N1J02 Test#2 Notes

Assessment &
Physical Exam of the Abdomen
N1J02 – Week 7 - W2022
Presented by –
Doug Wonnacott, RN, BScN, Med.
Reminder:
Just a reminder that Test #1 is coming up on
this Friday, March 4th at 7:30pm, on-line.
The content will include everything from Week 1 to

6 and you will have 60 minutes to complete the test.
There are 39 multiple choice, and 1 select all that apply

questions.
COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA,
LTD.
2
Focus-Large Group Class
•Abdominal assessment-normal findings and common
variations
•Questions for a focused GI & abdominal health history
•Adaptations for age & culture
•Discuss clinical judgment scenario & how you would respond
3
Structure and Function
• Surface landmarks
▫ Borders of abdominal
cavity
▫ Abdominal muscles
▫ Linea alba
• Abdominal wall divided into
four quadrants
▫ Right upper (RUQ)
▫ Left upper (LUQ)
▫ Right lower (RLQ)
▫ Left lower (LLQ)
Can you identify the organs
found in each quadrant?
COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD.

4
Internal Anatomy RUQ LUQ
• Internal anatomy (viscera)

• Solid viscera
• Liver
• Pancreas
• Spleen
• Adrenal glands
• Kidneys
• Ovaries
• Uterus
• Hollow viscera
• Stomach
• Gallbladder
• Small intestine
• Colon
• Bladder
RLQ LUQ
© Pat Thomas, 2006.
5
Deep Internal
Anatomy
© Pat Thomas, 2006.

6
Developmental Considerations
• Infants and children
▫ Prominence of umbilical cord, contains 2 arteries
& 1 vein
▫ Liver is larger and urinary bladder position is
higher
▫ Abdominal wall less muscular
▫ Risk for GI illness and dehydration related to
diarrhea and vomiting
https://en.wikipedia.org/wiki/Umbilical_cord

7
• Pregnant women
▫ Morning sickness
▫ Heartburn
▫ Hemorrhoids
▫ Intestines pushed upward and
posteriorly
▫ Decreased GI motility and delayed
gastric emptying
▫ Constipation and decreased bowel
sounds

8
• Older adults
▫ Suprapubic fat accumulation in women; abdominal accumulation in
men
▫ Decreased salivation, gastric acid secretion, delayed esophageal
emptying (risk of aspiration)
▫ Constipation; More susceptible to dehydration
▫ Decreased liver size and increased gallstones
▫ Decreased renal function (adverse drug effects)
▫ Increased risk of colon cancer, need for screening

9
Cultural and Social Considerations
• breast feeding vs formula; cultural practice, cost & availability
• food security; food backs and school food programs
• cultural dietary variations
• dietary preferences ie vegetarianism
• religious or faith requirements ie fasting
• allergies and food tolerances
• social influences: body image & exercise and dieting practices
• lifestyles: smoking, alcohol,

10
•Increasing rates of obesity, especially in lower income populations;
•Obesity is increased risk for diabetes, gall stones, some types of

cancer, fatty liver and cirrhosis, and GERD
•Prevalence of lactose intolerance – research that moderate milk products

can be consumed
•Rates of celiac disease – auto-immune disease related to gluten in diet;

inherited autoimmune condition, many affected individuals not diagnosed

11
•GI & Peptic ulcer disease (Canada has highest incidence in world);
risk factor include NSAIDS, smoking, alcohol, H. pylori infection
•Inflammatory bowel disease, IBD (Canada has one of the highest

rates)
• Early age at onset for Crohn’s disease (20-30 yrs)
•Relationship of hepatitis A and GI illnesses to socioeconomic

factors ie housing, sanitation, water quality, hand washing, food
handling
•Increased risk of parasitic diseases in refugees and immigrants

from some countries where endemic

12
Abdominal Assessment:
Health History

LTD.
13
Subjective Data: Health History
Abdominal pain: PQRSTU, associated factors or other symptoms,

treatments tried
Nausea/vomiting: presence, frequency, emesis: quantity, colour, odour,
any blood; other associated factors like pain/diarrhea/fever,
Bowel habits: regularity, frequency, colour, consistency, diarrhea,
constipation, recent changes, use of laxatives
Past abdominal history: personal history of ulcers, gallbladder disease,
hepatitis/jaundice, appendicitis, colitis, hernia; any GI surgeries and
problems after surgery, abdo X-rays, CT or US, colonoscopy or sceening

14
▫ Liver: RUQ or epigastrium
Common Sites of
Referred ▫ Esophagus: midepigastrium or lower sternum
Abdominal Pain ▫ Gallbladder: right or left scapula
( ie PQRSTU) ▫ Pancreas: midepigastric, radiating to back
▫ Duodenum: does not radiate
▫ Stomach: epigastric, radiates to back or substerna
▫ Appendix: periumbilical, shifts to RUQ
▫ Kidney: flank or lower abdominal
▫ Small intestine: diffuse abdominal
▫ Colon: lower abdomen

15
Referred
Abdominal
Pain
See - Jarvis,
chapt. 22
p. 600
table 22.3

LTD.
16
Appetite: change/loss in appetite, change in weight, how much, over what
time period, intentional loss due to diet, anorexia
Diet & Nutritional assessment: 24 hour diet recall, adherence to Canada’s

Food Guide, fibre and fluid intake, access to fresh foods, caffeine &
alcohol, supplements
Dysphagia: difficulty swallowing, onset
Food intolerance & allergies: foods you cannot eat, what happens
(nausea, vomiting, heartburn, indigestion, bloating),
GI medications – antacids, laxatives, stool softeners etc.; use/frequency

17
Medications: prescription, over the counter, herbal & natural remedies

traditional medicines, probiotics
Alcohol and tobacco: quantity and frequency of each
ADLs: leisure, exercise, work, chores, sexual activity, sleep, grooming &
hygiene
Travel and exposures: close contacts with others with similar symptoms
Family history of IBD, colorectal cancer, gall stones

18
Female Clients: sexually active (intercourse)
possibility of being pregnant
LMP – last menstrual period;
normal menstrual pattern?
Obstetrical History - G - # of times pregnant
T - # of full term pregnancies
P - # premature births
A - # of abortions and/ or miscarriages
L - # of living children/ live births
- complications
- vaginal or caesarian births
19
Additional Health History Questions
Infants and children
• Infant feeding - breast feeding
versus formula
• Table foods
• Eating patterns
• Constipation
• Abdominal pain
• Under weight or overweight
children

20
Adolescents
• Schedule and content
• Exercise & activity pattern
• Underweight: self/ body image,
Menstrual history - irregularity/
• amenorrhea
• Sexually active (intercourse) & birth
control
• Perceptions of parents/friends

21
Older adults
◦ Food access & security
◦ ADLs – food preparation, shopping
◦ Emotional/social characteristics
◦ Diet, food tolerances, allergies etc
◦ Adequate hydration
◦ Bowel movements
◦ Incontinence
◦ Activity
◦ Oral / dental health – dentures?
◦ Other: chronic illness, mobility,
dependence on care givers

22
Abdominal Assessment:
Objective Data
The Physical Examination

LTD.
23
Physical Exam
• Preparation patient comfort, bathroom?
▫ Lighting and draping; privacy; door, curtains,
▫ Raise bed
▫ Measures to enhance abdominal wall relaxation: warm room, knees flexed on pillow, arms at
sides; patient lying supine (or head slightly elevated if not tolerated)
• Equipment needed
▫ Stethoscope
▫ Alcohol swab
▫ Always consider need for PPE
Quick Example Assessment:

▫ https://static.us.elsevierhealth.com/jarvis_hao_videoseries/headtoe_abdomen_inguinal_area_HIres
_4_5.mp4
▫ Stop at 1:48 when they start to demonstrate deep palpation (you are not learning deep palpation)

24
Physical Exam
Recall reason for being seen & area of focus (ie pain or discomfort)
Examine in order: (IAPP) * note change in general sequence

• Inspection
• Auscultation
• Palpation
• Percussion

25
Physical Exam - Inspection
▫ Skin colour, striae, moles, lesions, hair distribution, scars
▫ Pulsation or movement
▫ Contour . shape In Clinical
▫ Symmetry Skills
▫ Umbilicus Essentials:
▫ Demeanor & facial expression
1. Watch:
Assessing
the
Abdomen
(start-2.59)
2. Complete
the practice
test
26
Incisional hernia
Umbilical hernias
Umbilical hernia (adult and infant)

LTD.
27
Abdominal distention Ascites (fluid)

LTD.
28
Distended Abdomen? Fat (obesity)
Flatus (gas)
Fetus (pregnant)
Fundus (post pregnant)
Fatal Tumors (mass ie cancer)
Fluid (ascites)
Fibroids (scar tissue)
Full bladder
Faeces (stool)
Foreign body

LTD.
29
Physical Examination - Auscultation
▫ Bowel sounds
▫ Use diaphragm, press lightly
▫ Start in RLQ and listen in all 4 quadrants, zigzag across In Clinical
abdomen Skills
▫ Note character & frequency
▫ High pitched, gurgling, irregular 5-30 times per minute Essentials:
▫ Vascular sounds (bruits)
▫ Use bell, normally none present 1. Watch:
▫ Do NOT palpate or percuss if a bruit is heard Assessing the
Abdomen
(3.00-4.06)
• Sample bowel sounds on Jarvis-Evolve
https://coursewareobjects.elsevier.com/objects/elr/Canada/Ja
rvis/examination3e/audio/audio_abdomensounds/
• Normal bowel sounds
▫ Hyper- and hypoactive bowel sounds
▫ Bruits (turbulent blood flow – abnormal finding)
30
Auscultation Pattern-Vascular Sounds

31
Physical Exam-Palpation:
• Surface/light palpation:
▫ Assess texture, temperature, ◦ If you identify a mass, note:
moisture, swelling, rigidity, ◦ Location
pulsations, tenderness/pain,
masses ◦ Size
▫ Measures to enhance ◦ Shape
muscle relaxation
◦ Consistency
▫ Light palpation
 Voluntary guarding ◦ Surface
◦ Mobility
 ** Rebound tenderness = acute
abdomen, peritoneal irritation ◦ Pulsatility
◦ Tenderness
32
Light Palpation
▫ Deep palpation- In Clinical

not expected to Skills
perform in Level Essentials:
1
1. Watch:
▫ Understand Assessing the
difference Abdomen
between light vs. (6.26-7.58)
deep palpation 2. Complete
the practice
test
▫ Palpating vs
“poking”

LTD.
33
Referred
Abdominal
Pain
See - Jarvis,
chapt. 22
p. 600
table 22.3

LTD.
34
Physical Exam- Abdomen Percussion
▫ Percussion identifies abdominal In Clinical
contents, locates organs, screens Skills
for fluid and masses Essentials:
▫ Move clockwise
Watch:
▫ General tympany; dullness over
Assessing the
solid organs or masses Abdomen
▫ Auscultation done before (4.06-6.26)
percussion and palpation so bowel
sounds are not altered
Note– you are not expected to percuss to locate the liver or spleen,
but do consider the expected locations of a normal vs enlarged organs
35
Infants
◦ Newborns: inspection of umbilical cord Older adults
◦ Umbilical hernia ◦ Increased fat deposits on abdomen and
◦ Movement with respirations hips
◦ Differences in percussion and palpation ◦ Less specific, more vague in describing
◦ Meconium symptoms
◦ Rectum, perineum, scrotum ◦ Thinner abdominal musculature
◦ Auscultation & crying
◦ Organs easier to palpate (unless obese,
Children in which case, more difficult)
◦ Protuberant abdomen
◦ Positioning for palpation
◦ Use objective signs to aid assessment

36
Abdomen – Normal Findings
Shape – flat or slightly rounded; not distended; symetrical

Soft – no masses
Non-tender – no pain or discomfort
Normal bowel sounds; no abnormal vascular sounds
Tympanic in all areas (except normal solid organs (ie liver_

LTD.
37
Other useful stuff …..
Inspect emesis & stool: color, frequency, consistency, amount, odor,
blood, undigested food or other material,
Check urine: color, odour, turbidity (clarity), specific gravity (concentration)
Breath odour; fecal smell?
Pregnancy Test ? (urine) if within scope of practice ie family practice clinic
CVA tenderness: Blunt percussion of the costo-vertebral angle:

= inflammation of the kidney (kidney stone or pyelonephritis)
(See Jarvis, Chapt. 22, p. 588 and fig. 22.21)

LTD.
38
Sample Charting-Subjective Data

39
Sample Charting-Objective Data

40
Mr. Emerson Scenario
41
Mr. Emerson Scenario
What findings are normal? Abnormal?
What additional history is needed? Assessment?
What do you think is happening?
How would you intervene? What nursing care is

needed?
42
Mr. Emerson
Abnormal findings: What additional history is needed? What do you think is
Normal Assessment? happening?
findings: - knee pain
- How long has he had urinary Urinary Tract Infection
- improved -difficulty ambulating frequency, dysuria, and lower (UTI) from holding,
eating abdominal pain? decreased fluid intake
- holding urine (due to
- daily bowel pain when - VS→ ? Fever-- > infection? How would you
movements intervene? What nursing
ambulating) - What is the colour, odor of urine? care is needed?
- no nausea - urinary incontinence - pain assessment (abdominal and
or vomiting - obtain urine sample →
knee) antibiotics if prescribed
- dysuria (pain when
- abdomen urinating) - diet– 24 hr diet recall (esp fluid intake) - increase fluid intake &
soft education
- urinary frequency - mobility assessment
- regular (having to urinate - pain management (for
bowel - How is he managing ADLs (i.e.
often) bathing, dressing, showering)? What UTI and knee) and
sounds education
home care services are provided?
- lower quadrant
- education re: use of
abdominal pain - sleep and rest pattern
walker
- sleeping on couch
43
Abdominal Assessment: Post op care
You arrive to the pediatric ward for your 0700 shift. You will be caring for 8 year old Ben who
returned from the OR at 2100h last night following a laparoscopic appendectomy. The surgeon
orders say “clear fluids to DAT (Diet As Tolerated)”. Ben’s mom is wondering if he can have
some toast for breakfast now?
In order to accurately answer the mother, what assessment data will you collect? What will your
nursing actions be?
◦ Pain and Vital signs
◦ Focused abdominal assessment:
◦ Inspect (contour, incision sites)
◦ Auscultate (listening for bowel sounds in all quadrants)
◦ Percuss (no– painful)
◦ Palpate (do last, painful, gently)
◦ Respiratory assessment (post operative atelectasis)
◦ Health teaching– pain management, ambulating, food intake
Questions?
Test #1 Friday March 4th
at 7:30 pm
Weeks 1 to 6
See Course Home Page – Announcements for
More Information
Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 45
Class 8, N1J02, Winter, 2022
Head to Toe Physical Examination
Doug Wonnacott. BSc, BScN, MEd.

Nursing Faculty, Mohawk College
McMaster Collaborative BScN Program
Learning Outcomes -
• Review vital signs and health assessment skills
• Application of Tanner’s (2006) Clinical Judgment Model
• Steps for conducting a Head-to-Toe assessment for hospitalized

adults
Prior-to-Class** Activities
• Review & practice taking vital signs, pain assessment and physical examination skills.
• Review Tanner’s Clinical Judgment Model and the McMaster Model of Nursing
• Read Jarvis text, Chapter 29 – Bedside Assessment and Electronic Health Recording,
p. 841-846
• View Head-to-Toe Assessment video on Clinical Skills Essentials
** This should have been done prior to the lecture!

Tanner’s
Model of
Clinical
Judgment
McMaster Model
of Nursing
(see McMaster BScN Program
Handbook 2021-22)
Noticing:
Health History and Physical Examination
Client focused care

“Knowing” the client
Knowing their context
Listening to their story or lived experience
Complete Health Assessment -
• Subjective Data – Complete health history
biographical data
reason for seeking care
present health or history of present illness
past health history
family health history
review of body systems
functional assessment or ADLs
• Objective Data – Head-to-Toe Physical Examination:
general survey
measurements (weight, height, BMI etc)
vital signs
skin
head & face
eyes, ears, nose, mouth & throat
neck
chest – anterior & posterior
heart
upper extremities (shoulders, upper & lower arm, wrists, hands & fingers
• Objective Data – Head-to-Toe Physical Examination cont’d,
breasts (male & female)

neck vessels (carotids & jugular veins)
abdomen & inguinal areas
lower extremities (pelvis, hips, knees, ankles, feet & toes)
musculo-skeletal
neurological
male & female (genitlia and rectum)
Bedside Assessment ….
• “In a hospital setting, patients after being admitted, do not require a
complete head-to-toe physical examination during every 24 hr. stay”
• “Patients do require a consistent specialized examination that focuses on

certain parameters at least every 8 hours.”
• Some data such as daily weights, abdominal girth, or circumference of a

limb, must be measured carefully
• Must be consistency procedures from nurse to nurse
Jarvis, chapt 29, p. 841

Bedside Assessment ….
• Assessment findings must be documented and communicated
• Some form of the SOAP (subjective, objective, assessment, plan) charting format
is commonly used to organize findings.
• Situation, background, assessment, recommendations (SBAR) is used to facilitate

communication
• The frequency of assessments may vary with the stability of the patient’s
condition, any changes in condition, treatments, procedures, changes in
medications, beginning of your shift, end of shift.
• Some assessments may utilize specific tools or check lists
Jarvis, chapt 29, p. 841

Performance Guideline: * Head-to-Toe Assessment
Bedside Re-assessment – Adult Acute Care
• Preparation
• General appearance
• Vital Signs
• Neurological System
• Respiratory System
• Cardio-vascular System
• Skin
• Abdomen
• Genito-urinary
• Activity & Musculo-skeletal * Course Manual p.86-88
Performance Guideline – Head-to-Toe Assessment
Preparation
• Attend to patient comfort
• Gather equipment
• Raise the bed to comfortable
• Verify allergies, precautions – safety
working height (side rail up)
or falls, special needs, PPE etc
• Assess patient for pain or
• Introduce yourself
discomfort
• Hand hygiene
• Gather relevant subjective data
• Begin general survey observations from the patient to assess
• Verify patient’s ID overall condition as needed:
(feeling better, sleep, appetite
etc)
General appearance • Speech characteristics: fluent,
• Facial expression, appropriate content, articulation
appropriateness • Apparent hearing (hearing aid?)
• Body position & comfort • Vision (glasses?)
• Level of consciousness, • Level of personal hygiene
orientation, attention,
responding appropriately
• Skin color
• Nutritional status, weight, body
fat, hydration status
Vital Signs -
• Temperature
• Pulse
• Respirations
• Oxygen saturation
• Blood pressure
Neurological System –
- Glasgow Coma scale parameters:
Eyes open spontaneously?
Verbal response (appropriate, speech, oriented)?
Motor response?
R & L Pupil size, reaction to light
- Muscle strength bilaterally – hand grasps
- Motor response in upper & lower extremities,
strength bilaterally
- Facial asymmetry, ptosis, drooping,
- Ability to swallow, gag reflex
Respiratory System-
• Airway? Color, signs of hypoxia?

• Respiratory effort, use of accessory muscles,
rate, effort, pursed-lip breathing
• Dyspnea with rest or activity
• Auscultate breath sounds
• Encourage patient to cough & deep breath
• Assess sputum characteristics, if any?
• Supplemental oxygen?
Cardio-vascular System –
• Auscultate apical pulse & rhythm
• Compare apical & radial rates
• Auscultate heart sounds (bell & diaphragm)
• Check capillary refill – fingers & toes
• Check for pre-tibial edema
(lower legs & feet)
• Assess dorsalis pedis &
posterior tibial pulses
Skin Assessment -
• Skin color?
• Temperature & moisture,
• diaphoresis?
• Turgor & mobility
• Skin integrity, lesions, breakdown,
• Condition of any dressings, drains
• Braden scale – assess for risk of skin breakdown
Abdomen -
• Shape & contour, distention?
• Auscultate bowel sounds (X4 quadrants)
• Light palpation (X4 quadrants)
• Nausea, vomiting, pain or discomfort
• Passing gas (flatus)
• Bowel movement – most recent; diarrhea or
constipation
• Stool characteristics (as appropriate)
• Diet tolerance (clear fluids, liquids, DAT etc)
• Nutritional deficiency risk
Genito-urinary system-
• Voiding – frequency, amount, dysuria

• Assess indwelling catheter; catheter care, skin
• Assess urine output, amount, color, clarity, odor
• If decreased output – assess bladder for
distention and urinary retention; intake vs
output
• Assess 24 hour fluid balance ( assessing for fluid
status, renal function, kidney perfusion)
Activity & Musculo-skeletal-
• If bed rest: head of bed elevated,
positioned for comfort or as ordered.
• Skin assessment for breakdown
• Ambulatory: dizziness, balance orthostatic
hypotension when sitting?
• Mobility & transfers; gait and balance,
• Transfer assistance required?
• Mobility aids or equipment
• Risk of falls assessment
Good Nursing Health Assessments -
• Respects the clients privacy and dignity
• Focuses on the client, their story & experience
• Systematic and complete health history
• Systematic and organized ie IPPA, PQRSTU, etc
• Use anatomical landmarks and assessment terminology
• Accuracy, correct techniques & assessment skills
• Thorough & complete history and
physical examination
Good Nursing Health Assessments -
• Documentation and reporting:
• also systematic and organized;
• uses profession terminology and appropriate
abbreviations,
• accurate,
• objective language (non-judgmental).
Any questions?
Time for a Break
10 minutes please.
Scenario:
Mr. Mancini is 85 years old, and lives at home with his wife. He is finding it difficult
being away from his family and adjusting to all the commotion in his shared room. He
has a history of type 2 diabetes, asthma, and mild dementia. He wears glasses and a
hearing aid. His first language is Italian, and he speaks some English. He enjoys
spending time with his family and friends and hopes to return home soon.
After completing Transfer of Accountability, you meet your patient, Mr. Mancini, and
assess his vital signs and complete an initial head to toe assessment.
For example, if you noticed the following in your initial
assessment of Mr. Mancini, how would you interpret and
respond?
● He didn’t sleep well during the night and was up several times to urinate.
● He mentions twice how tired he feels.
● When you lower the bed to reposition him, you notice he gets
short of breath.
● BP 158/92, HR 110, T 36.7, RR 24, SaO2 94%.
● He states he isn’t experiencing any pain.

When you chat with Mr. Mancini, he is friendly and
insists you call him Mario. He is interested in your
nursing studies as one of his grandchildren is studying
nursing as well.
● You notice a slight language barrier, but he is able to

clearly communicate his thoughts to you and find
another word if there isn’t an English word that he uses.
What are the salient pieces of information?
What cues would you follow-up on?
What focused assessment would you do next?

Any questions?
Have a good week.
Be good to yourself !
Class 8, N1J02, Winter, 2022
Review of Systems,
Elizabeth Ledwell, RN, MA (Ed.), MScN
Nursing Faculty
Conestoga – McMaster Collaborative BScN Program
Presented by Doug Wonnacott. BSc, BScN, MEd. (Mohawk)
Learning goal and Outcomes
Learning Goal:
In this class students will expand their general health history to include the final
component - the review of systems. Students will use their professional practice
knowledge gained throughout the year to select appropriate questions under each
area, and practice taking a comprehensive health history on peers including the
review of systems component.
Learning Outcomes:
Through individual research, class discussion & in class learning activities, the
student is able to:
1. Discuss the purpose of conducting the review of systems component of the
health history.
2. Identify appropriate areas for assessment during the review of systems and
develop an organized approach for ensuring no areas are missed.
3. Conduct a comprehensive general health history that includes the review of
systems component.
Learning Activities Class and Lab
Prior to Class
Read the section on review of systems in Jarvis, chapter 5, p. 65-68.
Large Group Class

1. Discuss the purpose of completing a review of systems, and how
this component fits in with the general health history.
2. Discuss pertinent questions that may be asked in the review of
systems.
Small Group Lab

Interview a partner using pertinent questions for a general health
history, including a thorough review of systems.
Outline of class
 Review purpose of Review of Systems

(ROS) and where it fits in the general
health history
 Quick review of General Health History
 Review pertinent questions the nurse will
ask in ROS
Purpose of Review of systems
(ROS)
 To check the past and present health of
each system
 To check for any data omitted in the
“current illness” section
 To determine health promotion
practices
Jarvis, p. 65
The Health
History
1. Biographical data
2. Reason for seeking care
3. Current health or history of current
illness
4. Past health
5. Family history
6. Review of systems…subjective data
7. Functional assessment and ADLs
6
Past Medical History
 Childhood illnesses
 Accidents or injuries
 Chronic illnesses
 Hospitalizations
 Surgeries
 Obstetrical history (LMP, GTPAL)
 Immunizations
 Allergies
 Medications
Review of systems
 The order of the exam is approximately
head to toe
 Remember:
◦ Avoid medical terms
◦ You would not ask if patient has “angina”,
“tinnitus”, “pruritis”, etc.
◦ The history is subjective data: what the
patient says, not what you measure or
observe
Review of systems
You have covered 5 in detail:
◦ Neurological
◦ Musculoskeletal
◦ Cardiac and peripheral vascular
◦ Respiratory
◦ Abdominal
 Each system has a focused (detailed)
subjective history, and objective (physical)
assessment
Review of systems
 If the current illness section covered one
body system in detail you do not need to
repeat all the data in this section (ROS)
 ie. if you did a focused MSK history in

current illness you would not need to
repeat those questions in ROS
Review of Systems-  Skin, hair, and nails
 Head
see your N1J02  Eyes – eyeglasses
guideline, and  Ears – hearing, aids
Jarvis p. 65-68  Nose and sinuses
 Mouth and throat
 Neck
Ask about general overall  Breasts/Axilla
health state, then ask a
few questions from these  Respiratory
areas:  Cardiovascular
 Peripheral vascular
 Gastrointestinal
 Urinary
 Genitalia/sexual
 Musculoskeletal
 Neurological
 Hematological
 Endocrine
11
Review of systems (Jarvis, p.65)
 General overall Possible questions
health  How do you feel
overall?
 Any recent changes
to overall health
status?
Review of Systems
 Skin, Hair, Nails (p. 65)  Eczema
 Moles
 Pruritus
 Bruising etc.
Health Promotion
 Sunscreen used?
 Amount of sun
exposure?
 Skin care for diabetic
Jarvis, p. 249 feet
Urticaria
(Hives)
Review of systems
 Nails  For nails: any change
in shape, colour,
brittleness?
Review of Systems
 Head  Headaches,
 Head injury,
 Dizziness (syncope)
Health Promotion:
 Use of helmets or
other protectives?
Review of Systems
 Vision? Difficulty?
 Glasses or contacts
 Blurred vision
 Double vision
 Pain or discomfort?
Health Promotion:
 Eye examinations?
 Can you afford eye
This Photo by Unknown Author is licensed under CC BY
exams/glasses?
Review of Systems
 Ears
 Earaches, infections,
 Discharge?
 Hearing loss
 Hearing aids
 Pain or discomfort
Health Promotion:
This Photo by Unknown Author is licensed under CC BY-SA
 ?Protection from
environmental noise?
Review of Systems
Nose and sinuses

 Colds
 Discharge
(runny nose?)
 Hay fever; seasonal
allergies
 Smell
Review of Systems
 Mouth and throat  Bleeding gums
 Toothache
 Altered taste
 Dysphagia
Health Promotion:
 Dental care?
 Can you afford
dental care?
Review of Systems
 Neck  Limitations of
motion
 Pain or discomfort?
 Swelling?
 Difficulty or
abnormal sensation
of swallowing?
Review of Systems
 Breasts, axilla  Surgery; Implants,
reconstructions
 Lumps
 Nipple discharge
 Tenderness
Health Promotion:
 Mammograms?
 BSE?
 See box 18-1 in Jarvis for
Breast Cancer screening
recommendations
Review of systems
Respiratory
 History of lung
disease, (eg asthma,
pneumonia, wheezing,
 How much activity
produces shortness
of breath?
 Any cough or
sputum?
Health Promotion
 Ask about the date of
last chest x ray
 TB testing / screening
Review of systems
Cardiovascular
◦ Any pain or discomfort? shortness of breath,
amount of exertion that triggers SOB,
◦ Palpitations, irregular or rapid pulse
◦ Dizziness, fainting, or collapse
◦ Hypertension, dyspnea, anaemia, coronary
artery disease
◦ Health Promotion ? Has the patient ever had
an electrocardiogram, or other tests of heart
function (stress test, echocardiogram)
This Photo by Unknown Author is licensed under CC BY-NC-ND
Review of Systems
Peripheral vascular
 Any coldness,
numbness, tingling, burning
 Varicose veins,
 Lower leg pain
 Thrombophlebitis,
 Ulcers?
Health Promotion Jarvis, p. 540
 Does the patient’s work involve long term sitting or

standing?
 Patients with vascular systems issues should be advised to
avoid crossing legs at the knees, and to wear support
hose
Review of systems
Gastrointestinal
 Ask about appetite , food
intolerance, nausea,
 bowel movements, etc. as
per focused history
• Weight loss or gain
Health promotion:
 Enquire about the use This Photo by Unknown Author is licensed under CC BY-NC-ND
of antacids, laxatives, diet

Review of systems
 Urinary  Urine color
 Incontinence
 Dysuria; urinary tract
infections (UTIs)
 Nocturia
 Frequency, urgency
Health Promotion:
 measures to avoid
UTI?
 hydration
Review of Male:
systems  Testicular pain, swelling
 Discharge
Genitalia/s
 STI
Health Promotion:
Testicular self exam
exual

 Prostate (PSA)
Female:
 Menstrual history
 Menopause
 Sexually transmitted illnesses?
(STI)
Health Promotion:
 Pap smear
This Photo by Unknown Author is licensed under CC

BY
Review of systems
 Depending on rapport
 Sexual Health with patient, and
purpose of history:
Health Promotion:
 Is person in
relationship?
 Contraception?
 Exposure to STI?
 Safe sex practices
 Birth control
This Photo by Unknown Author is licensed under CC BY-SA-NC

Review of systems
Musculoskeletal
• Ask about arthritis, gout,
joint pain, deformity,
limited movement
• History of back pain,
muscle aches, stiffness
• Assistive mobility devices
• Activity, exercise
Health Promotion
 How does the patient
manage with ADls?
 For older adults, ask about assessments
for Fall prevention
Review of systems
Neurological
 Seizures, strokes,
 Headaches
 Numbness, tingling
 Coordination, balance etc.
 Ask about Mental Health
Health promotion
 Jarvis suggests that information about
interpersonal relationships can be
placed in this section
This Photo by Unknown Author is licensed under CC BY
Review of systems  Excessive bruising
 Blood transfusions
 Hematological  Bleeding tendency
 Anemia
Endocrine: ?
• Diabetes?
• Intolerance to heat, cold
 Endocrine • Hormone therapy
• Hair thinning or loss
• Weight gain or loss
• Fatigue
Health Promotion:
Foot care if diabetic?
Properly fitting shoes
Diabetic blood work/
regular monitoring
Activites of Daily Living (ADLs)
 Self-concept/ self-esteem
 Activity & mobility, exercise, stamina
 Sleep & rest
 Nutrition & elimination
 Relationships & resources
 Spiritual resources, faith, beliefs
 Coping & stress management, behaviors
 Smoking history
 Substance use history
 Environmental & occupational hazards
The Health
History
1. Biographical data
2. Reason for seeking care
3. Current health or history of current
illness
4. Past health
5. Family history
6. Review of systems…subjective data
7. Functional assessment and ADLs
33
Review of Systems-see your N1J02
guideline, and Jarvis p. 65-68
Ask about general overall health
state, then ask a few questions  Skin, hair, and nails
from these areas:  Head
 Eyes – eyeglasses
 Ears – hearing, aids
 Nose and sinuses
 Mouth and throat
 Neck
 Breasts/Axilla
 Respiratory
 Cardiovascular
 Peripheral vascular
 Gastrointestinal
 Urinary
 Genitalia/sexual
 Musculoskeletal
 Neurological
 Hematological
 Endocrine
34
ROS Example of interview
 https://www.youtube.com/watch?v=3ogLf
VVRU04
 Jane Crone, NP, University of Wisconsin
 Complete Medical History (Review of Systems). University of Wisconsin School of
Medicine and Public Health. Video 07/07
 This is “extra”
 Great example of Nurse Practitioner
interviewing a patient for ROS.
 You are accountable for your readings in
Jarvis.
References
Jarvis, C. (2019). Physical examination & health assessment (3rd Canadian
ed.). A.J. Browne, J. MacDonald-Jenkins, & M. Luctkar-Flude, (Eds.).
Elsevier Canada.
University of Wisconsin School of Medicine and Public Health (2010).
Video 07/07, Review of Systems.
https://www.youtube.com/watch?v=3ogLfVVRU04
Questions?
Time for a Break (10 minutes please)

N1J02
Winter 2022
Urinary Elimination, Fluid Balance
Week 9 &
Assessment of Intake and Output
Amy Palma, RN, MSc, BScN, Hon.BSc

W2022 - Presented by – Doug Wonnacott RN, BSc. BScN, MEd
mcmaster.ca | 1
Learning Objectives
• Distribution and regulation of body fluids
• Assessment of and risk factors for fluid imbalance
• Measurement of intake & output
• Subjective & objective assessment of fluid balance
• History & physical assessment of urinary elimination
• Variations based on age & developmental stage
• Nursing interventions to promote healthy urination
mcmaster.ca | 2
Resources - See Course Manual, p 89
• 1. Review relevant content on fluid balance, intake and output,

and urinary elimination in Potter & Perry (2019):
• Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pages
1016-1019, 1028-1033.
• Chapter 43: Urinary Elimination, pages 1166-1188.
• 2. Practice measuring and documenting the amount of fluids you

drink within a 24-hour period.
• 3. View the “Measuring Intake and Output” video from the

Elsevier Clinical Skills: Essentials Collection.
mcmaster.ca | 3
A Quick Review of
Urinary, Renal – Fluid & Electrolyte
Physiology
mcmaster.ca |
Fluid Balance
• Fluid balance within the body is essential for
normal body function
• This balances are maintained by ingestion,
distribution, and excretion of water and
electrolytes
• Fluid balance primarily maintained by the
renal system
• Imbalance can result from decreased intake
of fluids, or increased loss of fluid
• Fluid imbalance can effect body at cellular,
tissue, and body systems levels This Photo by Unknown Author is
licensed under CC BY-NC-ND
mcmaster.ca | 5
Body Fluid Distribution
• Intracellular fluid (ICF)-fluids within
cells
60% of total body fluids
• Extracellular fluid (ECF)-fluid outside

of cells
Interstitial: fluid between cells in the
tissue
Intravascular: blood and plasma
Transcellular: fluid separated by
epithelium
For example, cerebrospinal,
pleural, peritoneal, synovial,
gastrointestinal (GI) fluids
mcmaster.ca | 6
ICF
Interstitial Fluid
Extracellular (ECF)…. Interstitial fluid

ECF
Vascular fluid (blood volume)
blood plasma is 92% water
mcmaster.ca |
ICF
Interstitial Fluid
Fluid intake Fluid output

IV fluids, oral intake emesis, bleeding
urine
respiration, perspiration
mcmaster.ca |
ICF
Interstitial Fluid
edema – increased interstitial fluid
mcmaster.ca |
Assessment
Skin turgor, texture, moisture peripheral edema
mucous membranes
ICF
Interstitial Fluid
Fluid intake Fluid losses

IV fluids, oral intake emesis, bleeding
urine output
other losses
serum: Na+, osmolarity, hematocrit
mcmaster.ca |
Endocrine effects -
Affecting water reabsorption, Na+, Ca+2, urine output,
• Antidiuretic hormone (ADH – pituitary)

• Adreno-corticotropic hormone (ACTH – adrenal glands)
• Parathyroid hormone & Calcitonin (thyroid & parathyroid
glands)
• Angiotensin I and II and Renin (kidneys)
• Aldosterone (aldosterone)
• Drugs or health conditions which affect these glands,

may affect fluid balance
mcmaster.ca |
Fluid Balance / Urinary - Terminology
• Fluid balance (positive / • Frequency, urgency,

negative) hesitancy,
• Intake / output • Dysuria
• Fluid volume deficit • UTI – urinary tract
• Fluid volume excess infection
• Urinal • Nocturia
• Incontinence
• NPO
• Bladder scanner
mcmaster.ca |
Movement of Water and Electrolytes
• Movement of both water and electrolytes important
• Constant shifting between compartments
• Osmosis
o Movement of water through a semipermeable membrane from
an area of lesser solute concentration to one of greater
concentration
• Osmotic pressure
o Pressure needed to counter the movement of water across a
semipermeable membrane from an area of low solute
concentration to an area of high concentration
o A solution with a high solute concentration: high osmotic
pressure; draws water into itself
mcmaster.ca | 13
mcmaster.ca |
Movement of Water and Electrolytes
• Diffusion - movement of ions and molecules across a semipermeable
membrane, from area of high to low concentration (diffusion gradient)
o Diffusion of oxygen and carbon dioxide between alveoli and lung blood
vessels
• Active transport
o Movement of molecules across a concentration gradient, using
chemical energy
o Example: sodium-potassium pump keeps intracellular K+ high and
blood levels of K+ low
• Filtration - uses hydrostatic pressure gradient and results in 2-4L of fluid
per day entering the interstitial fluid from intravascular space
o Also important in urine production
mcmaster.ca | 15
Fluid Regulation & Homeostasis
• Body fluids regulated by hormones, fluid intake, and fluid
output
• Fluid output regulation
o Output through four organs of water loss: the kidneys,
the skin, the lungs, and the gastrointestinal tract
o Obligatory water loss-500 mL per day
o Sensible water loss-urine and feces
o Insensible water loss-skin and respiratory system
mcmaster.ca | 16
Fluid Regulation & Homeostasis
• Fluid intake regulation
o Thirst mechanism
o Osmoreceptors in hypothalamus stimulated when
serum osmolality increases or blood volume decreases
o Hormonal control: ADH and aldosterone
mcmaster.ca | 17
Adult Average
Daily Fluid Intake & Output
Normal per day (mL)
Intake 2200-2700 mL
• Oral fluids 1100-1400
• Food 800-1000
• Metabolism 300
Output 2200-2700 mL
• Skin 500-600*
• Lungs 400*
• GI 100-200
• Urine
mcmaster.ca
1200-1500 | 18
Disturbances in Fluid Balance
• Fluid disturbances
o Volume imbalances: disturbances in
the amount of ECF
• Fluid volume deficit
o Eg. dehydration, vomiting,
decreased oral intake, extreme
heat, diarrhea
• Fluid volume excess
o Heart failure, kidney disease, IV This Photo by Unknown Author is licensed under
CC BY-ND
therapy
mcmaster.ca | 19
Fluid Status Assessment
• Health history
o Age
• Infants, children, older adults at higher risk
o Environmental factors-exposure to extreme heat and risk of
dehydration
o Diet
• Intake, ability to chew and swallow
• Decreased protein intake can alter colloid osmotic
pressure and result in fluid shifts to interstitial spaces
o Lifestyle & ADLs
o Medication - laxatives, diuretics & antihypertension drugs
mcmaster.ca | 20
Fluid / Hydration Status Assessment
• Medical history
o Acute illness
• Burns, GI disturbances, trauma or blood loss, head injury,
recent surgery
o Chronic illness
• Cancer - lack of appetite, nausea, vomiting
• Cardiovascular disease - decreased perfusion to kidneys
results in decreased urine output and fluid retention
• Renal disorders-can result in increased or decreased urine
output
• GI disorders - IBD, liver failure, vomiting, diarrhea
mcmaster.ca | 21
Nursing Process: Physical Assessment
• Fluid balance chart

• Includes all intake and output over a 24-hour period, and
the 24-hour fluid balance (fluid excess or fluid deficit)
• Intake: oral fluids, IV, feeding tube
• Output: urine, NG drainage, wound drainage, loose
stool, vomitus, other drainage tubes
• Need to look at trends over time
• Daily intake – output should be 500mL
mcmaster.ca | 22
• Daily weight - consistent time, scale, same
clothing (may reflect fluid retention)
o Change of more than 1 kg per day is
significant
• Cardiovascular:
o Blood pressure, pulse rate and quality,
capillary refill, peripheral edema
• Respiratory
o Presence of crackles on auscultation
pulmonary edema
o Decreased breath sounds
mcmaster.ca | 23
• Renal
o Urine output-decreased amount, dark
yellow color, odor,
elevated specific gravity
• Integumentary
o Mucous membranes, skin turgor
• Other - thirst, behaviour (restlessness,
confusion), saliva, tears
mcmaster.ca | 24
Renal Physical Assessment
Inspection –
• Abdominal (supra pubic) distention
• Urine characteristics
• Positioning, splinting or guarding
• Urinary drainage devices
ie urinary catheter
Palpation -
• Distended, full feeling lower abdomen; palpable bladder
• Discomfort or pain- lower abdomen or lower back & flank
• Costo-vertebral (CVA) tenderness on blunt percussion
• Pain or discomfort radiates to inguinal areas
mcmaster.ca | 25
Sample
Fluid Balance
Chart
mcmaster.ca | 26
Interpreting Fluid Balance
• Intake – output
• Positive fluid balance
o Assess patient for signs of fluid overload
o Look at trends
o Consider patient context & condition
• Negative fluid balance
o Assess patient for signs of dehydration
o Look at trends
o Consider patient context and condition
mcmaster.ca | 27
Urinary Elimination
• Micturition (urination or voiding)
o Complex neural response that allows the bladder to contract,
the urethral sphincter to relax, and urine to leave the body
through the urethra
• Upper urinary tract
o Kidneys
• Remove waste from the blood to form urine
• Normally protein and RBC’s do not filter through glomerulus
o Ureters
• Transport urine from the kidneys to the bladder
mcmaster.ca | 28
Urinary Elimination
• Lower urinary tract
o Bladder - reservoir for urine until the urge to urinate develops
o Urethra
• Passage through which urine travels from the bladder, ending at the
urethral meatus, through which urine exits
• Traverses pelvic floor muscles
• 3-4 cm in females; 18-20cm in males
• Act of urination
o Sensory nerves from the bladder carry signals to the brainstem when
the bladder is full
o Urge to void first felt when bladder is 250-300 mL full
o Strong urge to urinate at 500 mL capacity
mcmaster.ca | 29
Factors Influencing Urination
o Psychological factors: anxiety and stress
o Sociocultural factors: cultural, gender, and religious
practices
o Fluid balance: caffeine, alcohol, natural diuretics
o Diagnostic examination ie cystoscopy
o Surgical procedures: anaesthesia
o Pathological conditions: neurological disease, altered
mobility, renal disease, bladder cancer, prostate BPH
o Medications: diuretics, ani-hypertensives
mcmaster.ca | 30
Common Urinary Alterations
• Urinary tract infections (UTIs): commonly result from
catheterization; may have other causes
o Dysuria, hematuria, fever, malaise, cloudy urine
o Can lead to bacteremia and urosepsis (in hospital –
antibiotic resistant infections)
• Urinary incontinence: involuntary leakage of urine, lack of

voluntary control, prostate enlargement, bladder & uterine
support.
o Increased risk of skin breakdown
mcmaster.ca | 31
Common Urinary Alterations
• Nocturia: waking at night to urinate
• Urinary retention: an accumulation of urine caused by the

inability of the bladder to empty
o Underactive detrusor muscle, urethral obstruction, after
surgery, medication side effect, fecal impaction, prostate
enlargement, altered bladder innervation
• Urinary diversions: diversion of urine to external source
mcmaster.ca | 32
Factors Impacting Urination
• Infection control and hygiene
o Urinary tract is considered sterile
o Asepsis to prevent infection with invasive procedures
o Catheterization and other procedures-sterile technique
• Psychosocial and cultural considerations
o May also alter sexuality and self-concept
o Need for comfort and privacy
o Gender
mcmaster.ca | 33
Growth & Development
o Infants and young children cannot concentrate
urine effectively
o Toilet training – full control by 4-5 years of age
o Adults - 1500-1600 mL urine daily; approx.
every 4-5 hours
o Increased frequency with pregnancy
o Changes with menopause
o Prostate enlargement in older men
o Older adults: reduced GFR, nocturia,
decreased bladder contraction can lead to
This Photo by Unknown Author is licensed under
residual post-void volume CC BY-SA-NC
mcmaster.ca | 34
Assessing Urinary Function
• Health history
• Pattern of urination - recent changes, bladder diary
• Symptoms of urinary alterations
o Incontinence, urgency, frequency, hesitancy, dribbling
o Dysuria, polyuria, oliguria, nocturia, hematuria
o Elevated post void residual volume
• Factors affecting urination
o Medical and surgical history
o Bowel elimination pattern
o Mobility
o Impact on quality of life
mcmaster.ca | 35
Physical Assessment - Urinary Elimination
• Skin and mucosal membranes - oral

mucosa, skin turgor
• Kidneys – flank pain, renal artery bruit
• Bladder – full bladder palpable between
symphysis pubis and umbilicus
• Female perineum - skin integrity, rash,
inflammation, discharge
o Urethral meatus
• Male perineum - urethral meatus
mcmaster.ca | 36
Assessing Urine
• Assessment of urine
o Intake and output
• Change in urine volume is a significant indicator of fluid
alterations or kidney disease
• Amount – measured with urine hat, urinal, bedpan, catheter
collection bag (urometer), weighing diapers or briefs
• Hourly output of less than 30 mL/hr for 2 hours is cause for
concern
• Pediatrics:
o Up to age 2: 2ml/kg/hour
o Age 2+: 1 ml/kg/hr
o Characteristics
• Colour, clarity, odour
mcmaster.ca | 37
Calculating Urine Output
• Adults – ml/hr
o 350 ml between 0700 -1200 = 70 ml/hr
o Over a 12 hour shift, output of 500 ml = 41.67 ml/hr
o From 1200-1600, urine catheter emptied for 100 ml = 25 ml/hr
• Pediatric – ml/kg/hr
o Example: 10kg 1 year old
o Over a 12 hour shift, urine output of 360 ml = 360ml/10kg/12hr = 3
ml/kg/hr
o 2 wet diapers from 0700 until 1200: 120g and 40g = 160 ml/10kg/5 hr
= 3.2 ml/kg/hr
o Diaper change at 0700, last changed before bed at 2000, diaper
weighs 100ml = 100 ml/10kg/11hr = 0.91 ml/kg/hr
mcmaster.ca | 38
Supplies to Support Urinary
Elimination
mcmaster.ca | 39
Emptying a Urine Catheter
mcmaster.ca | 40
Urine Testing
o Random specimen, clean-voided, catheter specimen, timed

o Urine collection in children
o Urinalysis – protein, glucose, ketones, blood, WBC, bacteria,
casts
o Specific gravity - concentration of urine particles, osmolality
even more accurate
o Urine culture
mcmaster.ca | 41
Nursing Diagnosis
Examples of nursing diagnoses
o Disturbed body image
o Pain (acute, chronic)
o Self-care deficit, toileting
o Impaired skin integrity
o Impaired urinary elimination
o Urinary incontinence
o Urinary retention
mcmaster.ca | 42
Promoting Healthy Urination
• Promoting regular micturition
o Voiding every 3-4 hours
o Avoid constipation and promote regular bowel habits
o Assist patient to a normal position for voiding – sitting,
standing
o Promote privacy and relaxation
o Maintain adequate fluid intake – concentrated urine
irritates the bladder
• Promoting complete bladder emptying
mcmaster.ca | 43
Promoting Healthy Urination
• Preventing infection
o Good perineal hygiene, cleansing meatus
• Catheters and incontinence products
o Use of a urinary catheter requires a prescriber’s order
o Incontinence alone is not a reason to insert a urinary
catheter
mcmaster.ca | 44
Preventing Catheter Associated Urinary
Tract Infections (CAUTI)
• Only inserted when absolutely indicated
o Urological surgery, monitoring urine output in critical care, prolonged
immobilization with trauma, acute urinary retention or outlet obstruction, end of
life care for comfort, stage 3 or 4 sacral pressure injury
• Use should be re-assessed daily
• Maintain closed system
• Properly secure tubing
• Allow unobstructed urine flow
• Routine hygiene
• No routine use of antibiotics needed
https://www.cdc.gov/infectioncontrol/guidel
ines/cauti/recommendations.html
mcmaster.ca | 45
Using a Bladder Scanner
• Identify patient, perform hand hygiene
• Place patient supine with head slightly
elevated; expose lower abdomen
• Turn scanner on, clean scanner with
alcohol
• Palpate pubic bone, apply ultrasound gel
to midline abdomen above pubic bone
• Place scanner on gel and apply light
pressure, point downward slightly toward
bladder
• Can be used to assess whether bladder is
full (eg. acute urinary retention), or to
assess post-void residual
mcmaster.ca | 46
Quick Quiz!
A nurse delegates the task of intake and output (I&O)
measurement to a nursing student. Which statement
demonstrates that the nursing student understands the task of
I&O measurement?
A. “I will record the amount of all voided urine.”
B. “I will not record the liquid stools as output.”
C. “I will not record the popsicle as intake.”
D. “I will record the perspiration in millilitres.”
mcmaster.ca | 47
Quick Quiz!
An 85 yr old woman experiences dizziness when sitting up from
a lying position. You recognize this as orthostatic hypotension.
You also notices that her urine is dark yellow in color and has
some odor. You also observe that her urine output is 200 ml
over the past 8 hours and her recorded fluid intake is only 400
ml. You suspect …..
A) She has a urinary tract infection

B) She is dehydrated (fluid volume deficit)
C) Her fluid status is normal for an 85 yr old woman
D) She appears to be retaining fluid
mcmaster.ca | 48
Quick Quiz!
When might a health care provider suspect that a patient is

experiencing urinary retention?
A. The patient indicates pain in the suprapubic region.
B. The patient indicates spasms and difficulty during
urination.
C. The patient voids small amounts of urine two to three
times per hour.
D. The patient voids large amounts of foul-smelling, cloudy
urine.
,
mcmaster.ca | 49
Quick Quiz!
A 60 year old gentleman with congestive heart failure is
experiencing shortness of breath. His abdomen is obese and
distended. His lower extremities are slightly swollen.
Auscultating his lungs you hear diffuse end inspiratory crackles
and slight decreased air entry to his lower lung lobes.
These findings suggest ….
A) He is developing pneumonia
B) He is having a heart attack
C) He is retaining fluid in his lungs (pulmonary edema)
D) He needs more fluids to clear out secretions in his lungs
mcmaster.ca | 50
Quick Quiz!
A young mother presents with a one year infant with a fever of

24 hours, and reports the child had two episodes of vomiting in
the same time period.
What two questions will help you assess the child’s hydration
status?
A) How many wet diapers changes in the past 24 hours?

B) Did you give the child any Tylenol at home?
C) In the past 24 hours, how much has the child had to drink?
D) Did you try breast feeding?
mcmaster.ca | 51
mcmaster.ca |
Scenario 1
Mrs. Rodriguez is 77 years old and has been having problems with
urinary urgency for the last 2 years. The episodes are becoming
increasingly more frequent. She has been dealing with the problem by
using absorbent pads but is worried that everyone knows about her
incontinence. The embarrassment is keeping her from doing her usual
activities.
What assessments need to be completed?

What nursing diagnoses apply to Mrs. Rodriguez?
What nursing interventions might help assist Mrs. Rodriguez?
mcmaster.ca |
Scenario 2
Grace is a 15 month old who is in hospital for vomiting and diarrhea.
Her mom thinks she may have picked up a GI illness while at day care.
She is currently drinking small amounts of water by sippy cup and is
occasionally breastfed before bed. Since midnight, she has had 2 wet
diapers. Since midnight, she has had 50ml of water at 0800, she had 1
wet diaper of 75ml at 0600, she vomited 200 ml at 0400, and had
another wet diaper of 50ml at 1145. She has an IV that is providing
10ml of fluid every hour. Grace weighs 10kg.

If it is currently noon, what is Grace’s fluid balance for the last 12
hours? What does the number mean?
What is Grace’s urine output in ml/kg/hr? Is this normal?
mcmaster.ca |
Scenario 3
Mr. Tyson is 50 years old and had a total knee replacement earlier
today. He has been NPO since midnight. He has had an IV running at
75ml/hr since the OR at 8am. It is now 1600. His surgery finished at
1200. He had a urinary catheter in the OR which drained 250 ml of
urine at 1130. He has not had any urine output since then. He tried
some sips of water at 1400 and tolerated 150ml. He just rang the call
bell to tell you he tried to void but was not able to go. He states that
he feels his bladder is full.

What is Mr. Tyson’s urine output in ml/hr? Is this normal?
What is his fluid balance for the last 16 hours? What does the
number mean?
mcmaster.ca |
Summary
• Fluid regulation & fluid balance
• Assessment of intake & output
• Micturition & factors influencing urination
• Assessment of fluid balance & urinary elimination
• Promoting healthy urination
• Nursing care to support clients with elimination
mcmaster.ca | 56
References
• Potter, P. A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019).
Canadian Fundamentals of Nursing (6th ed.). B.J. Astle & W.
Duggleby (Eds.). Toronto, ON: Elsevier Canada.
o Chapter 40: Fluid, Electrolyte, and Acid-Base Balances

o Chapter 43: Urinary Elimination
mcmaster.ca | 57
Next Week: Week 10
Lab - Practice Assessment (SP) #2
- details to be posted
Lecture - Nursing Care Plans
see Course Manual, p.95-101
Up - coming:
• Test #2 – Week 11 Friday April 1st,
mcmaster.ca |
Have a good week,
Be good to yourself
mcmaster.ca |
N1J02
Week 6, February, 2021
Liz Ledwell, RN, MA(Ed.), MScN
BScN Nursing Faculty
Conestoga College
 You can continue to follow the posted lecture slides /notes
 Continue to practice for clinical skills, history taking and physical

examination skills.
 There may be lab practice times available at the IAHS campus.
 Check your Mohawk College and A2L e-mails daily for updates.
 Check the course Discussion folder for any additional postings.
 Stay connected with your peers.

Learning Goal:
➢ In this class student will review clinical reasoning and judgement
and apply using the nursing process to develop care plans for
clients.
Learning Outcomes: Through preparatory activities, class discussion
and in-class learning activities, learners are able to:
 1. Review clinical judgment and clinical reasoning and the nursing
process
 2. Understand the relationship between clinical judgment and
development of a care plan to inform nursing care.
 3. Demonstrate the development of a nursing plan of care that is
patient-centered to patient care scenarios
1. Review Tanner’s Clinical Judgment Model and Clinical Reasoning from N1I02.
2. Read: Orchard, C. (2019). Patient-centered care: Interprofessional collaborative practice. In B.J.

Astle, & W. Duggleby (Eds.), Potter & Perry: Canadian fundamentals of nursing (6th ed.). Elsevier. pp.
295-299).
3. Review as well readings on nursing process from last term from the Mrs. Adams scenario:
Nursing Assessment and Planning: Kramer, M.L., & Ryan, S.M. (2019). Nursing assessment and
diagnosis. In P. A. Potter, A. G. Perry, P. A Stockert, A. M Hall, B. J. Astle, & W. Duggleby (Eds.),
Canadian fundamentals of nursing (6th ed., pp. 187-211). Elsevier Canada. Read pages 187-195
(stop at end of Analysis and Interpretation).
Kramer, M.L., & Ryan, S.M. (2019). Nursing assessment and diagnosis. In P. A. Potter, A. G. Perry, P. A
Stockert, A. M Hall, B. J. Astle, & W. Duggleby (Eds.), Canadian fundamentals of nursing (6th ed., pp.
187-211). Elsevier Canada. Read pages 203-206 (Begin at Establishing Priorities stop at end of
section on goals - Written Plans of Care
1. Review Clinical Judgment Model (CJM), and Nursing Process
2. Review process for Creating Nursing Care Plans
 In the mid 1970’s Ida Jean Orlando, a nursing theorist,
focused on the process that nurses used to arrive at good
outcomes for their patients.

This Photo by Unknown Author is
licensed under CC BY-ND
 Orlando called these processes “deliberate formulations”
which later became known as the “Nursing Process.”
 Later, the nursing process was seen to be a very linear
process which did not allow for or explain the thinking
process of the nurse.
 Thus, in 2006 Tanner proposed the Clinical Judgment Model
 CJM attempts to describe the internal cognitive processes of
clinical reasoning and clinical judgment
 However, these two models can work well together to help
nurses create a care plan for the client.
 Clinical reasoning: the processes by which nurses make
judgments, including generating alternatives, weighing them
against evidence, choosing the most appropriate. Also involves
recognizing patterns, using intuition, and tacit knowledge.
 Clinical judgment: an interpretation or conclusion about a

patient’s needs, concerns or health problems, and/or the
decision to take action (or not), use or modify standard
approaches, or develop new ones as deemed appropriate by the
patient’s response.
 Clinical Reasoning is the process, Clinical Judgment is the
outcome
Noticing
Focused observation
Recognizing deviations from expected
patterns
Information seeking
Interpreting
Developing a sufficient understanding of the
situation.
Involves using one or more reasoning patterns
to interpret the meaning of the data and
determine an appropriate course of action.
Making sense of and prioritizing data
Responding
Deciding on a course of appropriate action for
the situation.
Reflecting
Involves both reflection-in-action (while
caring for the client) and reflection–on-action.
(Evaluation and self-analysis)
9
Tanner Nursing Process
Noticing Assessment
Interpreting Diagnosis
Planning
Responding Implement
Reflection Evaluate
Interpreting Responding
Recognizing patterns Determining a course
and interpreting data of action
Key Issues Rationale: What are the Priority setting SMART goals Nursing Evaluation-how do you
Most important issues assessment data? The What issues should be /outcomes actions/interventions determine the success
for your patient? subjective and attended to first and What are the desired to address the issue? (outcome) of your
objective cues shown why short and long term interventions?
by your patient? goals
Source: N1J02
Manual, page 61
(2021)
 It is a step by step process that nurses use to provide
appropriate and effective nursing care
 To create the plan of care we use critical thinking and
problem solving
 One model for this type of critical thinking and problem
solving is known as “Nursing Process”
 It follows a similar process to the Tanner Clinical Judgment
Model
 See the previous slide for the comparison between the 2
models
 A large body of knowledge has been developed to support the nursing process
model by NANDA International
 This organization was formerly known as “North American Nursing Diagnosis
Association”
 It is now known as NANDA International
 The vision of NANDA International: “a global force for the development and use of nursing’s
standardized terminology to ensure patient safety through evidence-based care, thereby
improving the health care of all people.”
(However, CJM is not described by NANDA-I)
https://nanda.org/who-we-are/our-story/
 Ms. Devine is a 52-year-old woman who was injured
in a fall two months ago that caused rupture of a lumbar disc.
She is scheduled for a lumbar laminectomy this afternoon.
 Ms. Devine is the office manager for a realty business she runs
with her husband. She was not able to work regularly over the first
month after the injury.
 The pain worsens when she sits.
(Potter and Perry, 2014)

 Her vital signs are as follows:
 T. 37.3°C; BP, 138/82 mm Hg; pulse, 84/ min; Resp 24/ min
 She has a slight limp when she walks, you also note facial
grimacing.
 She states her pain is 8/10

on a numerical pain scale
This Photo by Unknown Author is licensed under CC BY-

ND
 Deliberate, systematic collection of data
◦ Which structured ways have we discussed for data
collection?
 We need subjective data from the health history
 We need objective data from General Survey and Physical

examination, lab data etc.
Subjective: what a person says about him or herself (Interview)
Feelings, perceptions, self–report of symptoms.
ie. “ some mornings, it hurts so much I can’t get out of bed”
Can reflect physiological symptoms which you further explore

through physical examination
ie. “the pain goes down the back of my leg”

Subjective
 Only clients provide subjective data (Potter and Perry, 2019. p. 191)
◦ ie “I have back pain”
◦ ie “I am very anxious about my surgery tomorrow”
Ms. Devine states her pain is 8/10

on a numerical pain scale
Objective:
Data from a general survey,
physical examination, AND
laboratory and diagnostic studies.
ie. Vital signs, condition of a wound, hemoglobin level
We observe Ms. Devine limping, or her facial grimace
Can also observe the patients non-verbal behavior.

(enhances the objective data base-Potter and Perry, p.191)
Potter and Perry, p. 192
 Primary
◦ Client
 Secondary
◦ Family, care providers, and significant others, bystanders,
◦ Health Care team, including first responders (Paramedics)
◦ Medical records
 Tertiary
◦ Literature
◦ Nurses experience
 After you have collected data on your client, you need to make
a nursing diagnosis
 Nursing diagnosis determines health problems
within the domain of nursing (Potter, p. 196)
Ms Devine has suffered the rupture of a

lumbar disc, her response is pain
A nursing diagnosis is a clinical judgment about
 individual,
 family,
 or community responses to actual or potential health
problems within the domain of nursing.
 “A nursing diagnosis focuses on a client’s actual or potential
response to a health problem rather than on the physiological
event, complication or disease.
 Medical diagnosis:
◦ Pneumonia
 Nursing diagnosis
◦ Impaired airway clearance
*** Nursing Diagnosis reflect the wholistic approach to nursing

and health
 Nurses also encounter client problems that must be managed
collaboratively with personnel from other health disciplines
◦ For example is a client hemorrhages we need orders from a physician to be

able to initiate care, but we monitor the vital signs
◦ Collaborative problems see p .196 Potter
 Other examples:
◦ Dietician
◦ Physiotherapy
◦ Social work
◦ Public health,
◦ Social services
Diagnostic label: (Problem)
 ie. Acute pain
Related to
The etiology identified from the patient’s data base
 ie. Acute pain related to herniated disc (in the spine) (physical
pressure on spinal nerves)
Defining characteristics (clustering cues)

 ie. client reports pain at level of 8/10 (supports the nursing
diagnosis)
(see page 201Potter& Perry text)
 Actual client problem
 Health Risk
 Health promotion challenge
 Wellness
Types of nursing diagnosis- see page 166 Potter and Perry
Actual client problem:

a problem that the client actually has
◦ Sufficient assessment data are actually
available to say this is a problem for the
client,
◦ eg in a post operative patient: pain
Health risk:
◦ a problem that could develop in a vulnerable
individual,
◦ e.g. a patient who has had surgery of the
lower extremities is at risk for developing a
Deep Vein Thrombosis (DVT)
◦ (Burke, Mohn-Brown, Eby 2011)
Health promotion challenge:
a person expresses readiness to enhance
specific health behaviors such as improving
nutrition, increasing exercise,
 ie.
a person who has had cardiac surgery may
need to change diet, patterns of activity
Wellness:
 this represents a level of wellness the client
has achieved, but the client could move to a
higher level of wellness, improving the level of
coping of the client
 E.g. readiness for enhanced coping related to
successful cancer treatments
 You developed a nursing care plan for Mrs. Adams, where you
were asked to identify
◦ An actual problem
◦ A health risk
◦ And a health promotion challenge
 For Mrs. Adams
 Planning is a category of nursing behaviour in which a nurse
sets client-centered goals, outlines expected outcomes,
plans nursing interventions that will resolve the client’s
problems (p. 203 Potter)
You may need to collaborate with

 the family,
 the health care team,
 the client,
 and review related literature.
 Priority setting is the ranking of the nursing diagnoses, or
client issues, determining which problem is more important or
urgent
 Establish a preferential order for the nursing actions (P. 203

Potter and Perry)
 Requires critical thinking
 You attend to the client’s most important need first
 You must consider the client’s physiologic condition
◦ Eg if a client has difficulty breathing, this is a priority
 The order of priorities changes as a client’s condition changes
 “PRIORITY SETTING”
 For Ms. Devine, at this time, we might consider her priority need
is pain relief.
 You must set goals
◦ What do you plan to achieve?
◦ What specific client behaviours do you want to see?
◦ What specific physiological responses do you expect?
◦ How will you know you have achieved your goal?
 You will apply knowledge from nursing, medical, and

sociobehavioral sciences to plan care (think about ways of
knowing!!)
Goals need to be
• Specific,
• Measurable,
• Achievable,
• Realistic (relevant)
• Time limited
“SMART” GOALS!
 Goals can be short term (maybe less than a week)
 Or long term (several days, weeks or even months)
 Mutual goal setting with client and family is important.
 The time span for client goals depends on the patient’s context…
◦ ie. we would not wait a week to have relief of acute pain, twenty
minutes would be reasonable. On the other hand a week might be a
short term goal for relief of chronic pain
An expected outcome: is a specific measurable change in a client’s

status.
S.M.A.R.T.
 Client will state “my pain is 2/10 on a numerical pain scale”
 Client will be able to cough and deep breathe with minimal

pain
 A nursing intervention is any treatment, action or intervention
based on clinical judgment and knowledge, to enhance client
outcomes
 (Potter and Perry, p. 214)
 Interventions are evidence informed

 EIDM
Interventions are based on client needs and can be:
 Nurse initiated (independent nursing actions) eg elevating a
swollen extremity, instructing clients about side effects of
medication, having a client splint an incision while coughing
 Physician initiated: example: written orders from physicians

regarding medications or wound care
 Collaborative: example: having a social worker assist a client

 Nurses need to review literature, standard protocols, or guidelines,
policy or procedure manuals, textbooks,
◦ Evidenced informed decision making is utilized (EIDM)
◦ Need to consider: What is the research that guides our client interventions?
 Need to collaborate with other professionals
 Continually review the client’s priorities, consider your previous

experiences
 All of the above are necessary to select the appropriate

intervention for your client
What level of the 6S pyramid will you find
the highest (usable) level of evidence?
What are these resources called?
Why are they the highest level of evidence?

 Nursing practice requires cognitive, interpersonal, and
psychomotor skills
◦ Cognitive: the use of critical thinking
◦ Interpersonal: the nurse has a trusting relationship, a caring attitude,

and communicated clearly with the client
◦ Psychomotor skills: this is the integration of cognitive AND motor

activities.
(See Potter and Perry, p. 220)

Even though you have planned a set of interventions for a
client,
……. good judgment, decision making and reassessment are
needed before each intervention is actually performed
 Clients conditions sometimes change rapidly

 (Reflection-in action!)
 This enables you to determine the client’s response to your
nursing care
 Did the client reach the level of wellness, or recovery that that
the health care team and the client established?
 Were expected outcomes achieved?
 Ms. Devine is a 52-year-old woman who was injured in a fall two months
ago that caused rupture of a lumbar disc. She is scheduled for a lumbar
laminectomy this afternoon. Ms. Devine is the office manager for a realty
business she runs with her husband. She was not able to work regularly
over the first month after the injury.
 She has sciatic pain that is sharp and burning, radiating down from her
right hip to her right foot.
 The pain worsens when she sits.
 Her vital signs are as follows: temperature 37.3°C; blood pressure,
138/82 mm Hg; pulse, 84 beats per minute; and respirations, 24 breaths
per minute.
 She has a slight limp when she walks, you also note facial grimacing.
 She states her pain is 8/10 on a numerical pain scale
Includes subjective and objective data
 Observe client's body movements. (Obj.)

◦ Client limps slightly with right leg. Turns in bed slowly.
 Observe client's facial expression. (Obj.)

◦ Client grimaces when she attempts to sit down.
 Ask client to rate pain at its worst.

◦ Client rates pain on a scale of 0 to 10 at an 8 or 9 at its worst.
 Nursing Diagnosis (Interpreting -What is a possible
explanation for what is happening here?)
Analyze the data, identify the problem
 Acute pain related to pressure on spinal nerves as evidenced

by limping when walking, facial grimacing, etc.
Identify Priorities, Determine your goals, Determine
interventions
 -Pain Control is the Goal
 -Client will achieve improved pain control before surgery.
 Expected Outcomes (how will I know I have reached the goal)

 -Client's self-report of pain will be 3 or less
on a scale of 0 to 10 (in 15 minutes)
 -Client's facial expressions reveal less discomfort when
turning and repositioning.
Analgesic Administration (medication for pain)
 -Give analgesic 30 minutes before turning or positioning client and

before pain increases in severity.
 -Medication will exert peak effect when client increase movement.
Non-pharmacological Pain Management

 -Reduce environmental factors in client's room (e.g., noise, lighting,
temperature extremes).
 -Offer client information about any procedures and efforts at reducing -
discomfort.
 -Information satisfies client's interests and enables client to evaluate and
communicate pain
 Progressive Muscle Relaxation
Ask client to report severity of pain 15 minutes after analgesic
administration.
 Ms. Devine still reports pain at a level 5 on a scale of 0 to 10.
◦ Pain is reduced, but necessitates further nonpharmacological
intervention to achieve outcome.
 Observe client's facial expressions.
◦ Ms. Devine is observed to have a relaxed facial expression.
 Client's level of comfort is improving.
◦ Client can turn and reposition in bed without minimal discomfort
Interpreting Responding
Recognizing patterns Determining a course
and interpreting data of action
Key Issues Rationale: What are the Priority setting SMART goals Nursing Evaluation-how do you
Most important issues assessment data? The What issues should be /outcomes actions/interventions to determine the success
for your patient? subjective and objective attended to first and What are the desired address the issue? (outcome) of your
cues shown by your why short and long term interventions?
patient? goals
Subjective: Pain rating Pain management Client's self-report of Analgesic Ms. Devine still reports
Acute pain related to of 8/10 on numerical pain will be 3 or less on a Administration pain at a level 5 on a scale
pressure on spinal scale scale of 0 to 10 (in 15 (medication for pain) of 0 to 10.
minutes) Pain is reduced, but
nerves as evidenced by necessitates further
-Give analgesic 30
limping when walking, Objective: nonpharmacological
-Client's facial minutes before turning or
facial grimacing, etc Facial grimace intervention to
expressions reveal less positioning client and
Patient is limping discomfort when turning before pain increases in achieve outcome.
.
and repositioning severity.
Ms. Devine is
-Medication will exert
observed to have a
peak effect when client
relaxed facial
-Client can turn and increase movement. expression.
reposition in bed with Non-pharmacological
minimal discomfort Pain Management Client's level of comfort is
-Reduce environmental improving.
Client will state that factors in client's room Yes, Client can turn
comfort level has (e.g., noise, lighting, and reposition in
increased overall over 24 temperature extremes). bed with minimal
hours. discomfort
-Offer client information
about any procedures and The Information provided
efforts at reducing - satisfies client's interests
discomfort. and enables client to
evaluate and communicate
Observe client's facial pain
expressions
Progressive Muscle
Astle, B.J. & Duggleby, W. (2019). Potter & Perry: Canadian fundamentals of nursing. (6th ed.). Toronto, ON:
Elsevier
Burke, K., Mohn-Brown, E. & Eby, L. (2011).Medical-Surgical Nursing Care. Upper Saddle River, NJ : Pearson.
Cullum, N., Cilaska, D., Haynes, R.B., & Marks, S. (2008). Evidence-based Nursing: An introduction.
Oxford, UK: Blackwell Publishing
McMaster University School of Nursing (2011), Evidence Informed Decision Making resource
modules, Module 1, Hamilton, Canada: McMaster University
Potter, P & Perry, A. (2014) Canadian Fundamentals of Nursing, 5th ed. Toronto, ON Canada: Elsevier
NANDA INTERNATIONAL
https://nanda.org/who-we-are/our-story/

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Assessment &

Physical Exam of the Abdomen

N1J02 – Week 7 - W2022

The content will include everything from Week 1 to

There are 39 multiple choice, and 1 select all that apply

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• Internal anatomy (viscera)

© Pat Thomas, 2006.

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•Obesity is increased risk for diabetes, gall stones, some types of

•Prevalence of lactose intolerance – research that moderate milk products

•Rates of celiac disease – auto-immune disease related to gluten in diet;

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•Inflammatory bowel disease, IBD (Canada has one of the highest

•Relationship of hepatitis A and GI illnesses to socioeconomic

•Increased risk of parasitic diseases in refugees and immigrants

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Abdominal pain: PQRSTU, associated factors or other symptoms,

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Diet & Nutritional assessment: 24 hour diet recall, adherence to Canada’s

Dysphagia: difficulty swallowing, onset

GI medications – antacids, laxatives, stool softeners etc.; use/frequency

Medications: prescription, over the counter, herbal & natural remedies

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Quick Example Assessment:

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Examine in order: (IAPP) * note change in general sequence

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Umbilical hernia (adult and infant)

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▫ Deep palpation- In Clinical

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Shape – flat or slightly rounded; not distended; symetrical

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CVA tenderness: Blunt percussion of the costo-vertebral angle:

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What additional history is needed? Assessment?

What do you think is happening?

How would you intervene? What nursing care is

Head to Toe Physical Examination

Doug Wonnacott. BSc, BScN, MEd.

• Review vital signs and health assessment skills