Nursing Process

• Is a critical thinking process that professional nurses use to apply the best
available evidence to caregiving and promoting human functions and responses to
health and illness. (American Nurses Association, 2010)
• Is a systematic method of providing care
to clients.
• Is a systematic method of planning and providing individualized nursing care.
Nursing Care Plan
• Written guidelines for client care
• Organized so nurse can quickly identify nursing actions to be delivered
• Coordinates resources for care.
• Enhances the continuity of care
• Organizes information for change of shift report
Critical Thinking
Ability to
• identify a problem
• analyze it
• develop a response
• follow through
Based on
• experience
• Knowledge
• Intuition
Why critical thinking is important? How can this affect your diagnostic reasoning and
clinical judgment to manage patient care?

ASSESSMENT
The first step in determining a patients's health
status. Is collecting, validating, organizing and
recording data about the patient's health status.
Purpose
1. To establish a database concerning a client's physical, psychosocial, and
emotional health. 2. To identify health-promoting behaviors as well as actual and/or
potential health problems.
FOUR TYPES OF ASSESSMENT
• Initial comprehensive assessment An initial assessment, also called an
admission assessment, is performed when the client enters a health care from a
health care agency. The purposes are to evaluate the client's health status, to
identify functional health patterns that are problematic, and to provide an in-depth,
comprehensive database, which is critical for evaluating changes in the client's
health status in subsequent assessments.
• Ongoing or Partial assessment
Also knows as time lapsed assessment. Takes place after the initial assessment to
evaluate any changes in the client’s functional health. Nurses perform this type of
assessment when substantial periods of time have elapsed between assessment.
• Problem-focused assessment
A problem focus assessment collects data about a problem that has already been
identified. This type of assessment has a narrower scope and a
shorter time frame than the initial assessment. In focus assessments, nurse
determine whether the problems still exists and whether the status of the problem
has changed (i.e. improved, worsened, or resolved). This assessment also includes
the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care
units, may perform focus assessment every few minute.
• Emergency assessment
Emergency assessment takes place in life threatening situations in which the
preservation of life is the top priority. Time is of the essence rapid identification of
and intervention for the client's health problems. Often the client's difficulties involve
airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-
concept (suicidal thoughts) or roles or relationships (social conflict leading to violent
acts) can also initiate an emergency. Emergency assessment focuses on few
essential health pals and is not comprehensive.
ACTIVITIES DURING ASSESSMENT
1. Collecting the data - this involves gathering the information about the patient,
considering the physical, psychological, emotional, socio- cultural and spiritual
factors that may affect his/or her health status.
2. Verifying/validating data - making sure your information is accurate.
TYPES OF DATA
Subjective Data
• Data from client's (and sometimes family's) point of view. Includes feelings,
perceptions, and concerns. (interview) Ex: Vertigo, tinnitus, pain, nausea, anxiety,
weakness, fatigue, anorexia, thirst, nervousness
Objective Data
• Also called signs. Observable and
measurable data obtained through physical examination and laboratory and
diagnostic testing.
Ex: BP 170/100 mmHg. Temp. 37.9, reddish urine, jaundice, rbc 4.5 million/cu.mm,
edema,weight loss, poor skin turgor, tachycardia and wheezing.
SOURCES OF DATA
• Primary Source: The client/patient.
• Secondary Source: The client's family members, other health care providers,
and medical records.
DIAGNOSING
• It is a process which results to a diagnostic statement or Nursing Diagnosis.
• Diagnosis-it is the clinical act of identifying problems.
• To diagnose in nursing, it means to analyze assessment information and
derive meaning from this analysis.
Purpose
to identify the patient's health care needs and to prepare diagnostic statements.

WRITING A NURSING DIAGNOSIS STATEMENT

Problem - Statement of the client’s response -
Activity intolerance
Etiology – Factors contributing to or a probable cause of the response. "Related to"
imbalance between oxygen supply and demand Signs and symptoms - Defining
characteristics manifested by the client. Verbal reports of fatigue, exertional dyspnea
("difficulty breathing when walking"), and dysrhythmia ("racing heart")
OUTCOME IDENTIFICATION
refers to formulating and documenting measurable, realistic, patient-focused goals.

Purposes
1. To provide individualized care
2. To promote patient satisfaction.
3. To plan care that is realistic and measurable.
4. To allow involvement of support people.
PLANNING
involves determining beforehand the strategies or
course of actions to be taken before
implementation of nursing care.
Purposes
1. to identify the patient's goals and appropriate nursing interventions.
2. to direct patient care activities.
3. to promote continuity of care.
4. to focus charting requirements.
5. to allow for delegation of specific activities.
IMPLEMENTATION
Putting your plan into action
Purposes
to carry out planned nursing interventions to help the patient attain goals and
achieve optimal level of health.
INTERVIEW
•
• is a purposeful conversation between the nurse and the patient.
• it consists of asking questions designed to elicit subjective data - what the person
says about himself or herself.
PURPOSE OF INTERVIEW
1. Gather organized, complete, and accurate data about patient's health state,
including the description and chronology of any signs and symptoms of illness. 2.
Establish rapport and trust
3. Teach the client about the health state 4.Build rapport for a continuing nurse-
patient relationship
5.Begin teaching for health promotion and disease prevention.
PROCESS OF COMMUNICATION
1. Sending-is done through verbal and nonverbal communication is through
spoken or written words, vocalizations.
o Nonverbal - gestures, facial expressions, posture, body movement, voice tone
and volume, rate of speech and dress.
o Nonverbal is under less conscious control thus it is a more accurate
expression of one's inner thoughts and feelings than verbal communication.
2. Receiving-Words and gestures must be interpreted in a specific context to
have meaning.
FACTORS THAT AFFECT COMMUNICATION
Internal Factors
• Liking others
• Empathy
• Ability to listen
External Factors
The physical setting of interview Ensure Privacy.
• Refuse Interruptions
• Physical Environment
• Dress
• Note- Taking
• Tape and Video Recording
FACTORS THAT AFFECT COMMUNICATION
• Intimate Zone - 0 to 1 ½ feet Best for assessing breath and other body
odors.
• Personal Distance 1½ to 4 feet Physical Assessment
• Social Distance - 4 to 12 feet Interview
• Public Distance 12 feet or more Health Teaching in a Community
INTERVIEW & HEALTH Data collection methods
OBSERVATION
• gathering of data by using the five senses. Includes looking. watching,
surveying, scanning and appraising.
ASPECTS OF OBSERVATION
• 1.Noticing the data
• 2.Selecting, organizing and interpreting the data
EXAMINATION
• Obtain baseline data.
• Supplement, confirm data obtained in NSG history.
• Obtain data that will help the nurse establish a nursing diagnosis and plan the
client's care.
INTERVIEW
• is a purposeful conversation between the nurse and the patient.
• it consists of asking questions designed to elicit subjective data- what the
person says about himself or herself.
PHASES OF INTERVIEW
Preparatory Phase or Preinteraction Phase - occurs before the nurse meets the
patient.
a. Review as much information as possible about the patient.
b. Decide what data are needed and what type of data collection will be used.
c. Review the literature pertinent to the patient's developmental age,
psychosocial aspects and pathophysiological considerations if needed.
d. Assess own feelings or reactions to previous patients that might interfere with
the nurse- patient relationship.
e. Seek assistance from more experienced nurses, mentors or supervisors as
needed.
f. Plan for a private, quiet setting for the interview: schedule a mutually
convenient time of day, and determine the length of time needed for data collection.
g. Modify the environment to facilitate the interview.
Introductory Phase/Orientation Phase/Pre helping Phase - it begins when the nurse
and the patient meet.
a. Introduce self by name and position and explain the purpose and content of
the interview.
b. Begin to establish rapport with the patient by conveying a caring, interested
attitude.
c. Observe the patient's behavior, and listen attentively to determine the
patient's self perceptions and how the patient views his or her health problems.
d. Let the patient know how long the nurse- patient relationship is expected to
last.
e. Inform the patient how the information collected will be used and that
confidentiality will be maintained.
f. Start with non-threatening, specific questions and proceed to open-ended
questions.
Maintenance Phase/Working Phase- the client begin to view each other as unique
g. Establish a verbal contract with the patient, incorporating the goals of the
interview. the nurse and
individuals.
a. Keep focused on the tasks or goals to ensure that the needed data are
obtained and goals are achieved.
b. Encourage the patient to express his or her feelings, concerns and questions.
c. Use techniques that facilitate communication between the nurse and patient.
d. Observe the nonverbal behavior that accompanies verbal responses.
e. Assess the patient's ability to continue the interview.
f. Facilitate goal attainment by moving to the next step of discussion after
needed data are collected.
Concluding Phase/Termination Phase- often expected to be difficult and filled with
ambivalence
a. Review goal or task attainment.
b. Summarize the highlights of the interview and its meaning to the nurse and
patient.
c. Encourage the patient to express and share his or her feelings regarding the
termination of the nurse-patient relationship.
d. Use language congruent with the client's cultural background and local
custom.
CONTRACT
1. Time and place of the interview and succeeding physical examination which is
the next data collection step.
2. Introduction of self and the brief explanation of the nurse's role.
3. The purpose of the Interview,
4. How long will it take?
5. Expectation of participation for each patient.
6 Presence of any other people
7. Confidentiality
8. Any costs that the patient may pay
TRAPS IN INTERVIEWING
1. Providing false assurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using of professional jargon
7. Using biased questions
8. Talking too much
9. Interrupting
10. Using "Why" questions
MODES OF COMMUNICATION
1. VERBAL COMMUNICATION is Through spoken or written words, vocalizations.
2.NONVERBAL COMMUNICATION gestures, facial expressions posture, body
movement, voice tone and volume, rate of speech and dress.
DEVELOPMENTAL CONSIDERATIONS
Infants
• interviewing the parents.
Preschoolers
 • Egocentric
School aged
• Can tolerate and understand other's viewpoints.
• More objective and realistic.
• Has the ability to add important data to the history. Pose questions about
school, friends or activities directly to the child.
• Wants to know functional aspects - how things work and why things are
done.
Adolescent
• Keep question short and simple.
Older Adult
TECHNIQUES OF COMMUNICATION
Closed/Direct
• it asks for specific information. Elicit a short, one or two word answer, a yes
or no, or a forced choices.
• Use direct question after the person's opening narrative to fill in any details
he or she left out.
• Use direct question when you need many specific facts, such as about past
health problems or about review of systems
• It limits rapport and leaves interaction neutral.
1. Facilitation of General Leads.
• Encourages the patient to say more
2. Silence
• "Yes, go on, I'm with you."
3. Reflection
• The patient is able to collect his thoughts
4. Empathy
• Repeating part of what the patient has just said.
5. Clarification
• Used when person's word choice is ambiguous.
6. Confrontation
• Honest feedback of the nurse
7. Interpretation
• Based on influence or conclusions.

• Final review and signals the termination of the interview.

Open Ended
• it asks for narrative information.
• It leaves the person free to answer in any way.
• it encourages the patient to respond in paragraphs and to give a spontaneous
account in any order chosen.
• It lets the person express herself or himself.
• It builds and enhances rapport.
PEOPLE UNDER THE INFLUENCE OF STREET DRUG OR ALCOHOL
Substance Abuser
• Ask simple and direct questions.
• Make your manner of questioning non threatening.
• Be aware of hospital security or other personnel who could be called on for
assistance.
• Find out the time of the client's lost drink and how much he or she drank at
this episode as well as the name and amount of other drugs taken.
Sexually Aggressive
• Communicate that you accept the client. but YOU CANNOT TOLERATE
SEXUAL ADVANCES. You need to set appropriate verbal boundaries.
• Maintain professional relationship. Acutely Ill
• Prompt action is required.
• Ask brief and concise questions.
• Attend to the comfort first of a client with critical or severe Illness.
• Establish priority. Be sure that your statements are very clear.
Anxiety
• Allow the client to verbalize feelings, fears and concerns before proceeding
with the Interview for health history.
Treat of Violence
• Be aware of the "red flag" behaviors of a potentially disruptive or violent
patient.
• Trust your instincts. Do not raise your voice or try to argue.
• Be calm and act calm.
• Your most important goal is safety; avoid taking any risks.
Hearing Impaired
• Be aware of the clues of hearing deficit of a client.
• Ask the client his or her preferred way to communicate. Avoid shouting.
• Speak slowly. Use gestures.
• Written communication is efficient.
BE SURE THE CLIENT UNDERSTANDS YOUR QUESTIONS
Anger
• Try not to personalize the anger of the client. Usually, it does not relate to
you.
• Deal with the angry feeling before you ask anything else.
Crying
• During the interview, when you say something that "makes the client cry," do
not think you have hurt him or her. You have just hit a topic that is important.
• Do not go on to a new topic. Just let the person cry and express his or her
feelings fully. You can offer a tissue and wait until crying subsides to talk.
Adolescent
• Communicate with respect and be honest.
• Stay in character. Do not try to be his or her peer.
• Focus first on the adolescent, not on the problem.
• Do not assume he / she knows anything about a health interview or a
physical examination.
• Keep questions short and simple. Be aware of non verbal communications.
• Take every opportunity for positive reinforcement.
Older Adult
• Always address the person by the last name. Avold calling the client
"Grandma" or "Grandpa."
• Adjust the pace of the interview to the aging person.
• Consider physical limitations when planning the interview.
Holistic Nursing Assessment Functional Assessment
The purpose of functional assessment is for the nurse to learn how the client
function in terms of daily activies.
Two Categories of Functional Assessment
Physical Activities of Daily Living (ADLs)
• Bathing
• Dressing
• Toileting
• Transfers
• Continence
• Feeding
• Managing Money
Instrumental Activities of Daily Living (IADLs)
• Using the telephone
• Shopping
• Preparing food
• Housekeeping
• Laundry
 Mental Status
• Refers to a client’s level of cognitive
functioning (thinking, knowledge,
problem solving) and emotional
functioning (feelings, mood, behaviors,
stability)
• A state of well-being in which an individual realized his or her own
abilities, can cope with the normal stresses of life, can work productively and is
able to make a contribution to his or her community.
• It is reflected in one’s appearance, behaviors, speech, thought patterns,
decisions, and in one’s ability to function in an effective manner in relationships in
home, work, social, and recreational settings.
Factors affecting Mental Health
1. Economic and social factors e.g, rapid
changes, stressful work conditions, and
isolation.
2. Unhealthy lifestyle choices e.g, sedentary
lifestyle or substance abuse
3. Exposure to violence e.g, being a victim
of child abuse
4. Personality Factors e.g, poor decisionmaking skills, low self-concept, poor
selfcontrol
5. Spiritual factors e.g, belief system, spirituality, spiritual community, practices and
restrictions.
6. Cultural factors e.g, beliefs and values
7. Change or impairments in the structure and function of the neurologic system e.g,
cerebral abnormalities, disturbs the client intellectual, communication abilities or
emotional behaviors.
8. Psychosocial developmental level and issues.
Assessing Violence
Domestic Violence versus Family Violence
Domestic Violence
A pattern of abusive behavior in any relationship that is used by one partner to gain
or maintain control over another intimate partner.
Family Violence
Violent or threatening behavior, or any other form of behavior, that coerces or
controls a family member or causes that family member to be fearful.
Abuse
Physical-Slapping, hitting, kicking, punching, burning
Emotional-Threats of physical harm, financial harm, harm to child or pet, or suicide;
harassment; insults and other verbal abuse; isolation; intimidation; mind games;
throwing objects
Sexual-incest or rape
Violence versus Aggression
Violence-The use of physical force to harm
someone, to damage property, etc
(-)murder, torture, hate
(+)self-defense, acts of war
Aggression-A forceful action or procedure (as an unprovoked attack) especially when
intended to dominate or master.
(-)to dominate/master another family member (+)drive for success

Theories of Family Violence

1. Psychopathology Theory
• Batterer suffers personality order
2. Social learning
• Violence is a learned behavior from childhood
3. Biologic Theory
• Physiologic changes from childhood trauma, head injuries, or through
heredity cause violent behavior
4. Family Systems Theory
• Violence grows through family
system function, but some criticize this theory as blaming the victim
5. Feminist Theory
• Male/female inequity in
patriarchal societies leads to violence
6. Walker’s Cycle of violence
• Cyclic nature of violence
• Violence occurs in a predictable manner
Phases of the Walker’s Cycle of Violence
1. Tension-building phase
2. Acute battering stage
3. Honeymoon phase
7. Cycle of Domestic Violence Model (Center for Hope and Safety Organization
1. Abuse
2. Guilt
3. Rationalization
4. “Normal” behavior
5. Fantasy about the abuse
6. Planning
7. Set-up to fail
Categories of family violence
• Intimate partner violence (IPV) physical, sexual or psychological harm by a
current or former partner or spouse, progressive isolation, stalking, deprivation,
intimidation, reproductive coercion.
Signs and symptoms: chronic pain, headaches difficulty sleeping, poor physical and
mental health.
• Child abuse
any recent act or failure to act on the part of a parent or caretaker, which results in
death, serious physical or emotional harm, sexual abuse or exploitation.
Categories: neglect, emotional abuse, sexual abuse, physical abuse, abandonment,
parental substance abuse.
Long term consequences: physical, psychological, behavioral, societal
• Elder mistreatment/elder abuse
includes neglect, physical abuse, sexual
abuse, financial abuse, psychological abuse, (including humiliation, intimidation and
threats), exploitation, abandonment or prejudicial attitudes that decrease quality of
life and are demeaning to those over the age of 65 years.
Effects: physical, psychological.
Nursing assessment for family violence
Assessment tool (Hurt Insult Threaten Scream
HITS)
How often does your partner physically hurt you? How often does your partner
insult or talk down to you?
How often does your partner threaten you with physical harm?
How often does your partner scream or curse at you?
Nursing considerations:
• Examine your feelings beliefs and biases regarding violence.
• Be aware of “red flags”.
• Create a safe and confidential environment.
• Establish a trusting report and to patiently listen to the client
• Use simple direct questions with a relaxed and calm approach.
• Allow client to talk freely as you listen.
• Asking the client if they want to press charges, is NOT part of assessing the
client.
• Methods: interview and physical examination.
Assessing culture Definition of terms
Acculturation
The circumstance when a person gives up the traits of his or her culture of origin as
a result of context with another culture, to variable degrees.
Assimilation
the gradual adoption and incorporation of characteristics of the prevailing culture.
cultural diversity
The co-existence of a difference in behavior, traditions and customs, AKA “cultural
pluralism”.
Cultural imposition
The intrusive application of the majority group’s cultural view upon individuals and
families.
Cultural relativism
The belief that the behaviors and practices of people should be judged only from
the context of their cultural system.
Culture
The totality of socially transmitted behavioral patterns, arts, beliefs, values,
customs, lifeways and all other products of human work and thought characteristics
of a population or people that guide the worldview and decision making.
Enculturation
A natural conscious and unconscious conditioning process of learning accepted
cultural norms, values and roles in society and achieving competence in one’s culture
through socialization.
Ethnicity
A socially culturally and politically constructed group that holds in common a set of
characteristics not shared by others with whom members of the group come into
contact.
Ethnocentrism
The universal tendency of humans to think their ways of thinking, acting, and
believing are the only right, proper and natural ways.
Stereotyping An oversimplified conception, opinion, or belief about some aspect of
an individual or group.
Subculture
A group of people with a culture that differentiates them from the larger culture of
which they are a part.
Values
Learned beliefs about what is held to be good or bad.
Norms
Learned behaviors that are perceived to be appropriate or inappropriate.
Cultural competence
Cultural awareness
Ask yourself how aware you are of your own biases and prejudices toward people
different from you.
Cultural skill
Ask yourself if you can complete a cultural assessment being sensitive to cultural
differences and sensitivities.
Cultural knowledge
Ask yourself, how much you know about different cultures and ethnic groups, about
their beliefs, customs, and biologic variations.
Cultural encounters
Ask yourself what level of interest you have in interacting with people from different
cultures or ethnicities.
Cultural desire
Ask yourself if you really have interest in becoming culturally competent.
Contexts for assessments
• beliefs and behaviors
• family structure and function
• spirituality and religion
• community.
Spiritual assessment
The nurse must be objective during the assessment. The nurse would not need to
share his or her views in open dialogue.
Benefits of spiritual care:
• support for healthy grieving
• support for improved self-esteem and confidence
• assistance with maximization of potential in the current circumstances
• support to improve relationships with self, others and with an absolute/God.
• Assistance in renewing a sense of meaning and hope
• Enhancement of the client’s sense of belonging
• Assistance in improving problem solving.
• Help with enduring problems that cannot be solved, and with continuing
distress and disability.
• Help in finding renewed hope.
Assessing nutritional status nutrition hydration food and safety.
Nutrition
Refers to the process by which substances include are transformed into body tissues
and provide energy for the full range of physical and mental activities that make up
human life.
Carbohydrates CHO
• Simple vs complex CHO
• Protein sparing
• help to burn fats more effectively and completely
• stored in the liver and muscle.
Fiber
both soluble and insoluble; helps to promote normal bowel function, lowers
cholesterol levels, controls, blood sugar levels and aids in weight management.
Proteins CHON
• for normal growth and development
• made up of amino acids and stored in muscle, skin, bone, blood, cartilage and
lymph tissue.
• Less efficient form of energy production.
Fats
• stored in adipose cells and are classified as triglycerides
• saturated - ingested fats; animal sources
• unsaturated - plant sources
• Trans fatty acids (transfats) less desirable dietary fats.
Functions:
• providing concentrated energy
• aiding in absorption of fat soluble vitamins
• supplying essential fatty acids for healthy skin.
Cholesterol
• a fat like substance that the liver produces
• animal sources
• necessary as a component of bile salts and aid in digestion serves as an
essential element in all cell membranes, is found in brain and nerve tissue, and
essential for the production of several hormones, such as estrogen, testosterone and
cortisone.
Vitamins
• required for energy to be released from CHO, CHON, and fats
• necessary for the formation of RBC’s hormones, and genetic material and for
a properly functioning nervous system,
• fat and water soluble.
• Because vitamins can be destroyed or reduced by overcooking, assessment of
food preparation methods should be part of the traditional assessment.
Water
• most basic nutritional needs
• 50% to 75% body weight
Functions:
• serving as building blocks of cells or insulator an internal temperature
regulator
• metabolizing CHONs and CHOs
• Lubricating joints
• Insulating the brain, spinal cord, internal organs and a fetus
• flushing toxins and waste.
Hydration
Factors affecting hydration
• Exposure to excessively high environmental temperatures
• Inability to access fluids, especially water (e.g, unconscious patients,
physically or mentally disable)
• Excessive intake of alcohol or other diuretic fluids (e.g, coffee, soft drinks,
etc.)
• People with impaired thirst mechanism
• People taking diuretic medicines
• Diabetic clients with severe hyperglycemia
• People with high fevers
Food and safety
Food storage and preparation
food-borne diseases and poisoning.
Food allergies and intolerances
mild and severe signs and symptoms, lactose intolerance
Food and medication interactions
spices, herbs versus medications
Measurement
Weight
Height
Body mass index
This is a practical marker of optimal weight for height and an indicator of obesity, or
protein calorie malnutrition.
Body Mass Index = weight in kg over height in meters squared.
Waist to Hip Ratio = waist circumference/hip circumference.
Head Circumference – 6 months to 2 years HC and
CC are the same; After 2 years, CC is greater than
HC; newborn (32-38 cm)
Chest Circumference – newborn (31-33 cm)
Vital Signs
A BODY TEMPERATURE is the balance between the heat produced by the body and
the heat loss from the body.
2 types of body temperature
Core temperature
Temperature of the deep tissues of the body.
Measured by taking oral and rectal temperature.
Surface departure
Temperature of the skin, subcutaneous tissue, and fat.
Measured by taking axillary temperature.
Factors affecting heat production
Basal Metabolic Rate (BMR)
the younger the person the higher the BMR, the older the person, the lower the BMR
Muscle activity
increases cellular metabolic rate
Thyroxine Output
increases cellular metabolic rate
Epinephrine, Norepinephrine and Sympathetic Stimulation
increase the body temperature
Increased temperature of body cells
increase the rate of cellular metabolism.
Process involved in heat loss
Radiation -the transfer of heat from the surface of one object to the surface of
another without contact between two objects. Ex. it feels warm in a crowded room.
Conduction-the transfer of heat from one surface to another. it requires temperature
difference between the two surfaces. Ex. application of moist wash cloth over the
skin.
Convection. -The dissipation of heat by air currents. Ex. exposure of the skin
towards electric fan.
Evaporation -the continuous vaporization of moisture from the skin, oral mucosa,
respiratory tract. Ex. Tepid sponge bath increases peripheral circulation, thereby
increasing heat loss by evaporation.
Factors affecting body temperature
1. Age
2.Diurnal variations
3.Exercise
4.Hormones
5.Stress
6.Environment.
1.Pyrexia -body temperature above normal range
2.Hyperpyrexia-very high fever, 41 degrees Celsius and above
3.hypothermia-subnormal core body temperature

Types of fever
1.Intermittent-temperature fluctuates between periods of fever and periods of
normal/subnormal temperature.
2.Remittent-temperature fluctuates within a wide range over the 24 hour period but
remains above normal range.
3. Relapsing- temperature is elevated for few days, alternated with 1 or 2 days of
normal temperature.
4. constant- temperature is consistently high. Could cause irreversible brain damage.

Sites for measuring Body Temperature

1. Oral – most accessible and convenient. Take for 2-3 minutes.
2. Rectal – most accurate measurement. Lubricate before insertion. Insert by 0.5-1.5
inches.
3. Axillary – safest and most non-invasive method.
4. Tympanic – useful with toddlers who squirm at the restraint needed for the rectal
route.
A PULSE is a wave of blood created by contraction of the left ventricle of the heart
and is regulated by the autonomic nervous system.
PULSE SITES
 Temporal
 Carotid
 Brachial
 Radial
 Femoral
 Posterior tibial
 Popliteal
 Pedal
 Apical
Assessment of the pulse
Rhythm -the pattern and interval of beats
volume -the strength of the pulse normal - felt with moderate pressure
full or bounding - obliterated by great pressure
thready - can easily obliterated (weak, feeble)
arterial wall elasticity
artery feels straight, smooth, soft and pliable.
Presence/absence of bilateral equality
absence indicates cardiovascular disorder.
RESPIRATION is the act of breathing inhalation or inspiration refers to the intake of
air into the lungs.
Exhalation or expiration refers to breathing out or the movement of gases from the
lungs to the atmosphere.
Process of respiration ventilation
Ventilation -movement of gases in and out of the lungs.
Diffusion -the exchange of gases from an area of higher pressure to an area of lower
pressure which occurs at the alveolo-capillary membrane
Perfusion -The availability and movement of blood for transport of gases, nutrients
and metabolic waste products.
Breathing patterns
Rate
Eupnea -normal respiration, quiet, rhythmic, and effortless
Tachypnea -quick, shallow, breaths
Bradypnea -abnormally slow breathing
Sites for measuring Body Temperature
Apnea-cessation of breathing
Volume
hyperventilation -over expansion of the lungs characterized by rapid and deep
breaths
hypoventilation -under expansion of the lungs, characterized by shallow
respirations.
East or effort
Dyspnea -Difficult and labored breathing during which the individual has a
persistent, unsatisfied need for air and feels distressed.
Orthopnea -ability to breathe only in upright sitting or standing positions.
BLOOD PRESSURE is the measure of the pressure exerted by the blood as it
pulsated through the arteries.
BP = cardiac output x Total peripheral resistance.
MEASUREMENTS OF BLOOD PRESSURE
Systolic pressure - Is the pressure of blood as a result of contraction of the
ventricles. (100-140 mmHg)
Diastolic pressure - Is the pressure when the ventricles are at rest. (60-90 mmHg)
Pulse Pressure – Is the difference between the systolic and diastolic pressures. 30-
40 mmHg
Hypertension-an abnormally high blood pressure over 140 mmHg systolic and above
90mmHg diastolic
Hypotension – an abnormally low blood pressure,systolic pressure below 100/60
mmHg
Orthostatic hypotension - a drop in systolic pressure more than 20 mmHg. It may
occurs with a quick change to a standing position

Assessing Pain: The 5th Vital Sign

What is Pain?
• Pain - An unpleasant sensory and emotional experience, which
• We primarily associate with tissue damage or describe in terms of such
damage (International Association for the Study of Pain, 2011).
• "Pain is whatever the person says it is."
(Mc Caffery andPasero, 1999)

Physiologic Responses to Pain

• 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;
increased blood pressure
• Increased respiratory rate and sputum retention, resulting in infection and
atelectasis, decreased gastric and intestinal motility
• decreased urine 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
Classification of Pain
1. Nociceptive » represents the normal response to noxious insult or injury of tissues
such as skin, muscles, visceral organs, joints, tendons, or bones.
• Somatic » musculoskeletal (joint pain, myofascial pain), cutaneous; often well
localized
• Visceral » hollow organs and smooth muscle; usually referred
2. Neuropathic » pain initiated or caused by a primary lesion or disease in the
somatosensory nervous system
• Examples include, but are not limited to, diabetic neuropathy, postherpetic
neuralgia, spinal cord injury pain, phantom limb (post amputation) pain, and
poststroke central pain.
3. Inflammatory » a result of activation and sensitization of the nociceptive pain
pathway by a variety of mediators released at the site of tissue inflammation.
• Examples include appendicitis, rheumatoid arthritis, inflammatory bowel
disease, and herpes zoster
Duration and Etiology
1. Acute Pain » usually associated with a recent injury
2. Chronic Nonmalignant Pain » usually associated with a specific cause or injury
and described as a constant pain that persists for more than 6 months
3. Cancer Pain » often due to the compression of peripheral nerves or meninges
or from the damage to structures following surgery, chemotherapy, radiation, or
tumor growth and infiltration.
4. Intractable Pain » defined by its high resistance to pain relief
Pain Location
1. Cutaneous Pain » skin or subcutaneous tissue 2. Visceral Pain » abdominal cavity,
thorax, cranium
3. Deep Somatic Pain » ligaments, tendons, bones, blood vessels
4. Radiating » perceived both at the source and extending to other tissues
5. Referred » perceived in body areas away from the pain
6. Phantom pain » perceived in nerves left by a missing, amputated, or
paralyzed body part
7 Dimensions of Pain
1. Physical dimension » includes the patient's perception of the pain and the
body's reaction to the stimulus.
2. Sensory dimension » includes the patient's perception of the pain's location,
intensity, and quality.
3. Behavioral dimension » refers to the verbal and nonverbal behaviors that the
patient demonstrates in response to the pain.
4. Sociocultural dimension » concerns the influences of the patient's social
context and cultural background on the patient's pain experience.
5. Cognitive dimension » concerns "beliefs, attitudes, intentions, and motivations
related to the pain and its management" which are affected by all of the dimensions
mentioned but can be associated with the management part of the pain experience,
which is dependent on cognitive.
6. Affective dimension » concerns feelings, sentiments, and emotions related to
the pain experience. The pain can affect the emotions and the emotions can affect
the perception of pain.
7. Spiritual dimension » refers to the meaning and purpose that the person
"attributes to the pain, self, others, and the divine."
Physiologic factors affecting pain perception
• Estrogen » decreases tolerance to pain and to pain threshold
• Testosterone » increases pain tolerance
1. Developmental Level
2. Culture
Nursing Considerations:
• Do not stereotype! Treat each client as a unique individual, assess each
client, respect each client's response to pain, and treat each client with dignity and
consideration.
• Recognize you own response to pain.
To be culturally competent nurse caring for clients in pain:
1. Be aware of your own cultural and family values.
2. Be aware of your personal biases and assumptions about people with
different values than yours.
3. Be aware and accept cultural differences between yourself and individual
clients.
4. Be capable of understanding the dynamics of the difference. 5. Be able to adapt
to diversity.
Barriers to Pain Assessment
Barriers based on beliefs:
1. Acknowledging pain is not manly; it is a sign of weakness.
2. Pain is a punishment (often thought to be from God) for past mistakes, sins,
or behaviors, and must be tolerated.
3. Pain indicates that my condition/disease is getting worse, and that I am going
to die soon. If I don't acknowledge it, it won't be so bad.
4. Pain medications are addictive; cause awful side effects; and make you
confused, and sleepy or unconscious.
Barriers based on Physical Conditions
1. The disease/illness/injury for which the patient is being treated is not the source
of the pain.
2. Both the current disease and another disease are causing pain.
3. The patient expresses few, if any, painrelated behaviors once accommodated
to prolonged chronic pain conditions.

Barriers based on health care providers' beliefs

1. Patients who complain of pain frequently are just trying to get more pain
medicine or are addicts wanting more narcotics.
2. Patients who complain of pain but do not show physical and behavioral signs
of pain do not need more pain medication, whether they are chronic pain patients or
acute pain patients.
3. Old people simply have more pain. 4. Pain medication causes
addiction/respiratory or too many side effects.
Tips for Collecting Subjective Data
1. Quiet and calm environment
2. Privacy and confidentiality
3. Open-ended questions
4. Quote client's verbal descriptions 5. Observe client's facial expressions and
grimaces
6. DO NOT put words in the client's mouth.
7. Past experiences with pain 8. Believe the client's expression of pain.
Hierarchy of Pain Assessment
1. Self-report
2. Search for potential causes of pain
3. Observe patient behaviors
4. Surrogate reporting (family members, parents, caregivers) of pain and
behavior/activity changes.
5. Attempt an analgesic trial
Assessment Tools
Assessment Scales
1. Visual Analog Scale (VAS)
2. Numeric Rating Scale (NRS)
3. Numeric Pain Intensity Scale (NPI)
4. Verbal Descriptor Scale
5. Simple Descriptive Pain Intensity Scale
6. Graphic Rating Scale
7. Verbal Rating Scale
8. Faces Pain Scales
Assessment Scales: For neonates and infants
1. N-PASS: Neonatal Pain, Agitation, and Sedation Scale
2. Wong-Baker FACES Pain Rating Scale 3. FLACC Scale Consolability)
Assessment Scales: For initial assessment
1. Initial Pain Assessment Tool
2. Brief Pain Inventory
3. Initial Pain Assessment for Pediatric Use
Objective Data
1. Observe posture.
2. Observe facial expression.
3. Assess Face, Legs, Activity, Cry, and Consolability using FLACC Behavioral
Scale.
4. Inspect joints and muscles.
5. Observe skin discoloration. for scars, lesions, rashes, changes, or
discoloration.
6. Measure vital signs.
Steps in Health Assessment
Types of Data
• Subjective Data - Signs
• Objective Data - Symptoms
Subjective: Data from client's (and sometimes family's) point of view. Includes
feelings, perceptions, and concerns. Collected by the interview.
• Ex: Vertigo, tinnitus, pain, nausea, anxiety, weakness, fatigue, anorexia,
thirst, nervousness
Objective: Observable and measurable data obtained through physical examination
and laboratory and diagnostic testing.
HEALTH HISTORY
COMPONENTS OF HEALTH HISTORY
1. Biographical Data
1. Name
2. Address and phone number
3. Age and birth date
4. Birthplace
5. Gender
6. Marital Status
7. Race, Ethnic Origin
8. Occupation
9. Language and communication needs

2. Reasons for Seeking Health Care (Chief

Complaint of Present Illness)
SOURCE OF DATA
1. Record who furnishes the information
2. Judge how reliable the information seems and how willing he or she is to
communicate.
3. Note any special circumstances, such as the use of interpreter.
A brief spontaneous statement in the patient's own words that describes the
reason for the visit.
Ex:
"Chest pain for 2 hours"
"Earache and fussy all night" "Dizziness
and ringing of the right ear"
3. Present Health or History of Present Illness
-Chronological record of the reason for seeking care, from the time the symptom
firststarted until now.
Ex:
"Please tell me your headache, from the
time it started until the time you came to the
hospital"
• Location-localization of the pain.
• Quality or Character - calls for
specific like burning, sharp, dull,
aching, gnawing, throbbing etc.
• descriptive terms
• Quantity or Severity
• Timing (Onset, Duration, Frequency)
• Setting
• Aggravating or relieving factors
4. Past Health History
• Problems at birth
• Childhood Illness
• Immunizations to date Adult Illnesses
(Physical, Emotional, Mental)
• Surgeries
• Accidents
• Prolonged pain or pain patterns Allergies
5. Family Health History
• Cause of death of relatives
• Communicable disease within the family
• Family History of Diseases.
PHYSICAL EXAMINATION
is defined as a complete assessment of a patient's physical and mental status
PURPOSES OF PHYSICAL EXAMINATION
1. To obtain baseline data about the client's functional abilities.
2. To supplement, confirm, or refute data obtained in the nursing history.
3. To obtain data that will help establish nursing diagnoses and plans of care. To
evaluate the physiological outcomes of health care and thus the progress of a
client's health problem.
4. To make clinical judgments about a client's health status.
5. To identify areas for health promotion and disease prevention.
PRINCIPLES OF PHYSICAL EXAMINATION
• Proceed in a systematic manner.
• Use a planned sequence.
• Use specific landmarks to locate areas to be assessed.
PREPARATION THE CLIENT FOR PHYSICAL EXAMINATION
1. Prepare the patient physically and psychologically to allay anxiety.
2. Provide adequate information about the procedure, what to expect during the
procedure and what is expected of the client, to gain his cooperation.
3.Provide privacy to prevent feelings of embarrassment. 4. Provide a new clean
gown
PREPARATION THE ENVIRONMENT FOR PHYSICAL EXAMINATION
1. The examination room should be adequately ventilated, comfortable, quiet,
private with adequate lighting.
2. Position the examination table so that both sides of the patient are easily
accessible.
3. The examination table should be at a height that prevents the examiner from
stooping and should be equipped to raise the head up to 45 degrees.
4. A bedside stand or table should be available to lay out all equipment needed.

Techniques
I - INSPECTION
P - PALPATION
P - PERCUSSION
A - AUSCULTATION
INSPECTION.
• It is concentrated watching; involves the use of sense of sight.
• Observe the patient as a whole then each body system.
• Done first when assessing each body system.
• Inspect both sides for body symmetry.
• It requires good lighting and adequate exposure of body parts.
• It requires occasional use of certain instruments.
INSPECTION focuses on:
• Overall appearance of health or illness
• Signs of distress
• Facial expression or mood
• Body size
• Grooming and personal hygiene
PALPATION.
Process of examining the body by using the sense of touch to assess the
characteristics of the body structures underlying the skin: texture, temperature,
moisture of the skin; organ location and size; any swelling: vibration or pulsation;
rigidity or spasticity; crepitation; presence of lumps or masses; and presence of
tenderness or pain.
USING THE PARTS OF THE HANDS
• Fingertips-tactile discrimination like skin texture, swelling, pulsation. and
presence of lumps.
• Grasping Action of the
• Fingers and Thumb - position, shape, and consistency of an organ or mass.
• Back of Hands and Fingers - temperature Ulnar or Palmar Surface-best for
vibration
Principles of PALPATION
• You should have short fingernails.
• You should warm your hands prior to placing them on the patient.
• Encourage the patient to continue to breathe normally throughout the
process.
• If pain is experienced during palpation, discontinue Immediately.
• Inform the client where, when and how the touch will occur.
DEEP PALPATION
• In deep bimanual palpation, the nurse extends the dominant hand then
places the finger pads of the nondominant hand on the dorsal surface of the
dominant hand.
• For deep palpation using one hand, the finger pads of the dominant hand
press over the area to be palpated.
LIGHT (SUPERFICIAL) PALPATION
• The nurse extends the dominant hand's fingers parallel to the skin surface
and presses gently while moving the hand in a circle
• If it is necessary to determine the details of a mass, the nurse presses lightly
several times rather than holding the pressure.
PERCUSSION.
It is tapping the patient's skin with short, sharp strokes to assess underlying
structures. The characteristic sound produced during percussion depicts the location,
size and density of the underlying organ.
Purposes of PERCUSSION
• Mapping out the location and size of an organ.
• Detecting the density (air, fluid or solid) of a structure by a characteristic
note.
• Detecting an abnormal mass,
whether it is superficial or deep.
• Eliciting pain if the underlying structure is inflamed, as with sinus areas or
over the kidney.
• Eliciting a deep tendon reflex using the percussion hammer.

Differentiation of PERCUSSION NOTES

• Amplitude - (INTENSITY) is the loud or soft sound may be produced,
depending on the force of the blow and the ability of the body part to vibrate.
• Pitch - (FREQUENCY) - more
rapid vibrations produced a high pitched tone; slower vibrations yield a low pitched
tone. This is expressed in terms of "cps" cycles per second or number of vibrations
per second.
• Quality - (TIMBRE) - A pure tone is a sound of one frequency. Variations
within a sound wave produce overtones.
• Duration - the length of time the note lingers. A structure with relatively more
air produces a ouder, deeper and longer sound because it vibrates freely. A denser,
more solid structure gives a softer, higher, shorter sound because it does not vibrate
as easily.

AUSCULATATION.
Is listening to sounds produced by the body with the use of stethoscopes.
The two end pieces of the stethoscopes are the diaphragm and bell.
Principles of AUSCULTATION
• Warm the end piece by rubbing it in your skin.
• Never listen through a patient's gown or clothing.
• Avoid on breathing on the tubing or bumping of the tubing together.
Guidelines on PHYSICAL EXAMINATION
1. Wash hands before and after the procedure. 2. The general sequence of
performing the techniques of physical examination is as follows: Inspection,
Palpation, Percussion and Auscultation (IPPA).
3. Begin physical examination procedure by measuring the person's height,
weight, blood pressure, temperature, pulse and respiration.
4. Explain each step in the examination and how the patient can cooperate.
5. Touch the patient's hands, check the skin color, nail beds,
metacarpophalangeal joints.
6. Organize the steps of physical examination so the patient does not change
position too often and to avoid omissions.
7. Write out the examination sequence and refer to it as needed, or use a
printed form of the procedure, initially.
8. Perform the procedure using head to toe sequence.
9. The sequence of techniques for examination of the abdomen is as follows:
Inspection, Auscultation, Percussion and palpation (IAPP).
10.During examination of the abdomen, it is important to flex the patient's knees to
relax the abdominal muscles.
11.The sequence of examining the quadrants of the abdomen is as follows: RLQ,
RUQ, LUQ, LLQ 12. Avoid abdominal palpation among patients with tumor of the
liver and tumor of the kidneys.
13. Do auscultation of the abdomen for 5 minutes before concluding absence of
bowel sounds.
14. If ophthalmolscopy is done, darken the room for better illumination.
15. PE is done in an ethical manner and to prevent cases/ issues of sexual
harassment.
General Guidelines of Clients Undergoing
DIAGNOSTIC TEST
1. Prepare the client physically and psychosocially.
2. Provide privacy.
3. Provide adequate information.
4. NPO (Nothing Per Orem)
A. Upper gastrointestinal tract
B. Lower gastrointestinal tract
C. Body cavities that involve insertion of instruments through the nose or mouth.
5. Written Consent
a. Invasion of body cavities
b. Tissue injury
c. Use of anesthesia
d. use of contrast medium, either radiopaque dye or radioisotope dye.
6. Assess for allergy to seafoods and iodine.
7. Assess for history of claustrophobia
8. Increase fluid intake
9. The sequence of methods for examination of abdomen: IPP 10. No abdominal
Palpation
11. During examination of the abdomen it is important to flex the knees.
12. The sequence of examining the quadrants of the abdomen: RLQ, RUQ, LUQ,
LLLLQ
13. The best position when examining the chest is sitting/upright position.
14.To palpate the neck for lymphadenopathy and enlargement of the thyroid gland
the nurse should stand behind the client.
15.If ophthalmology is done, darken the room for better illumination. 16. For culture
and sensitivity test of various specimen, obtain the specimen before the first dose of
antimicrobials and use strictly sterile specimen container.
17.If a female client is to be examined by a male physician, a female nurse must be
in attendance.
RESPIRATORY SYSTEM
• Chest X-ray - a radiographic visualization of the lungs and other thoracic
structures.
• Chest Fluoroscopy - studies the lung and the chest in motion.
• Bronchography - a radiopaque medium is instilled directly into the traches and
bronchi through bronchoscope and the entire bronchial tree or selected areas may
be visualized through x-ray.
• Bronchoscopy - the direct inspection and observation of the larynx, trachea
and bronchi through a flexible or rigid bronchoscope.
• Lung Scan - following injection of a radioisotope, scans are taken with a
scintillation camera. Measures blood perfusion through the lungs. Confirms
pulmonary embolism or other blood flow abnormalities.
• Lung Biopsy-it is collection of lung tissues to detect presence of cancer cells.
• Sputum examination -
a. Gross appearance may
indicate certain diseases.
b. Sputum culture and sensitivity test - to detect the actual microorganism
causing infection and determine the appropriate antibiotics/treatment.
c. AFB-acid fast bacilli staining; to assist in the diagnosis of tuberculosis (TB). d.
Cytologic examination/Papanicolau examination - to detect cancer cells.
• Pulmonary Function Studies - to measure lung volume and capacities.
• Arterial Blood Gas Studies - to assess ventilation and acid base balance.
• Thoracentesis-aspiration of fluid or air from the pleural space.
CARDIOVASCULAR AND HEMATOLOGIC SYSTEM
• Complete Blood Count - for evaluation of general health status.
• Prothrombin Time - measures the time required for clotting to occur after
thromboplastin and calcium are added to decalcified plasma.
• Blood Urea Nitrogen- an indicator of renal function.
• Blood Lipids (Cholesterol and triglycerides)