Table of Contents

Nursing health Assessment

Unit 1
Holistic health assessment
1.1 Concept of health assessment
 Health W.H.O define health as:
A state of complete physical mental and social well being not merely the absence of
disease or infirmity.
 Mental health: ability to learn and think clearly
 Social health: -ability to make and maintain acceptable interactions with other
people
 Illness: is the subjective state of a person who feels aware of not being well.
 Sickness: is a state of social dysfunction a role that an individual assumes when
ill.
Risk factors of developing illness
A risk factor: is any situation habit social or environmental condition developmental or
intellectual condition spiritual or other variable that increases the vulnerability of an
individual or group to an illness or accident.
The presence of risk factors does not mean that a disease will develop but risk factors
increase the chance that the individual will experience particular disease or dysfunction.
Risk factors some times called health hazards.
Risk factors can be place in the following inter related categories
1. Genetic and physiological factors
2. Age
3. Physical environment
4. Life style
1. Genetic and physiological factors
Physiological risk factors involve the physical functioning of the body.
E.g. pregnancy, over weight place increased stress on physiological system
Heredity or genetic predisposition to specific illness is a major physical risk factor
Eg, a person with family history of diabetes mellitus is at risk for developing the disease
later in life. Others disease with genetic risk include family history of caheart mental
illness.
2. Age
Age increases or decrease susceptibility to certain illnesses.
E.g. Risk of heart disease increase with age for both sexes.
The risk of birth defect and complications of pregnancy increase in women bearing
children after age 35.
3. Environment
The physical environment in which a person works or lives can increase the likelihood
that certain illness will occur E.g. Some kinds of cancer and other disease are more likely
to develop when likely to develop when industrial workers are exposed to certain
chemicals.
Poor housing e.g. over crowding
Pollution

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 4. Life style
Many activates, habits and practices involve risk factors
Life style practices and behaviors can also have positive or negative effect on health.
Practices with potential negative effects are risk factors; these include overeating or poor
nutrition.
Other habits that put a person at risk for illness include tobacco use alcohol or drug
abuse, and activities involving a threat of injury such sky diving (sport jump from plane
before opening parachute)
Excessive sun bathing increase the risk of skin Ca
Stress can be a lifestyle risk factor if it sever or prolonged or if the person is unable to
cope with life events adequately.
 Wellness and well being
 Wellness : is a state of well – being
 Wellbeing: is a subjective perception of vitality and feeling well can be described
objectively experienced and measured.
 Disease: denotes the condition of the human body in which some thing has gone
wrong and has upset the normal functions of the body including the mind.
The international classification of disease (ICD) distinguishes between three
terms:
Impairment: this is any loss or abnormality of mental .anatomical physiological
structure of function.
Disability: is any restoration of lack resulting from impairment of the ability to
perform an activity in a manner or range considered normal for
ahuman being thus the loss of a finger may be impairment but not a
disability because it is unlikely to restrict normal activity.
Handicap:Is along term disadvantage which adversely affects an individual’s
person.Thus for example female circumcision would be considered
impairment but in some cultures not being circumcised would be
considered handicap because it reduces a girl’s chance of getting
married and achieving independence form her parents.

1.2 Introduction to nursing process

Nursing process: -is asystemic, rational method of planning and
providing individualized nursing care.
Goal of nursing processes is to:
1. Care may be terminated if goals are achieved or
2. The cycle may continue with re- assessment or
3. Plan may be modified.
Components of nursing process (the phases/steps of nursing process)
1st Assessing
2nd Diagnosing
3rd planning
4th implementing
5th Evaluating
Assessment
Assessment is the first step of nursing process.
Activities of assessment include:
 Collect data

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  Organize data
 Validate data
 Document date
Types of assessment are:-
1. Initial/comprehensive assessment - provide base line data for reference and
future comparison.
2. Focus assessment -determines status of specific problem identified during
previous assessment.
3. Time/lapsed assessment - comparison of the patient’s current status with
base line obtained previous.
4. Emergency assessment: identification of life threatening situation.
The assessments data are obtained by five methods:
 Interview
 Physical examination
 Observation
 Review of records and diagnostic reports
 Collaboration with colleagues
The data collection focuses on identifying:
 Present and past health status
 Present and coping patterns(strength and limitations)
 Present and past functional status
 Risk for potential problems
 Desire for higher level of wellness.
Functional health patterns (Gordon’s approach)
It used to direct the nurse in collecting data to determine an individual or group’s
health status and functioning.
Gordon has developed a system for organizing a nursing assessment based on
function.
The eleven functional health patterns are:-
1. Health perception & health management
Subjective data:
 Information concerning patient’s perception of his/her health and methods
used to maintain health.
 Visit to health professionals
 Recreational drugs such as alcohol.
 Prescription drugs/ non prescription drugs
Objective data:
 Direct observation of a patient health practice is usually not possible.
 The number of appointments the patient lost
 Drug that are not taken timely
 Blood sugar level of diabetic patient
 BP of hypertensive patient
2. Activity and exercise
Three areas will be assessed
2.1 Mobility and self care
Subjective data on mobility and self care:
 Activates of daily living (self care skills) bathing, toileting,
feeding.

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  Simple motor activities- sitting, standing, walking opening doors.
 Home maintenance skill eg, cooking, bed making
 Any restriction of activity
Objective data on mobility and self- care:
 Musculoskeletal assessment
 Motor examination(gait and balance, abnormal movement)
 Muscle characteristics (tone, strength, bulk)
2.2 Respiratory function
Subjective data on respiratory function:
 Risk factor for lung disease e.g.contact with known TB patient,
smoking
 Symptoms of respiratory dysfunction e.g cough, sputum
production chest pain, shortness of breathing etc
 Medication
Objective data on mobility and self care:
 Respiratory pattern assessment
 Assessment of lung and thorax
2.3 Cardiovascular function
Subjective data on cardiovascular system:
 Risk factor for cardiovascular functioning e.g. family history of
elevated cholesterol, hypertension, smoking
 Symptoms of CVS dysfunction such as shortness of breathing, use
of extra pillows, orthopnea, fainting dizziness etc
 Medications
Objective data on cardiovascular assessment:
 Pulse rate, rhythm, strength
 Assessment of cardiovascular system
3. Nutrition and metabolism
Subjective data
 Normal food & fluid intake
 Alteration in normal eating
e.g. -Dietary restriction such as salt and sugar, NPO
-Vomiting, nausea, loss of appetite
Objective data:
 Wt, ht, BMI
 Mouth exam (dryness of lip, buccal mucosa, any ulceration, teeth)
 Abdominal exam
4. Elimination
4.1 Urinary elimination
4.2 Bowel elimination
Subjective data of urinary elimination:
 Change in pattern (frequency, quantity)
 Problems such as pain, hesitation, urgency, incontinence
 History o bladder surgery
 Blood or pus in the urine

Objective data of urinary elimination

 Inspection or urine

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  Exam of lower abdomen ( light palpation and percussion of the
bladder)
Subjective data of bowel elimination:
 Difficulty in bowel regularity(constipation, frequency)
 Action taken to keep regularity (certain foods enemas laxatives
exercise)
 Color and consistency
 History of bowel surgery
Objective data of bowel elimination:
 Inspection of the of the feces consistency
5. Sleep and rest pattern
Subjective data
 Normal hours of sleep per day
 Nap during the day
 Whether the pt feels generally rested and energetic during the day
or not
 Satisfaction with sleep
 Any difficulty of going asleep
 Any measure taken to induce sleep including sleep medications
Objective data
 Frequent yawing
 Decreased attention span
6. Cognition and perception
For assessment purpose cognition and perception are divided in to three areas.
6.1 cognitive function
6.2 Sensory fun
6.3 pains
Subjective data of cognitive function:
 The level of education
 Ability to learn
 Difficulty of decision making
Objective data of cognitive function:
 Mental status examination
 Level of consciousness
 Orientation
 Judgment
 Concentration
Subject data sensory function
 Include information about sense organ
Objective data sensory function
 Sensory assessment such as redness of the eye, discharge from the
eye, presence of follicles and panus, corneal ulceratin,use of Visual
aid (eye glass)
 Auditory assessment such as ear discharge, perforation of ear
drum,
 Other sensory assessment such as ability of smelling by use of
alcohol, tasting by use of salt or sugar.
Subjective data of pain
 Verbal report of pain

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  Effect of pain on daily activities
 Effect of pain on social function
Objective data of pain
 Sign of sympathetic stimulation such as elevation of BP,P,RR,T
 Guarding
7. Self perception and self conception
Focus on the content and feelings associated with self evaluation
Component of self concept includes:
 One’s sense of power
 Acceptance and valve by other
 Competence in physical, intellectual and social dimensions
Subjective data self perception and self conception
 How the pt describes himself
 What the person considers to be his/ her weakness or strength
 Whether the pt feels good or bad, most of the time about him/herself.
Objective data of self perception and self conception
 Eye contact
 Personal appearance
 Posture and body movement
 Mood and emotion
 Voice and speech pattern

8. Roles and relation ship

Subjective data
 Family and home situation
 How the family has been affected by the pt’s illness
 Problems of the family that the patient has failed to fulfill
 The effect of the pt’s illness on his daily functioning
 Work satisfaction and harmony
 Current change I the relation of the pt with the family coworkers and other
 Belief on the pt whether his neighborhood and community are supportive
to him or not
Objective data:
 Observe interaction of patient with families, friends.
 Observe repeated unexplained injuries such as bruise burns, and fracture
9. Coping and stress tolerance
Assessment of this helps to identify:
 Current stressors the pt is experiencing
 To determine how the pt has handled stressful evnt
 To identify current methods the pt is using to cope
Subjective Data:-
Observation of sympathetic stimulation for sudden stress
Objective data:
Observation of sympathetic stimulation
10. Sexuality and reproduction pattern
Subjective data:
 Puberty, menstruation, menopause and number of children
 Sexually transmitted disease,

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  Use of contraception (FP)
 Change in functioning of sexuality
 Details of obstetric histories and belief of patient to function as a mother

Objective data:
 Examination of breast
 Examination of reproductive organ
11. Belief and value
This pattern is also called spiritual assessment because it focuses on the spiritual
dimensions of life.
Subjective data
 Religious practice important to the person
 Religion of the patient
 Impacts of illness on the patients belief
 Patients need to see the chaplain (priest)
Objective data:
 Observation of religious articles
 Observation of patient while praying
 Observations of visit from clergy etc.
Nursing diagnose
In this phase the nurse clusters, and analyses the data and asks, what are the actual and
potential health problem the clientsneeds nursing assistance and what factors contribute
to this problem, establish the nursing diagnosis.
Types of Nursing Diagnosis
1. Actual nursing diagnosis
2. Risk/ poetical nursing diagnosis
3. Possible nursing diagnosis
4. Syndrome nursing digonosis
5. syndrome nursing diagnosis
One part- one part statements conations only the diagnostic label, as in wellness and
syndrome nursing diagnoses.
Two part - two part statements contain the diagnostic label and the factors that have
contributed or could contribute to a health status change, as in possible and
high risk diagnoses.
Three part- three part statements contain the diagnostic label, the contributing factor and
the sign and symptoms, as in actual nursing diagnose.
1. Actual nursing diagnosis
Actual nursing diagnosis represents a state that has been clinically validated by
identifiable major defining characteristics.
This type of nursing diagnose has three parts.
1. Diagnostic label
2. Contributing factor or related factor
3. Sign and symptoms
E.g.Altered nutrition, related to in adequate calory in take, as evidenced by weight loss.
2. Risk nursing diagnose:
As defined by NANDA a risk nursing diagnosis is a “clinical judgment that an individual
family or community is vulnerable to develop the problem than others in the same or
similar situation.
It has two parts:
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 1. Diagnostic label
2. Contributing factor or related factor
For example: High risk for impaired skin integrity, related to immobility secondary to
pain.
3. Possible Nursing diagnosis
 Possible nursing diagnoses are statements describing a suspected problem for
which additional data are needed to confirm or rule out.
 With possible nursing diagnosis the nurse has some data to support a confirmed
diagnose but they are they are insufficient.
 One must reserve judgment until all necessary information has been gathered and
analyzed to arrive at a sound scientific conclusion.
 NANDA doesn’t address possible nursing diagnoses because they are not a
classification issue but instead, an option available for all approved NANDA
diagnoses.
 Possible nursing diagnosis are two part statements consisting of:
1. Diagnostic label
2. Contributing factor or related factor
 For example:- possible self- concept disturbance, related to recent loss of role
responsibilities
4. Wellness nursing Diagnosis
According to NANDA a wellness nursing diagnose “clinical judgment about an
individual group or community in transition from a specific level of wellness to higher
level of wellness.
For an individual or a group to have a wellness nursing diagnosis two cues should be
present.
1. Desire for a higher level of wellness
2. Effective present statues or function
Wellness nursing diagnosis one part statements containing the diagnostic label only.
For example: potential for enhanced family process.
5. Syndrome nursing diagnosis
Syndrome in medicine represents a cluster or group of sign and symptoms.
Syndrome nursing diagnoses comprises a cluster of high risk nursing diagnose that are
predicted to preset because of a certain event or situation.
Syndrome nursing diagnoses are usually one part diagnostic statement containing the
diagnostic label only.
For example: impaired physical mobility risk for impaired tissue integrity risk for
activity intolerance, risk for constipation, risk for infection, risk for injury, risk for
powerlessness, impaired gas exchange .
Planning
Care plans have two professional purposes:
1. Administrative purpose
Eg, Differentiates the accountability of the nurse form that of other members of
the health team.
2. Clinical purpose
E.g. Communicate for the nursing staff what to each what to observe and what to
implement .
Activities of planning phase are:-
1. Establishing a priority set of diagnosis
2. Establish goals/ out come criteria
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 3. Selecting nursing interventions
4. Writing nursing order ( interventions)
Out come criteria-
Used to:-
 Direct interventions to achieve the desired change or maintenance
 Measure the effectiveness and validity of the interventions.
The essential characteristics of out come criteria are as follows:-
1. Be log term or short term
2. Have measurable behavior that can be validated (eg, by seeing or hearing)
Examples of verbs that are measurable include: states, performs, identifies,
reports e.t.c
3. Be specific in content and time
 To be specific O.C should answer the question who what action, what and
when (specific time)
 To be specific in time we can use
 By discharge e.g the client will be able to feed himself by discharge after one
mouth
 Continued (e.g. the client will demonstrate continued in tack skin)
 After one mount (e.g. the client will able to demonstrate walk after one
month)
4. Be attainable
Developing nursing care plan
The nurse should use the following guidelines when writing care plans:
1. Write date and sign the plan
 Date is used for evaluation, review and future planning
 The nurse’s signature shows accountability to the client and to the profession
2. Use category heading:
 Nursing diagnoses
 Goals /out comecriteria
 Nursing interventions and
 Evaluation
3. Use standardized medical or English symbols and key words rather than complete
sentences to communicate your ideas.
E.g. turn q 2hrs rather than turn the client every two hours.
4. Be specific
E.g . Change incision dressing BID (6Am, 6PM)

Date_________________
Goals /out come
Nursing Diagnose criteria Nursing intervention Evaluation
Ineffective breathing, The client will  Monitor respiratory q 4hrs After 1 wk,
related to RTI, as demonstrate average  Maintain semi sitting posit the client’s RR
evidence by dyspnea. RR after 1 week  Administer the order drug becomes
20/min.
Activity intolerance, The client will able  Assist in ADL The client is
related to leg fracture, to walk with  Reassure the client not yet able to
as evidenced by crutches after two  Give balanced diet walk.
inability to walk. months.
Signature___________________
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Implementation
 Implementation refers to the action phase of the nursing process in which nursing
care plan is put in to action or implement the nursing interventions.
 Document nursing activities.
Evaluation
To check if goals are achieved or not that is,
 Met goals
 Partially met goals
 Unmet goals

Summary of Nursing process in action

Activities of Assessing PHASE:
 Collect data
 Organize data
 Validate data
 Document data
Activities of Diagnosing PHASE:
 Analyze data
 Identify health problems, risk and strengths
 Formulate diagnostic statement
Activities of planning PHASE
 Prioritize problem/ diagnosis’s
 Formulate goals/ desired out comes
 Select nursing interventions
 Write nursing orders
Activities of implementing PHASE
 Reassess the client
 Determine the nurse’s inversions
 Implement the nursing interventions
 Supervise delegated case
 Document nursing activates.
Activities of Evaluating PHASE
 Collect data related to outcomes
 Compare data with out comes
 Relate nursing actions to client goals out
 Draw conclusions about problem status
 Continue modify terminate the clients care plan

Unit 2
Nursing Health History
Definition of nursing health history:
It is data collected about the client’s current level of wellness, including a review of body
systems, family and halt history, sociocultural history, spiritual health, and mental and
emotional reactions to illness.

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2.1 Components of nursing health history
Components of nursing health history
A. Biographic Data:
Client’s,
name
a. address
b. age
c. sex
d. marital status
e. occupation
f. religious preference
g. source of medical care
h. vital sign
i. C.No
j. data of admission
k. condition on admission
`B. Chief Complaint or Reason for visit:
 Itis one ormoresymptoms or other concerns for which the client is seeking
care or advice.
 The answer given to the question “what is troubling your” or “what
brought you to the hospital or clinic?”
 The chief complain should be recorded in the client’s own words.
C. History of present illness
It is amplification or elaboration of the chief complaint. It includes:
 When the symptom started
 Whether the onset of symptoms was sudden or gradual
 How often the problem occurs
 Exact location of the distress
 Character of the complaint (e.g. intensity of pain, quality of sputum
emesis, or discharge )
 Activity in which the client was involved when the problem occurred
 Factors that aggravate or alleviate the problem
D. past history
 Child hood illnesses, such as chicken pox,mumps, measles, streptococcal
infections, scarlet fever, and other significant illnesses
 Child hood immunization
 Allergies to drugs
 Accidents and injuries: how when and where the incident occurred, type of
injury treatment received any complications.
 Hospitalized for serious illness reasons for hospitalization
 Medications: all currently use prescription and over- the counter
medications, such as aspirin, nasal spray vitamins or laxatives
E. Family History of Illness
To ascertain risk factors for certain diseases, the age of siblings, parents, grand
parents and their current state of health or, if they are deceased, the cause of death
areobtained. Particular attention should be given to disorders such as heart
disease, cancer, diabetes, hypertension, obesity, allergies, arthritis, tuberculosis,
bleeding, alcoholism, and any mental disorders.

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F. Life style/social data
 Personal habits: substance use ( tobacco, alcohol, coffee, cola, tea
recreational drugs)
 Hobbies/recreation
 Social data the clients support in the time of stress.

UNIT 3
Physical assessment
3.1 Introduction to physical assessment
Purpose of physical assessment
A. To obtain baseline data about the client’s functional abilities
B. To supplement, confirm, or refute data obtained in the nursing history
C. To obtain data that will help establishing nursing diagnoses and plan of care
D. To evaluate the physiologic out comes of health care and thus the progress of a
client’s health problem
E. To make clinical judgments about a client’s health status
F. To identify areas for health promotion and disease prevention
Patent’s preparation for physical assessment
 The nurse should explain when and where it will take place, why it is important,
and what will happen during the examination.
 Empty the bladder
Preparing the environment
 It is important to prepare the environment before staring the assessment
 The time for the physical assessment should be convenient to both the client and
the nurse.
 The environment needs to be well lighted and the equipment should be organized
for use
 Providing privacy is important
 The room should be warm enough to be comfortable for the client
Positioning
 Several positions arefrequently require during the physical assessment
 It is important to determine in advance any positions that are contra- indicated for
a particular client
 It is important to consider the client’s ability to assume a position
 Some positions are embarrassing and uncomfortable and there foreshould not ne
maintained for long
Draping
 Drapes should be arranged so that the area to be assessed in exposed and other
body areas are covered
 Drapes provide not only a degree of privacy but also warmth.

Techniques of physical assessment

Four primary techniques are used in the physical examination:
 Inspection
 Palpation

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  Percussion
 Auscultation
Inspection:
Inspection- is the visual examination that is, assessing by using sense of sight.
 The nurse inspects with the naked eye and with a lighted instrument such as an
otoscope (used to view the ear).
 Nurses frequently use visual inspection to assess moisture, color, and texture of the
body surfaces, as well as shape, position, size, and symmetry of the body.
Palpation:
Palpation in the examination of the body using the sense of touch
The pads of the fingers are used because their concentration of nerve endings
makes them highly sensitive to tactile discrimination.
Palpation is used to determine:
 Texture (eg of the hair)
 Temperature
 Vibration
 Position, size, consistency, and mobility of organs or masses
 Distention (e.g. of the urinary bladder)
 Pulsation
 The presence of pain up on pressure
 To test temperature use the dorsum or back of the hand and fingers, where the
skin is thinnest.
 To test vibrations use the palmer surface of the hand.
General guidelines for palpation
1. The nurse’s hands should be clean and warm, and the finger nails short.
2. Areas of tenderness should be palpated last
3. Deep palpation should be done after superficial palpation

Percussion:
Percussion: -is the act of striking the body surface to elicit sounds that can be heard or
vibrations that can be felt.

There are two types of percussions:

Direct percussion
Indirect percussion
During direct percussion- the nurse strikes the area to be percussed directly with the pad
of two, three, or four fingers or with the pad of middle finger.
The strikes are rapid, and the movement is from the wrist.
N.B direct percussion is not generally used to percuss the thorax but useful in percussing
an adults sinuses.
Indirect percussion- is the striking of an object (eg, a finger) held against the body area
or be examined.
In this technique, the middle finger of the non – dominant hand, referred to as the
pleximeter, is placed firmly on the client’s skins.
Only the distal phalanx and the joint of this finger should be in contact with the skin.
Using the tip of the flexed middle finger of the other hand, called the plexor, the nurse
strikes the pleximeter, usually at the distal inter phalangela joint.

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Some nurses may find a point between the distal and proximal joints.
The motion cones from the wrist; the forearm remains stationary
The angle between the plexor and the pleximeter should be 90 0 (degrees) and the blows
be firm, rapid and short to obtain a clear sound.
Percussion is used to determine the size and shape of internal organs by establishing their
border.
It indicates whether tissue is fluid filled, air filled or solid.
Percussion elicits five types of sound:
 Flatness
 Dullness
 Resonance
 Hyper resonance
 Tympany
Flatness: is an extremely dull sound produces by very dense tissue, such as a musle or
bone.
Dullness: is like sound produced by dense tissue such as the liver, spleen, or heart.
Resonance: is a hollow sound such as that produced by lungs filled with air.
Hype resonance:is not produced in the normal body. It is described as booming and can
be heard over an emphysematous lung.
Tympany: is amusical or drum like sound produced from an air filled stomach.
N.B – Generally, flatness reflects the most dense tissue (the last amount of air)
and tympany the least dense tissue (the greatest amount of air).
Auscultation:
 Auscultation is the process of listening to sounds produced within the body.
Auscultation may be direct or indirect.
 Direct auscultation is the use of the unaided ear, for example, to listen to a
respiration wheeze or the grating of a moving joint.
 Indirect auscultation is the use of a stethoscope, which transmits the sounds to the
nurse’s ears.
 A stethoscope is used primarily to listen to sounds from within the body, such as
bowel sounds or valve sounds of the heart and blood pressure.
 The ausculatedsounds are described according to their pitch, intensity, duration,
and quality of their sound.
-Pitch – frequency of vibration
-Intensity- amplitude
-Duration of a sound – (long or short)
-Quality of sound e.g. whistling, gurgling, or snapping – it is a subject
description

3.2Survey of Body System

General assessment including vital signs
 Health assessment beings with a general survey that involves observation of the
client’s general appearance and mental status, and measurement of vital signs, height,
and weight.
 Many components of the general survey are assessed while taking the client’shealth
history, such as the client’s body build, posture, hygiene and mental status.
Vital signs
1. Pulse

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Apical pulse- is located at apex of heart.
A peripheral pulse- is pulse located a way from the heart
Pulse sites:
a. Temporal
b. Carotid
c. Apical
d. Radial
e. Brachial
f. Radial
g. Femoral
h. Popliteal
i. posterior tivial
j. pedal ( dorsalis pedal)
The difference between apical pulse and radial pulse is called pulse deficit.
2. Respiration–respiratory rate of adult
3.Body temperature:
Body To is frequently measured
 orally
 Rectally
 Axillary
 In addition forehead by chemical
4. Blood pressure:
 Systolic pressure – the pressure of blood as a result of contraction of ventricles
 Diastolic pressure- the pressure when ventricles are at rest.
 The difference betweensystolic pressure anddiastolic pressureis the pulse
pressure
Assessment of the integument
 The integument includes the skin, hair and nails
 The examination begins with inspection
Skin:
 Assessment of the skin involve inspection and palpation
 Inspect for color such as pallor, cyanosis, jaundice, Erythema(Which is associated
with a redness associated with variety of rashes)
 Vitligo- seen as patches of hypo pigmented skin.
 Albinism- is the complete or partial lack of melanin in the skin, hair and eyes
 Palpate for edema by pressing ( the presence of excess interstitial fluid)
 Assess the skin turgor- pinch and release
 Palpate for nodule (elevated tumor)

Hair:
 Assessing the client’s hair includes inspecting and palpating the hair.
 In kwashiorkor patient the hair color faded and the texture is course and dry
 Some therapies cause alopecia (hair loss)
 Some disease affect coarseness of hair eg, hypothyroidism can cause very thin
and brittle hair.
Nails:-
 Are inspected for nail plate shape, angle between the nail and the nail bed, nail
texture, nail bed color, and intactness of the tissue around the nails
 The plate is normally color less and a convex curve
15
  Clubbing may be caused by a long term lack of oxygen
 A bluish nail bed reflect cyanosis
 Pallor may reflect poor circulation
 Excessively thick nails can appear in the elderly, poor circulation, or in fungal
infection.
Assessment of the HEENT(Head, Eye, Ear, Nose, Throat)
The head:
 The assessment of head includes inspection and palpation of the hair, scalp, skull
and face.
 On the hair assess, quanity, distribution, texture, loss nits.
Example: fine hair in hyperthyroidism, coarse hair in hypothyroidism, silking of
hair in AIDS, alopecia (hair lose) in some therapy.
 Scalp – for scaliness, lumps, lesions
 Skull- size, contour of the skull, deformity, lumps and tenderness
They eye:
Examination of the eye includes assessment of:
1. Visual acuity- the degree ofdetail the eye can discern in an image
Snellen’s chart-is used to test visual acuity.
Technique:
 Ask the patient to stand 6m(20feet) way from the chart
 Cover the eye not being tested
 Ask the pt to read the chart
 Normal 6/6m or 20/20 feet
 The valve”20/x” is interpreted in such a way that 20 is the distance of the patient
from the chart, and “X” is the distance at which an average eye can read the
same line of print.
2. Visual fields the area an individual can see when looking straight ahead
Technique:
 Instruct the client to sit 2feet in front of you. Your eyes should be at same level as
those of the person being tested.
 Have the person corer one eye and stare at your eyes directly opposite close your
other eye.
 Move a pen between you and the person in the common field of vision after
instructing the person to tell you when the finger or pencil is first seen.
 Normally, you and the person should see the object at the same time. The object
should be seen with in 50 degrees superiorly, 60 degrees nasally, 70 degrees
inferiorly and 90 degrees temporally.

3. External structures:
Eye brows- is specs its quantity and distribution
- ask if it has been plucked
- inspect color or hematomas, edemas
Palpate lacrimal gland and observe the discharge.
Conjunctiva and Sclera - Inspect color of scalier eg jaundice
Cornea and lens: Inspect for opacity of cornea and lenses
Pupils: test papillary reaction to light.
The ears and hearing:-

16
 Assessment of the ear includes direct inspection and palpation of the external ear,
inspection of the remaining parts of the by an otoscope, inspects any discharge, foreign
body, redness, lesions, inspect ear drum and determination of auditory acuity.
Hearing – is assessed, one ear at a time, by determining if the client can hear the nurses
whispered voice or a ticking watch from 1-2 feet. When hearing loss is found, tuning fork
is used for assessment.
Hearing loss may be:
1. Conduction hearing loss- is the result of interrupted transmission of sound waves
through the outer and middle ear structures.
E. gtears of tympanic membrane
2.Sensory neural hearing loss- is the result of damage to the inner ear, the auditory
nerve.
3.Mixed
Weber’s test (used to assess bone conduction):
Technique - hold the tuning fork at the base and strike it against the palm of the opposite
hand so the fork vibrates (activated)
 Place the base of the tuning fork on the center of the top of the client’s head
 Ask the client where the sound is heard best
 Normally the sound is heard equally in both ears
 Client with conductive hearing loss hear the sound better in the affected ear
because bone transmits the sound directly to the ear.
Rinnetest (comparing air conduction and bone conductions):
 Activated the turning fork
 Place a lightly vibrating tuning fork on the mastoid bone with its base, behind the
ear and level with the canal
 Immediately when the patient can no longer hear the sound quickly place the “U”
of the fork near the canal and ascertain whether the sound can be heard again
 Normally the sound is heard longer through air than through bone(AC>BC)
 In conductive haring loss, sound is heard through bone as long as or longer than it
is through air (BC>AC)
The nose and Para nasal sinuses:
 Inspect the nose with a pen light
 Note any asymmetry of the nose
 Test for nasal obstruction and note the nasal mucosa and the septum for ulcers or
polyps
 Palpate for sinus tenderness; press frontal sinus and maxillary sinus
 Local tenderness
The mouth and the pharynx:
 Inspect the lips for moisture lumps, color, pallor or cyanosis
 Inspect the oral mucosa for color ulcer swelling, and white patches
 Observe the gums and teeth for color, swelling, missing and loosening
 Inspect roof of mouth and tongue for color, ulcer, white patches, and deviation of
tongue
Asses the pharynx in the following way:
 Ask the patient to say “ah ‘ or yawn, or press a tongue blade firmly on tongue and
simultaneously ask for “ah”
 Inspect the soft palate, anterior and posterior pillar, uvula, tonsils and pharynx for
color, symmetry, exudates, swelling, ulceration, and tonsil enlargement.

17
The neck
 Inspect the neck for symmetry, masses and scars.
 Palpate the parotid , submanibular salivary glands, lymph nodes on the neck
 Note their size, shape, mobility, tenderness and consistency
 Small, mobile, discrete, non tender nodes are found in normal person
 Tender nodes suggest inflammation
 Hard or fixed nodes suggest malignancy
 Inspect deviation of the trachea from the midline which is caused by mass in the
neck, atelectasis large pneumothrax.
To assess thyroid gland on the neck:
 Ask the patient to drink a sip of water and observe for symmetry
 Palpate the gland
Assessment of lung and thorax
Landmarks on the chest:
 Anteriorly, the sternal angle (angle of Louis) is the best guide
 Moving laterally from angle of Louis, you find adjacent second rib and costal
cartilage.
 Posteriorly,12th rib give an otherstating point for counting the ribs.
 The inferior angle of scapula lies at the level of the seventh rib or interspaces.
Imaginary lines to thorax:
1. Mid sternal line
2. Mid clavicular line
3. Anterior axillary line - drop form anterior axillary folds.
4. Mid axillary - drop from apex of axilla
5. Posterior axillary line- drop from posterior axillary fold
6. Scapular line
7. Vertebral line
Lung fissures and lobes:
 Anteriorly, the apex of each lung rises about 2-4cm above the inner third of the
clavicle.
 Posteriorly the lungs extend from just above the scapula to about the level of the
tenth thoracic spinous process on quite respiration
 The trachea and major bronchi
The trachea bifurcates in to main bronchi at the level of:
 The sternal angle ( angle of louis) anterioly
 The 4thspinous process Posteriorly

Examining the thorax and the lungs

General guide lines:
Examined in order:
 Inspection
 Palpation and
 Percussion
 Auscultation
Compare one side with other
Examine posterior thorax in sitting position

18
Examine anterior thorax in supine position
Relate findings in the thorax with findings such as shape of the fingernails, postion of the
trachea.
Inspection
I. Inspect the shape of the chest
In thenormal adult the thorax is wider than it is deep
A barrel chest- has an increase anterior posterior diameter e.g. in asthma
Funnel chest – depression in lower portion of the sternum
Pigeon chest – sternum is displaced anteriorly
Kyphoscoliossis- abnormal spinal curvature
II. Inspect respiratory rate, depth rhythm, effort
 Normal RR 16-20 rates/ min.
 Rapid an deep breathing (hyperpnea, hyperventilation) caused by e.g.exercise,
metabolic acidosis
 Kussmal– breathing is deep breathing due to metabolic acidosis
 Bradynea- slow breathing caused by diabetic comma.
 Cheyne- stokes breathing- period of deep breathing alternate with periods of no
breathing may be normal in children and aged.
III. Observe for cyanosis of the nail beds mucus membrane
Palpation:
Palpation has the following use:
i. Identification of areas of tenderness
ii. Assessment of observed abnormalities e.g. mass
iii. Assessment of respiratory expansion – to determine range and
symmetry of respiratory movement
Technique: place your thumb about at the level and parallel to the tenth ribs
posteriorly and at the level of the lower costal margin in the midline anteriorly,
your hands grasping the lateral cage.
 Ask the pt to repeat 99 or ‘arbaarat’
 Palpate with your hand and compare symmetrical areas deeply
and watch the divergence of your thumbs.
 Normally divergence should be symmetrical and range of
expansion should not < 1-2 inches.
iv. Assessment of tactile fremitus- it is the palpable vibrations
transmitted through broncho- pulmonary tree to the chest wall
when the pt speaks.

Technique - ask the pt to repeat “ 99” or “ArbaArat

-palpate with your hand and compare symmetrical areas of the
lungs
Normally fremitus is more prominent in the interscapular area and on right side
than left
Fremitus is decreased or absent in obstructed bronchus, chronic obstructive
disease, separation of the pleura surface by fluid, air.
Fremitus is increased when transmission vibration is increased through the
consolidates lung of lobar pneumonia.

19
Percussion:
Used:-
1. to determine whether the underlying tissues are filled, fluid filled or solid
2. To estimate diaphragmatic excursion
3. to identify level of diaphragmatic dullness
Technique: starting above the expected level of dullness, percuss down ward unitl
dullness replaces resonance during quiet respiration.
To estimate diaphragmatic excursion the technique is:
 Ask the pt to exhale fully and keep
 Percuss the chest down from area of resonance toarea of dullness and
mark.
 Then ask the patient to breath in deep and hold, continue percussing down
until resonance changes to dullness and mark
 Measure the vertical distance between the two points
 Normally it should be 5-6cm
Auscultation:
 It is most important examining technique for assessing airflow through the
broncho tracheal tree
 Instruct the pt to breath deeply through an open mouth
 Using the diaphragm of the stethoscope, auscultate areas suggested by
percussion and compare symmetrical areas.
 You should auscultate between the rib snot on the ribs.
Auscultation has the following three main purposes:
1. To healthy breath sounds are decrease, absent or abnormally located
2. To identify the presence of added(adventitious) sounds
3. To identify extent of transmission of voice sounds
The normal breath sounds:
1. Vesicular breath sounds – normally hand over most areas of both lungs
2. Bronchial breath sounds – the is over the trachea
3. Broncho vesicular breath sound –normally it can be heard in the first and
Second interspace anteriorly and between the scapulas posteriorly.
Added (adventitious) sounds:
1. Crackles /rales/ cripitation- discontinuous(intermittent), non musical sounds of
brief like dots. Caused by pneumonia.
Dividedin to:
 Fine cripition
 Coarse crpition
2. wheezes – relatively high - pitched, continuous, musical sound which are longer
than crackles caused by asthma, chronic bronchitis
3. pleural friction rub- are discrete grating sounds that appear continuous
because they are numerous.
- Usually confined to small area of chest.
- Typically heard in both phases of respiration
Assessment of the cardio vascular system
A comprehensive cardio vascular examination should include the assessment of:
 Appearance  The hands
 Arterial pulse  The jugular vein
 Blood pressure distension

20
  The heart  The feet and legs
 The lungs
 The abdomen
The arterial pulse: should be examined for its rate, rhytm, amplitude, and condition of
blood vessels.
Jugualr venous pressure:
The purpose of measuring jugular venous distension is to estimate the central venous
pressure.
Techniqe:adjust the head of the bed to 15-20 degrees
 Look the pulsation of internal jugular veins in the suprasternal notch, or just
posterior to the sternomastiid
 Identify the highest point of pulsation and with centimeter ruler measure the
vertical distance between this point and the sternal angle.
 Normal < 3cm
 Elevated ( increased pressure) = 3-4 cm
 When bilateral elevation it suggests right sided heat failure
 Unilateral distension of external JV is usually due to local kinking
Assessment of the heart
The heat is examined indirectly by:
 Inspecting
 Palpating
 Percussing
 Auscultating
Examination of the chest wall performed in the following six areas:
 Second intercostal spaces to the right of the sternum (aortic area)
 Second inter costal space to the left of the sternum ( pulmonary area)
 Third left inter space near the sternum (Erb’s point)
 4th and 5th interspaces to the left of the sternum (right ventricular or tricuspid area)
 Fifth interspaces or slightly medial to the mid clavicular line in the left, 7-9cm
from the mid sternal line (life ventricle or mitral area)
 Below the xiphoid process (epigastric area) - with flatten hands; press your index
finger up to ward left shoulder try to feel right ventricular pulsation. Used in
increased anterior posterior diameter.
Inspection and palpation:
Inspect the location of:
 Apical impulse and
 Ventricularmovements (less common)
Palpationis done to characterize:
 The apical impulse (size of left ventricle). Location, diameter, amplitude,duration
 Left parasternal impulse (size of right ventricles)
 Thrill of aloud murmur ( palpable murmur)
A. The normal location of the apical impulse is at or medial to mid clavicular line in the
fifth or possible fourth interspaced on the left, 7-9 cm from the midsternal line.
Cardiac impulse lateral to the mid clavicular line suggests cardiac enlargement or
cardiac displacement.
B. Right ventricular area (3rd , 4th and 5th inter spaces on the left sternal border)
Technique:

21
  On 30 supine patient, place the tips of your curved fingers in the 3 rd, 4th, and 5th
inter space and try to feel the systolic impulse of the right ventricle.
 Ask the pt to breath out and hold to accentuate the pulsations.
 A marked increase in amplitude with little or no change in duration suggests
chronic volume over load as in atrial septal defect.
C. The pulmonary artery:
During held expiration, look and feel for an in the second interspaced on the life
A palpable second heart sound suggests increased pressure in pulmonary artery
as in pulmonary hypetension.
D. The aorta
During held expiration, look and feel an impulse in the second interspace
A Prominent palpable second heart sound suggests systemic hypertension, and
pulsation here suggest aneurismal or dilated aorta.
Percussion:
Percuss from resonance toward cardiac dullness in the 3rd,4th,5th, and possibly
6thiterspaces
Percussion is not the preferred technique to determine the size of the heart
Auscultation:
Staring from the right second interspace, continue auscualting along the left second
inter space then 3rd,4th,5th interspaces in the left sternal border to the apex of the heart
(mitral area)
During auscultation listen for:
 The 1stand 2nd heart sounds for intensity and split
 For extra heart sounds in systole
 For extra heart sound in diastole ( 3rd heart sound 4th heart sound )
 For murmurs
The 1st heart sounds in produced by the closure of aterioventricular valves as the
ventricles contaract.
2ndheart sound is produced by closure of the closure of aortic and pulmonic valves as the
two ventricles relax.
2nd heart sound is usually detected in the second and third left inter spaces and appears
only during inspiration.
The most common extra heart sounds in systole: is the ejection click. It is
immediately heard after the 1st sound.
Extra heart sound sin diastole:
 Opening
 3rd heart sound / ventricular gallop/
 4th heart sound/atrial gallop/
Murmurs:
Murmurs are differentiated from heart sounds by their prolonged duration
The intensity of murmurs is graded on a six- point scale
Grade 1- it is very faint and may not be heard at all positions
Grad 2- it is quiet but heard immediately up on placing the stethoscope on
the chest
Grad 3- moderately loud
Grade 4- loud and often associated with a thrill.
Grade 5- very loud; it may be heard with a stethoscope partly of the chest
wall

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Grade 6- may be heard with the stethoscope entirely of the chest wall
Mid - systolic murmur- is pathologic murmurs, commonly caused by pulmonic
stenosis, aorticstenosis and hypertrophic cardio mayoapthy
Pansystolic murmur- is heard when blood flows from chamber of a high pressure to one
of lower pressure through a valve or other structure that should be
closed.
Causes are – mitral regurgitation
-tricuspid regurgitation
-Ventricular septal defect
Diastolic murmurs are pathologic murmurs:
Causes- Aortic regurgitation – pt sit, lean for ward, expiration held
- Mitral stenosis – place bell on apical impulse, turn pt to left lateral
Position, breath held in exhalation.
Assessment of the breast and axilla
The best time to examine breast is following one week after menstruation
The techniques used are inspection and palpation
Inspection of the breast:
With the pt in sitting position, disrobed to the waist, and with her arms at sides inspect:
 Appearance of skin (redness may suggest infection or inflammation)
 Size and symmetry (some difference in normal)
 Contour of breasts (masses, dimpling)
 Nipple for size, shape(inverted, any discharge or ulceration)
In order to bring out dimpling, or retractions that may other wise be invisible, ask the
patient to:
 Raise her arms over her head
 Press her hands against her hips
 If the breasts are large, ask the pt to stand and lean for ward, supported by
examiners hand or chair.
Palpation of the breast:
 Ask the pt to lie supine with small pillow under her shoulder on the side you are
examining and her arms rested over her head ( to spread breast tissue & to make
nodules easy to palpate)
 With your fingers flat, compress breast tissues. you may use the follwing patterns:
Concentric circles
Parallel lines
Consecutive lock times
Note :Consistency, tenderness, characterized any abnormalities in terms of location
size, shape and mobility
 Palpate nipple for elasticity and discharge
 Thickening of nipple and lose of elasticity suggest an underlying cancer.
Breast self examination:-
 Teach the mother how to examine her self
 Advice her to use mirrors to inspect her own breast
 Advice her to do it on similar time of her cycle to detect the changes
 Tell her which findings are abnormal and to report them immediately
The axilla:-
 Palpate the lymph nodes draing the breast
 Normally one or more soft, small (<1cm) nontender nodes are frequently felt in
the central axillary nodes.
23
Assessment of the musculoskeletal
In this assessment, direct your attention to both structure and function, keepingactivity
of daily living (ADL) in mind.
Using inspection and palpation examine joints for:
1. Range of motion
2. Any signs of inflammation, this includes:
Swelling Increase heat
Tendreness Redness of the skin
3. Crepitation
4. Deformities
5. The condition of the surrounding tissues, not any muscle atrophy
6. Muscular strength example atrophy and weakness in rheumatoid arthritis
7. Symmetry of involvement
If rheumatoid arthritis involve only one joint increases the likelihood of bacterial
arthritis.
Rheumatoid artist typically involve several joints with symmetrical distribution.

Examination of the abdomen

Locating findings on abdominal wall
One method of locating abdominal findings is by dividing the abdomen in to four
quadrants by two perpendicular lines crossing at the umbilicus hence the four quadrants
should be:

Right upper quadrant, which contains:

 The right adrenal gland  Liver
 Part of colon (hepatic flexor of  Gall bladder
colon, portions of ascending and  Head of pancreas
transverse colon)  Pylorus and loops of small
 Duodenum intestine
 Portion of right kidney

Right lower quadrant which contains:

 The appendix
 The distended bladder  The right salpinx
 Cecum  The right spermatic cord
 Portion of the ascending colon  The right ureters
 Lower pole of the right kidney  The enlarged uterus
 The right ovary  Loops of the small intestine
Left upper quadrant, which contains:

 The right adrenal gland  Spleen

 Portion of the colon  Stomach
 Portion of the left kidney  Lops of the small intestine
 Body of pancreas
Left lower quadrant, which contins:
 The distended ladder  The sigmoid

24
  Portion of descending colon  The left salpinx
 The lower pole of the kidney  The left spermatic cord
 The enlarged uterus  The left ureters
 Loops of the small intestine
 The left ovary
Techniques of abdominal examination
Position the patient supine, relaxes him and avoid full bladder
Use adequate light and proceed in the order:
1stinspection
2nd Auscultation
3rdpercussion
4thpalpation
Inspection of the abdomen:-
 Inspect the sin for scars, straie (stretch marks), dilated veins, rashes and lesions,
Veins commonly dilated in hepatic cirrhoses
 Inspect the umbilicus for contour, signs of inflammation, or hernia
 Inspect the contour of abdomen for:
-Shape (flat, round, protuberant)
-Bulges at the flunks
-Symmetry
 Normally, the abdomen may be flat or round and symmetrical
 Supra pubic bulges suggest distended bladder or pregnancy
 Flunk bulges may suggest ascites
 Mostly peristalsis is observed in pathology such as mechanical obstruction of
intestine
 Inspect pulsation of aorta in the epigastria area
Auscultation of the abdomen:-
 Auscultation of the abdomen before palpation and percussion as the later
maneuvers (palpation and percussion) may alter bowel sounds of the abdomen.
 Auscultate for bowel motility and note the character and frequency of bowel
sounds
 Listening at a point such as the right lower quadrant may be enough
becausebowel soundsare transmitted.
 Normally, clicks and gargles are heard at frequency of 5-34/minute
 You should be sure to listen at least for five minutes before concluding that
bowel sounds are absent.
 Bowel sounds decreased or absent in peritonitis
 Bowel sound increase diarrhea and intestinal obstraction
Percussion of the abdomen:
Abdominal percussion has the following purposes
1. To assess the amount and distribution of gas in the abdomen
2. To identify possible massesthat are solid or fluid filled
3. To estimate size of liver and spleen
 Normally, percussion all over abdomen provides predominantly tympany,
because of gas in the GIT , but scattered areas of dullness due to fluid and feces
there are also typical
 Tympanythrough out a protuberant abdomen suggest intestinal obstruction
 While dullness in the flunks of a protuberant abdomen suggest indicates ascites.

25
Palpation of the abdomen:
Consider the following advises before abdominal palpation:
 Ask the patient to point you any areas of pain and palpate it last
 Monitor your examination by watching the patient’s face for assigns of
discomfort.
 Distract patient in necessary with conversation or questions this decrease
voluntary guarding.
Abdominal palpation may be light or deep
Light palpation used to identify:
 Abdominal tenderness
 Muscular resistance
 Superficial organs and masses
If resistance is present, try to distinguish voluntary guarding from involuntary muscular
spasm /resistance/ rigidity e.g.by asking pt to mouth- breath, involuntary rigidity persists
to occur, as its common cause is peritonitis.
Deep palpation used to identify:
 Abdominal masses
 Abdominal organs
 Deep pain
Assessment of peritonitis:
 Abdominal pain, tenderness, and involuntary guarding(muscular spasm)suggest
peritonitis .
 Test for rebound tenderness by
 Pressing your finger in firmly and slowly and slowly and then with draw them
quickly, pain induced by quick with drawl suggest rebound tenderness.
Assessment of the liver:
Percussion and palpation used to assess:
Percussion of the liver can be used:
 To estimate size and shape of the liver
 To determine the vertical span of the liver
Palpation of enlarged liver is used in the assessment of the liver to determine:
1. Tenderness
2. Consistency
3. Surface and perhaps size and shape of the live
To measure the liver span, percuss down from areas of resonance to area of dullness in
the mid clavicular line until you get dullness and mark
Similarly percuss up from area of tympani to area dullness in the mid clavicular line and
mark at the border of dullness.
Measure the distance between the marks. Normally 6-12cm.0
Assessment of the spleen:
 Percussion and palpation are the techniques used to assess the spleen.
 Percussion of the spleen cannotconfirm spleenic enlargement but raise the
suspicions.
 Palpation of the spleen can be used to confirm enlarged spleen
Technique-
 With your left hand, press forward the lower left rib cage.
 With your right hand below the left costal margin, press in toward the spleen
 Ask the patient to breath in deep and try to feel the tip or edges of the spleen

26
 The following help to differentiate an enlarged spleen from an enlarged left kidney:
 The spleen passes mid line of the body but the kidney does not.
 The palpating hand can not be inserted between mass and lowet rib cage in case
of spleen.

Assessment of kidney:
 Tenderness of kidney may be assessed by using percussion of hand resting on
costovertebral angle with the eye of the fist.
 Pain with fist percussion suggests kidney infection
Assessment of the ascites:
Protuberant abdomen with bulged flunks is an indication for assessment of possible
ascites.
Techniques used for assessments of ascites:
1. Check for shifting dullness
 Map borders of tympany and dullness bypercussion
 Ask the pt to turn to one side
 Peruses and map the borders again
 Dullness shifting to the more dependent side suggest ascites
2. Test for fluid thrill(Fluid wave)
 Ask some one to press the edge of his hands against the midline of the abdomen
(this stops the transmission of pressure through fat) and tap one flank sharply
with your fingers.
 Feel the impulse transmitted though the fluid on the opposite flank with your
opposite hand.
 An easy palpable impulse suggests ascites
Assessment of appendicitis:-
History of the pin is very helpful
Rebound tendrrness –
Press deeply and evenly in the left lower quadrant and quickly with draw your fingers .
Pain induced by quick withdrawal suggests rebound tenderness.
Assessment of cholecystis:-
 History of the pain is very helpful
 Rebound tenderness –
-Press deeply and evenly in the left lower quadrant and quickly with draw
your fingers.
-Pain induced by quick withdrawal suggests rebound tenderness.
 Psoas sign:
-Put your hand just above the patient’s knee and ask him to flex at the hip
against your resistance
-Increased abdominal pain, called positive psoas sign, suggests
appendicitis.
Assessment of cholecysitis:
 Hook your finger of right hand under the costal margin
 Ask the pt to deep breath
 A sharp increase in tenderness with a sudden stop in breathing is appositive
murphy’s sign, suggests a cute cholecysitis.
Neurological Examination

27
 Assessment of level of consciousness
 The Glasgow commascale is used to assess changes in consciousness.
 This method is based on the eye opening, best motor responses and verbal
responses to different stimuli.
 The values in this scale range from 3(the deepest comma) to 15 (the full alertness)
 i,e (3-15)
 A score of seven or less (<7) is accepted as comma and requires the appropriate
nursing intervention for the commutes patient.

Eye open:
 Spontaneously 4
 To speech 3
 To pain 2
 No response 1
Best motor:
 Obeys command 6
 Localize pain 5
 Withdraws to pain 4
 Abnormal flexion to pain 3
 Extends to pain 2
 No response 1
Verbal responses:
 Oriented 5
 Confused conversation 4
 Inappropriate words 3
 Incomprehensible sounds 2
 No response 1
Total Score 3-15
Assessment of the cranial nerves
Cranial nave I (olfactory nerve):
Ask the patient to identify substances with his eyes closed by smelling
Eg, alcohol
Cranial nerve II (optic nerve)
 Examine visual fields
 Test visual acuity
Cranial nerve III (occulomotor) – test pupilary reactions (refex)
Cranial nerve V (trigeminal nerve) - the corneal reflex test (the blinking reflex)
Cranial nerve VII(Facial nerve)- tests for facial movement such as frowning whistling,
smiling, ability of eye to remain closed against your resistance.
Cranial nerve VIII (auditory) - test for hearing
Cranial nerve IX, X – test for gage reflex
Muscle Bulk:
 When you assess the muscle bulk of your patient pay attention to the muscles of
the hands, shoulders and thighs
 You can used tape measure to measure muscle waste
Atrophy of muscles may be caused by:
 Motor neruron diseases

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  Rheumatoid arthritis
 Protein energy malnutrition
Muscle tone;
Feeling the muscles resistance to passive stretch assess muscle tone
Muscle strength
Technique
 Ask the pt to move against your resistance
 If the muscles are too weak to move against your resistance, move them only
against gravity.
 If still weak, test them both resistance and gravity free
 If the patient fail to move the body part watch or feel for weak muscular
contraction, flicker
Grade the strength of individual muscles on a 0-5 scale according to the following
criteria:
Grade-0- no muscular contraction detected
Grad-1 –a barely detectable flicker or trace of contraction
Grad -2- active movement with gravity eliminated
Grad-3- active movement against gravity
Grad-4- active movement against gravity and some resistance
Grad-5- active movement against full resistance.
Assessment of touch sensation
 Using a sharp instrument, asks the patient to tell you whether you are touching
him with sharp object.
 Identify areas of analgesia (absence of pain sensation) hypolgesia(decreased
sensitivity to pain)
 Compare the distal with proximal areas of the extremities.
Assessment of touch sensation
 With cotton, touch the skin lightly (avoid pressure), and ask the patient to tell you
when he feels it.
 Identify areas of anesthesia (absence of touch sensation, hyposthesia(decreased
sensitivity to touch)
Assessment of reflexes
Reflexes may be absent or decreased, when:
 Sensation is lost
 The relevant spinal nerves are damaged
 The peripheral nerves are damage
 There is disease of the muscles
 The neuromuscular junctions are diseased.
Increased reflexes suggest central nervous system disease
Always compare one side with the opposite side
The following two groups of reflexes are usually included in the general physical
examination.
Deep tendon reflexes:
The biceps reflex
The triceps reflex
The knee-jerk reflex
Cutaneous reflexes:
Plantar reflex

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Assessment of the biceps reflex
Technique:
 Flex the patient’s arm partially at the elbow with palm down
 Place your thumb or finger on the biceps tendon
 Strike your thumb or finger with the reflex hammer
 Observe flexion at the elbow, watch for and feel the contraction of the biceps
muscles
Assessment of the triceps reflex
Technique:
 Flex the patient’s arm at the elbow with the palm facing his body and pull it
slightly across his chest.
 Strike directly at the triceps tendon above the elbow.
 Observe extension at the elbow, and contraction of the triceps muscle

Assessment of knee-jerk reflex

Technique:
 Flex the knee partially (the patient may be in a sitting or lying position). In both
cases the leg should be relaxed and supported.
 Tap the patellar tendon with your percussion hammer just below the patella
briskly
 Observe the contraction of the quadriceps muscle and for extension at the knee
Assessment of plantar response:
Technique:
 Stroke the lateral aspect of the sole from the heel to the ball of the foot, curving
medially across the ball with a spatula or similar material.
 Observe the moment of the toes
 Normally the toes plantar flex in response to your stoke
 Dorsiflexion of the big toe accompanied by fanning of the other toes (the
babinskiresponse) often indicates lesion in corticospinal tract of the central
nervous system.
Assessment of gentalia
Assessment of genitalia of male
 The penis
 Inspect the penis, including
o The skin for e.gherps, syphilitic chancer
o The prepuce (foreskin)- if it is present, retract it or ask the patient to retrace it
o The glans- look for any ulcers, scars, sign of inflammation
 Palpation- between your thumb and 1st two fingers noting any discharge.
The scrotum and its contents
Inspect the scrotum including
The skin- lift up the scrotum so that you can see its posterior surface
Palpation
 Palpate each testis andepididmis between your thumb and first two fingers
 Not their size, shape, consistency and tenderness feel for any nodules
 Any painless nodule in the testis must raise the possibility of testicular cancer.
Evaluating the scrotal mass
 If the scrotal mass returns when the patient lies, it is hernia.

30
 If scrotal mass do not return when the patient lies, try to get your fingers above the
mass in to the inguinal canal. If you can it is not hernia.
 Light on the scrotal mass from the bottom if it is translucent, it is hydrocele
Assessment of prostate
 The prostate gland is a solid, hear shaped structure about 2.5cm in length
 The posterior wall is in contact with rectal wall and it is the only potion accessible
to palpation.
 Using gloved lubricated index finger palpates the prostate and note the consistency,
size and tenderness.
 In benign prostate hypertrophy, which is common in men over 50 years, the prostate
may bulge more than 1cmin to the rectal lumen.
Assessment of genitalia of female
 Note any inflammation, ulceration, discharge, swelling or nodules, if there is any
lesions palpate them.
 If there is a history of an appearance of labial swelling Palpate bartholins glands for
infection
 Inspect for discharge a yellowish discharge caused by gonorrhea
 Palpate battalions gland, palpate the urethra (by pressing using finger via vagina)
 Inspect by using vaginal speculum.
Appendix I
American Nursing diagnosis association (NANDA)

Accepted Nursing Diagnoses

Copy Right c 2003 by Lipincott Williams and wiikins, instructor’s resource manual and
bank to Accompany
* Activity intolerance * Coping, Readiness for enhance community
* Activity intolerance, risk for * Coping , compromised family
* Adaptive capacity, Decreased * Coping, Disabled family
intracranial * Coping, Readiness for enhanced
* Adjustment, Impaired * Decisional Conflict
* Adult failure to Thrive * Decreased cardiac output
* Airway clearance, Ineffective * Denial, Ineffective
* Alcoholism, Dysfunctional Family * Dentition, Impaired
Responses * Development, Risk for delayed
* Allergy Responses, LateX, Risk for * Diarrhea
* Anxiety * Disproportionate Growth, risk for
 Disturbed Body Image
* Anxiety, Death * Disuse syndrome, risk for
* Aspiration , Risk for * Diversional Activity, Deficient
* Attachment, Risk for impaired * Dressing/Grooming Self- Care Deficit
Parent/infant/ Child * Elimination, lmpaied Urinary
* Autonomic Dysreflexia, Risk for * Energy field, Disturbed
* Bathing/ Hygiene self-care deficit * Environmental interpretation syndrome
* Bed mobility, impaired impaired
* Body Temperature, Risk for imbalanced * Excess fluid volume
* Bowel incontinence * Failure to Thrive, adult
* Breast feeding , Effective * Falls, Risk for
* Breast feeding, Infective * Family processes, Dysfunctional: alcoholism
* Breast feeding, Interrupted Alcoholism
* Breast feeding, Interrupted * Family processes, Dysfunctional: alcoholism,
Inturupted
* Breathing pattern, Ineffective * Fatigue

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* Cardiac out put, Decreased
* Caregiver Role strain
* Caregiver role strain, Risk for
* Chronic confusion
* Chronic pain
* Chronic sorrow
* Communication, Impaired verbal
* Compromised family coping
* Conflict, Decisional
* Conflict, parental Role * Growth and Development, Delayed
* Confusion, Acute
* Confusion, Chronic
* Constipation
* Constipation, perceived
* Constipation, Risk for
* Coping, Defensive
* Coping, Ineffective
* Coping, Ineffective community
* Imbalanced fluid volume, risk for
* Incontinence, Bowel
* Incontinence, Functional Urinary
* Incontinence , Reflex urinary
compound
* Incontinence, Stress Urinary
* Incontinence, Total Urinary
* Incontinence,Urge urinary
* Incontinence,Risk for urge urinary
* Infant behavior, Disorganized
* Infant behavior, Readiness for
Enhanced
* Infant Behavior, Organized
* Infant feeding pattern, Ineffective
* Infection, Risk for
* Injury, Risk for
* Injury, Risk for perioperative-positioning
* Intracranial adaptive capacity,
Decreased
* Interrupted breastfeeding
* Knowledge, Deficient
* Latex Allergy Response, Risk for
* Loneliness, Risk for
* Memory, impaired
* Mobility, impaired Bed
* Mobility, impaired wheelchair
* Nausea
* Neglect, Unilateral
* Neurovascular Dysfunction, Risk for
peripheral
* Noncompliance
* Nutrition, imbalanced:- less than body
* Requirements
* Nutrition, Imbalanced: less than body
* Fear
* Feeding self- care Deficit
* Fluid volume, Deficient
* Fluid volume, Excess
* Fluid volume, Risk for deficient
* Fluid volume, Risk for imbalanced
* Gas Exchange, impaired
* Grieving, Anticipatory
* Grieving,Dysfunctional
* Growth, Risk for Disproportionate
* Health maintenance, Ineffective
* Home maintenance, Impaired
* Hopelessness
* Hypethermia
* Hypothermia
* Identity, disturbed personal
* powerlessness, Risk for
* protection, Ineffective
* Rape- trauma syndrome
* Rape- trauma syndrome,
Reaction
* Recovery, Delayed surgical
* Relocation Stress syndrome, Risk for
* Retention, Urinary
* Role conflict, parental
* Role performance, Ineffective
* Role strain, caregiver
* Role strain, caregiver, risk for
* Self- care Deficit, Bathig/Hygiene
* Self- CareDeficit, Dressinng/Grooming
* Self- care deficit, feeding
* Self- care deficit, Toileting
* Self –Easteem, Low
* Self- Esteem, Situational low
* Self- Esteem, Risk for situational low
* Self- Mutilation
*Self – Mutilation, Risk for
* Sensory perception, Disturbed
* Sexual dysfunction
* Sexuality patterns, ineffective
* Skin integrity, impaired
* Skin integrity impaired, Risk for
*. Sleep deprivation
* Sleep pattern, Disturbed
* Social interaction, impaired
*Social isolation
* Spiritual Distress
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 requirements
* Nutrition, Risk for imbalanced: more
han body requirements
* Oral mucous membrane, lmpaired
* Organized infant Behavior, readiness
for enhanced
* Pain, Acute
* Pain chronic
* Parental role conflict
* Parent/infant/ child attachment, Risk for
Impaired
* Parenting,Impaired
* Parenting, Impaired, Risk for
* Perceived constipation
* Preoperative- positioning injury, risk for
* Peripheral neurovascular dysfunction
Risk for
* Personal identity, disturbed
* Physical mobility, impaired
* Poisoning, risk for
* Post- Trauma syndrome
* Post trauma syndrome, risk for
* Powerlessness
33
* spiritual distress, Risk for
* spiritual well- being, Readiness for
Enhanced
* suffocation , Risk for
* Suicide, Risk for
* surgical recovery, Delayed
* Swallowing, Impaired
* syndrome, risk for disuse
* syndrome, impaired environmental
interpretation
* Therapeutic Regimen management
Effective
* Therapeutic Regimen Management
ineffective
* Therapeutic Regimen management
infective, community
* Ventilation, impaired spontaneous
* ventilator ,weaning response
Dysfunctional
* Violence, Risk for other- directed
* Violence , Risk for self- directed