TUAZON, T.J.A.

HEALTH ASSESSMENT - NCMA 121 HEALTH ASSESSMENT

prELiMS rEVIEWEr
 First step of Nursing Process
W1: THE NUrSE’S rOLE IN HEALTH  Most important because it DIRECTS the rest of the
process.
ASSESSMENT
 A thinking, doing, and feeling process – THINK and ACT
and INERACT with patients
 THINK CRITICALLY as you go with the process
NUrSiNg prOCESS
 Prioritizing according to the patient’s ABC –
Airway, Breathing, Circulation
“Combines the most desirable elements of the art of nursing
 A SKILL
with the most relevant elements of systems theory, using
 LEARNING the normal
the scientific method.”(Shore, 1988)
 IDENTIFY the normal and DIFFERENTIATE from the
abnormal
“This process incorporates an interactive/interpersonal
 Will USE in every areas of nursing
approach with a problem-solving and decision-making
process.” (Peplau, 1952)
* This phase is considered the most important or crucial
phase because it upholds the data collected from the patient.
 It is a systematic, organized method of planning, quality,
With this said, if a nurse mistakenly collect a bit of data or if
and individualized nursing care.
it is insufficient or have the wrong judgments, it would affect
 It is to IDENTIFY potential problems.
the other phases of the ADPIE as well.
 A systematic problem-solving approach.
 GOSH Approach is used for effective and efficient
According to Carpenito: Assessment is the deliberate and
provision of nursing care:
systematic collection of data to determine a client’s current
G - Goal-Oriented
and past health status functional status and to determine
O - Organized
the client’s present and coping patterns.
S - Systematic
H - Humanistic Care
According to Atkinson and Murray (1991): Assessment is a
 It is cyclical and dynamic
part of each activity the nurse does for and with the patient.
* NOTE that their could be a change from the NCP’s ADPIE if
TWO TYPES OF DATA IN HEALTH ASSESSMENT
the nurse realizes a different illness from the patient.
* one component may be involved in one time, but you
Data Collection - is the process of gathering information
cannot evaluate without assessment.
about a client’s health status.
pUrpOSES OF THE NUrSINg prOCESS
1. Subjective Data - sensations or symptoms (e.g. pain,
hunger), feelings (e.g. happiness, sadness), perceptions,
1) To identify a client's health status, his actual/present and
desires, preferences, beliefs, ideas, values, and personal
potential/possible health problems or needs.
information that can be elicited and verified ONLY BY THE
2) To establish a plan of care to meet identified needs.
CLIENT. Skills includes the following: Interview and
3) To provide nursing interventions to meet those needs.
therapeutic communication skills, caring ability and empathy,
4) To provide an individualized, holistic, effective and
and listening skills.
efficient nursing care.
 Biographical information (name, age, religion,
* Individualized means it is possible to encounter the same
occupation, etc.)
case of illness or needs , but different approach,
 History of present health concern: physical symptoms
interventions and nursing process. (For instance, all patients
related to each body part or system (e.g. eyes and ear,
feel pain, but what specific pain do they feel?)
abdomen )
 Personal health history
CHArACTErISTICS OF NUrSINg prOCESS  Family history

 Dynamic and cyclic 2. Objective Data - obtained by general observation and by

 Patient-centered using the four physical examination techniques (skills):
 Goal-directed inspection, palpation, percussion, and auscultation.
 Flexible
 Problem-oriented  Physical characteristics (e.g. skin color, posture)
 Cognitive  Body functions(e.g. heart rate, respiratory rate)
 Action-oriented  Appearance (e.g. dress, hygiene)
 Interpersonal  Behavior (e.g. mood, affect)
 Holistic  Measurement (e.g. blood pressure, temperature,
 Systematic height, weight)
 Results of laboratory testing (e.g. platelet count, x-ray
findings)
TUAZON, T.J.A.
SOURCES OF DATA IN HEALTH ASSESSMENT
Subjective: Client
Objective:
+ Observations and physical assessment findings of the
nurse or other health care professionals
+ Documentation of assessments made in client record
+ Observations made by the client’s family or significant
others
QUESTIONS ASKED IN EACH PHYSICAL SYSTEM THAT ARE
BROKEN DOWN INTO FOUR SECTIONS:
 History of present health concern
 Personal health history
 Family history
 Lifestyle and health practice
TYPES OF HEALTH ASSESSMENT
1. Initial comprehensive assessment - involves collection of
subjective data about the client’s perception of their health
of all body parts or systems, past health history, family
history, and lifestyle and health practices (which include
information related to the client’s overall functioning as well
as objective data gathered during a step-by-step physical
examination.
2. Ongoing or partial assessment - consists of data
collection that occurs after the comprehensive database is
established. This consists of a mini overview of the client’s
body systems and holistic health patterns as a follow-up on
health status. Any problems that were initially detected in
the client’s body system or holistic health patterns are
reassessed to determine any changes (deterioration or
improvement) from the baseline data. It is usually
performed whenever and wherever the nurse or another
health care professional has an encounter with the client,
whether in the hospital, community, or home setting.
3. Focused or problem-oriented assessment - is a thorough
assessment of a particular or specific client problem and
does not address areas not related to the problem.
4. Emergency assessment - is a very rapid assessment
performed in life-threatening situations. In such situations
(choking, cardiac arrest, drowning), an immediate
assessment is needed to provide prompt treatment.
* In such situations, ABC is the priority – Airway, Breathing,
Circulation
* Assessment of the carotid pulse is vital in an emergency
assessment.
STEPS OF HEALTH ASSESSMENT
 Collection of Subjective Data (description is given)
 Collection of Objective Data (description is given)
 Organizing Data (additional)
 Validating Data - is a crucial part of assessment that
often occurs along with the collection of subjective and
objective data. It serves to ensure that the assessment
process is not ended before all relevant data have been
collected and helps to prevent documentation of
inaccurate data.
 Documentation of Data - is an important step of
assessment because it forms the database for the
entire nursing process and provides data for all other
members of the health care team. Thorough and
accurate documentation is vital to ensure that valid
conclusions are made when the data are analyzed in
the second step of nursing process.
PROCESS OF DATA ANALYSIS
To identify client concerns, collaborative problems, or need
for referral, you must go through the steps of data analysis.
This process requires diagnostic reasoning skills, often called
critical thinking. The process requires diagnostic reasoning
skills, often called critical thinking. The process can be
divided into six major steps:
1. Identify abnormal cues and supportive cues
2. Cluster cues
3. Draw inferences and identify and prioritize client
concerns
4. Propose possible collaborative problems to notify
primary care provider
5. Identify need for referral to primary care provider
6. Document conclusions
DIAgNOSIS
 The second phase of the Nursing Process
 Analyzing subjective and objective data to make and
prioritize professional clinical judgments (client
concerns, collaborative problems, or referral)
TWO TYPES OF DIAGNOSIS
 Medical Diagnosis - the process of identifying a disease,
condition, or injury from its signs and symptoms; from
the doctor.
 Nursing Diagnosis - a clinical judgment about individual,
family, or community responses to actual or potential
health problems/life processes; from the nurse;
response of the patient towards the illness.
As an example regarding a problem in the airway:
For Nursing Diagnosis: difficulty of breathing; chest pain;
ineffective airway clearance As Evidenced By mucus.
For Medical Diagnosis: Acute Bronchitis
Actual Nursing Diagnosis - a statement about a health
problem that the client has and the benefit from nursing
care; an occurring disease
Potential Nursing Diagnosis - an issue that could occur with
the patient’s medical diagnosis, but there are no current
signs and symptoms of it; high risk.
Possible Nursing Diagnosis - statements describing a
suspected problem for which additional data are needed to
confirm or rule out the suspected problem; in other ways,
there is a lack or insufficient data or information.
TYPES OF NURSING DIAGNOSIS (PRHS)
1. Problem-Focused Nursing Diagnosis
- Problem + Etiology + Signs and Symptoms
ex. Acute pain related to trauma of surgical incision as
evidenced by facial grimace and guarding behavior
TUAZON, T.J.A.
2. Risk Nursing Diagnosis DIFFERENT TYPES OF APPROACHES
- Problem + Etiology
1. Direct Care - action that the nurse initiates without
3. Health Promotion Nursing Diagnosis supervision or direction from others.
- Problem
- Grieving hopelessness 2. Indirect Care - performed away from the patient like
arranging their rooms or organizing their medications.
4. Syndrome Nursing Diagnosis
- specific cluster of nursing diagnosis that occur together rATIONALE
and have similar nursing interventions tor resolve the
situation.  Reason of the Intervention that addresses the problem.

* Etiology - what causes the problem EVALUATION

* Signs and symptoms - defining characteristics; observable
* one-part statement - health education; syndromes  The fifth and final phase of the Nursing Process
 Phase where we modify, terminate, or continue the
pLANNINg Nursing Care Plan
 Involves the effectiveness of the plans
 Third phase of the Nursing Process  Assessing whether outcomes have been met and
 Prioritize nursing problems or prioritizing nursing revising the plan if the interventions did not make a
diagnoses . difference
 Developing a plan and generating solutions
 Formulate goals and desired outcomes * Nurse must be creative and adaptive.
 Determining what outcomes need to be met first
 Priority setting must be based on the ABC (Airway,
Breathing, and Circulation), urgency, and Maslow’s
Hierarchy of Needs of the patient / client.
 SHOULD follow the SMART mnemonic (Smart,
Measurable, Attainable, Realistic, Time-bound).

Short-Term Goal - objectives achieved within a few hour to

less than a week.

Long-Term Goal -objectives achieved within a week to four

weeks, to months, to years.

IMpLEMENTATION

 Fourth phase of the Nursing Process

 Defined as any treatment based on clinical judgments
and knowledge that a nurse performs to enhance
patient outcomes.
 Putting plan into action
 Involves carrying out your plan to achieve goals and
outcomes
 The “DOING” phase
 Taking action. Prioritizing and implementing the
planned interventions
 In the Nursing Care Plan, INTERVENTION is the used
term, wherein it consists of Independent, Dependent,
and Collaborative.

 Independent - without the doctor’s assistance; a

nurse that can perform on their own without
assistance from other medical personnel.

 Dependent - some actions require instructions or

input from a doctor, such as prescribing new
medication.

 Collaborative - is based on a foundation of client-

centered care, open communication, mutual trust,
shared decision-making and accountability, and
respect and value of the knowledge and
experience EACH unique nursing profession
provides as PART of the CARE TEAM.
TUAZON, T.J.A.
HEALTH ASSESSMENT - NCMA 121
prELiMS rEVIEWEr
W2: COLLECTINg SUBJECTIVE DATA: THE
INTErVIEW AND HEALTH HISTOrY //
COLLECTINg OBJECTIVE DATA: pHYSICAL
EXAM TECHNIQUES
SUBJECTiVE DATA
Is an integral part of interviewing the client to obtain a
nursing health history; collecting data is a key step of
nursing health assessment. It consists of information elicited
and verified ONLY by the client.
 Sensation / symptoms
 Feelings
 Perceptions
 Desires
 Preferences
 Beliefs
 Ideas
 Values
 Personal information
INTErVIEWINg
Obtaining a valid nursing health history requires
professional, interpersonal, and interviewing skills.
The nursing interview is a communication process that has
two focuses:
1. Establishing rapport and a trusting relationship with the
client to elicit accurate and meaningful information.
2. Gathering information on the client’s developmental,
psychological, physiologic, sociocultural, and spiritual
statuses to identify deviations that can be treated with
nursing and collaborative interventions or strength that can
be enhanced through nurse-client collaboration.
pHASES OF THE INTErVIEW
 Pre-Introductory Phase
- The nurse reviews the medical record before
meeting with the client. This information may assist the
nurse with conducting the interview by knowing some of the
client’s biographical information that is already documented.
 Introductory Phase
- After introducing himself to the client, the nurse
explains then purpose of the interview, discusses the type of
questions that will be asked, explains the reason for taking
notes, and assures the client that confidential information
will remain confidential.
 Working Phase
- During this phase, the nurse elicits the client’s
comments about major biographic data, reasons for seeking
care, history of present health concern, past health history,
family history, review of body systems for current health
problems, lifestyle and health practices, and developmental
level.
 Summary and Closing Phase
- during the summary and closing, the nuse
summarizes information obtained during the working phase
and validates problems and goals with the client. She also
identifies and discusses possible plans to resolve the
problem (nursing diagnoses and collaborative problems)
with the client.
COMMUNICATION TO AVOID
NONVERBAL COMMUNICATION TO AVOID
 Excessive or insufficient eye contact
 Distraction and distance
 Standing
VERBAL COMMUNICATION TO AVOID
 Biased or leading questions
 Rushing through the interview
 Reading the questions
VErBAL COMMUNICATION
Tone of voice, right enunciation, clarity of communication,
and correct choice of words.
As well as the right gestures, and respectful facial
expressions and correct way to comfort (Nonverbal
communication).
 Open-ended Questions
- used to elicit the client’s feelings and perceptions.
They typically begin with the words “how” or “what.”
 Close-ended Questions
- used to obtain facts and to focus on specific
information; words; the questions typically begin with the
words “when” or “did.“
 Laundry List
- another way to ask questions is to provide the
client with a list of words to choose from in describing
symptoms, conditions, or feelings.
- obtains specific answers and reduces the
likelihood of the client perceiving or providing an expected
answer.
 Rephrasing
- an effective way to communicate during the
interview since it helps clarify information the client has
stated; it also enables you and the client to reflect on what
was said.
 Well-placed Phrases
- encourage client verbalization by using well-placed
phrases.
 Inferring
- what the client tells you and what you observe in
the client’s behavior may elicit more data or verifying
existing data. Be careful not to lead the client to answers
that are not true.
TUAZON, T.J.A.
 Providing Information
- make sure to answer every question and explain to
the client. However if you do not know the answer, explain
them that you will find out and research in-depth
information regarding the matter.
COMpLETE HEALTH HISTOrY
Is an excellent way to begin the assessment process because
it provides the foundation for clinical judgments in
identifying nursing problems, where to focus, and areas
where a more detailed physical examination may be needed.
Health History is subdivided into eight sections:
I. Biographic data - personal information / data that
distinguishes one individual from another.
 Name
 Address
 Phone
 Gender
 Provider of history
 Birth date
 Place of birth
 Race or ethnic background
 Primary or secondary languages (spoken and read)
 Marital status
 Religious or spiritual practices
 Educational level
 Occupation
 Significant others or support persons (availability)
II. Reasons for seeking health care
 Reason for seeking health care (major health
problem or concern) - assists the client in focusing
on the most significant health concern and
answers the nurse’s question, “Why are you here?”
or “How Can I help you?”
 Feelings about seeking health care (fears and past
experiences) - encourages the client to discuss
fears or other feelings about having to see a
health care provider.
III. History of Present Health Concern using COLDSPA - this
section of the health history takes into account several
aspects of the health problem and asks questions whose
answers can provide a detailed description of the concern.
 Character (How does it feel, smell, sound, etc.?)
 Onset (When did it begin; is it better, worse, it the
same since it began?)
 Location (Where is it? Does it radiate?)
 Duration (How long does it last? Does it recur?)
 Severity (How bad is it on a scale of 1 to 10?)
 Pattern (What makes it better? What makes it
worse?)
 Associated factors / How It Affects the Client
(What other symptoms do you have with it? Will
you be able to continue doing your work or other
activities [leisure or exercise]?)
COLDSPA is designed to help the nurse explore symptoms,
signs, or health concerns; as well as the PQRST.
 Provocative/Palliative - what were you doing
when the pain started? What caused it? What
makes it better or worse? What seems to trigger it?
Position? Certain activities? What provokes or
relieves the pain?
 What relives it? - medications, massage,
heat/cold, changing position, being active,
resting?
 What aggravates it? - movement, bending,
lying down, walking, standing?
 Quality / Quantity - what does it feel like? Or
what describe the character of the pain? Use
words to describe the pain such as sharp, dull,
stabbing, burning, crushing, throbbing, nauseating,
shooting, twisting or stretching
 Radiates / Radiation / Region - is the pain
localized or does it spread to other areas? Where
is the pain located? Does the pain radiate? Where?
Does it feel like it travels/moves around? Did a
start elsewhere and is now localized to one spot?
 Severity scale - How severe is the pain on a scale
of 0 to 10, 0 = lowest, 10 = highest? Does it
interfere with activities? How bad is it at its worst?
Does it force you to sit down, lie down, slow down?
How long does on episode lost? H
 Timing - when/what time did the pain start? How
long did it last? How often does it occur: hourly?
Daily? Weekly? How long before it recurs?
IV. Personal Health History / Past Health History - this
portion of the health history focuses on questions related to
the client’s personal history, from the earliest beginnings to
the present.
 Problems at birth
 Child-hod illnesses
 Immunizations to date
 Adult illnesses (physical, emotional, mental)
 Surgeries
 Accidents
 Prolonged pain or pain patterns
 Allergies
 Physical, emotional, social, or spiritual weaknesses
 Physical, emotional, social, or spiritual strengths
* Acute illnesses - generally develop suddenly and last a
short time, often only a few days or weeks.
* Chronic illnesses - develop slowly and may worsen over an
extended period of time; months to years.
V. Family Health History - in addition to genetic
predisposition, it is also helpful to be aware of other health
problems that may have affected the client by virtue of
having grown up in the family and being exposed to these
problems.
 Age of parents (Living? Deceased date?)
 Parents’ illnesses and longevity
 Grandparents’ illnesses and longevity
 Aunts’ and uncles’ age and illnesses and longevity
 Children’s ages and illnesses or handicaps and
longevity
VI. Review of body systems (ROS) for current health
problems - each body system is addressed and the client is
asked specific questions to elicit further details of current
health problems or problems from the recent past that may
still affect the client or that are recurring.
TUAZON, T.J.A.
 Skin, hair, and nails: color, temperature, condition,  Use of medications and other substances (caffeine,
rashes, lesions, excessive sweating, hair loss, nicotine, alcohol, recreational drugs)
dandruff  Self-concept
 Head and neck: headache, stiffness, difficulty  Self-care responsibilities
swallowing, enlarged lymph nodes, sore throat  Social activities for fun and relaxation
 Ears: pain, ringing, buzzing, drainage, difficulty  Social activities contributing to society
hearing, exposure to loud noises, dizziness,  Relationships with family, significant others, and
drainage pets
 Eyes: pain, infections, impaired vision, redness,  Values, religious affiliation, spirituality
tearing, halos, blurring, black sports, flashes, * Transcultural Nursing Theory by Madeleine Leininger
double vision
 Mouth, throat, nose, and sinuses: mouth pain,  Past, current, and future plans for education
sore throat, lesions, hoarseness, nasal obstruction,  Type of work, level of job satisfactions, work
sneezing, coughing, snoring, nosebleeds stressors
 Thorax and lungs: pain, difficulty breathing,  Finances
shortness of breath with activities, orthopnea,  Stressors in life, coping strategies used
cough, sputum, hemoptysis, respiratory infections  Residency, type of environment, neighborhood,
 Breasts and regional lymphatics: pain. Lumps, environmental risks
discharge from nipples, dimpling or changes in
breast size, swollen and tender lymph nodes in VIII. Developmental level
axilla  Youngadult: Intimacy versus isolation
 Heart and neck vessels: chest pain or pressure,  Middlescent: Generativity versus stagnation
palpitations, edema, last blood pressure, last  Older adult: Ego integrity versus despair
electrocardiogram (ECG)
 Peripheral vascular: leg or feet pain, swelling of * adapts the theory of the following theorists:
feet or legs, sores, on feet or legs, color of feet and 1. Lawrence Kohlberg - Theory of Moral Development
legs 2. Sigmund Freud - Psychoanalytic Theory
 Abdomen: pain, indigestion, difficulty swallowing, 3. Jean Piaget - Theory of Cognitive Development
nausea and vomiting, gas, jaundice, hernias 4. Erik Erikson - 8 Stages of Development
 Male genitalia: painful urination, frequency or
difficulty starting or maintaining urinary system,
blood in urine, sexual problems, penile lesions, OBJECTiVE DATA
penile pain, scrotal swelling, difficulty with
erection or ejaculation, exposure to STIs Information about the client that the nurse directly observes
 Female genitalia: pelvic pain, voiding pain, sexual during interaction with the client and information elicited
pain, voiding problems (dribbling, incontinence) through physical examination techniques.
age of menarche or menopause, pregnancies and
types of problems, abortions, STIs, HRT, birth EQUIpMENT
control methods
 Anus, rectum, and prostate: pain, with defecation, Each part of the physical examination requires specific
hemorrhoids, bowel habits, constipation, diarrhea, pieces of equipment.
blood in stool
 Musculoskeletal: pain, swelling, red, stiff joints, EXAMINATIONS EQUIPMENTS
strength of extremities, abilities to care for self
and work All examinations  Gloves and gown
 Neurologic: mood, behaviour, depression, anger, Vital signs  Sphygmomanometer
headaches, concussions, loss of strength or and stethoscope
sensation, coordination, difficulty with speech,  Thermometer (oral,
memory problems, strange thoughts or actions, rectal, tympanic)
difficulty reading or leaning  Watch with second
hand
VII. Lifestyle and health practices profile - this is a very  Pain rating scale
important section of the health history because it deals with
the client’s human responses; clients describe how they are Nutritional status  Skinfold calipers
managing their lives, their awareness of healthy versus toxic examination  Flexible tape measure
living patterns, and the strengths and supports they have or  Skin-marking pen
use.  Platform scale with
height attachment
 Description of a typical day (AM to PM)
 Nutrition and weight management
 24-hour dietary intake (foods and fluids)
 Who purchases and prepares meals
 Activities on a typical day
 Exercise habits and patterns
 Sleep and rest habits and patterns
TUAZON, T.J.A.
Skin, hair, and nail  Examination light, Male genitalia and rectum  Gloves and water-
examination penlight examination soluble lubricant
 Mirror  Penlight
 Metric ruler  Specimen card
 Magnifying glass
Female genitalia and rectum  Vaginal speculum and
 Wood’s light
examination water-soluble lubricant
 Braden scale for
 Bifid spatula,
predicting pressure
endocervical broom
sore risk
 Large swabs
 Pressure injury Scale for
 Liquid pap medium
Healing (PUSH)
 Specimen card
Head and neck examination  Stethoscope
 Small cup of water prEpAriNg FOr THE EXAMiNATiON
Eye examination  Penlight
 Snellen E chart PREPARING THE PHYSICAL SETTING
 Newspaper
 Opaque card The physical examination may take place in a variety of
 Ophthalmoscope settings such as hospital room, outpatient clinic, physician’s
office, school health office, employee health office, or
Ear examination  Tuning fork client’s home. It is important that the nurse strive to ensure
 Otoscope that the examination setting meets the following conditions:
Mouth, throat, nose, and  Penlight
 Comfortable, room temperature: provide a warm
sinus examination  4x4 in small gauze pad
blanket if the room temperature cannot be
 Tongue depressor
adjusted.
 Otoscope with wide-tip
 Private area free of interruptions from others: close
attachment
the door or pull the curtains if possible.
Thoracic and lung  Stethoscope  Quiet area free of distractions: turn off the radio,
examination (diaphragm) television, or other noisy equipment
 Metric ruler and skin-  Adequate lighting: it is best to use sunlight.
marking pen However, good overhead lighting is sufficient. A
Heart and neck vessel  Stethoscope (bell and portable lamp is helpful for illuminating the skin
examination diaphragm) and for viewing shadows or contours.
 Two metric rulers  Firm examination table or bed at a height that
prevents stooping: a roll-up stool may be useful
Peripheral vascular  Sphygmomanometer when it is necessary for the examiner to sit for
examination and stethoscope parts of the assessment.
 Flexible metric  A bedside table/tray to hold the equipment needed
measuring tape for the examination
 Tuning fork
 Doppler ultrasound PREPARING ONESELF
device and conductivity
gel As an examiner, it is essential to be able to gather objective
data, hence, it is important to prepare yourself for the
Abdominal examination  Stethoscope
physical examination of your client to prevent the
 Flexible metric
transmission of infectious agents. General principles to
measuring tape and
keep in mind while performing a physical assessment
skin-marking pen
include the following:
 Two small pillows

Muscoloskeletal  Flexible metric  Wash your hands before beginning the examination,
examination measuring tape immediately after accidental direct contact with
 Goniometer blood or other fluids, and after completing the
physical examination or after removing gloves.
Neurologic examination  Cotton-tipped  Always wear gloves if there is a chance that you will
applicators and come in direct contact with blood or other body
substances to smell and fluids; open cut or skin abrasion; when performing
taste an examination of the mouth, an open wound,
 Same equipment as for genitalia, vagina, or rectum.
eye examination  If a pin or other sharp object is used to assess
 Objects to feel, such as sensory perception, discard the pin and use a new
a coin or key one for your next client.
 Reflex (percussion)  Wear a mask and protective eye goggles (possible
hammer for blood splashes or other body fluid droplets).
 Cotton ball and paper
clip
TUAZON, T.J.A.
APPROACHING AND PREPARING THE CLIENT
 Establish the nurse-client relationship during the
client interview before the physical examination
takes place. This is important because it helps to
alleviate any tension or anxiety that the client is
experiencing.
 At the end of the interview, explain to the client
that the physical assessment will follow and
describe what the examination will involve.
 Respect the client’s desires and requests related to
the physical examination. Some client requests
may be simple, such as asking to have a family
member or friend present during the examination.
 Another request may involve not wanting certain
parts of the examination (e.g. breast, genitalia) to
be performed. In this situation, you should explain
to the client the importance of the examination
and the risk of missing important information if
any part of the examination is omitted.
PHYSICAL EXAMINATION TECHNIQUES
Four basic techniques must be mastered before you can
perform a thorough and complete assessment of the client.
These techniques are the IPPA: Inspection, Palpation,
Percussion, and Auscultation.
POSITIONING THE PATIENT (under examination techniques)
a. Sitting position - the client should sit upright in the side
of the examination table. This position is good for
evaluating the head, neck, lungs, chest, back, breasts,
axillae, heart, vital signs, and upper extremities;
permits the full expansion of the lungs and it allows the
examiner to assess symmetry of upper body parts.
b. Supine position - ask the client to lie down ith the legs
together on the examination table. A small pillow may
be placed under the head to promote comfort. This
position allows the abdominal muscles to relax and
provides easy access to peripheral pulse sites. Areas
assessed with the client in this position may include
head, neck, chest, breasts, axiallae, abdomen, heart,
lungs, and all extremities.
c. Dorsal recumbent position - the client lies down on the
examination table or bed with the knees bent, the legs
separated, and the feet flat on the table or the bed.
This position may be more comfortable than the supine
position for clients with pain in the back or the
abdomen. Areas that may be assessed with the client in
this position include head, neck, chest, axillae, lungs,
heart, extremities, breasts, and peripheral pulses.
Abdomen should not be assessed because the
abdominal muscles are contracted.
d. Sims position - the client lies on the right or left side
with the lower arm placed behind the body and the
upper arm flexed at the shoulder and the elbow. The
lower leg is slightly flexed at the knee, while the upper
leg is flexed at a sharper angle and pulled forward. This
position is useful for assessing the rectal and vaginal
areas. The client may need some assistance getting into
this position. Clients with join problems and elderly
clients may have some difficulty assuming and
maintaining this position.
e. Standing position - the client stands still in a normal,
comfortable, resting posture. This position allows the
examiner to assess posture, balance, and gait. This
position is also used for examining the male genitalia.
f. Prone position - the client lies down on the abdomen
with the head to the side. This position is used
primarily to assess the hip joint. The back can also be
assessed with the client in this position. Clients with
cardiac and respiratory problems cannot tolerate this
position.
g. Knee-chest position - the client kneels on the
examination table with the weight of the body
supported by the chest and the knees. The client
should be kept in this position as limited as possible.
Elderly clients and clients with respiratory and cardiac
problems may be unable to tolerate this position. This
position is useful for examining the rectum.
h. Lithotomy position - the client lies back with the hipsat
the edge of the examination table and the feet
supported by stirrups. It is used to examine the female
genitalia, reproductive tracts, and the rectum.
IPPA
* note that the abdomen uses the IAPP format (Palp & Per)
I. INSPECTION
 Involves using the senses of vision, smell, and
hearing to observe and detect any normal or
abnormal findings.
 This technique is used from the moment that you
meet the client and continues throughout the
examination.
 Precedes palpation, percussion, and auscultation
because the latter techniques can potentially alter
the appearance of what is being inspected.
 Involves the use of the senses only, a few body
systems require the use of special equipment (e.g.
ophthalmoscope for the eye inspection, otoscope
for the ear inspection).
Use the following guidelines as you practice the technique
of inspection:
 Make sure the room is a comfortable temperature. A
too cold or too hot room can alter the normal behavior
of the client and the appearance of the client’s skin.
 Use good lighting, preferably sunlight. Fluorescent
lights can alter the true color of the skin. In addition,
abnormalities may be overlooked with dim lighting.
 Look and observe before touching. Touch can alter
appearance and distract you from a complete, focused
observation.
 Completely expose the body part you are inspecting
while draping the rest of the client as appropriate.
 Note the following characteristics while inspecting the
client: color, patterns, size, location, consistency,
symmetry, movement behavior, odors, or sounds.
 Compare the appearance of symmetric body parts (e.g.
eyes, ears, arms, hands) or both sides of any individual
body part.
TUAZON, T.J.A.
II. PALPATION
 Consists of using parts of the hand to touch and
feel for the following characteristics:
 Texture (rough/smooth)
 Temperature (warm//cold)d
 Moisture (dry/wet)
 Mobility (fixed/movable/still/vibrating)
 Consistency (soft/hard/fluid/filled)
 Strength of pulses
(strong/weak/thready//bounding)
 Size (small/medium/large)
 Shape (well defined/irregular)
 Degree of tenderness
 Three different parts of the hand — the
fingerpads, ulnar/palmar surface, and dorsal
surface — are used during palpation.
 Each part of the hand is particularly sensitive to
certain characteristics.
HAND PART SENSITIVE TO
Fingerpads Fine discriminations: pulses,
texture, size, consistency,
shape, crepitus
Ulnar or palmar surface Vibratios, thrills, fremitus
Dorsal (back) surface Temperature
Four types of palpation:
 Light palpation: to perform light palpation, place
your dominant hand lightly on the surface of the
structure. There should be very little or no
depression (<1 cm). Use this technique to feel for
pulses, tenderness, surface skin texture,
temperature, and moisture.
 Moderate palpation: depress the skin surface 1 to
cm (0.5 - 0.75 in.) with your dominant hand, and
use a circular motion to feel for easily palpable
body organs and masses. Note the size,
consistency, and mobility of structures you
palpate.
 Deep palpation: place your dominant hand on the
skin surface and your nondominant hand on top of
your dominant hand to apply pressure. This should
result in a surface depression between 2.5 and 5
cm. This allows you to feel very deep organs or
structures that are covered by thick muscle.
 Bimanual palpation: use two hands, place one on
each side of the body part being palpated. Use one
hand to apply pressure and the other hand to feel
the structure. Note the size, shape, consistency,
and mobility of the structures you palpate.
III. PERCUSSION
 Involves tapping body parts to produce sound
waves. These sound waves or vibrations enable
the examiner to assess underlying structures.
 Eliciting pain: percussion helps to detect
inflamed underlying structures. If an inflamed
area is percussed, the lient’s physical
response may indicate or the client will
report that the area feels tender, sore, or
painful.
 Determining location, size, and shape:
percussion note changes between borders of
an organ and its neighboring organ can elicit
information about location, size, and shape.
 Determining density: percussion helps to
determine whether an underlying structure is
filled with air or fluid or is a solid structure.
 Detecting abnormal masses: percussion can
detect superficial abnormal structures or
masses. Percussion vibrates penetrate
approximately 5 cm deep. Deep masses do
not produce any change in the normal
percussion vibrations.
 Eliciting reflexes: deep tendon reflexes are
elicited using the percussion hammer.
The three types of percussion are direct, blunt, and indirect:
 Direct percussion is the direct tapping of a body
part with one or two fingertips to elicit possible
tenderness.
 Blunt percussion is used to detect tenderness over
organs (e.g., kidneys) by placing one hand flat on
the body surface and using the fist of the other
hand to trike the back of the hand flat on the body
surface.
 Indirect or mediate percussion is themost
commonly used method of percussion. The
tapping done with this type of percussion
produces a sound or tone that varies with the
density of underlying structures. As density
increases, the sound of the tone becomes quieter.
Solid tissue produces a soft tone, fluid produces a
louder tone, and air produces an even louder tone.
These tones are referred to as percussion notes
and are classified according to origin, quality,
intensity, and pitch.
The following techniques help to develop proficiency in the
indirect percussion:
 Place the middle finger of your nondominant hand on
the body part you are going to percuss.
 Keep your other fingers off the body part being
percussed because they will damp the tone you elicit.
 Use the pad of your middle finger of the other hand
(ensure that this fingernail is short) to strike the middle
finger of your nondominant hand that is placed on the
body part.
 Withdraw your finger immediately to avoid damping
the tone.
 Deliver two quick taps and listen carefully to the tone.
 Use quick, sharp taps by quickly flexing your wrist, not
your forearm.
IV. AUSCULATION
 Is a type of assessment technique that requires the use
of a stethosschope to listen for heart sounds,
movement of blood through the cardiovascular system,
movement of the bowel, and movement of air through
the respiratory tract.
 A stethoscope is used because these body sounds are
not audible to the human ear. The sounds detected
using auscultation are classified according to the
intensity (loud or soft), pitch (high or low), duration
(length), and quality (musical, crackling, raspy) of the
sound.
TUAZON, T.J.A.
TUAZON, T.J.A.
HEALTH ASSESSMENT - NCMA 121
prELiMS rEVIEWEr
W3: ASSESSINg gENErAL STATUS AND VITAL
SIgNS
gENErAL HEALTH STATUS
General Survey:
 The first part of the physical examination that
begins the moment the nurse meets the client.
 Observations lead to clues about the health status
of the client.
 The general survey includes observation of the
client’s:
 Physical development and body build
 Gender and sexual development


 Apparent age as compared to reported age
 Skin condition and color
 Dress and hygiene or posture and gait
 Level of consciousness
 Behaviors, body movements, and affect
 Facial expression
 Speech
 Vital signs
VITAL SigNS
 Are the body’s indicators of health
 Also known as “Cardinal Signs”
 Common, noninvasive physical assessment procedure
that most clients are accustomed to:
 First step in physical assessment
 Provide data that reflect the status of several body
systems, including but not limited to the cardiovascular,
neurologic, peripheral vascular, and respiratory
systems.
WHEN TO ASSESS VITAL SigNS
* Vital Signs serves as the baseline data.
 Upon admission
 A change in health status
 Pre and Post Op / Procedure
 Pre and Post medication administration
* You should also know the adverse effects of the
medications before giving it to the patient
 Before and after any nursing intervention that could
affect the vital signs .
 Activity, talking, gum - chewing, and anxiety affect
pulse, respirations and blood pressure
 ALLOW 5 minutes to 15 minutes of REST before
beginning to take Vital Signs
TEMPERATURE
 A core body temperature between 36.5OC and 37.7OC
must be maintained for the body to function at a
cellular level.
 Approximately reading of core body temperature can
be taken at various anatomic sites but none of them is
completely accurate - they are simply an approximation
of the core body temperature.
 Oral temperature - between 35.9OC - 37.5OC
 Axillary temperature - between 35.4OC - 37.0OC
 Temporal artery temperature - 36.3OC - 37.9OC
 Rectal temperature - 36.3OC - 37.9OC
 Tympanic membrane temperature - 36.7OC -
38.3OC
* Axillary temperature is the most safest; noninvasive
* Rectal temperature is the most accurate way on getting
one’s temperature since it is located internally; invasive
 Temperature is measured in degrees (Celsius or
Fahrenheit)
 Body temperature is:
 Lowest early in the morning (4:00 AM to 6:00 AM)
 Highest early in the morning (8:00 PM to 12:00 MN)
 Regulated by the hypothalamus
* If there is an increase in the metabolic activity in the body,
there will be an increase in the metabolic rate, hence an
increase to the vital signs. - kaya sa gabi, there are no
actions / activities, hence the temperature (one of the vital
signs) is low. Vice versa na mataas sa gabi because lahat na
ng activities nagawa na from the time we wake up.
PURPOSE OF TEMPERATURE:
 Purpose, is also the rationale - why do we do a
specific intervention to our patient, what is the
reason?
 To establish Baseline data for subsequent
evaluation.
 To identify whether the core temperature is within
normal range.
 To determine changes in core temperature in
response to specific therapies.
 To monitor clients at risk for imbalanced body
temperature.
FACTORS THAT AFFECT HEAT PRODUCTION:
 Basal Metabolic Rate (BMR)
 Rate of energy utilization in the body
required to maintain essential activities.
 Cool someone down and their metabolic rate
slow down, heat them up and their
metabolism increases up.
 A thermoneutral environment is one in which
nothing except basal metabolic rate is
required to maintain core body temperature
at 37 degrees.
 The cooler the environment, the more your
body will attempt to keep you warm by
cranking up your metabolism.
TUAZON, T.J.A.
 Muscle activity
 Increases metabolic rate
 Using large muscles to make heat rather than
movement
 Strenuous exercises cause normal variations
in the body temperature
 SHIVERING (using large muscles to make heat
rather than movement) is the most obvious
outward sign.
 Thyroxine (T4) output
 A Thyroid hormone for regulation of
metabolism (BMR)
 Increased Thyroxine output increases
metabolism (Chemical Thermogenesis)
 Thyroid hormones affect blood vessels to
determine body temperature
 Affect protein synthesis
 An overactive thyroid (HYPERTHYROIDISM)
can cause a person to feel too hot.
 An underactive thyroid (HYPOTHYROIDISM)
can cause a person to feel too cold.
 Sample thyroid hormones
 Thyroxine (T4)
 Triiodothyronine (T3)
 T0, T1, T2 - hormone precursors -
byproduct of thyroid hormones but do
not act on thyroid hormone receptor
and appear to be totally inert.
 Epinephrine, Norepinephrine and Symphathetic
Stimulation
 Sympathetic Nervous System - fight or flight
response
 Plays important role on the maintenance of
core body temperature through
thermoregulatory processes
 Thermoregulation is a process that allows
your body to maintain its core temperature
* additional information, parasympathetic is when your
body is at rest.
 Fever
 Increase in the body temperature’s set point
 Increases cellular metabolic rate
 Increase in set point triggers increased
muscle contractions
 Can be caused by medical conditions (viral,
bacterial, parasitic infections)
 Pyrexia / Hyperthermia / Fever / Febrile /
Hyperprexia
 A body temperature above the usual range.
* Hyperpyrexia - above 41OC
* if above 43OC, the cells would die (hence death),
afterwards, it affects the tissues - organs - organ system.
* Hypothermia - below normal core temperature
TYPE OF HEAT TRANSFER:
 Conduction - transfer of heat from one molecule to a
molecule of lower temperature.
 Radiation - transfer of energy in the form of waves and
particles.
 Convection - is the dispersion of heat by air currents.
 Vaporization / Evaporation - is a continuous
evaporation of moisture from the respiratory tract and
from the mucosa of the mouth and from the skin.
FACTORS AFFECTING BODY TEMPERATURE:
 Age - infants and older clients are greatly influenced by
environment
 Diurnal variations - temperature normally change
throughout the day (fluctuating temperature, there is a
rate or magnitude of change)
 Exercise - strenuous activity = high temperature
 Hormones - women = progesterone increases
temperature (.3-.6OC)
* Additional information: menarche - first occurrence of
menstruation
 Stress - stimulates sympathetic nervous system =
increase metabolic activity
 Environment or room temperature may affect
assessment
TYPES OF FEVERS:
 Intermittent - alternates at regular intervals between
periods of fever and periods of normal/subnormal
temperatures.
 Remittent - wide range of temperature fluctuations all
of which are above normal.
 Relapsing - short febrile periods of a few days are
interspersed with periods of 1 or 2 days of normal
temperature.
 Constant - fluctutates minimally but always remain
above normal.
CLINICAL MANIFESTATIONS OF FEVER:
 ONSET (COLD OR CHILL PHASE)
 Increases heart rate
 Increased respiratory rate and depth
 Shivering
 Palid, cold skin
 Complaints of feeling cold
 Cyanotic nail beds
 “Gooseflesh” appearance of the skin
 Cessation of sweating
TUAZON, T.J.A.
 COURSE (PLATEAU PHASE) 3.) Axillary Safe and  The
 Absence of chiils noninvasive thermometer
 Skin that feels warm may need to be
 Photosensitivity - sensitive to light left in place a
 Glassy-eyed appearance long time to
 Increased pulse and respiratory rates obtain an
 Increased thirst accurate
 Mid to severe dehydration - prone to dehydration measurement.
 Drowsiness, restlessness, delirium, or convulsions
4.) Tympanic Readily accessible;  Can be
 Herpetic lesions of the mouth
membrane reflects the core uncomfortable
 Loss of appetite (ifthe fever is prolonged)
temperature; very and involves
 Malaise, weakness, and aching muscles
fast risk of injuring
the membrane
 DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
if the probe is
 Skin that appears flushed and feels warm
inserted too
 Sweating
far.
 Decreased shivering
 Repeated
 Possible dehydration
measurements
may vary; right
NURSING INTERVENTIONS DURING FEVER:
and left
 Monitor vital signs and skin color
measurements
 Monitor lab values
can differ.
 Provide adequate nutrition and fluids
 Presence of
 Oral hygiene
cerumen can
 Tepid sponge bath - means look warm because we try
affect the
to balance the temperature because if we use cold
reading.
sponge bath, the fever will compensate more, which
will lead to more complications. 5.) Temporal Safe and  Requires
 Dry clothing and linens artery noninvasive; very electronic
 Antipyretics - thilenon, paracetamol, etc. fast equipment that
may be
expensive or
Advantages and Disadvantages of Sites Used for Body unavailable.
Temperature Measurements Variation in
Site Advantages Disadvantages technique
needed if the
1.) Oral Accessible and  Thermometers client has
convenient can break if perspiration on
bitten. the forehead.
 Inaccurate if
client has just
ingested hot or * Rectal thermometer - never force the thermometer if
cold goofd or resistance is felt; insert 1.5 inch. In adults.
fluid or * Axillary thermometer - the stem and bulb should be on the
smoked. axilla.
 Could injure
the mouth
following oral PULSE
surgery.
 A shock wave produced by the ontraction of the heart
2.) Rectal Reliable  Inconvenient and forceful pumping of blood out of the venricles into
measurement and more the aorta.
unpleasant for  Commonly called the arterial or peripheral pulse.
clients; difficult  Is an indirect measurement of cardiac output obtained
for client who by counting the number of apical or peripheral pulse
cannot turn to waves over a pulse point.
the side.  A normal pulse rate for adults is between 60 and 100
 Could injure beats per minute.
the rectum.
 Presence of PULSE SITES:
stool may  Temporal pulse
interfere with  Carotid pulse
thermometer  Brachial pulse
placement.  Radial pulse
 Femoral pulse
 Popliteal pulse
TUAZON, T.J.A.
 Posterior tibial pulse
 Dorsalis pedis pulse
ASSESSING THE PULSE RATE:
1. Thew nurse should begin the assessment by speaking with
the client about the normal pulse rate.
2. Palpate a peripheral pulse by placing the first two fingers
on the pulse point with moderate pressure.
3. Count the rate for a full minute, noting the regularity
(rhythm).
* moderate pressure =
* lab-dub sound
When an irregular peripheral pulse is present, the nurse
needs to assess for a pulse deficit.
 Pulse deficit
 Condition in which the apical pulse rate is
greater than the radial pulse rate.
 A pulse deficit results from the ejection of a
volume of blood that is too small to initiate a
peripheral pulse wave.
 A deficit or a discrepancy may present heart
condition such as in atrial fibrillation
When a discrepancy exists between the apical and radial
pulses, the deficit is assessed by simultaneously measuring
the apical and radial pulses for a minute.
FACTORS AFFECTING THE PULSE:
The rate of the pulse is expressed in beats per minute
(beats/min). A pulse rate varies according to a number of
factors. The nurse should consider each of the following
factors when assessing a client’s pulse:
 Age. As age increases, the pulse rate gradually
decreases overall.
Age Pulse Average Respirations
(and Ranges) Average (and
Ranges)
Newborn 130 (80-180) 35 (30-60)
1 year 120 (80-140) 30 (20-40)
5-8 years 100 (75-120) 20 (15-25)
10 years 70 (50-90) 19 (15-25)
Teen 75 (50-90) 18 (15-20)
Adult 80 (60-100) 16 (12-20)
Older adult 70 (60-100) 16 (15-20)
 Sex. After puberty, the average male’s pulse rate is
slightly lower than the female’s.
 Exercise. The pulse rate normally increases with
activity. The rate of increase in the professional athlete
is often less than in the average person because of
greater cardiac size, strength, and efficiency.
 Fever. The pulse rate increases (a) in response to the
lowered blood pressure that results from peripheral
vasodilation associated with elevated body
temperature and (b) because of the increased
metabolic rate.
 Medications. Some medications decrease the pulse
rate, and others increase it. For example, cardiotonics
(e.g. digitalis preparations) decrease the heart rate,
whereas epinephrine increases it.
 Hypovolemia / dehydration. Loss of blood from the
vascular system increases the pulse rate. In adults, the
loss of circulating volume results in an adjustment of
the heart rate to increase blood pressure as the body
compensates for the lost blood volume.
 Stress. In response to stress, sympathetic nervous
stimulation increases the overall activity of the heart.
Stress increases the rate as well as the force of the
heartbeat. Fear and anxiety as well as the perception of
severe pain stimulate the sympathetic system.
 Position. When a person is sitting or standing, blood
usually pools in dependent vessels of the venous
system. Pooling results in a transient decrease in the
venous blood return to the heart and a subsequent
reduction in blood pressure and increase in heart rate.
 Pathology. Certain diseases such as some heart
conditions or those that impair oxygenation can alter
the resting pulse rate.
PULSE CHARACTERISTICS:
 A normal pulse has defined characteristics: quality, rate,
rhythm, and volume (strength or amplitude) and
elasticity.
 Pulse quality refers to the “feel” of the pulse, its
rhythm and forcefulness.
 Normally, pulsation is equally strong in both wrists.
 Amplitude can be quantified as follows:
 0 - absent
 1 + Weak, diminished, easy to obliterate
 2 + Norma, obliterate with moderate pressure
 3 + Bounding, unable obliterate or requires firm
pressure (e.g. if angry)
 Pulse rhythm - is the regularity of the heartbeat; there
are regular intervals between beats.
 Dysrhythmia - arrhythmia; irregular heart beat.
 Pulse volume - is a measurement of the strength or
amplitude of force exerted by the ejected blood against
the arterial wall with each contraction.
TUAZON, T.J.A.
 Arterial elasticity - artery feels straight, resilient, and
springy.
 Bradycardia - is a heart rate less than 60 beats per
minute in an adult; may be normal in well - conditioned
clients.
 Tachycardia - is a heart rate in excess of 100 beats per
minute in an adult; may be normal in clients who have
just finished strenuous exercise.
RESPIRATIONS
 The act of breathing.
 Rate and character are additional clues to the client’s
overall health status.
PROCESS OF RESPIRATION:
 External respiration - interchange of Oxygen and
Carbon Dioxide between alveoli and the pulmonary
blood.
 Internal respiration - interchange of Oxygen and
Carbon Dioxide between the circulating blood
(pulmonary blood) and body tissues.
 Inhalation - intake of air into the lungs.
 Exhalation - movement of air from lungs to the
atmosphere.
 Ventilation - movement of air in and out of the lungs.
TYPES OF BREATHING:
 Costal / Thoracic
 External intercostal muscles
 Accessory muscles
 Chest upward then outward
 Chest expansion is centered at midpoint
 More work to be done in lifting the rib cage
 Useful for vigorous activities
 Usually occurs when the individual is aroused
by challenges or danger (tension and anxiety)
 Abdominal / Diaphragmatic
 Contraction and relaxation of the diaphragm
 Movement of the abdomen
 Diaphgragm is the principal muscle of use
(strong dome - shaped sheet of muscle that
separates chest cavity from the abdomen)
 Breath-in, diaphragm CONTRACTS - lungs
expand, creating a partial vacuum, allows air
to be drawn in (INHALATION)
 Breath-out, diaphragm RELAXES - abdominal
muscles contract and expel air that contains
carbon dioxide.
 Diaphragmatic breathing is the most efficient
because greater expansion and ventilation
occurs in the lower part of the lung where
blood perfusion is the greatest dual is
aroused by challenges or danger (tension and
anxiety).
NORMAL BREATHING IS ACCOMPLISHED BY:
1. The downward and upward movement of the diaphragm
to lengthen or shorten the chest cavity.
2. The elevation and depression of the ribs to increase and
decrease the anteroposterior diameter of the chest cavity
MAJOR PHYSICAL PULMONARY FUNCTIONS:
 Ventilation - the inflow and outflow of air between the
atmosphere and the lung alveoli.
 Circulation - the quantity of blood flowing through the
lungs is approximately 4 to 6 l/min.
 Diffusion - the exchanghe of oxygen and carbon dioxide
between the alveoli and the blood.
 Transport - the carrying of oxygen and carbon dioxide
in the blood and body fluids to and from the cells.
ASSESSING RESPIRATION:
 Normal breathing is slightly observable, effortless,
quiet, automatic, and regular.
 It can be assessed by observing chest wall expansion
and bilateral symmetrical movement of the thorax.
 Sites:
 Chest wall
 Thorax
 Nose and mouth
HOW TO DO IT?
 Place your hand over client’s wrist and observe one
complete respiratory cycle.
 Start to count with first inspiration while looking at
second hand sweep of watch.
 Nursing consideration
 Observe respirations without alerting the client by
watching the chest movement while continuing to
palpate the radial pulse.
BREATHING PATTERNS:
Rate
 Tachypnea - quick, shallow breaths
 Bradypnea - abnormally slow breathing
 Apnea - cessation of breathing
Volume
 Hyperventilation - overexpansion of the lungs
characterized by rapid and deep breaths.
 Hypoventilation - underexpansion of the lungs,
characterized by shallow respirations
Rhythm
 Cheyne-Stokes breathing - thythmic waxing and
waning of respirations, from very deep to very
shallow breathing and temporary apnea
Ease 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.
* 12 to 20 normal respiration
BREATH SOUNDS:
Audible Without Amplification
 Stridor - a shrill, harsh sound heard during
inspiration with laryngeal obstruction.
 Stertor - snoring or sonorous respiration, usually
due to a partial obstruction of the upper airway.
 Wheeze - continuous, high-pitched musical squeak
or whistling sound occurring on expiration and
sometimes on inspiration when air moves through
a narrowed or partially obstructed airway.
 Bubbling - gurgling sounds heard as air passes
through most secretions in the respiratory tract.
TUAZON, T.J.A.
Chest Movements
 Intercostal retraction - indrawing between the ribs.
 Substernal retraction - indrawing beneath the
breastbone.
 Suprasternal retraction - indrawing above the
clavicles.
Secretions and Coughing
 Hemoptysis - the presence of blood in the septum
 Productive cough - a cough accompanied by
expectorated secretions
 Nonproductive cough - a dry, harsh cough without
secretions.
BLOOD PRESSURE
 Blood pressure is the measure of pressure exerted as
blood flows through the artery.
 Measurement of the pressure of the blood in the
arteries when the ventricles are contracted systolic
blood pressure - SBP) and when the ventricles are
relaxed (diastolic blood pressure - DBP).
 It is measured in terms of millimeters of mercury
(mmHg) and written in fraction form.
 NORMAL VALUE is below 120 (systolic) and below 80
(diastolic).
FACTORS AFFECTING BLOOD PRESSURE:
 Age. Newborns have a systolic pressure of about 75
mmHg. The pressure rises with age, reaching a peak at
the onset of puberty, and then tends to decline
somewhat. In older adults, elasticity of the arteries is
decreased —the arteries are more rigid and less
yielding to the pressure of the blood pressure. Because
the walls no longer retract as flexibly with decreased
pressure, the diastolic pressure may also be high.
* Low cardiac output = low blood pressure
* Increase cardiac output = increase blood pressure
 Exercise. Physical activity increases the cardiac output
and hence the blood pressure. For reliable assessment
of resting blood pressure, wait 20 to 30 minutes
following exercise.
 Stress. Stimulation of the sympathetic nervous system
increases cardiac output and vasoconstriction of the
arterioles, thus increasing the blood pressure reading:
however, severe pain can decrease blood pressure
greatly by inhibiting the vasomotor center and
producing vasodilation.
 Race. African Americans older than 35 years tend to
have higher blood pressures than European Americans
of the same age althought the exact reasons for these
differences are unclear (Covelli, Wood, & Yarandi,
2012).
* Asians are prone to hypertension
 Sex. After puberty, females usually have lower blood
pressures than males of the same age; this difference is
thought to be due to hormonal variations. After
menopause, women generally have higher blood
pressures than before.
 Medications. Many medications, including caffeine,
may increase or decrease the blood pressure.
 Obesity. Both childhood and adult obesity predispose
to hypetension.
 Diurnal variations. Pressure is usually lowest early in
the morning, when the metabolic rate is lowest, then
rises throughout the day and peaks in the late
afternoon or early evening.
 Medical conditions. Any condition affecting the cardiac
output, blood volume, blood viscosity, and/or
compliance of thearteries has a direct effect on the
blood pressure.
 Temperature. Because of increased metabolic rate,
fever can increase blood pressure. However, external
heat causes vasodilation and decreased blood pressure.
Hypertension
 A blood pressure that is persistently above normal.
 A single elevated blood pressure reading indicates the
need for reassessment.
 Cannot be diagnosed unless an elevated blood pressure
is found when measured twice at different times.
 It is usually asymptomatic and is often a contributing
factor to myocardial infarctions (heart attacks).
 It is a widespread health problem.
 An elevated blood pressure of unknown cause is called
PRIMARY HYPERTENSION.
 An elevated blood pressure of known cause is called
SECONDARY HYPERTENSION.
* If there are no medical history and/or hereditary history of
hypertension, then it is PRIMARY HYPERTENSION. Vice versa
to the secondary hypertension.
Classification of Blood Pressure
Category Systolic BP Diastolic BP
(mmHg) (mmHg)
Normal <120 and <80
Prehypertension 120-139 or 80-89
Hypertension, 140-159 or 90-99
stage 1
Hypertension, >160 or >100
stage 2
* As said by ma’am, you can base here or the book regarding
the classification of BP
Hypotension
 Is a blood pressure that is below normal, that is, a
systolic reading consistently between 85 and 110
mmHg in an adult whose normal pressure is higher
than his.
 Orthostatic hyptension - is a blood pressure that
decreases when the client sits or stands. It is usually the
result of periphreal vasodilation in which blood leaves
the central body organs, especially the brain, and
moves to the periphery, often causing the person to
feel faint.
 Can also be caused by analgestics such as meperidine
hydrochloride (Demerol), bleeding, severe burns, and
dehydration. It is importnt to monitor hypotensive
clients carefully to prevent falls. When assessing for
orthostatic hypotension:
 Place the client in a supine position for 10 minutes.
 Record the client’s blood pressure.
 Assist the client to slowly sit or stand. Support the
client in case of faintness.
 Immediately recheck the blood pressure in the
same sites as previouslu.
TUAZON, T.J.A.
 Repeat the pulse and blood pressure after 3
minutes.
 Record the results. A drop in blood pressure of 20
mmHg systolic or 10 mmHg diastolic indicates
orthostatic hypotension (Mager, 2012).

ASSESSING BLOOD PRESSURE:

BLOOD PRESSURE ASSESSMENT SITES:

 The blood pressure is usually assessed in the client’s
upper arm using the brachial artery and a standard
stethoscope. Assessing the blood pressure on a client’s
thigh is indicated in these situations:
 The blood pressure cannot be measured on either
arm (e.g., because of burns or other trauma).
 The blood pressure in one thigh is to be compared
with the blood pressure in the other thigh.
 Blood pressure is not measured on a particular client’s
limb in the following situations:
 The shoulder, arm, or hand (or the hip, knee, or
ankle) is injured or diseased.
 A cast or bulky bandage is on any part of the limb.
 The client has had surgical removal of breast or
axillary (or inguinal) lymph nodes on that side.
 The client has an intravenous infusion or blood
transufion in that limb.
 The client has an arteriovenous fistual (e.g., for
renal dialysis)d in that limb.
Korotkoff phases:
 Phase 1: The pressure level at which the first faint,
clear tapping or thumping sounds are heard. These
sounds gradually become more intense. To ensure that
they are not extraneous sounds, the nurse should
identify at least two consecutive tapping sounds. The
first tapping sound heard during deflation of the cuff is
the systolic blood pressure.
 Phase 2: The period during deflation when the sounds
have a muffled, whooshing, or swishing quality.
 Phase 3: The period during which the blood flows freely
through an increasingly open artery and the sounds
become crisper and more intense and again assume a
thumping quality but softer than phase 1.
 Phase 4: the time when the sounds become muffled
and have a soft, blowing quality.
 Phase 5: the pressure level when the last sound is
heard. This is followed by a period of silence. The
pressure at which the last sound is heard is the diastolic
blood pressure in adults
.
TUAZON, T.J.A.
HEALTH ASSESSMENT - NCMA 121
prELiMS rEVIEWEr

W4: pAIN (THE 5TH VITAL SIgN)