Palpate for temperature along the legs down to feet comparing
symmetric spots.
Flex the person’s knee, then gently compress the gastrocnemius ( calf)
muscle anteriorly against the tibia; no tenderness should be present. Calf
pain with these maneuvers is a positive Homan’s sign.
Note shiny atrophic skin, thick-ridged nails, loss of hair, ulcers, and
gangrene.
The venous pattern is normally flat and barely visible. Note obvious
varicosities, these are best assessed while standing.
Both legs should be symmetric in size without any swelling or atrophy. If
the lower legs look asymmetric or if deep venous thrombosis is suspected,
measure the calf circumference with a non-stretchable tape measure.
Record your findings in centimeters.
Check for pretibial edema. Firmly depress the skin over the tibia or the
meadial malleolus for 5 seconds and release. Normally, your finger should
leave no indentation. If pitting edema is present, grade it on the following
scale:
1+ mild pitting, slight indentation, no perceptible swelling of the leg
2+ moderate pitting, indentation subsides rapidly
3+ deep pitting, indentation remains for a short time, leg looks swollen
4+ very deep pitting, indentation lasts a long time, leg is very swollen

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LEVEL OF CONSCIOUSNESS

GLASGOW COMA SCALE


-Level of consciousness (LOC) can lie anywhere along a continuum from state of
alertness to coma. A fully alert client responds to questions spontaneously; a comatose
client may not respond to verbal stimuli. The Glasgow Coma Scale was originally
developed to predict recovery from a head injury; however, it is used by many
professionals to assess LOC. It tests in three major areas: eye response, motor
response and verbal response.
* Score of 15 points indicates the client is alert and completely oriented.
* Score of 7 or less indicates that the patient is comatose.

Level of Consciousness: Glasgow Coma Scale


Faculty Measured Response Score
A. EYE OPENING Spontaneous 4
To verbal command 3
To pain 2
No response 1
B. MOTOR RESPONSE To verbal command 6
To localized pain 5
Flexes and withdraws 4
Flexes abnormally 3
Extends abnormally 2
No response 1
C. VERBAL RESPONSE Oriented, converses 5
Disoriented, converses 4
Uses inappropriate words 3
Makes incomprehensive sounds 2
No response 1

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MATERNAL AND CHILD ASSESSMENT

ASSESSMENTS DURING PREGNANCY


Gravida- number of times pregnant, regardless of duration, including the present
pregnancy.
Primigravida- pregnant for the first time.
Multigravida- pregnant for the second or subsequent time.
Para – number of pregnancies that lasted more than 20 weeks, regardless of
outcome.
Nullipara- a woman who has not given birth to a baby beyond 20
weeks’ gestation.
Primipara- a woman who has given birth to a baby more than 20
weeks’ gestation.
Multipara- woman who has had two or more births at more than
20 weeks’ gestation…twins or triplets count as 1 para.
TPAL- Para subdivided to reflect births that went to Term,
Premature births, Abortions and Living children. (Stein.2007)

DETERMINATION OF PREGNANCY

Presumptive Signs and Symptoms (Subjective)


-may noticed by the mother/health care provider but are not conclusive for
pregnancy.

A. Amenorrhea (cessation of menstruation)


B. Nausea and Vomiting
C. Urinary frequency
D. Fatigue
E. Breast changes
F. Weight changes

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G. Skin changes
H. Vaginal changes including leukorrhea
I. Quickening

Probable signs and symptoms (Objective)


- these changes are usually noted by the health care provider but are still not
conclusive for pregnancy.
A. Uterine enlargement
B. Changes in the uterus and cervix from increased vascularity
C. Ballotement: fetus rebounds against the examiner’s hand when pushed gently
upwards.
D. Braxton hicks’ contraction: occur early in pregnancy, although not usually sensed
by the mother until the third trimester.
E. Laboratory results:
1. Presence of HCG in the blood or urine of the woman.
2. Easy, inexpensive, but may give false readings with any handling error,
medications, or detergent residue in laboratory equipment.
3. Exception is the radioimmunoassay (RIA), which tests for the beta subunit
of HCG and is considered to be so accurate as to be diagnostic for
pregnancy.
F. Changes in skin pigmentation.

Positive signs and symptoms


- these signs emanate from the fetus, are noted by the health care provider, and
are conclusive for pregnancy.
A. Fetal heartbeat: detected as early as eighth week with an electronic device; after
16th week with a more conventional auscultory device.
B. Palpation of fetal outline
C. Palpation of fetal movements
D. Demonstration of fetal outline by either ultrasound (after sixth week) or X-ray
(after 12th week). (Stein.2007)

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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

*The 4th Maneuver is conducted while facing the patient’s feet.

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.

g. Remove the drape and assist mother in sitting position.


h. Inform the mother of the result.
i. Record result of the examination and evaluate the following:
1. Patient’s response
2. Fetal position

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3. The degree of fetal flexion and how far the head has descended
into the pelvis.
4. Fetal heartbeat.

MATERNAL AND FETAL ASSESSMENTS

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

Palpation- assess intensity of contraction by manual palpation of uterine fundus.


A. Mild: tense fundus, but can be indented with fingertips.
B. Moderate; firm fundus, difficult to indent with fingertips.
C. Strong: very firm fundus, cannot indent with fingertips.

Electronic Fetal Monitoring


A. Placement of ultrasound transducer and tocotransducer to record fetal heartbeat
and uterine contractions and display them on special graph paper for comparison
and identification of normal and abnormal patterns.
B. Can be applied externally to mother’s abdomen, or internally, within uterus.
4. External application
j. Less precise information collected
k. May be affected by maternal movements
l. Noninvasive; rupture of membranes not required, can be widely used
m. Little danger associated with use.
5. Internal Application
a. More precise information collected

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b. Cervix must be dilated and membranes ruptured to be utilized


c. Physician applies scalp electrode and uterine catheter
d. Sterile technique must be maintained during application to reduce risk of
intrauterine infection
e. Can yield specific short-term variability.

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

TRUE vs. FALSE LABOR


A. True Labor
1. Contractions increased in frequency, intensity and duration
2. Progressive cervical changes
3. Bloody show
4. Progressive fetal descent.
5. Walking intensifies contraction.
6. Discomfort begins in back then radiates to abdomen
B. False Labor
1. Irregular, inefficient contractions not causing the progressive changes associated with
true labor.
2. No bloody show
3. Discomfort primarily in abdomen, may be relieved by walking
4. Need to assess client over period of time to differentiate from true labor.

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FIRST STAGE OF LABOR


- from onset of labor until full dilation of cervix.
LATENT PHASE ( 0-4cm )
Assessments:
a. Contractions; frequency, intensity, duration
b. Membranes: intact or ruptured, color of fluid
c. Bloody show
d. Time of onset
e. Cervical changes
f. Time of last ingestion of food
g. FHR every 15 minutes; immediately after rupture of membranes
h. Maternal vital signs
1. Temperature every 2 hours if membranes ruptured, every 4 hours if intact.
2. Pulse and respirations every hour or prn as indicated.
3. Blood pressure every half hour or prn as indicated
i. Progress of descent (station)
j. Client’s knowledge of labor process
k. Client’s affect
l. Client’s birth plan.
ACTIVE PHASE ( 4-8cm )
Assessments:
a. Cervical changes
b. Bloody show
c. Membranes
d. Progress of descent
e. Maternal/fetal vital signs
f. Client’s affect
TRANSITION PHASE (8-10cm)
Assessments:

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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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FOURTH STAGE OF LABOR


-time after birth (usually 1-2hours) of immediately recovery.
Assessments:
a. Fundal firmness, position
b. Lochia: color, amount
c. Perineum
d. Vital signs
e. IV if running
f. Infant’s heart rate; airway, color, muscle tone, reflexes, warmth, activity stae
g. Bonding/family integration. (Stein.2007)

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)

Composite score interpretations


1. 0-4; prognosis for newborn is grave.
2. 5-7: infant needs specialized, intensive care.
3. 7 or above: infant should do well in normal newborn nursery.(Stein.2007)

SILVERMAN AND ANDERSON SCORING SYSTEM


Test used to evaluate the respiratory status/breathing performance of the
premature infants and of newborns with respiratory distress.

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

Score of 0 indicates no respiratory distress


A score between 4-6 means moderately depressed
A score between 7-10 means severely depressed. (Evangelista-Sia.2004)

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GESTATIONAL AGE ASSESSMENT


-after birth, direct examination of the infant leads to an accurate assessment of
maturity. This is important, as complications may vary with maturity level: pre and
postmature infants, in general, have greater difficulty adapting to extrauterine life.

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)

PHYSICAL FINDINGS AND VARIATIONS FROM NORMAL ASSESSMENT

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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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2.Tongue movement and excess salivation: possible esophageal atresia.


L. Neck
-Webbing: masses in muscle.
M. Chest: breast enlargement and milky secretions from breast (withc’s milk) is result of
maternal hormones.
N. Cord: fewer than 3 blood vessels may indicate congenital anomalies.
O. Nodule of tissue present in breasts.
P. Female Genitalia
1. Vernix seen between labia
2. Blood-tinged mucoid vaginal discharge from high levels of circulating maternal
Hormones.
Q. Male Genitalia.
1. Testes descended or in inguinal canal
2. Rugae cover scrotum
3. Meatus at tip of penis

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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2. Soles covered with creases in fully mature infant.


Variations:
- Extra toes
- Webbed toes
- Congenital hip dysplasia
- Few creases on soles of feet: prematurity
U. Muscle tone
1. Predominantly flexed
2. Occasional transient tremors of mouth and chin
3. Newborn can turn head from side to side in prone position
4. Needs head supported when held erect or lifted.
V. Reflexes present at birth
1. Rooting, sucking and swallowing.
2. Tonic neck, ―fencing‖ attitude
3. Grasp: newborn’s fingers curl around anything placed in palm.
4. Moro reflex; symmetric and bilateral abduction and extension of arms and
hands; thumb and forefinger form a C; the ―embrace‖ reflex.
5. Startle reflex; similar to Moro, but with hands clenched.
6. Babinski’s sign: flare of toes when foot stroked form based of heel along lateral
edge to great toe.
W. Cry
1. Loud and Vigorous.
2. Heard when infant is hungry, disturbed, or uncomfortable.
X. Spine
- Tuft of hair: possible occult spina bifida; assess pilonidal area for fistula.
Y. Anus
- Lack of meconium after 24 hours may indicate obstruction, disease.

BLOOD PRESSURE
- variation with activity: normal

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- - Major difference between upper and lower extremities: possible aortic


coarctation.

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

Pain is a common, uncomfortable sensation and emotional experience which is

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

is at unacceptable level. There is no universal standard.

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.

. Since pain is subjective, assessment is based mostly on history and patient’s

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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Review of Related History

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

Precipitating Factors: causes of increases or decreases in pain

Location: Where is the pain? Can the patient point a finger to it? Does it travel or

radiate?

Effect of pain on daily activities: limitation of activity, interruption of sleep, increased

need for rest periods, change in appetite

Effect of pain on psyche: change in mood or social interactions, poor concentration, can

think only about pain; irritability

Pain control measures: distraction, relaxation, heat, electrical stimulation

Medications: opioids, anxiolytics, NSAIDs, nonprescription medication

PERSONAL AND SOCIAL HISTORY:

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

control; fear of addiction

Current or past use of illicit substances

EXAMINATION OF THE PATIENT:

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

pattern from one episode of pain to the next.

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

Vocalizations: grunting, groaning, crying, talkative patient becomes quiet

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

Pallor and diaphoresis

Pupil dilatation

Dry mouth

Decreased attention span, greater confusion

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

Burning, shocklike pain may indicate nerve tissue damage

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.

Cramping spasm may define visceral or colic pain

PAIN ASSESSMENT SCALES

A variety of scales and instrument have been developed to obtain and measure a patient’s

perception of pain intensity and quality.

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.

Numerical Pain Intensity 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

representing the worst pain imaginable.

Pain Intensity Rating Scale

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

reliable and valid for assessing a child’s pain.

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Visual Analog Scale

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.

Visual analog scale

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

Verbal Descriptor Scale

With the verbal descriptor scale, the patient chooses a description of his pain from a list

of adjectives, such as ―none‖, ―agonizing,‖ ―uncomfortable,‖ ―dreadful‖, ―horrible‖, and

―annoying‖.

None Slight Mild Moderate Severe Worst Pain

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Pain scales for infants and neonates

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.

Changes can be observed and documented.

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

of circumstances whether it is a neurologic or cognitive handicap, an intubation, or a serious

injury.

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GORDON’S FUNCTIONAL HEALTH PATTERNS

GUIDE QUESTIONS:

A. Health Perception and Health Management Patterns


The data collection is focused on the client’s perception of his/her health status,
well-being and practices in maintaining health, the risk factors that may negatively or
positively affect health and the person’s family knowledge base and abilities related to
health promotion and disease prevention.

Prior to Admission:

How do you perceive your health?


Are you satisfied with your usual health status?
Do you have a yearly physical exam?
Do you seek healthcare only when ill?
What do you consider healthy about you?
How many times have you been admitted to the hospital? What are your
previous illnesses that prompt you to seek health care?
Any beliefs, practices or traditional concepts of health and illness
If this person has allergies, what does s/he do to prevent problems?
Do you have any medical problems in the family?
Have there been any important illnesses or injuries in this person's life?
What safety practices do you follow?
What do you do to stay healthy? Do you think these things will make a difference
to your health?
Personal Hygiene practices: bathing, grooming, hand washing, brushing, use of
deodorant, wearing of slippers
Substance use; use of cigarette, alcohol drugs? Kind, amount, frequency? What
are the reasons for using these? Are you aware of its effects to your health?
Environmental sanitation practices; water supply, toilet facilities, waste
management, food preparation, presence of vectors and other health hazards
Have you had any accidents/injuries/falls in the past year?

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(For mothers) Did you undergone prenatal check-ups? Is the child’s


immunization complete?

During Hospitalization:

How do you manage your illness during your hospitalization?


Can this person report the names of current medications s/he is taking and their
purpose?
Has it been easy to find ways to follow things the nurses/doctors suggest?
Check current laboratory values of the client: Complete Blood Count, Urinalysis,
Blood Urea Nitrogen test, etc.

B. Nutritional and Metabolic Pattern


The assessment focuses on the eating habits, the pattern of food and fluid
consumption relative to metabolic need. Special diets, food preferences, food allergies,
food preparations, weight changes and history of eating disorders are also noted as
these can affect the current nutritional status of the client. Actual or potential problems
regarding fluid balance, tissue integrity, and host defenses may be identified as well as
problems with the gastrointestinal system.

Prior to client’s admission:

Typical food intake?


What type and amount of fluids are consumed?
What is your usual dietary pattern?
What is your knowledge about proper nutrition?
Do you take any food supplements or vitamins?
Describe the food preparation
Where do you eat?
Whom do you eat with?
What is the usual income? Who budgets the food?
Do you have any food allergies?

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Describe food likes and dislikes


Do your wounds heal easily?
Weight loss or gain?
Do you experience any eating discomforts?
Food customs and beliefs
Do you have dental problems?
(For mothers) Do you breastfeed your baby? Describe the weaning patterns of
the child

During Hospitalization:

Note the general appearance of the person: subcutaneous fat distribution,


skeletal muscle mass, skin, hair and nails and mucous membranes that may be
associated with malnutrition.
Observe for the food and fluid intake: what is ingested or refused during meals?
Check for the condition that may alter metabolism, like surgery, burns, fever or
infection.
Review laboratory test especially the nitrogen balance measurements: Is this
person has positive or negative nitrogen balance?
Current height and weight
Body temperature: Is there hypothermia or hyperthermia?
If mother is breastfeeding, have infant weighed. Is infant’s weight within normal
limits?
Do you have any concerns about breast feeding?
Are you having any problems with breastfeeding?
C. Elimination Pattern

The assessment focuses on the client’s normal pattern of elimination, description


of usual feces and urine, past or current problems with elimination, the presence of an
ostomy and other factors influencing elimination.

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Prior to client’s admission:

Frequency of bowel movements, voiding patterns, pain on urination, appearance


of urine and stool
Does the person have any disease of the digestive system, urinary system or
skin?
Do dietary practices contribute to problems in elimination?
Do you have any practices done to achieve a normal elimination?
Do you suffer from constipation or diarrhea?

During Hospitalization

Check for presence of colostomy or any appliance associated with elimination


Does stool character suggest constipation? Diarrhea? Malbasorption?
Does urine character suggest infection? Check for urinalysis result.

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.

Prior to client’s admission:

Describe your usual activities in a day or week


Exercise habits: Type, frequency, duration and intensity
Describe your usual leisure time activities/hobbies
What type of work do you do for a living?
Does the person have any disease that affects her/ his cardio-respiratory system
or musculo-skeletal system?
Do you use assistive device like cranes, crutches or wheelchair when walking?

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Any complaints of weakness or lack of energy?


Any difficulties in maintaining activities of daily living?
Any difficulties when eating, bathing, dressing or grooming?
Do you experience chest pain, shortness of breath or difficulty breathing when
doing activities?

During Hospitalization:

Measurement of vital signs: pulse, respiration and blood pressure


Musculoskeletal examination: Is mobility adequate or restricted?
Laboratory test: What does the test results suggest about cardiovascular,
respiratory and musculoskeletal functions?
Does the person have the ability to engage in self-care activities?
General inspection including mental status, facial expressions, gross motor
movements, skeletal muscle mass, grooming and skin color
Inspect for thorax, lungs and musculoskeletal structures that may affect activity

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

Prior to client’s admission:

Describe this person's sleep-wake cycle.


Quality and quantity of sleep and energy; time of retiring and arising.
What are your routines before going to sleep?
Do you have any problems in sleeping?
What prevents you from 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:

Person’s appearance during designated sleep periods. Restless? Alert?


Are there signs of sleep deprivation? Note the mental status, facial expression,
movement and posture.
Do you get enough sleep during your admission here in the hospital?
Assess for the bedroom surroundings

F. Cognitive-Perceptual Pattern

Assessment is focused on the ability to comprehend and use information and on


the sensory functions. Data pertaining to neurologic functions are collected to aid this
process. Sensory experiences such as pain and altered sensory input may be identified
and further evaluated.

Prior to client’s admission:

Performance of activities of daily living: Do sensory deficits (impaired vision,


impaired hearing) influence the person’s ability to perform ADL?
Can this person express her/ himself clearly and logically?
What is your educational background?
Do you have any disease that affects mental or sensory functions?
Is the person able to remember past and present events?
Can the person has the right decision making or can decide to himself/herself?

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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

G. Self-Perception and Self-Concept Pattern

Self-concept is one’s mental image of oneself. Self-concept involves all of the


self-perceptions, that is the appearance, values, and beliefs that influence a person’s
behavior and self-esteem. Assessment will focus on the patient’s insights about oneself,
the appraisal of oneself in relationship to others, events, or situations. Anxieties, fears
and doubts are also included.

Prior to client’s admission:

Demographic profile: age, gender, ethnicity


Describe your family situation
What social groups are you involved and consider most important in your life
(church, school, clubs, and organizations)?
How would other people describe you?
How would you describe yourself as a person?
What do you like best and least about yourself?
What achievements are you proud of?
What concerns you most about your body?
What physical feature would you like most to change?

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.

Occupation of the person and the nature of his work


Do you live alone? Describe family structure? Significant people in life?
Who do you turn to for help?
Perception of current major roles and responsibilities (e.g., father, husband,
salesman)
How does this person describe her/ his various roles in life?
Which relationships are most important to this person at present?
Is this person currently going though any big changes in role or relationship?
What are they?
Are you satisfied with family, work, or social relationships?
How has your current status affects your relationship with others?
Ask both patient and family: Do you think this admission will cause any significant
changes in the patient’s usual family role?
If patient is a child, is there any physical or emotional evidence of physical or
psychosocial abuse?

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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How do you express yourself as a man/woman? Any difficulties expressing ones


sexuality?
How do you show affection to others?
How have the person's plans and experience matched regarding having
children?
Does this person have any disease/ dysfunction of the reproductive system?
Number and histories of pregnancy and childbirth (for women)
Are you using any contraceptives? Problems?
Female: When menstruation started? Last menstrual period? Menstrual
problems?
Male: History of prostate problems? History of penile discharge, bleeding, lesions
Difficulties with sexual functioning; satisfaction with sexual relationship.

J. Coping-Stress Tolerance

Stress is a condition in which a person responds to changes in the normal


balanced state. Assessing a client’s stress and coping may include client’s perception of
stress, perceived stressors, past and present coping strategies and manifestations of
stress. Support systems are evaluated, and symptoms of stress are noted.

Prior to client’s admission:

How does this person usually cope with problems?


Describe a stressful event for you
How do you handle stress or pressure?
Is there someone you rely on to help you solve problems?
Has this person had any treatment for emotional distress?
Do you have any support systems when you are under stress?
Have you or your family used any support or counseling groups in the past year?
Identify potential stressors in the environment
What are the major problems of getting older?

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During Hospitalization:

What kinds of problems that cause you to worry?


What frightens you or annoy you in this setting?
How do present circumstances in your life interfere with work or school?
How has this situation (illness) affected you family?
What do you believe is the primary reason behind a need for this admission?

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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SAMPLE DOCUMENTATION TABLE OF HEALTH HISTORY

BIOGRAPHICAL DATA

Name: ______________________________________________________________

Address: ____________________________________________________________

Home phone number: _________________________________________________

Work phone number: _________________________________________________

Sex: _______________________________________________________________

Age: _______________________________________________________________

Birth Date: __________________________________________________________

Place of birth: _______________________________________________________

Race: ______________________________________________________________

Nationality: _________________________________________________________

Culture: ____________________________________________________________

Marital status: _______________________________________________________

Dependents: ________________________________________________________

Contact Persons: ____________________________________________________

Religion: ___________________________________________________________

Educational status: __________________________________________________

Occupation: ________________________________________________________

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Health insurance: ___________________________________________________

Source and Reliability: _______________________________________________

Referral: ___________________________________________________________

REASON FOR SEEKING HEALTH CARE

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

CURRENT HEALTH STATUS

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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PAST HEALTH HISTORY

Childhood illnesses:

Hospitalizations and Surgeries:

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:

Head and Neck:

Eyes:

Ears:

Nose and Sinuses:

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Mouth and Throat:

Respiratory:

Cardiovascular:

Breasts:

Gastrointestinal:

Female Reproductive:

Male Reproductive:

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Musculoskeletal:

Neurological:

Endocrine:

Immune/Hematological:

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PSYCHOSOCIAL PROFILE

Hx Practices and Beliefs:

Typical Day:

Nutritional Patterns:

Activity and Exercise Patterns:

Recreation, Hobbies, Pets:

Sleep/ Rest patterns:

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Personal Habits:

Occupational Hx Patterns:

Socioeconomic Status:

Environmental Hx Pattern:

Roles, Relationship, Self-Concepts:

Cultural Influences:

Religious/ Spiritual Influences:

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Family Roles and Relationship:

Sexuality Pattern:

Social Supports:

Stress and Coping Patterns:

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SAMPLE PHYSICAL EXAMINATION

General Appearance

Measurement
Weight __________
Height __________
Skinfold thickness ___________
Vision using Snellen’s eye chart __________

Vital signs
Temperature ________
Hypothermia __________
Hyperthermia _________
Pulse ______________
Respiration ___________
Blood pressure __________

I. Skin and accessory body parts


A. Skin Color __________________
B. General pigmentation
Freckles (ephelides) ________
Moles (nevus) Birthmarks ________

Others: __________
C.Widespread color change
Pallor ____
Erythema ___
Cyanosis ____
Jaundice ____
Others: ______

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D.Moisture

Diaphoresis _________
Dehydration __________
Others: __________

E.Texture and turgor


Thickness _______
Edema (if present) ___________
1 + mild pitting,
2 + moderate pitting
3 + deep pitting
4 + very deep pitting
a. Mobility and turgor _____________________
b. Vascularity or bruising __________________
c. Lesions
If any lesions are present, note the:
Color ___________
Elevation. ________
Shape:
Discoid
Annular
Target (bull’s eye)
Pattern
Discrete
Grouped
Confluent
Dermatoral
Size (in centimeters): ___________

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Location and distribution on body:


Generalized _____
Regionalized. _____
Localized ____
Scattered ____
Exposed areas ______
Imtertriginous ______
Type:
Pustule _____ Cyst ______ Nodule ______ Wheal ______
Fissure _____ Macule _____ Vesicle _____ Papule ______

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

Iris and pupil


.

B. Ears
External ear
Size and shape
Microtia ______
Macrotia ______

Skin condition
Tenderness

The external auditory meatus

The external canal

The tympanic membrane


Color and characteristics

Position

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Integrity of membrane

Hearing Acuity

C. Nose

External nose

Nasal cavity

Abnormalities of the nose


Choanal atresia_________ Epistaxis __________ Foreign body__________
Perforated septum_________ Furuncle________ Acute rhinitis __________
Allergic rhinitis ___________Sinusitis __________ Nasal polyps _________
Carcinoma __________
D.Mouth
Lips
Teeth and gums
Tongue
Buccal mucosa
Palate
Throat
E. The Neck
Symmetry
Range of Motion
Lymph Nodes
Trachea
Thyroid gland

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F. Breasts

General appearance

Skin

Nipple

G .Anterior and posterior chest


Thoracic cage

Symmetric chest expansion

Thickness of the chest wall

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

HYPERACTIVE SOUNDS ___________


HYPOACTIVE SOUNDS ____________

i. Vascular sounds

j. General tympany

I .EXTREMITIES

Upper Extremities:

Lower Extremities:

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GORDON’S FUNCTIONAL HEALTH PATTERN

I. Health Perception and Health Management Patterns

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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II. Nutritional and Metabolic Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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III. Elimination Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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IV. Activity-Exercise Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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V. Sleep-Rest Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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VI. Cognitive-Perceptual Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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VII. Self Perception and Self-Concept Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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VIII. Role-Relationship Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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IX.Sexuality-Reproductive Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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X. Coping-Stress Tolerance

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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XI.Value-Belief Pattern

Prior to Admission:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

During Hospitalization:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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ADMISSION ASSESSMENT

DEMOGRAPHIC DATA Date: ______________ Time: ______________

Name: _______________________________________________________

Date of Birth: _________________________ Age: ________ Sex: ________

Primary significant other: ____________________ Telephone: ___________

Name of primary information source: _______________________________

Admitting medical diagnosis:______________________________________

VITAL SIGNS:

Temperature: ____F ____C ; oral__ rectal __ axillary __ tympanic __

Pulse Rate: ____bpm; radial __ apical ___; regular ___ irregular __

Respiratory Rate: ___cpm; abdominal ___ diaphragmatic ___

Blood Pressure: left arm ___ right arm___;

standing__ sitting__ lying down ___

Weight: __ pounds; ___kg

Height: ___feet ___inches; ___meters

Do you have any allergies? No__ Yes__ What?! ________________

(Check reactions to medications, foods, cosmetics, insect bites, etc.)

Review admission CBC, urinalyses and chest-xray. Note any abnormalitites here:
________________________________________________________

_____________________________________________________________

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HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

OBJECTIVE

1. Mental Status (indicate assessment with a )


a. Oriented__ Disoriented__
Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__;

b. Sensorium
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__

Cooperative__ Combative__ Delusional__

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__

c. Pupil reaction: 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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7. Cranial Nerves: Normal__ Abnormal__ Describe deviations:_________


_________________________________________________________

8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.)


Normal__ Abnormal__ Describe:______________________________

_________________________________________________________

9. Reflexes: Normal__ Abnormal__ Describe: ______________________


_________________________________________________________

10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
_________________________________________________________
_________________________________________________________

11. General appearance:


a. Hair: __________________________________________________
b. Skin: __________________________________________________
c. Nails: _________________________________________________
d. Body odor: _____________________________________________
SUBJECTIVE

1. How would you describe your usual health status?


Good__ Fair__ Poor__

2. Are you satisfied with your usual health status?


Yes__ No__ Source of dissatisfaction: ____________________________

3. Tobacco use? No__ Yes__ Number of packs per day? _______________


4. Alcohol use? No__ Yes__ How much and what kind? ________________
5. Street drug use? No__ Yes__ What and how much? _________________
6. Any history of chronic disease? No__ Yes__ Describe: _______________
___________________________________________________________

7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__


Hepatitis B__
8. Have you sough any health care assistance in the past year? No__ Yes__ If yes,
why? _________________________________________________
9. Are you currently working? No__ Yes__ How would you rate your working
conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation)?
Excellent__ Good__ Fair__ Poor__ Describe any problem
areas:______________________________________________________
10. How would you rate living conditions at home? Excellent__ Good__ Fair__
Poor__ Describe any problem areas: ________________
__________________________________________________________

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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:
______________________________________________________
__________________________________________________________

12. Medications (over-the-counter and prescription)

Name Dosage Times/Day Reason Taken as


Ordered

Yes__ No__

13. Have you followed the routine prescribed for you?


Yes__ No__ Why not? ______________________________________

14. Did you think this prescribed routine was best for you?
Yes__ No__ What would be better? ____________________________

15. Have you had any accidents/injuries/falls in the past year?


No__ Yes__ Describe: ______________________________________

16. Have you had any problems with cuts healing?


No__ Yes__ Describe: ______________________________________

17. Do you exercise on a regular basis?


No__ Yes__ Type & Frequency: ______________________________

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: ______________________________________

_________________________________________________________

23. Do you do (breast/testicular) self-examination? No__ Yes__


How often? _______________________________________________

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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

b. Periorbital: No__ Yes__ Describe:_____________________________


c. Dependent: No__ Yes__ Describe:_____________________________
Ankle girth: Right:__ inches; Left__inches

4. Thyroid: Normal__ Abnormal__ Describe: _________________________


5. Jugular vein distention: No__ Yes__
6. Gag reflex: Present__ Absent__
7. Can patient move easily (turning, walking)? Yes__ No__
Describe limitations: __________________________________________

8. Upon admission, was patient dressed appropriately for the weather?


Yes__ No__ Describe: ________________________________________

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For breastfeeding mothers only:

9. Breast exam: Normal__ Abnormal__ Describe:______________________


___________________________________________________________

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): _____
___________________________________________________________

___________________________________________________________

7. Describe an average day’s fluid intake for you. _____________________


___________________________________________________________

8. Describe food likes and dislikes. _________________________________


___________________________________________________________

9. Would you like to: Gain weight?__ Lose weight?__ Niether__


10. Any problems with:
a. Nausea: No__ Yes__ Describe: _______________________________
b. Vomiting: No__ Yes__ Describe: ______________________________
c. Swallowing: No__ Yes__ Describe: ____________________________
d. Chewing: No__ Yes__ Describe: ______________________________
e. Indigestion: No__ Yes__ Describe: ____________________________
11. Would you describe your usual lifestyle as: Active__ Sedate__

For breastfeeding mothers only:

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: _______
_________________________________________________________

e. Overflow urine when bladder palpated? Yes__ No__

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: ___________________________

4. Ostomy present: No__ Yes__ Location: ___________________________


SUBJECTIVE

1. What is your usual frequency of bowel movements? _________________


a. Have to strain to have a bowel movement? No__ Yes__
b. Same time each day? No__ Yes__

2. Has the number of bowel movements changed in the past week?


No__ Yes__ Increased?__ Decreased?__

3. Character of stool
a. Consistency: Hard__ Soft__ Liquid__
b. Color: Brown__ Black__ Yellow__ Clay-colored__
c. Bleeding with bowel movements: No__ Yes__

4. History of constipation: No__ Yes__ How often? ____________________


Do you use bowel movement aids (laxatives, suppositories, diet)?

No__ Yes__ Describe:_________________________________________

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5. History of diarrhea: No__ Yes__ When?___________________________

6. History of incontinence: No__ Yes__ Related to increased abdominal pressure


(coughing, laughing, sneezing)? No__ Yes__

7. History of travel? No__ Yes__ Where?____________________________

8. Usual voiding pattern:


a. Frequency (times per day) ____ Decreased?__ Increased?__
b. Change in awareness of need to void: No__ Yes__ Increased?__ Decreased?__
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__
e. Color: Yellow__ Smokey__ Dark__
f. Incontinence: No__ Yes__ When? _____________________________
Difficulty holding voiding when urge to void develops? No__ Yes__

Have time to get to bathroom: Yes__ No__ How often does problem reaching
bathroom occur? ___________________________________

g. Retention: No__ Yes__ Describe: _____________________________


h. Pain/burning: No__ Yes__ Describe: ___________________________
i. Sensation of bladder spasms: No__ Yes__ When? ________________

ACTIVITY-EXERCISE PATTERN

OBJECTIVE

1. Cardiovascular
a. Cyanosis: No__ Yes__ Where? _______________________________

b. Pulses: Easily palpable?


Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__

Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;

Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__

c. Extremities:
i. Temperature: Cold__ Cool__ Warm__ Hot__
ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
____________________________________________________

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iv. Homan’s sign: No__ Yes__


v. Nails: Normal__ Abnormal__ Describe: _____________________
vi. Hair distribution: Normal__ Abnormal__ Describe: ____________
____________________________________________________

vii. Claudication: No__ Yes__ Describe: _______________________


____________________________________________________

d. Heart: PMI location: ________


i. Abnormal rhythm: No__ Yes__ Describe: ___________________
____________________________________________________

ii. Abnormal sounds: No__ Yes__ Describe: ___________________


____________________________________________________

2. Respiratory
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________
_________________________________________________________

c. Fremitus: No__ Yes__


d. Any chest excursion? No__ Yes__ Equal__ Unequal__
e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
____________________________________________________

f. Have patient walk in place for 3 minutes (if permissible):


i. Any shortness of breath after activity? No__ Yes__
ii. Any dypnea? No__ Yes__
iii. BP after activity: ___/___ in (right/left) arm
iv. Respiratory rate after activity: _______
v. Pulse rate after activity: _______

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: ________________________________________________

e. Hand grasp: Right:: Normal__ Decreased__


Left: Normal__ Decreased__

f. Toe wiggle: Right: Normal__ Decreased__


Left: Normal__ Decreased__

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g. Postural: Normal__ Kyphosis__ Lordosis__


h. Deformities: No__ Yes__ Describe: ____________________________
i. Missing limbs: No__ Yes__ Where? ____________________________
j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
_________________________________________________________

k. Tremors: No__ Yes__ Describe: ______________________________


_________________________________________________________

4. Spinal cord injury: No__ Yes__ Level: ____________________________


5. Paralysis present: No__ Yes__ Where? ___________________________
6. Developmental Assessment: Normal__ Abnormal__ Describe: _________
___________________________________________________________

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

1 – requires use of equipment or device

2 – requires help from another person for assistance, supervision or teaching

3 – requires help from another person and equipment device

4 – dependent; does not participate in activity

Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__;


Care of home__; Shopping__; Meal preparation__; Laundry__; Transportation__

2. Oxygen use at home? No__ Yes__ Describe: ______________________


3. How many pillows do you use to sleep on?_____
4. Do you frequently experience fatigue? No__ Yes__ Describe: _________
___________________________________________________________

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? _________________

8. Occupation (if retired, former occupation): _________________________


9. Describe you usual leisure time activities/hobbies: ___________________
___________________________________________________________

10. Any complaints of weakness or lack of energy? No__ Yes__ Describe:


___________________________________________________
11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe:
_____________________________________________
12. Any problems with concentration? No__ Yes__ Describe: ______
_____________________________________________________________

SLEEP REST PATTERN

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

1. Review sensory and mental status completed in health perception-health


management pattern
2. Any overt signs of pain? No__ Yes__ Describe: _____________________

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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__

SELF-PERCEPTION AND SELF-CONCEPT PATTERN

OBJECTIVE

1. During this assessment, does patient appear: Calm__ Anxious__ Irritable__


Withdrawn__ Restless__
2. Did any physiologic parameters change? Face reddened: No__ Yes__; Voice
volume changed: No__ Yes__ Louder__ Softer__; Voice quality changed: No__
Yes__ Quavering__ Hesitation__ Other: ______________
___________________________________________________________

3. Body language observed: ______________________________________


4. is current admission going to result in a body structure or function change for the
patient? No__ Yes__ Unsure at this time__

SUBJECTIVE

1. What is your major concern at the current time? ____________________


___________________________________________________________

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? ___________________________________________

4. My usual view of myself is: Positive__ Neutral__ Somewhat negative__


5. Do you believe you will have any problems dealing with your current health
situation? No__ Yes__ Describe: ___________________________
6. On a scale of 0 to 5 rank your perception of your level of control in this situation:
___________________________________________________
___________________________________________________________

7. On a scale of 0 to 5 rank your usual assertiveness level: ______________

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

1. Does patient live alone? Yes__ No__ With whom? __________________


2. Is patient married? Yes__ No__ Children? No__ Yes__ Ages of Children:
___________________________________________________________
3. How would you rate your parenting skills? Not applicable__ No difficulty__
Average__ Some difficulty__ Describe: ___________________________
___________________________________________________________

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: ___________
___________________________________________________________

11. What activities or jobs do you dislike doing? 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

1. Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? No__


Yes__ Year__
2. Use of birth control measures? No__ N/A__ Yes__ Type: _____________
3. History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe:
___________________________________________________________
4. Pap smear annually: Yes__ No__ Date of last pap smear: ____________
5. Date of last mammogram: ______________________________________
6. History of sexually transmitted disease: No__ Yes__ Describe: _________
___________________________________________________________

If admission is secondary to rape:

7. Is patient describing numerous physical symptoms? No__ Yes__ Describe:


___________________________________________________
8. Is patient exhibiting numerous emotional symptoms? No__ Yes__ Describe:
___________________________________________________

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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

1. History of prostate problems? No__ Yes__ Describe: ________________


2. History of penile discharge, bleeding, lesions: No__ Yes__ Describe:
___________________________________________________
3. Date of last prostate exam: _____________________________________
4. History of sexually transmitted diseases: No__ Yes__ Describe: ________
___________________________________________________________

Both

1. Are you experiencing any problems in sexual functioning? No__ Yes__


Describe:___________________________________________________
2. Are you satisfied with your sexual relationship? Yes__ No__
Describe:___________________________________________________
3. Do you believe this admission will have any impact on sexual functioning? No__
Yes__ Describe: ________________________________________

COPING-STRESS TOLERANCE PATTERN

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

1. Observe behavior. Is the patient exhibiting any signs of alterations in mood


(anger, crying, withdrawal, etc.)? Describe: ___________________
___________________________________________________________

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:

M Cubon, RN, MAN. 2008. http://nursingcrib.com


D Barrett, et. al. 2009. http://en.wikipedia.org/wiki/Nursing_care_plan
Charli Gorldberg, MD. 2008. http://meded.ucsd.edu/clinicalmed/history.htm
Karen Ericson, RN. 2002. http://www.healthline.com/galecontent/physical-examination
David Slotnick, MD. 2007. http://yourtotalhealth.ivillage.com/physical-examination.html

193
Manual on Nursing Health Assessment

Catherine Kuckyt, RN. 2009. http://home.cogeco.ca/~nursingprocess/health.htm

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