CHAPTER 4

NURSING PROCESS

This chapter covers concepts in applying nursing process and its components in the
delivery of nursing care.

Duration: 3 hours
Intended Learning Outcomes:
1. Define selected terms related to Nursing Process.
2. State the purpose of Nursing Process
3. State and describe each component of the process.

NURSING PROCESS
-Specific to the nursing profession
-A framework for critical thinking
- It’s purpose is to:“Diagnose and treat human responses to actual or potential health
problems”
- Organized framework to guide practice
- Problem solving method - client focused
- Systematic- sequential steps
- Goal oriented- outcome criteria
- Dynamic-always changing, flexible
- Involves looking at the whole patient at all times
- It provides a "road map" that ensures good nursing care & improves patient outcomes

Critical Thinking- nurses need to use Nursing process

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

Basis in using Critical Thinking:

 Deal w/ complex problems on a daily basis
 Work w/ pt that are unique
 Provide holistic care

Advantages of Nursing Process:

- Provides individualized care
-Client is an active participant
-Promotes continuity of care
-Provides more effective communication among nurses and healthcare professionals
-Develops a clear and efficient plan of care
-Provides personal satisfaction as you see client achieve goals
- Professional growth as you evaluate effectiveness of your interventions
 5 STEPS IN THE NURSING PROCESS

1. ASSESSMENT
-First step of the Nursing Process
- systematic, deliberate process by which the nurse collects and analyzes data about
the patient
-Gather Information/Collect Data through Nursing Interview (history), Health
Assessment -Review of Systems, Physical Exam
-Entire plan is based on the data you collect, data needs to be complete and accurate
- Make sure information is complete & accurate

5 Activities Needed to Perform a Systematic Assessment

-Collect data
-Verify data
-Organize data
-Identify Patterns
-Report & Record data
Sources of data:
a. Primary Source - Client / Family
b. Secondary Source - physical exam, nursing history, team members, lab reports,
diagnostic tests…..
Types of data:
a. Subjective -from the client (symptom) “I have a headache”
b. Objective - observable data (sign) Blood Pressure 130/80
Example:
 Obtain info from nursing assessment, history and physical (H&P) etc…...
 Client diagnosed with hypertension
 BP 160/90mmhg
 2 Gm Na diet and antihypertensive medications were prescribed
  Client statement “ I really don’t watch my salt” “ It’s hard to do and I just don’t get it

Comprehensive data collection:

- Begins before you actually see the patient (Nurse report from ER, Chart reviews)
-Continues with admission interview and physical assessment once you meet patient.
-Other information resources include: family, significant others, nursing records, old
medical records, diagnostic studies, relevant nursing literature.
-Consider age, growth & development

The 4 effective communication skills during patient assessment:

 Open-ended questions - prompts patients to describe a situation in more than one or
two words
 Back channeling - use of active listening prompts such as "all right", "go on", or "uh
huh"
 Probing - encouraging a full description without trying to control the direction the story
takes
 Close ended questions- limit answers to one or two words such as "yes" "no" or a
number or frequency of a symptom

VITAL SIGNS- indicators of health status, these measures indicate the effectiveness of
circulatory, respiratory, neural and endocrine body functions.
- it provides data to determine a client’s usual state of heath (baseline data).
-it is a quick and efficient way of monitoring a client’s condition or identifying problems
evaluating the client’s response to intervention.

Guidelines for Measuring Vital Signs:

a. Body Temperature - Reflects the balance between the heat produced and the heat lost
from the body
-Measured in heat units called degrees
Two kinds:
 Core temperature - The temperature of the deep tissues of the body and
remains relatively constant.
 Surface temperature - Is the temperature of the skin, in the subcutaneous
tissue, and fat.
- Rises and falls in response to environment.

Factors Affecting the Body’s Heat Production:

 Basal Metabolic Rate (BMR)
-The rate of energy utilization in the body required to maintain essential activities
such as breathing.
-Metabolic rates increase with age.
-In general, the younger the person, the higher the BMR.
 Thyroxine Output
-Increased thyroxine output increases the rate of cellular metabolism throughout
the body.
-Epinephrine, norepinephrine and sympathetic stimulation
 -These hormones immediately increase the rate of cellular metabolism in many
body tissues.
-Epinephrine and norepinephrine directly affect the liver and muscle cells,
thereby increasing cellular metabolism.
Factors affecting Heat Loss:
 Radiation
-Is the transfer of heat from the surface of one object to the surface without
contact between the two objects.
-Example: nude person standing in a room of a normal room temperature.
 Conduction
-Is the transfer from one molecule to a molecule of lower temperature.
-Conductive transfer cannot take place without contact between the molecules.
 Convection
- Dispersion of heat by air currents.
 Vaporization
- Is the continuous evaporation of moisture from the respiratory tract and from
the mucosa of the mouth and from the skin.

Factors Affecting Body Temperature:

 Age
-Infants are greatly influenced by the temperature of the environment.
-Children’s temperature continue to be more variable than those adults until
puberty.
-Many older people are at risk of hypothermia.
 Diurnal Variations (circadian rhythms)
-Body temperature normally change throughout the day,varying as much as 1.0C
-Highest body temperature: 1600-1800 hours
-Lowest: 0400 and 0600 hours
 Exercise
- Hardwork and strenuous exercise can increase body temperature to as high as
38.3 C to 40 C
 Hormones
- In women, progesterone secretion at the time of ovulation raises body
temperature by about .3 C to 0.6 C above basal temperature.
 Stress
-Stimulation of the SNS can increase the production of epinephrine and
norepinephrine, thereby increasing metabolic activity and heat production.
 Environment
-Extremes in environmental temperature affect a person’s temperature
regulatory systems.

Common Types of Fever:

 Intermittent
- Body temperature alternates at a regular intervals between periods of fever
and periods of normal or subnormal temperatures.
 Remittent
 - Wide range of temperature fluctuations (more than 2 C) over a period of 24
hours, all of which are above normal
 Relapsing
- Short febrile periods of a few days are interspersed with periods of 1-2 days of
normal temperature.
 Constant
- Fluctuates minimally but always remains above normal.
 Fever spike
- A temperature that rises to fever level rapidly following a normal temperature
and then returns to normal within a few hours.
Clinical Manifestations:
 ONSET (COLD OR CHILL PHASE)
-Increased heart rate, increased RR and depth, Shivering,Pallid, cold skin, Complaints of
feeling cold, Cyanotic nail beds ,“Gooseflesh” appearance of the skin,Cessation of
sweating.
 COURSE (PLATEAU)
-Absence of chills, Skin that feels warm, Photosensitivity, Glass-eyed appearance,
Increased PR and RR, Increased thirst, Mild to severe dehydration, Drowsiness,
restlessness, delirium, convulsions, Herpetic lesions of the mouth, Loss of appetite,
Malaise, weakness and aching muscles
 DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
-Skin that appears flushed and feels warm, Sweating, Decreased shivering, possible
dehydration
Assessing Body Temperature:
SITE ADVANTAGES DISADVANTAGES
ORAL Accessible and -Thermometers can break if bitten.
convenient -Inaccurate if client has just ingested hot or cold food or
fluid or smoked.
-Could injure mouth following oral surgery.
RECTAL Reliable -Inconvenient and more unpleasant for clients.
-Difficult for clients who cannot turn to the side.
-Could injure the rectum following rectal temperature.
- Presence of stool may interfere with the thermometer
placement.
AXILLARY Safe and non- -The thermometer must be left in place a long time to
invasive obtain an accurate measurement.
TYMPANIC Readily -Can be uncomfortable and involves risk of injuring the
MEMBRANE accessible; membrane if the probe is inserted too far.
reflects the core -Repeated measurements may vary.
temperature, - Presence of cerumen may affect the reading.
very fast
TEMPORAL Safe and -Requires electronic thermometers that may be inexpensive
ARTERY noninvasive; or unavailable.
very fast
b. Pulse
-Wave of blood created by contraction of the left ventricle of the heart.
-Peripheral pulse-a pulse located away from the heart.
-Apical pulse-central pulse, located at the apex of the heart, also called PMI
Factors AGE PULSE AVERAGE AND RANGES
Newborn 130 (80-180)
1 year 120 (80-140)
5-8 years old 100 (75-120)
10 years 70 (50-90)
Teen 75 (50-90)
Adult 80 (60-100)
Older adult 70 (60-100)
Affecting the Pulse:
 Age - As age increases, the pulse rate gradually decreases.
 Gender - After puberty, the average male’s pulse rate is lower than females.
 Exercise - the PR normally increases with activity.
 Fever - PR increases
 Medications- Digitalis-decreases PR
- Epinephrine-increases PR
 Hypovolemia - Loss of blood from the vascular system normally increases PR.
 Stress - Increases rate as well as the force of the heartbeat.
 Position Changes - When a person is sitting or standing, blood usually pools in
dependent vessels of the venous system.
-Pooling results in transient decrease in the venous blood return to the
heart and subsequent reduction in BP and increase in HR.
 Pathology- Certain diseases such as some heart conditions or those that impair
oxygenation can alter PR.

PULSE SITES:

PULSE SITE REASONS FOR USING SPECIFIC PULSE SITE

Radial -Readily accessible

Temporal -Used when radial pulse is not accessible

Carotid -Used during cardiac arrest/shock in adults
-Used to determine circulation to the brain
Apical -Routinely used for infants and children up to 3 years of
age.
-Used to determine discrepancies with radial pulse.
-Used in conjunction with some medications.
Brachial -Used to measure blood pressure
-Used during cardiac arrest for infants
Femoral -Used in cases of cardiac arrest/shock
-Used to determine circulation to the leg
Popliteal -Used to determine circulation to the lower leg
Posterior -Used to determine circulation to the foot
tibial
Dorsal Pedal -Used to determine circulation to the foot
Assessing the Pulse:
 Commonly assessed by palpation or auscultation.
 Use the middle three fingertips for all pulse sites except for the apex of the heart.
 Use moderate pressure.
 A doppler ultrasound stethoscope is used for pulses that are difficult to assess.
 The pads on the most distal aspects of the finger are most sensitive areas for
detecting pulse.
 The nurse should be aware of the following:
o Any medication that could affect the heart rate.
o Whether the client has been physically active. If so, wait 10-15 minutes until the
client has rested and the pulse has slowed to its usual rate.
o Any baseline data about the normal heart rate for the client.
o Whether the client should assume a particular position.

c. Respirations
 Act of breathing
 Inhalation or inspiration: intake of air into the lungs.
 Exhalation or expiration: refers to the breathing out or the movement of gases from the
lungs to the atmosphere.
 Ventilation: is also used to refer to the movement of air in and out of the lungs.
Two types of breathing:
 Costal (thoracic) breathing- involves the external intercostal muscles and other
accessory muscles, such as sternocleidomastoid muscles.
-Can be observed by the movement of the chest upward and outward.
 Diaphragmatic breathing - Involves the contraction and relaxation of the abdomen.
- Observed by the movement of the abdomen, which occurs as a result of the
diphragm’s contraction and downward movement
Assessing Respirations:
 Resting respirations should be assessed when the client is relaxed because exercise
affects respirations.
 Before assessing, a nurse should be aware of;
o patient’s normal breathing pattern
o influence of the client’s health problems on respirations
 Any medications or therapies that might affect respirations
 The relationship of the client’s respirations to cardiovascular function
What should be assessed?
 Rate
 Depth
  Rhythm
 Quality
 Special characteristics of respirations
RATE
Eupnea Normal rate & depth
Bradypnea Abnormally slow
Polypnea/Tachypnea Abnormally fast respirations
Apnea Cessation of breathing

Depth:
 Deep – are those in which a large volume of air is inhaled & exhaled, inflating most of
the lungs
 Shallow – involve the exchange of a small volume of air and often the minimal use of
lung tissue
Rhythm:
 Cheyne-stokes breathing- Rhythmic waxing and waning of respirations from very deep
to very shallow breathing and temporary apnea.
Ease of Effort:
 Dyspnea- difficult and labored breathing
 Orthopnea-ability to breathe only in upright sitting or standing positions.

BREATH SOUNDS:
 Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
 Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the
upper airway
 Wheeze – continous, high-pitched musical squeak or whistling sound occuring on
expiration and sometimes on inspiration when air moves through a narrowed or partially
obstructed airway
 Bubbling- gurgling sounds heard as air passes through moist secretions in the
respiratory tract
 Crackles – dry or wet crackling sounds simulated by rolling a lock of hair near the ear
 Gurgles – coarse, dry, wheezy or whistling sound more audible during expiration as the
air moves through tenacious mucus or narrowed bronchi
CHEST MOVEMENTS:
 Intercostal retractions-indrawing between the ribs
 Substernal retractions-indrawing beneath the breast bone
 Suprasternal retraction-indrawing above the clavicles

d. Blood Pressure
 A measure of the pressure exerted by the blood moves in waves
 SYSTOLIC PRESSURE – the pressure of the blood as a result of contraction of the
ventricles
 DIASTOLIC PRESSURE – the pressure when the ventricles are at rest
 PULSE PRESSURE-difference between SBP and DBP- Normal=40 mmHg
Factors Affecting Blood Pressure:
 Age- BP rises with age
 Exercise- Physical activity increases the cardiac output and hence the blood pressure.
 -Thus, 20-30 minutes of rest following exercise is indicated before the BP can be
assessed.
 Stress- Stimulation of the SNS increase CO and vasoconstriction of the arterioles, thus
increasing BP.
However, severe pain can decrease BP greatly by inhibiting the vasomotor center
and producing vasodilation.
 Race - African American males over 35 years have higher BP than European American
males of the same age.
 Gender - After puberty, females usually have a higher blood pressure than males of the
same age; d/t hormonal variations. After menopause, women generally have higher BP
than before.
 Medications- Many medications including caffeine, may increase or decrease BP.
 Disease process - Any condition affecting the cardiac output, blood volume, blood
viscosity, and/or compliance of the arteries has a direct effect of the BP.

Classification of Blood Pressure:

CATEGORY SBP DBP

Normal <120 <80
Prehypertension 120-139 80-89
Hypertension, Stage 1 140-159 90-99
Hypertension, Stage 2 >160 >100

e. Pain- The International Association for the Study of Pain (IASP) defines pain as “an
unpleasant sensory and emotional experience, which we primarily associate with tissue
damage or describe in terms of such damage, or both.
Pathophysiology of Pain:
-Pain is explained as a combination of physiologic phenomena in addition to a
psychosocial aspect that influences the perception of pain.
-The pathophysiologic phenomenon of pain is summarized by the processes of
transduction, transmission, modulation, and perception.
 Transduction
-Noxious stimuli(tissue injury) trigger the release of biochemical
mediators(e.g.,prostaglandins, bradykinin,serotonin, histamine, substance P)that
sensitize nociceptors.
-Noxious or painful stimulation also causes movement of ion across cel
membranes, which excites nociceptors.
-Pain medications can work during this phase by blocking the production of
prostaglandin(e.g.ibuprofen)or by decreasing the movement of ions across the
cell membrane(e.g.local anesthetic)
 Transmission
-The second process of nociception, transmission of pain, includes three
segments.
-Pain control can take place during this second process of transmission. For
example,opioids(narcotics)block the release of neurotransmitters, particularly
substance P, which stops the pain at the spinal level.
 First Segment- Pain impulse travels from the peripheral nerve fibers to the spinal
cord. Substance P serves as the neurotransmitter, enhancing the movement of
impulses across the nerve synapse from the primary afferent neuron to the
second-order neuron in the dorsal horn of the spinal cord. Two types of
nociceptor fibers cause transmission to the dorsal horn of spinal cord: C fibers
which transmit dull, aching pain and A delta which transmits sharp, localized
pain.
Second Segment- Transmission from the spinal cord and ascension, via
spinothalamic tracts, to the brainstem and thalamus.
Third Segment- Involves transmission of signals between the thalamus to the
somatic sensory context where pain perception occurs.
 Perception
-The third process is when the client become conscious pain.
-It is believed that pain perception occurs in the cortical structures, which allows
for different cognitive-behavioral strategies to be applied to reduce the sensory
and affective components of pain.
-For example, nonpharmacologic interventions such as distraction, guided
imagery, and music can help direct the client’s attention away from the pain.
 Modulation
-Often described as the “descending system”,this fourth process occurs when
neurons in the brainstem send signals back down to the dorsal horn of the spinal
cord. These descending fibers release substances such as endogenous opioids,
serotonin, and norepinephrine, which can inhibit the ascending noxious(painful
impulses in the dorsal horn.

Melzack and Wall in 1965 proposed the gate control model emphasizing the importance of the
central nervous system mechanisms of pain;this model has influenced pain research and
treatment.

Classifications of Pain:
 Acute pain-usually associated with an injury with recent onset and duration of less than
six months and usually less than a month.
 Chronic Pain- usually associated with a specific cause or injury and is described as a
constant
 Cancer Pain- often due to the compression of peripheral nerves or meninges or from the
damage to the structures following surgery, chemotherapy, radiation, or tumor growth
and infiltration
 Phantom Limb Pain – it is a pain perceived by a residual body part.

Physiologic Responses to Pain:

-Pain elicits stress response in the human body triggering the sympathetic nervous system,
resulting in physiologic responses such as the following:

 Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide

 Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
 Decrease in cognitive function, mental confusion, altered temperament, high
somatization, and dilated pupils
  Increased heart rate, peripheral, systemic, and coronary vascular resistance, blood
pressure
 Increased respiratory rate and sputum retention resulting in infection and atelectasis
 Decreased gastric and intestinal motility
 Decreased urinary output resulting in urinary retention, fluid overload, depression of all
immune responses
 Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons,
decreased insulin, testosterone
 Hyperglycemia. Glucose intolerance, insulin resistance, protein catabolism
 Muscle spasm resulting in impaired muscle function and immobility, perspiration
Factors Affecting the Pain Experience:

1. Ethnic and Cultural Values

2. Developmental Stage
3. Environment and Support People
4. Past Pain Experiences
5. Meaning of Pain
6. Anxiety and Stress
7.
Health Assessment for Pain

Collecting Subjective Data

 Pain is a subjective phenomenon and thus the main assessment lies in the client’s
reporting. The client’s description of pain is quoted. The exact words used to describe
the experience of pain are used to help in the diagnosis and management.
A. History of Present Illness
 Use the COLDSPA mnemonic as a guideline to collect information. In addition the
following questions help elicit important information .
Character: Describe the pain in your own words. How does it feel, look sound, smell and
so forth?

Clients are quoted so that terms used to describe their pain may indicate the type and
source. The most common terms used are: throbbing, shooting, stabbing sharp,
cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring-exhausting,
sickening, fearful, punishing.

Onset: When did the pain begin?

The onset of pain is an essential indicator for the severity of the situation and suggests
a source.
Location: Where is the pain located? Does it radiate or spread? The location of the pain
helps to identify the underlying cause.
Duration: How long does the pain lasts? Does it recur?Is the pain continuous or
intermittent?
Understanding the course of the pain provides a pattern that may help to determine the
source.
Severity: How bad is it?
To determine the degree of perceived pain.
 Pattern: What factors relieve your pain? What factors increase your pain?
Identifying factors that relieve or increase pain helps to determine the source and the
plan of care.
Associated factors: Are there any concurrent symptoms accompanying the pain?
Accompanying symptoms also help to identify the possible source. For example, right
lower quadrant pain associated with nausea, vomiting and the inability to stand up
straight is possibly associated with appendicitis.
B. Past Health History
 Have you had any previous experience with pain?
Past experiences of pain may shed light on the previous history of the client in
addition to possible positive or negative expectations of pain therapies.

C. Family History
 Does any in your family experience pain?
To assess possible family-related perception or any past experiences with person
in pain.

 How does pain affect your family?

To assess how much the pain is interfering with the client’s family relations.

D. Lifestyle and Health Practices

 What are your concerns about pain?
Identifying the client’s fears and worries helps in prioritizing the plan of care and
providing adequate psychological support.

 How does your pain interfere with the following?

-General Activity
-Mood/Emotions
-Concentration
-Physical Ability
-Work
-Relations with other people
-Sleep
-Appetite
-Enjoyment of life
These are the main lifestyle factors that pain interferes with. The more the pain interferes
with the client’s ability to function in his/her daily activities, the more it will reflect on the
client’s psychological status and thus the quality of life.

Collecting Objective Data:Physical Examination

 Objective data are collected by using one of the pain assessment tools.
 The main tool used are the Verbal Descriptor Scale(VDS), Wong-Baker Faces Scale,
Numeric Rating Scale(NRS) and Visual Analog Scale(VAS).
Verbal Descriptor Scale(VDS) -Ranges pain on a scale between mild, moderate, and
severe.
 Wong-Baker Faces Scale(FACES) -Shows different facial expression where the client
is asked to choose the face that best describes the intensity or level of pain being
experienced;this works well with pediatric clients.
Numeric Rating Scale(NRS) -Rates pain on a scale from 0 to 10 where o reflects no
pain and 10 reflects pain at its worst.
Visual Analog Scale(VAS) -Rates pain on a 10cm continuum numbered from 0 to 10
where 0 reflects no pain and 10 reflects pain at its worst.

 Physical Assessment(Patients with Pain)

Inspection:
1. Observe posture.
-Client appears to be slumped with the shoulders not straight indicate being
disturbed or uncomfortable.
-Client is inattentive and agitated.
-Client might be guarding affected area and have breathing patterns reflecting
distress.
2. Observe facial expression.
-Client’s facial expressions indicate distress and discomfort, including frowning,
moans, cries and grimacing.
-Eye contact is not maintained, indicating discomfort
3. Inspect joints and muscles.
- may result in muscle tension.
4. Observe skin for scars, lesions, rashes, changes or discoloration.
-Bruising, wounds, or edema maybe the result of injuries or infections, which may cause pain.

Pediatric and Geriatric Adaptations To Pain

INFANT
-perceives pain
-responds to pain with increased sensitivity
-older infant tries oavoid pain, for example. Turns away and physically resists
Selected Nursing Interventions:
 Give a glucose pacifier.
 Use tactile stimulation
 Play music or tapes of a heartbeat.

TODDLER AND PRESCHOOLER

-develops the ability to describe pain and its intensity and location
-often responds with crying and anger because child perceives pain as a threat to
security
-may consider pain as a punishment
-feels sad
-may learn there are gender differences in pain expression
-tends to hold someone accountable for the pain
Selected Nursing Interventions:
 Distract the child with toys,books, pictures. Involve the child in blowing bubbles as a
way of “blowing away the pain.
  Appeal to the child’s belief in magic by using a “magic” blanket or glove to take away
the pain.
 Hold the child to provide comfort.
 Explore misconceptions about pain.

SCHOOL-AGE CHILD
 tries to be brave when facing pain.
 rationalizes in attempt to explain the pain.
 responsive to explanations
 can usually identify the location and describe the pain
 with persistent pain, may regress to an earlier stage of development
Selected Nursing Interventions:
 Use imagery to turn off “pain switches”.
 Provide a behavioral rehearsal of what to expect and how it will look and feel.
 Provide support and nurturing.

ADOLESCENT
 may be slow to acknowledge pain
 recognizing pain or “giving in” may be considered weakness
 wants to appear brave in front of peers and not report pain
Selected Nursing Interventions:
 Provide opportunities to discuss pain.
 Provide privacy.
 Present choices for dealing with pain.Encourage music or TV for distraction.
 ADULT
 behaviors exhibited when experiencing pain may be gender-based behaviors learned as
a child
 may ignore pain because to admit it is perceived as a sign of weakness or failure
 fear of what pain means may prevent some adults from taking action
Selected Nursing Interventions:
 Deal with any misconceptions about pain.
 Focus on the client’s control in dealing with the pain.
 Allay fears and anxiety when possible.

ELDERLY
 may have multiple conditions presenting with vague symptoms
 may perceive pain as part of the aging process
 may have decreased sensations or perceptions of the pain
 lethargy, anorexia, and fatigue may be indicators of pain
 may withhold complaints of pain because of fear of the treatment, of any lifestyle
changes that may be involved, or of becoming dependent
 may describe pain differently,thatis,as “ache”, “hurt”, or “discomfort”
 may consider it unacceptable to admit or show pain
Selected Nursing Interventions:
 Thorough history and assessment is essential.
 Spend time with the client and listen carefully.
 Clarify misconceptions.
 Encourage independence whenever possible.
PHYSICAL EXAMINATION
 Conducted from head to toe (cephalo-caudal technique).
 Determine the mental status and level of consciousness (LOC) at the beginning of
examination.
PURPOSES
 Gather baseline data about the client’s health
 Supplement, confirm or refute data obtained in the midwifery history
 Confirm & identify midwifery diagnosis
 Make clinical judgments about a client's changing health status and management
 Evaluate the physiological outcomes of care

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

POSITIONS:

Sitting

 Use this position for the assessment of head,neck,

back,posterior thorax,and lungs,breasts,axillae,heart,
vital signs,and upper extremities
 It provides full expansion of lungs, and provides better
visualization of symmetry of upper body part.
Supine

 back lying position with legs extended, without small

pillow under the head
 for the assessment of head,and neck, anterior thorax,
and lungs, breasts, axillae, heart, abdomen, extremities,
pulses, vital signs, vagina
 Most normally relaxed position. It provides easy access to pulse sites.
Dorsal recumbent
 back lying position with knees flexed and hips
externally rotated, with small pillow under the head.
 Head, neck, anterior thorax and lungs, breasts, axillae,
heart and abdomen, extremities, peripheral pulses,
vital signs and vagina.
 Position is used for abdominal assessment because it
promotes relaxation of abdominal muscles.
Lithotomy

 back lying position with feet supported in stirrups;

hips should be in line with the edge of the table
 for the assessment of female genitalia, rectum and
female reproductive tract
 Provides maximal exposure of genitalia and facilitates
insertion of vaginal speculum
Sim’s
 side-lying position with lowermost arm behind the body
and uppermost leg flexed.
 For the assessment of rectum and vagina
 Flexion of knee and hip improves exposure of rectal area

Prone
 face-lying position with or without a small pillow
 assessment of posterior thorax, hip movement

Knee-chest (Genu-pectoral)
 kneeling position with torso at a chest.
 Assessment of rectum
 Provides maximal exposure to rectal area.
Fowler’s
 Semi-fowler’s – head of bed elevated at 15-45 degree angle.
 High Fowler’s – head of bed raised at 80-90 degree angle.
PHYSICAL EXAMINATION TECHNIQUES

Inspection
 visual examination
-Should be deliberate, purposeful, and systematic
-is concentrated watching
-it is close, careful scrutiny, first of the individual and as a whole and on each body
system
 begins the moment you first meet your client
 inspection always comes first
 the health care worker inspects with the naked eye and with a lighted instrument
 in addition to visual observations, olfactory and auditory cues are noted
 inspection is used to assess moisture, color, and texture if body surfaces as well as
shape , position ,size, symmetry of the body
 requires good lighting, adequate exposure, and occasional use of certain instruments to
enlarge your view.

Guidelines:
 Make sure the room has a comfortable temperature.
 Use good lighting, preferably sunlight.
 Look & observe before touching.
 Compare appearance of symmetric body parts or both sides of any individual body part.
 
Auscultation
 requires the use of stethoscope
 Guidelines:
1. Eliminate distracting noises
2. Expose the body part you are going to auscultate
3. Press the diaphragm firmly

Palpation
 Factors/ characteristics to assess are:
1.Texture Auscultation using stethoscope
2.Temperature of skin area
1. Location/position, size, consistency, mobility of organs or masses
2. Distention
3. Pulsation
4. Presence of pain upon pressure
5. Presence of lumps

 Different parts of the hands are best suited for assessing different factors:
 1. finger pads
2. grasping action of the fingers and thumb
3. dorsal
4. ulnar or palmar

TYPES OF PALPATION:
1. Light Palpation
-place dominant hand lightly on the surface of the structure
-there should be very little or no depression
-feel the surface using circular motion
-use this technique to feel for pulse, tenderness, surface, texture, temperature &
moisture
2. Moderate Palpation
-depress the skin surface 1-2 cm (.5-.75 in) with your dominant hand
-use circular motion to feel for easily palpable body organs and masses
-note for size, consistency and mobility of structures you palpate
3. Deep Palpation
-place your dominant hand on the skin surface and your non dominant hand on top of
your dominant hand to apply pressure
-surface depression should be 2.5 cm and 5 cm (1-2 in)
-allows you to feel very deep organs or structures that are covered by thick muscle
a. Bimanual Palpation
-use two hands, placing one on each side of the body part being palpated
-use one hand to apply pressure and the other hand to feel the structure
-note the size, shape, consistency and mobility of the structures you palpate

 
Moderate Palpation

Percussion Deep Palpation - bimanual Light Palpation - bimanual

 involves tapping body parts to produce sound waves that enable the examiner to assess
underlying structures
 Uses:
-Eliciting pain: percussion helps detect inflamed underlying structures.
-Determining location, size and shape
-Determining density
-Detecting abnormal masses
-Eliciting reflexes
 Types:
1.Direct Percussion
2.Indirect or mediate Percussion
Direct Percussion
 Procedure:
a. place middle finger of non-dominant hand on body part you are going to percuss
b. use pad of middle finger of the other hand to strike the middle finger of non-
dominant hand that is placed on the body part
c.withdraw finger immediately
d. deliver 2 quick taps and listen carefully
e. use quick, sharp taps by flexing wrist

 Sounds elicited by percussion:

1. Resonance
-intensity: LOUD Indirect percussion
-pitch: LOW
-length: LONG
-quality: HOLLOW
-origin: NORMAL LUNG
2. Hyper-resonance
-intensity:VERY,LOUD
-pitch:LOW
-length:LONG
-quality:BOOMING
-LUNG W/ EMPHYSEMA
3. Tympany
-intensity: LOUD
-pitch: HIGH
-length: MODERATE
-quality: DRUMLIKE
-PUFFED-OUT CHEEKS
4. Dullness
-intensity: MEDIUM
-pitch: MEDIUM
-length: MODERATE
-quality: THUDLIKE
-DIAPHRAGM, PLEURAL EFFUSION, LIVER
5. Flatness
-intensity: SOFT
-pitch: HIGH
-length: SHORT
-quality: FLAT
-MUSCLE, BONE
Special considerations:
1. The sequence of methods for physical examination of the abdomen is as follows:
Inspection, Auscultation, Percussion and Palpation (IAPePa). No abdominal palpation
among clients with tumor of the liver or the kidneys.
2. During physical examination of the abdomen, it is important to flex the knees to relax
the abdominal muscles , thereby facilitating the examination of abdominal organs.
3. The sequence of examining the abdomen is as follows: right lower quadrant, right upper
quadrant, left upper quadrant and left lower quadrant (RLQ, RUQ, LUQ, LLQ).
4. The best position when examining the chest is sitting/upright position. This permits the
examination of both the anterior and posterior chest.
5. The best position when examining the back is standing position. This enables the
examiner to assess the posture, and the gait of the client.
6. If instrumental vaginal examination is done, pour warm water over the vaginal speculum
before use. To ensure comfort.
7. Is a female client is examined by a male doctor, a female staff must be in attendance.
This ensures that the procedure is done in ethical manner.

 
LABORATORY AND DIAGNOSTIC EXAMINATIONS
Specimen used: Urine, Stool, Sputum, Blood, Body secretions

A. URINE SPECIMEN
Specimen Collection:
1. Clean-catch, midstream urine specimen for routine urinalysis, culture and
sensitivity test (C & S)
 the best time to collect: early morning, first voided specimen
 Provide sterile container
 Do perineal care before collection of urine specimen to reduce microorganisms at the
external genitals
 Discard the first flow of urine to ensure that the urine specimen is uncontaminated
 Collect the midstream: 30-50 ml, for routine urinalysis; 5-10 ml for urine C & S
 Discard the last flow of urine especially among males
 Label the specimen properly
 Send the specimen immediately to the laboratory

2. 24-hours urine specimen

 Discard first voided specimen
 Collect all specimen thereafter until same time the following day
 Soak specimen in a container with ice
 Add preservative as ordered/ according to the policy of the institution.
3. Second-voided urine specimen
 Ask the patient to void, discard the first urine specimen
 Give the patient one glass of water to drink
 After few minutes, ask the patient to void again, and collect this urine specimen
  This type of specimen is required for tests for glucose in urine
4. Catheterized Urine specimen
 Clamp the catheter for 30 minutes to I hour
 Cleanse the drainage port of the 2-way foley catheter with alcohol swab/cotton ball
 Use sterile needle and syringe to aspirate urine specimen from the drainage port

Test for glucose in urine

Benedict’s test:
 Collect urine specimen before meals
 Put 5 ml of Benedict’s solution into the test tube
 Heat the benedict’s solution; there should be no color change. (if the color of the
solution is altered upon heating, it is considered contaminated
 Add 8-10 drops of urine
 Heat the Benedict’s solution with urine (do not boil)
 Interpretation of results:
blue – (-) negative
Green - +
Yellow - ++
Orange - +++
Red - ++++
Test for Albumin in the Urine:

Heat and Acetic Acid Test:

 Collect urine specimen before meals

 Imaginary divide the test tube into three parts
 Put 2/3 parts of urine into the test tube
 Add 1/3 part acetic acid. DO NOT HEAT. Acetic acid explodes when heated
 CLOUDINESS indicates albuminuria

B. STOOL SPECIMEN

1. Routine Fecalysis – to assess gross appearance of ova/parasites

 Secure sterile specimen container
 Instruct patient to defecate in a bedpan. If desired, allow the patient to void first
 Use tongue depressor to collect the stool specimen
 Collect 1 teaspoonful or 1 inch of well-formed stool
 Label the specimen and bring immediately to the laboratory

2. Stool culture and sensitivity test

 To assess the specific etiologic agent causing gastroenteritis and bacterial sensitivity
to various antibiotic
 Use sterile test tube and sterile cotton-tipped applicator
 Label the specimen properly
 Send specimen immediately to the laboratory
 3. Guaiac Stool Examination (Occult blood determination) – microscopic study of
stool for presence of bleeding in the gastrointestinal tract

 Provide hemoglobin-free diet for 3 days

 Avoid red or dark-colored foods
 Temporarily discontinue iron therapy
 Positive guaiac stool exam indicates peptic ulcer disease and gastric cancer

C. SPUTUM SPECIMEN

1. Gross appearance of the sputum

 Collect early morning specimen
 Use sterile container
 Rinse mouth with plain water before collection of specimen. Do not use mouthwash
 Instruct patient to hack-up sputum to ensure that it comes from the lungs and lower
airways

2. Sputum Culture and Sensitivity test – to assess the specific etiologic agent causing
respiratory tract infection and bacterial sensitivity to various antibiotics.

 Use sterile container

 Collect sputum specimen before the first dose of antimicrobials

3. Acid-Fast Bacilli (AFB) staining – to assess presence of active pulmonary tuberculosis

- Collect sputum for 3 consecutive mornings.

2. NURSING DIAGNOSIS
- Second step of the Nursing Process
- provide a basis for selection of nursing interventions so that goals and outcomes can
be achieved
-Interpret & analyze clustered data
-Identify client’s problems and strengths
-Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-
Statement of how the client is RESPONDING to an actual or potential problem that
requires nursing intervention
- responsible for recognizing health problems, anticipating complications, initiating
actions to ensure appropriate and timely treatment.
- Apply critical thinking to problem identification
-Requires knowledge, skill, and experience

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

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

Formulating a Nursing Diagnosis

 Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)
 Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)
 Don’t state 2 separate problems in one diagnosis
 Refer to NANDA list in a nursing text book ( North American Nursing Diagnosis
Association it formally identifies, develops, and classifies nursing diagnoses)

Composed of 3 parts:
 Problem statement ( Diagnostic Label)-based on your assessment of clienT(gathered
information),
- pick a problem from the NANDA list
- the client’s response to a problem
 Etiology- what’s causing/contributing to the client’s problem
- determine what the problem is caused by or related to (R/T)
 Defining Characteristics- what’s the evidence of the problem
-then state as evidenced by (AEB) the specific facts the problem is based on…
EXAMPLE:
Ineffective therapeutic regimen management related to difficulty maintaining
lifestyle changes and lack of knowledge as evidenced by B/P= 160/90, dietary sodium
restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s
hard to do and I just don’t get it”.

TYPES OF NURSING DIAGNOSIS

 Actual- Patient problem & Causes if known
- Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and
pain AEB height 5’5” weight 105 lbs.
 Risk - Problem & Risk Factors
- patient is at risk for developing this problem
-Example: Risk for falls RT altered gait and generalized weakness
 Wellness- (NANDA) describes human responses to levels of wellness in an individual,
family, or community that have a readiness for enhancement
-Example: Family coping: potential for growth RT unexpected birth of twins.

COLLABORATIVE PROBLEMS:
-Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical diagnosis of pneumonia
Collaborative problem = respiratory insufficiency
Nursing interventions: Raise Head of the Bed, Encourage rest and deep breathing
Medical interventions: Antibiotics IV, O2 therapy

SOURCES OF DIAGNOSTIC ERROR:

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

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

3. PLANNING
- Third step of the Nursing Process
- This is when the nurse organizes a nursing care plan based on the nursing diagnoses.
- Nurse and client formulate goals to help the client with their problems
-Expected outcomes are identified
-Interventions (nursing orders) are selected to aid the client reach these goals.
- Begin by prioritizing client problems
-Prioritize list of client’s nursing diagnoses using Maslow
-Set your priorities of care, what needs to be done first, what can wait.
-Apply Nursing Standards, Nurse Practice Act, National practice guidelines, hospital
policy and procedure manuals.
-Identify your goals & outcomes, derive them from nursing diagnosis/problem.
-Determine interventions, based on goals.
-Record the plan (care plan/concept map)
-Client specific Priorities can change

Developing a Goal and Outcome Statement

- Goal and outcome statements are client focused.
-Worded positively
-Measurable, specific observable, time-limited, and realistic
-Goal = broad statement
-Expected outcome = objective criterion for measurement of goal or Measurable change
that must be achieved to reach a goal
EXAMPLE:
Goal: Client will achieve therapeutic management of disease process….
Outcome Statement: as evidenced by B/P readings of 110-120 / 70-80 and
client statement of understanding importance of dietary sodium restrictions by
day of discharge.
Types of Goals:
 Short term- goal can be achieved in a reasonable amount of time ( few hours to few
days)
 Long term- goals may take weeks/months to be achieved
 Cognitive goals
 Psychomotor goals
 Affective goals
- Goals are patient-centered and SMART (Specific Measurable Attainable Relevant Time
Bound)

Planning select interventions:

- Interventions are selected and written.
- The nurse uses clinical judgment and professional knowledge to select appropriate
interventions that will aid the client in reaching their goal.
- Interventions should be examined for feasibility and acceptability to the client
- Interventions should be written clearly and specifically.

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

4. IMPLEMENTATION- The fourth step in the Nursing Process

- This is the “Doing” step
- Interventions will be collaborative, combining nursing actions and physician orders.
- Carrying out nursing interventions (orders) selected during the planning step
-This includes monitoring, teaching, further assessing, reviewing NCP, incorporating
physicians orders and monitoring cost effectiveness of interventions

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

3 TYPES OF INTERVENTION
 Independent ( Nurse initiated )- any action the nurse can initiate without
direct supervision
 Dependent ( Physician initiated )-nursing actions requiring MD orders
 Collaborative- nursing actions performed jointly with other health care team
members
EXAMPLE:
-Monitor Vital Sign q4h
-Maintain prescribed diet (2 Gm Na)
-Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels,
food preparation and sodium substitutes
-Teach potential complications of hypertension to instill importance of maintaining Na
restrictions
-Assess for cultural factors affecting dietary regime

Factors to Consider When Selecting Interventions:

 Desired patient outcomes
 Characteristics of the nursing diagnosis.
 Research-based knowledge for the intervention
 Feasibility of the interventions
 Acceptability to the patient
  Nurse's competency

Model of Professional Nursing Practice Regulation

Tips for making decisions during implementation:

 Review the set of all possible nursing interventions for a patient's problem
 Review all possible consequences associated with each possible nursing action
 Determine the probability of all possible consequences
 Judge the value of the consequence to the patient

5. EVALUATION - To determine effectiveness of NCP

-Final step of the Nursing Process but also done concurrently throughout client
care
-A comparison of client behavior and/or response to the established outcome
criteria
- Step of the nursing process that measures the client’s response to nursing
actions and the client’s progress toward achieving goals
-Data collected on an on-going basis
-Supports the basis of the usefulness and effectiveness of nursing practice
-Involves measurement of Quality of Care
- Evaluation of individual plan of care includes determining outcome achievement
-Identify variables/factors affecting outcome achievement
-Decide where to continue/modify/terminate plan
-Continue/modify/terminate plan based on whether outcome has been met
(partially or completely)

Evaluation of Goal Achievement:

-Measures and Sources: Assessment skills and techniques
-As goals are evaluated, adjustments of the care plan are made
-If the goal was met, that part of the care plan is discontinued
-Redefines priorities
Reflection in Action:
Once you deliver an intervention, you continuously examine results by gathering
subjective and objective data from the patient, family, and health care team members.
At the same time you review knowledge regarding a patient's current condition, the
treatment, and the resources available for recovery.
By reflecting on previous experiences caring for similar patients, you are in a better
position to know how to evaluate your patient.

Perform the following steps to objectively evaluate the degree of success in

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

When do you discontinue a care plan?

- if the patient has met all goals and outcomes

Modifying a care plan

 Reassessment
 Redefining diagnoses
 Goals and expected outcomes
 Interventions