NCMA121: HEALTH ASSESSMENT

PRELIMS WEEK 1
1st year, 2nd SEMESTER | S.Y 2021-2022 TRANSCRIBED BY: KRISTINE CALDERON, ALYSSA JIMENEZ
LECTURER: Ma’am Cora P. Quinto

WHAT IS NURSING?
TOPIC
 Nursing is both a SCIENCE and AN ART that is
SUB TOPIC
concerned with the individual’s:
SUB-SUB TOPIC 1. Physical
2. Psychological
[@] – prof’s notes 3. Sociological
4. Cultural
[$] – from book 5. Spiritual
WEEK 1: INTRODUCTION TO THE HEALTH ASSESSMENT 4 ESSENTIALS FEATURES OF THE NURSING PRACTICE -
A. OVERVIEW OF THE NURSING PROCESS (ADPIE) ANA 1995

HEALTH ASSESSMENT 1. Full range of human experiences and responses to

health and illness w/o restriction to a problem
 “The very elements of nursing are all but unknown” – focused orientation (attention)
Florence Nightingale 2. Caring relationship that facilitates health and healing
3. Understanding and integration of objective data based
DEFINITION OF NURSING on the client’s subjective experience
4. Knowledge (scientific) for diagnosis and treatment
 Nursing is the diagnosis and treatment of human
responses to health and illness. - ANA 1995 HEALTH ASSESSMENT IS:
 “The protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation  The first step of the Nursing Process
of suffering through the diagnosis and treatment of  The most important because it DIRECTS the rest of the
human responses and advocacy in the care of process
individuals, families, communities and population”  A thinking, doing, and feeling process – THINK as you
(ANA, 2010) ACT and interact with patients
 THINK CRITICALLY as you go with the process
NURSING SCOPE AND STANDARD OF PRACTICE  A skill
STANDARD I – Registered nurse collects comprehensive  LEARNING the normal
data pertinent to the patient’s health or situation  IDENTIFY the normal and DIFFERENTIATE it from the
abnormal
 Collects data in a systematic and on-going process  Will USE in every area of nursing
 Involves the patient, family, and other health care
providers (holistic) How well you perform your assessment will affect everything
 Prioritizes data collection activities based on the else that follows. You will ask questions,
patient’s immediate condition and you will use four of your senses to collect data
 Uses appropriate evidence based assessment FUNDAMENTAL PHILOSOPHICAL BELEIFS IN NURSING
techniques and instruments in collecting data
 Uses analytical models and problem-solving tools 1. The client is a human being who has worth and has
 Synthesizes available data, information and knowledge dignity.
relevant to the situation to identify patterns and o That is why we care for life.
variances o Every human being has the right to proper
 Documents relevant data in a retrievable format healthcare to maintain its worth and dignity.
2. Humans manifest an essential unity of mind/body and
STANDARD II – The registered nurse analyses the spirit.
assessment data to determine the diagnoses or issues 3. There are basic human needs that must be met.
4. When these needs are not met, problems arise that
 Derives the diagnosis or issues based on assessment may require intervention by another person until the
data (both subjective and objective data) individual can resume responsibility for themselves.
 Validates the diagnoses or issues with the client, 5. Human experience is contextually and culturally
family, and other healthcare providers when possible defined.
and appropriate
 Document diagnoses or issues in a manner that
facilitated the determination
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 6. Clients have a right to quality health and nursing PHASE I – ASSESSMENT
care delivered with interest, compassion and
competence, with a focus on wellness and prevention.  Collecting subjective and objective data
7. The therapeutic nurse-client relationship is important in  Most critical phase of the nursing process. Why?
the nursing process. o Assessment is on-going and continuous
throughout all phases of the nursing process
WHAT IS THE NURSING PROCESS? o Assessment is more than just gathering of
information about health status; it is analysing
 “Combines the most desirable elements of the art of and synthesizing that data, making judgments
nursing with the most relevant elements of systems about the effectiveness of nursing
theory, using the scientific method” – Shore 1988 interventions and evaluating client care
 “This process incorporates an outcomes.
interactive/interpersonal approach with a problem  Systematic collection of data
solving and decision-  The most important step
making process” – Peplau 1952
 Sets the tone for the rest of the process, and the rest
 The nursing process entails the making of the nursing of the process flows from it
care plan.
 Identifies your patient’s strengths and limitations and is
 Without your nursing process, without your nursing performed not just once, but continuously throughout
care plan, you won’t be able to successfully help your the nursing process
patient get back to his/her normal state.
 Assessment is not just done in step one
 Is a SYSTEMATIC, organized method of planning,
and providing quality and individualized nursing care. PHASE II – DIAGNOSIS
 It is synonymous with the PROBLEM-SOLVING
APPROACH that directs the nurse and the client to  Analysing subjective and objective data to make a
determine the need for nursing care, to plan and professional nursing judgement (nursing diagnosis,
implement the care and evaluate the result collaborative problem or referral)
 IN SHORT – THE NURSING PROCESS IS A  Clinical judgment concerning a human response to
SYSTEMATIC PROBLEM-SOLVING APPROACH health conditions / life processes, or vulnerability for
 Where diagnosis and treatment are achieved that response by an individual, family or community
 It is a G O S H approach for efficient and effective that the nurse is licensed and competent to treat
provision of nursing care  Analysis of data to identify the problem
 Formulating a nursing diagnosis involves identifying
 G - oal oriented and prioritizing actual or potential health problems
 O - rganized or responses
 S - ystematic
 H - umanistic care  An actual nursing diagnosis identifies an occurring
health problem for your patient.
Effective Nurse Efficient Nurse  A potential nursing diagnosis identifies a high-risk
- Being able to assess and - Knowing that your patient health problem that most likely will occur unless
check that your patient is has a fever, you can be an preventive measures are taken.
actually suffering from a efficient nurse through your  A possible nursing diagnosis is one that needs further
fever. nursing interventions data to support it
(providing the appropriate
nursing care the patient Types of Nursing Diagnosis:
needs) in order to alleviate
the suffering of the patient so 1. Problem – focused ND
that your patient will have a  Problem + Etiology + Signs and Symptoms
normal body temp.  Acute pain related to trauma of surgical incision as
- Being able to help your evidenced by facial grimace and guarding behaviour
patient improve from one
2. Risk ND
status to another status.
 Problem + Etiology
 Risk for infection related to surgical incision
5 Steps in the Nursing Process (ADPIE): 3. Health Promotion ND
 Problem
1. Assessment  Grieving, Hopelessness
2. Diagnosis 4. Syndrome ND
3. Planning  Specific cluster of nursing diagnosis that occur
4. Intervention together and have similar nursing interventions to
5. Evaluation resolve the situation

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 Defining Characteristics (Signs and Symptoms)
 Observable assessment cues such as patient
behaviour, physical signs
 Related Factor (Etiology)
 Etiological cause or causative factor for
diagnosis
PHASE III – PLANNING
 Determining outcome criteria and developing a plan
 Desired outcomes
 Appropriate interventions
 Involves setting goals and outcomes
 Individualized plan of care for your patient is ready
once diagnosis have been prioritized
 Priority Setting
 Ordering of nursing diagnoses or patient
problems using notions of urgency and
importance to establish a preferential order
for nursing interventions
 Goals
 Broad statement that describes a desired
change in a patient’s condition, perceptions or
behaviour
 Types of Goals
 Long Term Goals
- Objective behaviour or response that you
expect a patient to achieve over a longer
period, usually over several days, weeks
or months
 Short Term Goals
- Objective behaviour or response that
you expect the patient to achieve in
short time usually few hours or less than
a week
 Planning should be
 Specific
 Measurable
 Attainable
 Realistic
 Time-bound
PHASE IV – INTERVENTION
 Carrying out of the plan
 You should also write a rationale (explaining why such
nursing interventions were made)
 Defined as any treatment based on clinical
judgment and knowledge that a nurse performs to
enhance patient outcomes
 Putting the plan of care into action
 Also called IMPLEMENTATION
 Involves carrying out your plan to achieve goals and
outcomes
 The “doing” phase
- Interventions are treatment performed
through interaction with patient
- Ex. Medication administration, VS
checking, insertion of IFC
 Indirect Care
- Interventions are treatments performed
away from a patient but on behalf of the
patient or group of patient
- Ex. Safety and Infection control,
Delegating nursing care
TYPES:
 Independent
- Action that the nurse initiates without
supervision or direction from others
 Dependent
- Actions that require an order from a
health care provider
 Collaborative
- Interdependent interventions
- Therapies that require the combined
knowledge, skills, and expertise of
multiple health care providers
PHASE V – EVALUATION
 Assessing whether outcome criteria have been met
and revising the plan as necessary
 Final step of the nursing process
 Crucial to determine if the patient’s condition improved
or worsen after application of the first four steps of
nursing process
 Monitoring of client’s progress
 Alter the plan as indicated
 Involves determining the effectiveness of your plan.
 Once again, assess your patient’s response based on
the criteria you set for the outcome.
THE NURSE MUST TAKE NOTE:
 The steps of the nursing process are interrelated
forming a continuous circle of thought and action that
is both dynamic and cyclic.
 The nurse must be able to apply some basic abilities
on the knowledge of science and theory.
 Creativity and adaptability are very important

APPROACH

 Direct Care
- Direct intervention

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 FOCUS OF HEALTH ASSESSMETNT IN NURSING  The nurse typically collects subjective data and
objective data in many settings (hospital, community,
 The purpose of nursing health assessment in to collect clinic, or home). Depending on the setting, other
holistic subjective and objective data to determine a members of the health care team may also participate
client’s overall level of functioning in order to make a in various parts of the data collection.
professional clinical judgment  Eg.
FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING o In a hospital setting the physician usually
performs a total physical examination when
 History of present health concern the client is admitted (if this was not previously
 Personal health history done in the physician’s office). In this setting,
 Family history the nurse continues to assess the client
 Lifestyle and health practices as needed to monitor progress and client
outcomes. A physical therapist may perform a
CHARACTERISTICS OF THE NURSING PROCESS? musculoskeletal examination, as in the case
of a stroke patient, and a dietitian may take
 Dynamic and cyclic anthropometric measurements in addition to a
 Patient centered subjective nutritional assessment.
 Goal directed o In a community clinic, a nurse practitioner
 Flexible may perform the entire physical examination.
 Problem oriented o In the home setting, the nurse is usually
 Cognitive responsible for performing most of the
 Action oriented physical examination.
 Interpersonal  Regardless of who collects the data, a total health
 Holistic assessment (subjective and objective data regarding
 Systematic functional health and body systems) is needed when
the client first enters a health care system and
PURPOSES OF THE NURSING PROCESS periodically thereafter to establish baseline data
against which future health status changes can be
1. To identify a client’s health status; his Actual/Present measured and compared.
and potential/possible health problems or needs. o Frequency of comprehensive assessments
2. To establish a plan of care to meet identified needs. depends on the client’s age, risk factors,
3. To provide nursing interventions to meet those needs. health status, health promotion practices, and
4. To provide an individualized, holistic, effective and lifestyle
efficient nursing care  Regardless of who collects the data, a total health
B. TYPES OF HEALTH ASSESSMENT DEFINITION OF assessment (S and O) is needed when client first
ASSESSMENT enters the health care facility to provide baseline data
for future health status changes.
ASSESSMENT o Example: A child with suspected dengue
hemorrhagic fever
 According to Carpenito: Assessment is the deliberate
and systematic collection of data to determine a client’s ON-GOING OR PARTIAL ASSESSMENT
current and past health status and functional status and
to determine the client’s present and coping patterns.  An on-going or partial assessment of the client consists
 According to Atkinson and Murray (1991): Assessment of data collection that occurs after comprehensive
is a part of each activity the nurse does for and with the database is established.
patient.  Mini overview of the client’s body systems and holistic
health patterns as a follow up health status
The 4 Basic Types of Assessment are:  Reassessment to detect new problem
o Example: Patient admitted to the hospital with
1. Initial comprehensive assessment lung cancer
2. On-going or partial assessment  Consists of data collection that occurs after the
3. Focused or problem-oriented assessment comprehensive database is established. This
4. Emergency assessment consists of a mini-overview of the client’s body systems
INITIAL COMPREHENSIVE ASSESSMENT and holistic health patterns as a follow-up on health
status. Any problems that were initially detected in the
 Involves collection of subjective data about the client’s client’s body system or holistic health patterns are
perception of his or her health of all body parts or reassessed to determine any changes (deterioration
systems, past health history, family history, and or improvement) from the baseline data. In addition, a
lifestyle and health practices (which includes brief reassessment of the client’s body systems and
information related to the client’s overall function) as holistic health patterns is performed to detect any new
well as objective data gathered during a step-by-step problems. This type of assessment is usually
physical examination. performed whenever the nurse or another health
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 care professional has an encounter with the client. the evaluation of the client’s airway, breathing, and
This type of assessment may be performed in the circulation (known as the ABCs) when cardiac
hospital, community, or home setting. The frequency of arrest is suspected. The major and only concern
this type of assessment is determined by the acuity of during this type of assessment is to determine the
the client. status of the client’s life sustaining physical functions.
 Eg.  Example: Choking, cardiac arrest, drowning
o A client admitted to the hospital with lung
cancer requires frequent assessment of STEPS OF HEALTH ASSESSMENT
lung sounds. A total assessment of skin
The assessment phase of the nursing process has 4 major
would be performed less frequently, with
steps:
the nurse focusing on the colour and
temperature of the extremities to determine 1. Collection of subjective data
level of oxygenation. 2. Collection of objective data
3. Validation of data
FOCUSED OR PROBLEM-ORIENTED ASSESSMENT
4. Document of data
 It is performed when a comprehensive database exist PREPARING FOR THE ASSESSMENT
for a client who comes to the health care agency with
a specific problem.  Review the medical records if available
 Consists of thorough assessment of a particular client  Know the client’s basic biographical data (age, sex,
problem and does not cover areas not related to the religion, educational level and occupation)
problem  Activities of daily living
o Example: patient with pain  Client’s previous and current health status (patient and
family)
Assessing pain:
 Keep an open mind and refrain from premature
 C – character (how the patient feels) judgment
 O – onset (when did it begin)  Educate self
 L – location (where is the pain coming from)  Reflect on your own feelings
 D – duration (how long does it last)  Obtain and organize materials that you will need for the
 S – severity (how bad is it) (using pain scale) assessment

 A focused or problem-oriented assessment does not COLLECTING SUBJECTIVE DATA

replace the comprehensive health assessment. It is
 These are the information that is verbalized by the
performed when a comprehensive database exists for
patient and only the patient can verify.
a client who comes to the health care agency with a
 Subjective data are sensations or symptoms (ex: pain,
specific health concern. A focused assessment
hunger, feelings) perceptions, desires, preferences,
consists of a thorough assessment of a particular client
beliefs, ideas, values, and personal information that
problem and does not cover areas not related to the
can be elicited and verified only by the client. To elicit
problem.
accurate subjective data, learn to use effective
 Eg.
interviewing skills with a variety of clients in different
o If your client, John P., tells you that he has
settings. The major areas of subjective data include:
pain you would ask him questions about the
o Biographical information
character and location of pain, onset, relieving
o History of present health concern: physical
and aggravating factors, and associated
symptoms related to each body part or system
symptoms. However, asking questions about
o Personal health history
his sexual functioning or his normal bowel
o Family history
habits would be unnecessary and
o Health and lifestyle practices – health
inappropriate. The physical examination
practices that put the client at risk, nutrition,
should focus on his ears, nose, mouth, and
activity, relationships, cultural beliefs or
throat. At this time, it would not be appropriate
practices, family structure and function,
to perform a comprehensive assessment by
community environment
repeating all system examinations such as
the heart and neck vessel or abdominal Subjective data include:
assessment.
 Sensation or symptoms
EMERGENCY ASSESSMENT  Feelings
 Perceptions
 An emergency assessment is a very rapid assessment
performed in life-threatening situations. In such  Desires
situations (choking, cardiac arrest, drowning), an  Preferences
immediate assessment is needed to provide prompt  Beliefs
treatment. An example of an emergency assessment is  Ideas

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  Values COLLECTING OBJECTIVE DATA
 Personal information
 The examiner directly observes objective data. These
Any data can be elicited and verified only by the client. data include:
o Physical characteristics (skin colour, posture)
The nursing interview is a communication process that o Body functions (heart rate, respiratory rate)
has two focuses: o Appearance (dress and hygiene)
o Behaviours (mood, affect)
1. Establishing rapport and a trusting relationship
o Measurements (blood pressure, temperature,
2. Gathering information on the client’s developmental,
height, and weight)
psychological, physiologic, sociocultural and spiritual
o Result of laboratory testing
statuses to identify deviations that can be treated with
 This type of data is obtained by general observation
nursing and collaborative interventions or strengths
and by using the four physical examination techniques:
that can be enhanced through nurse-client
inspection, palpation, percussion, and auscultation.
collaboration
Another source of objective data is the client’s medical
Phases of the interview: record. Objective data may also be observations noted
by the family or significant others.
 Pre introductory
 Involves only the nurse. STEP TWO – NURSING DIAGNOSIS
 As a nurse, before conducting an interview, you
 Analysis of data (often called nursing diagnosis) is the
should prepare yourself (reading the history of the
second phase of the nursing process. Analysis of the
patient, etc.).
collected data goes hand in hand with the rationale for
 Introductory
performing a nursing assessment.
 You will now introduce yourself to the patient and it is
 During this phase, you analyse and synthesize data to
the time when you, as a nurse, will establish rapport.
determine whether the data reveal a nursing concern
 Working Phase
(nursing diagnosis) a collaborative concern
 When you will conduct the interview itself.
(collaborative problem) or a concern that needs to be
 The time when you will elicit the interview questions to
referred to another discipline (referral)
the patient.
 A nursing diagnosis is defined by the North American
 Summary and Closing Phase
nursing Diagnosis Association (NANDA) as a “clinical
 Summarizing everything talked about to make sure that
judgment about individuals, family or community
there is no missing important information
responses to actual and potential health problems and
Communication during the interview: life process.

 Nonverbal Communication Process of Data Analysis

o Appearance
 To arrive at nursing diagnoses, collaborative problems
o Demeanour
or referral, you must go through the step of data
o Facial expression
analysis. This process requires diagnostic reasoning
o Attitude
skills, often called critical thinking. The process can be
o Silence
divided into seven major steps;
o Listening
1. Identify abnormal data and strengths
 Verbal communication
2. Cluster the data
o Open ended
3. Draw inferences and identify problems
o Close ended questions
4. Propose possible nursing diagnoses
o Laundry list
5. Check for defining characteristics of those diagnoses
o Rephrasing
6. Confirm or rule out nursing diagnoses
o Inferring
7. Document conclusions
o Providing information
TYPES OF NURSING DIAGNOSES
What to avoid?
PROBLEM – FOCUSED Ineffective breathing pattern
 Non Verbal Communication RISK Risk for infection
o Excessive or insufficient eye contact HEALTH PROMOTION Readiness for enhanced
family coping
o Distraction and distance (3-4 feet)
SYNDROME Chronic pain syndrome
o Standing
 Verbal Communication
o Biased or leading questions COMPONENTS OF A NURSING DIAGNOSES
o Rushing through the interview
o Reading the question  A nursing diagnosis is typically three components: (I)
the problem and its definition, (II) the etiology, and (III)
the defining characteristics

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Acute Pain related to tissue ischemia as evidence by STEP FIVE – EVALUATION
statement
 The outcomes of the patient after the interventions
(P) Problem (E) Etiology (S) Signs and were rendered.
Symptoms  Is the goal achieved?
 Did the plan work?
of “I feel severe pain on my chest”  Are the interventions effective and efficient?
Problem and Definition  Is there a need to revisit the entire nursing process?

VALIDATING AND DOCUMENTING DATA

 The problem statement, or the diagnostic label,
describes the client’s health problem or response for VALIDATION
which nursing therapy is given as concisely as
possible, a diagnostic label usually has two parts:  It ensures that the assessment process is not ended
qualifier and focus of the diagnosis. before all relevant data have been collected. It helps to
prevent documentation of inaccurate data.
QUALIFIER FOCUS OF THE  Documentation of assessment data is an important
DIAGNOSIS step of assessment because it forms the database for
Deficient Fluid volume the entire nursing process and provides data for all
Imbalanced Nutrition: less than body other member of the health care team
requirements
Impaired Gas exchange “What is not documented is not done”
Ineffective Tissue perfusion
Risk for Injury C. NURSE’S ROLE IN HEALTH ASSESSMENT

 In the 21st century, the nurse’s role in assessment

HOW TO WRITE A NURSING DIAGNOSES PES FORMAT continues to expand, becoming more crucial than ever.
The role of the nurse in assessment and diagnosis is
Writing Diagnostic Statements more prevalent today than ever before in the history of
nursing.
ONE-PART Readiness for enhanced
(Health Promotion) breastfeeding  The rapidly evolving roles of nursing (e.g., forensic
TWO-PART Risk for infection related to nursing) require extensive focused assessments and
(Risk) compromised host defenses the development of related nursing diagnoses.
THREE-PART Impaired physical mobility o The acute care nurse performs a focused
(Problem-coping) related to decreased muscle assessment, and then incorporates
control as evidenced by assessment findings with a multidisciplinary
inability to control lower team to develop a comprehensive plan of
care.
o Critical care outreach nurses need
STEP THREE – PLANNING enhanced assessment skills to safely
assess critically ill clients who are outside the
 “How to manage the problem”
structured intensive care environment
 Based on the assessment and diagnosis, the nurse
(Coombs & Moorse, 2002).
sets measurable and achievable short and long-range
o Ambulatory care nurses assess and screen
goals
clients to determine the need for physician
Short Term Goals referrals.
o Home health nurses make independent
Long Term Goals nursing diagnoses and referrals for
collaborative problems as needed.
S – Specific o Public health nurses assess the needs of
M – Measurable communities, school nurses monitor the
A – Attainable growth and health of children, and hospice
R – Realistic nurses assess the needs of the terminally ill
T – Time framed clients and their families
STEP FOUR – IMPLEMENTATION o There is tremendous growth of the nursing
role in the managed care environment. The
 Putting plan of care into action most marketable nurses will continue to be
 Also called intervention those with strong assessment and client
 Involves carrying out your plan to achieve goals and teaching abilities as well as those who are
outcomes technologically savvy.
 The “doing” phase  The following are factors that will continue to
promote opportunities for nurses with advanced
assessment skills:

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 o Rising educational costs and focus on primary
care that affect the numbers and availability of
medical students
o Increasing complexity of acute care
o Growing aging population with complex
comorbidities
o Expanding health care needs of single
parents
o Increasing impact of children and the
homeless on communities
o Intensifying mental health issues
o Expanding health service networks
o Increasing reimbursement for health
promotion and preventive care services
EVOLUTION OF THE NURSE’S ROLE IN HEALTH
ASSESSMENT
LATE 1800s – EARLY 1900s
assessments from which individualized plans of care
were established
 The start of the thorough physical assessment or
nursing process.
1990 – PRESENT
 Over the last 20 years, the movement of health care
from the acute care setting to the community and the
proliferation of baccalaureate and graduate education
solidified the nurses’ role in holistic assessment.
 In the 1990s, critical pathways or care maps guided
the client’s progression, with each stage based on
specific protocols that the nurse was responsible for
assessing and validating. Advanced practice nurses
have been increasingly used in the hospital as clinical
nurse specialists and in the community as nurse
practitioners

 Nurses relied on their natural senses; the client’s face

and body would be observed for “changes in colour,
temperature, muscle strength, use of limbs, body
output, and degrees of nutrition, and hydration”
(Nightingale, 1992).
 Palpation was used to measure pulse rate and quality
and to locate the fundus of the puerperal woman
(Fitzsimmons & Gallagher, 1978).
 Examples of independent nursing practice using
inspection, palpation, and auscultation have been
recorded in nursing journals since 1901.

1930 -1949

 The American Journal of Public Health documents

routine client and home inspection by public health
nurses in the 1930s.
 This role of case finding, prevention of communicable
diseases, and routine use of assessment skills in poor
inner-city areas was performed through the Frontier
Nursing Service and the Red Cross (Fitzsimmons &
Gallagher, 1978)
 The start of the public health nursing.

1950 – 1969

 Nurses were hired to conduct pre-employment health

stories and physical examinations for major
companies, such as New York Telephone, from 1953
through 1960 (Bews & Baillie, 1969; Cipolla
& Collings, 1971).
 The start of the employment health assessment.

1970 – 1989

 The early 1970s prompted nurses to develop an

active role in the provision of primary health
services and expanded the professional nurse role
in conducting health histories and physical and
psychological assessments (Holzemer, Barkauskas, &
Ohlson, 1980; Lysaught, 1970).
 Acute care nurses in the 1980s employed the “primary
care” method of delivery of care. Each nurse was
autonomous in making comprehensive initial
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 CONTINUATION… DATE COLLECTION METHODS

ASSESSMENT Observing

 Step One of the Nursing Process o To gather data using the senses
o Is the first and most critical phase of the o A conscious, deliberate skill
nursing process. o 2 aspects
o If data collection is inadequate or inaccurate, o Noticing the data
incorrect nursing judgments may be made o Selecting, organizing and interpreting the
that adversely affect the remaining phases of data
the process: diagnosis, planning,
implementation, and evaluation. Interview
o Although the assessment phase of the o Planned communication or conversation with a
nursing process precedes the other phases in purpose
the formal nursing process, be aware that o To get or give information
assessment is on-going and continuous o Identify problems of mutual concern
throughout all phases of the nursing process. o Evaluate change, teach, provide support
o Thus, health assessment is o Provide counselling or therapy
 Gathering information about the
health status of the client PHASES OF THE INTERVIEW
 Analysing and synthesizing that data
 Making judgments about the  Pre-introductory Phase
effectiveness of nursing o Nurse reviews the medical record before meeting
interventions with the client
 Evaluating client care outcomes o If a medical record is not established, the nurse will
 The nursing process should be thought of as circular, need to rely on interview skills to elicit valid and
not linear. reliable data from the client and that individual’s
family or significant other
TYPES OF DATA
 Introductory Phase
 Subjective Data o The nurse explains the purpose of the interview,
o symptoms or covert data discusses the types of questions that will be
o apparent only to the person affected asked, explains the reason for taking notes, and
 Objective Data assures the client that confidential information will
o signs or overt data remain confidential
o detectable by an observer o The nurse makes sure that the client is
o can be measured, tested comfortable (physically and emotionally) and has
SOURCES OF DATA privacy
o The nurse should develop trust and rapport at this
 Client point in the interview
o Best source of data, subjective data
 Working Phase
Support People o Longest Phase
o Verbal / Nonverbal
o Family members, friends and caregivers
o The nurse elicits the client’s comments about
o Important source of data if the client is young
major biographic data, reasons for seeking care,
unconscious or confused
history of present health concern, past health
Client Records history, family history, review of body systems for
current health problems, lifestyle and health
o Information documented by other healthcare practices, and developmental level
professionals o The nurse listens, observes cues, and uses critical
thinking skills to interpret and validate information
Health care Professionals received from the client
o The nurse and client collaborate to identify the
o Verbal reports
client’s problems and goals
Literature
 Summary and Closing Phase
o Journals, reference texts, published studies o Summarize / Restate
o Clarify
o The nurse summarizes information obtained
during the working phase and validates problems
and goals with the client

9|Page
 o The nurse identifies and discusses possible plans THINGS TO AVOID DURING AN INTERVIEW
to resolve the problem (nursing diagnoses and
collaborative problems) with the client  Leading the patient
o Finally, the nurse makes sure to ask if anything  Biasing yourself
else concerns the client and if there are any further  Letting family members answer for patient
questions  Asking more than one question at a time
 Not allowing enough response time
TYPES OF INTERVIEW  Using medical jargon
 Direct Interview  Assuming rather than clarifying and validating
o Highly Structured  Taking the patient’s responses personally
o Controlled by the Nurse  Feeling personally uncomfortable
o Elicits specific information  Using clichés
o Nurse uses directive questions  Offering false reassurance
 Non-directive Interview  Asking persistent or probing questions
o Rapport – building interview  Changing the subject
o Controlled by the client  Taking things literally
 Information Gathering Interview  Giving advice
o Combination of non – directive and directive  Jumping to conclusions
interview
EXAMINING
TYPES OF INTERVIEW QUESTIONS
 Physical Examination
 Closed Questions o Carried out systematically
o Used in directive interview o Cephalocaudal or head to toe approach
o Answerable only by Yes or No  Screening Examination
o Often begin with where, who, what, do, is o Also called review of systems
o For patients who are highly stressed and has o A brief review of essential functioning of various
difficulty communicating body parts or systems
o Ex. “Do you feel pain?”
 Open-ended Questions ACTIVITIES OF DAILY LIVING (ADL)
o Used in non – directive interview
 Hygiene
o Invites client to explore, elaborate, clarify thoughts
 Continence
or feelings
 Dressing
o Useful in eliciting attitudes and mental status
o Often begin with what and how  Eating
o Ex. “What brought you to the hospital?”  Toileting
 Neutral Questions  Transferring
o A question that the client can answer without INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
direction or pressure from the nurse
 Leading Questions  Finding and utilizing resources
o Closed o looking up phone numbers, using a telephone,
o Directive making and keeping doctors’ appointments
o Persuasive  Driving or arranging travel
o either by public transportation, such as
FACTORS TO CONSIDER DURING THE INTERVIEW
Paratransit, or private car
 Time  Preparing meals
o When the client is physically comfortable and free o opening containers, using kitchen equipment
of pain
REVIEW OF SYSTEMS
 Place  Each body system is addressed
o Well – lighted, well – ventilated room, free of noise o Skin, Hair, Nails – colour, Temperature, etc.
and distractions o Head and Neck – headache, swelling, etc.
 Seating Arrangement o Eyes – vision problems, etc.
o Ideal seating arrangement: the nurse and patient o Ears – Tinnitus, etc.
sit in two chairs placed at right angles to a desk or o Mouth – lesions
a table or a few feet apart with no table o Thorax and Lungs – DOB, etc.
 Distance o Breast / regional lymphatics – lumps, etc.
o Maintain a 2 to 3 feet distance during interview o Heart / neck vessels – BP, chest pain etc.
 Language o Peripheral vascular – edema, etc.
o Avoid medical jargon o Abdomen – constipation, etc.
o Translators, interpreters o Male genitalia – urination, erection, etc.
10 | P a g e
 o Female genitalia – dyspareunia, etc.
o Anus, rectum, prostate – bowel habits, pain
o Musculoskeletal – swelling, pain
o Neurologic – mood, behaviour etc
COMPLETE HEALTH HISTORY
 Lays the groundwork for identifying nursing problems
and provides a focus for the physical examination
 The importance lies in its ability to provide information
that will assist the examiner in identifying areas of
strength and limitation in the individual’s lifestyle and
current health status
 Data from health history provide the examiner with
specific cues to health problems that are most apparent
to the client
 Modified or shortened when necessary
o Eg. If the physical assessment will focus on
the heart and neck vessels, the subjective
data collection would be limited to the data
relevant to the heart and neck vessels
STEPS OF HEALTH ASSESSMENT
A. Collection of Subjective Data through Interview and
Health History
a. Biographical Data
 Usually include information that identifies the client,
such as name, address, phone number, gender, and
who provided the information—the client or significant
others
 The client is considered the primary source and all
others (including the client’s medical record) are
secondary sources
 In some cases, the client’s immediate family or
caregiver may be a more accurate source of
information than the client
o Eg. An older-adult client’s wife who has kept the
client’s medical records for years or the legal
guardian of a mentally compromised client. In any
event, validation of the information by a secondary
source may be helpful.
 A format summary used to obtain biographical data
may include:
 Name
 Address
 Phone
 Gender
 Provider of history (patient or other)
 Birth date
 Place of birth
 Race or ethnic background
 Primary and secondary languages (spoken and read)
 Marital Status
 Religious or Spiritual Practices
 Educational Level
 Occupation
 Significant others or support persons (availability)
b. Reasons for seeking health care
 Reason for seeking health care (major health problem
or concern)
 Feelings about seeking health care (fears and past
experiences)
 This category includes two questions:
 “What is your major health problem or concerns at
this time?”
- This question 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?”
- Physicians call this the client’s chief
complaint (CC)
 “How do you feel about having to seek health
care?”
- This question encourages the client to
discuss fears or other feelings about
having to see a health care provider.
- This question may also draw out
descriptions of previous experiences—
both positive and negative—with other
health care providers.
c. Chief compliant
 Questioning the client “What is your major health
problem or concerns at this time?” implies the client’s
chief complaint (CC), but a more holistic approach for
phrasing the question may draw out concerns that
reach beyond a physical complaint and may address
stress or lifestyle changes
d. History of
 Present illness
 History of Present Health Concern Using
COLDSPA
 Character
- Describe the sign or symptom
(feeling, appearance, sound, smell, or
taste if applicable)
- “What does the pain feel like?”
- How does it feel, look, smell, sound,
etc.?
 Onset
- When did it begin; is it better, worse,
or the same since it began?
- When did this pain start?
 Location
- Where is it? Does it radiate?
- Does it occur anywhere else?
- Where does it hurt the most?
- Does it radiate or go to any part of
your body?
 Duration
- How long does it last? Does it recur?
- How long does the pain last?
- Does it come and go or is it constant?
 Severity
11 | P a g e
 - How bad is it on scale of 1 (barely
noticeable) to 10 (worst pain ever
experienced)?
- How much does it bother you?
- How intense is the pain? Rate it on a
scale 1 to 10
 Pattern
- What makes it better? What makes it
worse?
- What makes your back pain worse or
better?
- Are there any treatments you’ve tried
that relieve the pain?
 Associated Factors
- What other symptoms do you have it?
- Will you be able to continue doing
your work or other activities (leisure or
exercise)?
- What other symptoms occur with it?
How does it affect you?
- What do you think caused it to start?
- Do you have any other problems that
seem related to your back pain? How
does this pain affect your life and daily
activities?
 Past health history
 Ask about
 Childhood illness
 Childhood immunizations
 Adult illnesses
 Past surgeries or accidents
 Experienced pain
 Allergies
 Hospitalizations
 Pregnancies
 Births
 Injuries
 Medications
 Emotional or psychiatric problems
 Sample questions may include:
 “What diseases did you have as a child?”
 “What immunizations did you get and are you up
to date now?”
 “Do you have any chronic illnesses? If so, when
were they diagnosed? How are they treated? How
satisfied have you been with the treatment?”
 “What illnesses or allergies did you have? How
were the illnesses treated?”
 Family health history
 Document information in a genogram and in a list
of familial diseases
 Nurses must be familiar with the field of genomics
 Current medications
 Sample questions may include:
 “What medications have you used in the recent
past and currently, both those that your doctor
prescribed and those you can buy over the counter
at a drug or grocery store? For what purpose did
you take the medication? How much (dose) and
how often did you take the medication? Do you
take any medications not prescribed for you but
prescribed for a family member/friend or
purchased on the street?”
 Lifestyle and health practices profile
 A very important section of the health history because
it deals with the client’s human responses, which
include
 Description of typical day
- Elicit an overview of how the client sees his
usual pattern of daily activity
- Encourage the client to discuss a usual day,
which, for most people, includes work or
school
 Nutritional and weight management
- These questions uncover food habits that are
health promoting as well as those that are less
desirable
- Ask the client to
 Recall what consists of an average 24-
hour intake with emphasis on what foods
are eaten and in what amounts
 What snacks, fluid intake, and other
substances they consumed
- Sample questions may include:
 “What do you usually eat during a typical day? Please
tell me the kinds of foods you prefer, how often you eat
throughout the day, and how much you eat?”
 “Do you eat out at restaurants frequently?”
 Activity and exercise patterns
- Assess how active the client is during an
average week either at work or at home
- Distinguish between activity done when
working, which may be stressful and fatiguing,
and exercise, which is designed to reduce
stress and strengthen the individual
- Explain to the client that regular exercise
reduces the risk of heart disease, strengthens
heart and lungs, reduces stress, and
manages weight
- Sample questions may include:
 “What is your daily pattern of activity?”
 “Do you follow a regular exercise plan? What types of
exercise do you do?”
 “Are there any reasons why you cannot follow a
moderately strenuous exercise program?”
 Sleep and rest patterns
- Questions should focus on specific sleeping patterns
such as how many hours a night the person sleeps,
interruptions, whether the client feels rested, problems
sleeping (e.g., insomnia), rituals the client uses to
promote sleep, and concerns the client may have
regarding sleep habits
- Sleep requirements vary depending on age, health,
and stress levels
- Sample questions may include:
 “Tell me about your sleeping patterns.”
 “Do you have trouble falling asleep or staying asleep?”
 “How much sleep do you get each night?”
 Substance use
- Information provides the nurse with information
concerning lifestyle and a client’s self-care ability
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- Use of substance can affect the client’s health and
cause loss of function or impaired senses
- Sample questions may include:
 “How much beer, wine, or other alcohol do you drink on
average?”
 “Do you drink coffee or other beverages containing
caffeine (e.g., cola)?” If so, how much and how often?”
 Self-concept and self-care activities
- Assessment of how the client views herself and
investigation of all behaviours that a person does to
promote her health
- Examples of subjects to be addressed include
 sexual responsibility
 basic hygiene practices
 regularity of health care check-ups (i.e., dental, visual,
medical) breast/testicular self-examination
 accident prevention
 hazard protection (e.g., seat belts, smoke alarms, and
sunscreen)
- Sample questions may include
 “What do you see as your talents or special abilities?”
 “How do you feel about yourself?” About your
appearance?”
 “Can you tell me what activities you do to keep yourself
safe, healthy, or to prevent disease?”
 “Do you practice safe sex?
 Social and community activities
- Help the nurse to discover what outlets the client has
for support and relaxation and if the client is involved in
the community beyond family and work
- Helps to determine the client’s current level of social
development.
- Sample questions may include:
 “What do you do for fun and relaxation?”
 “With whom do you socialize most frequently?”
 “Are you involved in any community activities?”
 Relationships
- Ask the client to describe the composition of the family
into which they were born and about past and current
relationships with these family members
- Information help assess problems and potential
support from the client’s family of origin
- Sample questions may include:
 “Who is (are) the most important person (s) in your
life? Describe your relationship with that person.”
 “What was it like growing up in your family?”
 “What is your relationship like with your spouse?”
 Values and beliefs system
- Assess the client values, and discuss the clients’
philosophical, religious, and spiritual beliefs
- Some clients may not be comfortable discussing
values or beliefs, feelings should be respected
- The data can help to identify important problems or
strengths
- Sample questions may include:
 “What is most important to you in life?”
 “What do you hope to accomplish in your life?”
 “What gives you strength and hope?”
 Education and work
- Helps to identify areas of stress and satisfaction in the
client’s life
- Questions should bring out data about the kind and
amount of education the client has, whether the client
enjoyed school, whether he perceives his education as
satisfactory or whether there were problems, and what
plans the client may have for further education, either
formal or informal
 Stress level and coping style
- Ask questions that address what events cause stress
for the client and how they usually respond
- Find out what the client does to relieve stress and
whether these behaviours or activities can be
construed as adaptive or maladaptive
 Environment
- To assess health hazards unique to the client’s living
situation and lifestyle
- Look for physical, chemical, or psychological situations
that may put the client at risk
- These may be found in the client’s neighbourhood,
home, work, or recreational environment.
- Controllable or uncontrollable
Developmental level
 Significantly impacts client’s health assessment
 The primary source of data varies depending on the
patient’s age and developmental level
 For patients with developmental alterations, findings
related to intellectual ability must be interpreted
according to the assessed developmental level not the
patient’s age
Psychosocial history
 Includes the way a person thinks, feels, acts and
relates to self and others
 It is the ability to cope and tolerate stress and the
capacity for developing a value and belief system
 Assessment must consider the interaction of body,
mind and spirit in their entirety rather than as separate
body systems
 Factors that influence psychosocial health
 Internal factors
- Genetics
- Physical health
- Developmental stage
- Physical fitness
 External factors
- Family
- Culture
- Geography
- Economic status
 Additional factors to consider in psychosocial health
 Self – concept
 Role development
 Sexuality
 Interdependent relationships
 Ability to manage stress
 To cope and adapt to change
 Develop a belief and value system
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 B. Collection of Objective Data assistance or may not be able to assume this
position
a. Physical Examination o SITTING
- Seated position, back unsupported and legs
 What is physical assessment?
hanging freely
 A systematic way of collecting objective data from a
- FOR: Head neck posterior and anterior thorax
client using the four examination techniques
breast Breasts axillae
 Use??
- heart vital signs, upper extremities lower
 to assess or identify current health status
extremities and reflexes
 Purpose of physical assessment - CI: Elderly and weak clients may require
 Obtain physical data about the client’s functional support
abilities o DORSAL RECUMBENT
 Supplement, confirm, or refute data obtained in the - Back lying position with knees flexed and hips
client’s health history externally rotated; small pillow under the
 Obtain data that will help the nurse data establish
head; soles of the feet on the surface
diagnoses and plan the client’s care - FOR: Head and neck, axillae, anterior thorax,
 Evaluate the physiologic outcomes of health care and lungs, breasts, heart, extremities, peripheral
thus the progress of a patient’s health problem
pulses, vital signs and vagina
 To make clinical judgments about a client’s health - CI: clients with cardio pulmonary problems.
status Not used for abdominal testing because of the
 To identify areas for health promotion and disease increased tension in abdominal muscles. If
prevention patient has abdominal pain, flexing knees is
PREPARATION GUIDELINES usually more comfortable
o SUPINE
o Preparatory Phase - The client is lying on the back. The head and
 Introduce self to the client. Verify his identity. Explain shoulders are usually elevated with a small
the purpose why such procedure is necessary and how pillow. The arms and legs are extended and
he could cooperate (i.e. positioning). the legs are slightly abducted
 Help him put on a clean gown and offers a bedpan or - FOR: head neck axillae, anterior thorax,
a urinal to empty his bladder. lungs, abdomen, extremities, peripheral
 Ensure privacy by closing the doors or pulling the pulses
curtains around him. - CI: Tolerated poorly by clients with
 Invite a relative or a significant other to stay with the cardiovascular and respiratory problems
client, as necessary o SIM’S
 Provide adequate lighting. - The client is lying on the side with the body
 Gather the Materials or Equipment. turned at 45 degrees. The lower leg is
extended, with the upper leg flexed at the hip
 Ensure the examination table is at a comfortable
and knee to a 45-to-90-degree angle.
working height.
- FOR: assessment of rectum and vagina
 Perform hand hygiene.
- CI: Difficult for elderly and people with limited
o Materials/Equipment Needed
joint movement
o height chart
o PRONE
o weighing scale
- The client is lying on the abdomen with head
o Snellen’s chart
turned to the side.
o Penlight
- FOR: Posterior thorax, hip joint movement
o card board
- CI: Often not tolerated by the elderly and
o sterile gloves
people with cardiovascular and respiratory
o tongue depressor
problem
o 4x4 Gauze
o LITHOTOMY
o tuning fork
- The client is lying on the back with the hips
o stethoscope
and knees flexed at right angles and feet in
o wrist watch
stirrups.
o tape measure
- FOR: assessment of female rectum and
o marker/pencil
vagina. (for a brief period only)
o record sheet
- CI: May be uncomfortable and tiring for elderly
o waste receptacle
people. Often embarrassing
o Positioning your Patient
o KNEE CHEST
o STANDING
- Assessment of rectal area
- FOR: assessment of posture, gait & balance
- assessment of rectal area (for brief period
- CONTRAINDICATION (CI): Patients who are
only)
weak, disabled, or paralyzed may need
- Jack Knife

14 | P a g e
 Techniques in physical assessment
o ADULT
- Cephalocaudal
o PEDIA
- Least invasive to more invasive areas
o ASSESSMENT TECHNIQUE
- Inspection (I)
 Visual examination of the patient done in a
methodical, deliberate, purposeful, and systematic
manner
o Palpation (P)
 The use of hand to touch and feel the patient’s
skin, organs, mass, and other delineated
structures in the body
 Assess temperature; turgor; texture; moisture;
vibrations; position, size, shape, consistency and
mobility of organ or masses; distension; pulsation;
and the presence pain upon pressure
 Palmar surfaces of the examiner's fingertips and
finger pads are used for discriminatory sensation,
such as texture, vibration, presence of fluid, or size
and consistency of a mass
 The dorsum, or back of the hand, is used to assess
surface temperature
 LIGHT PALPATION
- Place the hand with fingers together parallel
- Moving the hand in circle.
- 1/2 inch (1 cm)
- muscle tone
- tenderness
 DEEP PALPATION
- 1 inch (2 cm).
- Abdominal organs and abdominal masses.
- Two – handed deep palpation place the
fingers
- Of one hand on top of those of the other.
- The top hand applies pressure while the lower
- hand remains relaxed to perceive the tactile
- Sensation.
- pressure can damage internal organs
 BIMANUAL DEEP PALPATION
- Deep Palpation is done with two hands (bimanually) or
one hand
- Percussion (P)
 Striking of the body surface with short, sharp
strokes
 Palpable vibrations and characteristic sound
 location, size, shape
 density of underlying structures
 to detect the presence of air or fluid in a body
space
 elicit tenderness
 Types:
o DIRECT PERCUSSION
- using sharp rapid movements from the wrist, strike the
body surface to be percussed with the pads of two,
three, or four fingers or middle finger alone
- Primarily used to assess sinuses in the adult
- Using one hand to strike the surface of the body
o INDIRECT PERCUSSION
- percussion in which two hands are used and the plexor
strikes the finger of the examiner’s other hand, which
is in contact with the body surface being percussed
(pleximeter- the middle finger of the nondominant
hand)
- Using the finger of the one hand to tap the finger of the
other hand
 Percussion is used to access the location, shape, size,
and density of tissues
 (Left) The non-dominant hand is placed directly on the
area to be percussed, and the middle finger is placed
firmly on the body surface
 (Right) The tip of the middle finger of the dominant
hand strikes the joint of the middle finger of the
opposite hand
o TECHNIQUE
- Strike at a right angle to the pleximeter using quick,
sharp but relaxed wrist motion
- Withdraw the plexor immediately after the strike to
avoid damping the vibration. Strike each are twice and
then move to a new area
o TYPES OF SOUNDS HEARD WHEN
PERCUSSING
- FLAT – soft
- DULL – medium
- RESONANCE – loud
- HYPER RESONANCE – very loud
- TYMPANY – loud
- Auscultation (A)
 Listening to sounds produced within the body
 Characteristics of sound heard during auscultation
 PITCH – ranging from high to low
 LOUDNESS – ranging from soft to
loud
 QUALITY – gurgling or swishing
 DURATION – short, medium or long
 BELL
- Use the bell of the stethoscope to detect low-pitched
sounds
- The bell should be at least 1 inch wide.
- Hold the bell lightly against the body part being
auscultated
 DIAPHRAGM
- Use the diaphragm of the stethoscope to detect high-
pitched sounds
- The diaphragm should be at least 1.5 inches wide for
adults and smaller for children
- Hold the diaphragm firmly against the body part being
auscultated
b. Diagnostic Tests and Procedures
 DIAGNOSTIC TESTS
 Commonly called laboratory tests
 Used for basic screening as part of wellness check
 Used to help confirm diagnosis, monitor an illness, and
provide valuable information about the client’s
response to treatment
 Diagnostic Testing Phases
 PRETEST
- Client preparation
15 | P a g e
- A throughout assessment and data collection
(biological, psychologic, sociological, cultural and
spiritual) assist the nurse in determining
communication and teaching strategies.
 INTRATEST
- Specimen collection and performing or assisting with
certain diagnostic testing. o
- The nurse uses standard precaution, sterile technique,
provides emotional and physical support while
monitoring the client. Also the nurse ensures correct
labelling, storage, and transportation of specimen to
avoid invalid test result.
 POST-TEST
- On nursing care of the client and follow-up activities
and observation.
- The nurse compares the previous and current test
result and report this to appropriate health team
members
 Nursing Diagnosis Appropriate for Client’s Who
Will Undergo Diagnostic Testing
 Anxiety or Fear related to possible diagnosis of acute
or chronic illness pending conclusion of diagnostic
testing
 Impaired Physical Mobility related to prescribed bed
rest and restricted movement of involved extremity
after testing
 Deficient Knowledge (state diagnostic test) related to
misperceptions received from others regarding
process for test
 Common Diagnostic Tests
 BLOOD TESTS
- Commonly used diagnostic tests that can provide
valuable information about the hematologic system
- venipuncture (puncture of a vein for collection of a
blood specimen) is performed
 Complete Blood Count
- Includes hemoglobin and hematocrit measurements,
erythrocyte (red blood cells) count, red blood cell
indices, leukocyte (white blood cell) count, and a
differential white cell count
- CBC is a basic screening test and one of the most
frequently ordered blood tests
 Serum Electrolytes
 Often routinely ordered for any client admitted to a
hospital as a screening test for electrolyte and acid–
base imbalances
 also routinely assessed for clients at risk in the
community, for example, clients who are being treated
with a diuretic for hypertension or heart failure
 The most commonly ordered serum tests are for
sodium, potassium, chloride, and bicarbonate ions
 Specialty nurses, medical technicians, and respiratory
therapists normally take specimens of arterial blood
from the radial, brachial, or femoral arteries
- Check institutional policies also
 Because of the relatively great pressure of the blood in
these arteries, it is important to prevent haemorrhaging
by applying pressure to the puncture side for about 5
to 10 minutes after removing the needle
 Normal Values for Arterial Blood Gases
- pH ▪ 7.35 – 7.45
- PCO2 ▪ 35 – 45 mm Hg
- PO2 ▪ >80 mm Hg
- HCO3 ▪ 22 – 26 mEq/L
- O2 saturation ▪ >94%
 Blood Chemistry
 Include determining certain enzymes that may be
present (including lactic dehydrogenase [LDH],
creatine kinase [CK], aspartate aminotransferase
[AST], and alanine aminotransferase [ALT]), serum
glucose, hormones such as thyroid hormone, and other
substances such as cholesterol and triglycerides
 a common laboratory test is the glycosylated
hemoglobin or hemoglobin A1C (HbA1C) test
 Metabolic Screening
 R outinely screened for congenital metabolic
conditions for newborns
 conditions that are frequently screened for include
sickle cell disease and galactosemia
 screening involves collecting peripheral venous blood
(via a heel-stick) on prepared blotting paper and
sending the specimen to the state laboratory for
analysis
 discovered abnormalities allow the provider and
parents to plan early care (e.g., special diets for
children with PKU) that can prevent long-term
complications
 Capillary Blood Glucose
 A capillary blood specimen is taken to measure the
current blood glucose level
 less painful than a venipuncture and easily performed
 STOOL SPECIMENS
 Some of the reasons for testing feces include the
following:
 To determine the presence of occult (hidden) blood
(guaiac test)
 To analyze for dietary products and digestive
secretions
 excessive amount of fat in the stool (steatorrhea) can
indicate faulty absorption of fat from the small intestine
 decreased amount of bile can indicate obstruction of
bile flow from the liver and gallbladder into the intestine
 To detect the presence of ova and parasites
 To detect the presence of bacteria or viruses
 URINE SPECIMENS
 Clean Voided Urine Specimen
- A clean voided specimen is usually adequate for
routine examination
- Routine urine examination is usually done on the
first voided specimen in the morning because it
tends to have a higher, more uniform
concentration and a more acidic pH than
specimens later in the day
16 | P a g e
 - 10 mL of urine is sufficient
 Clean-Catch or Midstream Urine Specimen
- Clean-catch or midstream voided specimens are
collected when a urine culture is ordered to identify
microorganisms causing a urinary tract infection
- Care is taken to ensure that the specimen is as free as
possible from contamination by microorganisms
around the urinary meatus
- Clean-catch specimens are collected in a sterile
specimen container with a lid
 Timed Urine Specimen
- collection of all urine produced and voided over a
specific period of time, ranging from 1 to 2 hours to 24
hours
- generally, either are refrigerated or contain a
preservative to prevent bacterial growth or
decomposition of urine components
- purposes
o To assess the ability of the kidney to
concentrate and dilute urine.
o To determine disorders of glucose
metabolism, for example, diabetes mellitus
o To determine levels of specific constituents,
for example, albumin, amylase, creatinine,
urobilinogen, or certain hormones (e.g.,
estriol or corticosteroids), in the urine
 sample is cultured and examined for the presence of
disease-producing microorganisms
 Imaging studies
 Chest X-ray
- Detects densities produced by fluid, tumors, foreign
bodies and other pathologic conditions present on a
normal radiolucent pulmonary tissue
- Routine CXR consists of 2 views:
o Posteroanterior projection
o Lateral projection
- Obtained after full inspiration because the lungs are
best visualized when they are well aerated
- Patients are instructed to take a deep breath and hold
it without discomfort because the diaphragm is at its
lowest level and the largest expanse of lung is visible
- Contraindicated in pregnant women
c. Other Sources
 Client chart / medical or health record
 Contains information about what other health care
professionals (ie. Nurses, physicians, physical
therapists, dieticians, social workers, etc.) observed
about the client
 Family or significant others observations about the
client

 Indwelling Catheter Specimen

 Sterile urine specimens obtained from closed drainage
systems by inserting a sterile needle attached to a
syringe through a drainage port in the tubing

 SPUTUM SPECIMENS
 Sputum is the mucous secretion from the lungs,
bronchi, and trachea o It is important to differentiate it
from saliva, the clear liquid secreted by the salivary
glands in the mouth, sometimes referred to as “spit”
 Healthy individuals do not produce sputum
 Clients need to cough to bring sputum up from the
lungs, bronchi, and trachea into the mouth in order to
expectorate it into a collecting container
 Collected for the following reasons:
- For culture and sensitivity to identify a specific
microorganism and its drug sensitivities
- For cytology to identify the origin, structure, function,
and pathology of cells
- For acid-fast bacillus (AFB), which requires serial
collection, often for 3 consecutive days, to identify the
presence of tuberculosis (TB)
- To assess the effectiveness of therapy
 Often collected in the morning
- Upon awakening, the client can cough up the
secretions that have accumulated during the night
 sometimes collected during postural drainage
- When the client can usually produce sputum
- when a client cannot cough, the nurse sometimes use
pharyngeal suctioning to obtain a specimen

 THROAT CULTURE
 Collected from the mucosa of the oropharynx and
tonsillar regions using a culture swab

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 NCMA121: HEALTH ASSESSMENT
PRELIMS WEEK 2
1st year, 2nd SEMESTER | S.Y 2021-2022 TRANSCRIBED BY: KRISTINE CALDERON, ALYSSA JIMENEZ
LECTURER: Ma’am Cora P. Quinto

 Also known as “Cardinal Signs”

VITAL SIGNS
VITAL SIGNS
 The client’s vital signs (pulse, respirations, blood
pressure and temperature) are the body’s indicator of
health. Usually when a vital sign/s is abnormal,
something is wrong in at least one of the body systems.
 Today “pain” is considered to be the fifth vital sign. Pain
is inexpensive to assess and does not involve the use
of fancy instrument.
 Oxygen saturation is also considered as a vital sign, it
is the level in the blood. This can be measured with the
use of a pulse oximeter. Normal (95% - 100%)
 The “taking of vital signs” refers to measurement of the
client’s body temperature (T), pulse (P), and respiratory
(R) rates, and blood pressure (BP)
 The first step in the physical examination
 Establish baseline values
 An essential nursing function is performed on every
client.
 The measurement of vital signs and the execution of
the physical examination as party of the assessment
process are done to gather information regarding the
physiological functioning of the body.
WHEN TO ASSESS VITAL SIGNS

 Upon admission
 A change in health status
 Pre and Post Op/Procedure
 Pre and Post medication administration
 Before and after any nursing intervention that could
affect the vital signs
 Hospital/institutional policy (Routine)
 Depending on doctor’s order or patient’s current
condition

BODY TEMPERATURE

 It is a good idea to begin the “hands-on” physical  For the body to function on a cellular level, a core body
examination by taking vital signs. temperature between 36.58c and 37.2c (96.0F and
 This is a common, non-invasive physical assessment 99.9F orally) must be maintained. An appropriate
procedure that most clients are accustomed to reading of core body temperature can be taken at
various anatomic sites. None of these is completely
NORMAL VITAL SIGNS accurate; they are simply a good reflection of the core
ADULTS body temperature.
Temperature 36.5 -37.2  Several factors may cause normal c=variations in the
Adult PR 60 – 100 bpm core of the body temperature. Strenuous exercise,
Respiration 16 – 20 cycles or breathes stress and ovulation can raise temperature.
per minute  Body temperature is the lowest in the morning (4:00
BP 90/60 – 120/80 AM to 6:00 AM) and highest late in the evening (8:00 –
12 MN).
NEWBORN  Hypothermia may be seen in prolonged exposure to
Temperature 36.5 – 37.2 the cold, hypoglycaemia, hypothyroidism, or starvation.
Adult PR 120 – 160 bpm  Hyperthermia may be seen in viral or bacterial
Respiration 40 -60 rpm infections, trauma, and various blood, endocrine and
BP The average blood pressure immune disorders.
in a new born is 64/41. The  NORMAL TEMPERATURE IS 36.5 – 37.2 C
average blood pressure in a  Balance between the heat lost and produced
child 1 month through 2  Measured in degrees
years old is 95/58. It is
normal for these numbers to FACTORS THAT AFFECT HEAT PRODUCTION
vary.
 BMR
 Muscle activity = increases metabolic rate
 Thyroxine output = increased thyroxine output,
increased metabolic rate

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  Epinephrine, norepinephrine (synthetic adrenaline) FACTORS AFFECTING BODY TEMPERATURE
and sympathetic stimulation
 Fever  Age
 Diurnal variations
Basic Metabolic Rate (BMR)  Exercise
 Hormones
 Basal metabolic rate  Stress
 Rate of energy utilization in the body required to  Environment
maintain essential activities
 Cool someone down and their metabolic rate slow ALTERATIONS IN BODY TEMPERATURE
down, heat them up and their metabolism increases up
 Pyrexia
Muscle Activity - A body temperature above the usual range is called
Pyrexia, Hyperthermia or Fever.
 Increases metabolic rate o Hyperpyrexia
 Using large muscles to make heat rather than o Febrile
movement o Afebrile
 Strenuous exercise cause normal variations in the
body temperature TYPES OF FEVERS

Thyroxine (T4) Output 1. INTERMITTENT

- Alternates at regular intervals between periods of fever
 A thyroid hormone for regulation of metabolism (BMR) and periods of normal/subnormal temperatures.
 Increased Thyroxine output increases metabolism - Ex: malaria
(chemical thermogenesis) 2. REMITTENT
- Wide range of temperature fluctuations all of which are
Epinephrine, Norepinephrine and Sympathetic Stimulation
above normal.
 Sympathetic nervous system 3. RELAPSING
- Short febrile periods of a few days are interspersed
 Plays important role on the maintenance of core body
with periods of 1 or 2 days of normal temperature.
temperature through thermoregulatory processes
- Ex: typhoid fever
Fever 4. CONSTANT
- Fluctuates minimally but always remain above normal.
 Increase in the body temperature’s set point - Ex: urinary tract infection, pneumonia
 Increase cellular metabolic rate
 Increase in set point triggers increased muscle Clinical Onset of Fever
contractions
Onset / Chill
Types of Heat Transfer:
o Set point increases from normal to higher than
Conduction normal. The phase when you feel like you are
about to get sick
- Transfer of heat from one molecule to a molecule of o Chilling is your body’s response to
lower temperature compensate. It is your body’s response to
- Ex: ice pack, cool fever produce heat. Body is compensating to
decrease temperature.
Radiation - ↑ heart rate
- ↑ RR
- Transfer of energy in the form of waves and particles
- Shivering
- Ex: body heat (air conditioned room filled with many
- Cold, pallid skin
people will make the room feel hot)
- Cyanotic nail beds
Convection - “Gooseflesh”
- Cessation of sweating
- Is the dispersion of heat by air currents
- Almost the same with radiation the only difference is Course / Plateu
that convection requires air current
o You already have a fever.
- Ex: being in front of an electric fan
- Absence of chills
Vaporization / Evaporation - Skin that feels warm
- Photosensitivity
- Is a continuous evaporation of moisture from the - Glassy eyed appearance
respiratory tract and from the mucosa of the mouth and - ↑ PR and RR
from the skin - ↑ thirst
- Dehydration

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 - Drowsiness, restleness, delirium  Provide adequate nutrition and fluids
- Loss of appetite  Oral hygiene
- Malaise  Tepid sponge bath
 Dry clothing and linens
Defervescence
 Antipyretics
o Critical
ASSESSING TEMPERATURE
o It occurs when the cause of fever is suddenly
removed PURPOSE:
o Flushed defervescent state of pyrexia
- Flushed skin 1. To establish Baseline data for subsequent evaluation
- Sweating 2. To identify whether the core temperature is within
- Decreased shivering normal range
- Possible dehydration 3. To determine changes in core temperature in response
to specific therapies
Hypothalamus – controls our body temperature. 4. To monitor clients at risk for imbalanced body
temperature
ALTERATIONS IN THERMOREGULATION
Alteration Definition Characteristics PLACEMENT TIMES
Heat exhaustion An increase in Loss of excessive Site Time Adult Advantages
body temperature amounts of water /Pedia /Disadvantages
(38 – 40 C; 100.4 and sodium from Axilla Beeping Adult - Safest and non-
– 104.0 F) in perspiring leads to sound invasive
response to thirst, nausea, - Not as accurate
environmental vomiting, compared to others
conditions that in weakness, and Rectal Beeping Pedia - More accurate and
turn, causes disorientation. sound most reliable because it
diaphoresis is closest to core
(profuse temperature
perspiration). - Uncomfortable for
Heat stroke A critical increase Dry, hot skin is the patient
in body most important - New born: you check
temperature (41 – sign. The person temp. of new born using
44 C) resulting becomes rectal route to check the
from exposure to confused, or patency of the anus
high delirious, and Tympanic Depends Adult - Fastest way to get
environmental experiences thirst, on temperature of patient
temperatures. abdominal tympanic - However, although it’s
distress, muscle thermomet fast, it is not as accurate
cramps, and visual er as other sites
disturbances. Loss
Oral Beeping Adult - Most accessible
of consciousness
sound - This might injure your
occurs if
oral mucosa and it will
untreated.
require your patient to
Hypothermia A body Decrease in follow instructions like;
temperature of 35 metabolism leads to keep the oral temp. in
C or lower to impaired mental his or her mouth for a
resulting from cold functioning and specific period of time
weather exposure depressed pulse, until alarm is heard
or artificial respirations, and
induction. blood pressure;
can result in How to Do it?
cardiac arrest of
untreated. Temperature (Oral, Rectal, Axillary, Tympanic)
Frostbite Freezing of the Circulatory
body’s surface impairment may 1. Introduce yourself and verify client identity
areas (earlobes, be followed by 2. Hand hygiene and infection control procedure
fingers, and toes) gangrene. 3. Provide privacy
in extremely low 4. Position accordingly
temperatures. 5. Place thermometer and wait for the appropriate amount
of time
6. Remove and read temperature
NURSING INTERVENTION
7. Wipe he thermometer correctly\
 Monitor vital signs and skin colour 8. Document finding
 Monitor lab values

20 | P a g e
 PULSE PULSE CHARACTERISTICS

PULSE RATE Pulse Volume

 Is an indirect measurement of cardiac output obtained - Is a measurement of the strength or amplitude of

by counting the number of apical or peripheral pulse force exerted by the ejected blood against the
waves over a pulse point. A normal pulse rate for adults arterial wall with each contraction
is between 60 and 100 beats per minute.  Bradycardia
- Is a heart rate less than 60 beats per minute in an
Compliance adult
- Ability of your arteries to contract and expand  Tachycardia
- Is a heart rate in excess of 100 beats per minute
Cardiac output in an adult

- Volume of blood pumped into the artery by the How to Do it?

heart
- Important indicator of how efficiently your heart Peripheral Pulse
can pump blood to perform tissue perfusion 1. Introduce yourself and verify client identity
- How do we measure Cardiac Output? 2. Hand hygiene and infection control procedure
- SV (stroke volume) x Heart rate/minute 3. Provide privacy
- Stroke volume – is the amount of blood 4. Select the pulse point and position client accordingly
being pumped by the heart per pump. It 5. Palpate and count the pulse
is usually given 6. Assess the rhythm and volume
- Normal Cardiac Output = 4L – 8L blood 7. Document the pulse rate, rhythm and volume
Peripheral pulse RESPIRATION
- Pulse that is located away from the heart  Is the act of breathing
- What we use to check pulse rate o External Respiration
- Indication that your body has good volume and - Interchange of oxygen and carbon
that your heart is efficiently contracting dioxide between the alveoli and the
Apical pulse pulmonary blood
o Internal Respiration
- Central pulse or it can be appreciated at the apex - Interchange of oxygen and carbon
of the heart dioxide between the circulatory blood
- It is the one directly heard from the heart and body tissues
o Inhalation
Pulse Deficit - Intake of air from lungs to the atmosphere
o Exhalation
- It is the condition in which the apical pulse rate is
- Breathing out
greater than the peripheral pulse rate
o Ventilation
- The difference between the apical pulse and the
- Is the movement of air in and out of lungs
radial or peripheral pulse
- There should be no difference between the apical TWO TYPES OF BREATHING
pulse and peripheral pulse
Costal / Thoracic
ASSESSING THE PULSE RATE
- External inter costal muscles
 The nurse should begin the assessment by speaking - Accessory muscle
with the client about normal pulse rate - Chest upward then downward
 Palpate a peripheral pulse by placing the first two
fingers on the pulse point with moderate pressure Abdominal / Diaphragmatic
 Count the rate for a full minute, noting the regularity
- Contraction and relaxation of the
(rhythm)
diaphragm
 When an irregular peripheral pulse is present, the
- Movement of the abdomen
nurse needs to assess for a pulse deficit
 When a discrepancy exists between the apical and Diaphragmatic breathing is the most efficient because
radial pulses, the deficit is assessed by simultaneously GREATER EXPANSION AND VENTILATION OCCURS IN
measuring the apical and radial pulses for a minute THE LOWER PART OF THE LUNG WHERE BLOOD
PERFUSION IS THE GREATEST.

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 MAJOR PHYSICAL PULMONARY FUNCTION - Substernal Retractions
- Appreciated more with pediatric patients
Ventilation - Suprasternal Retractions
- Appreciated more with adult patients
- The function of your pulmonary system
- The inflow and outflow of air between the Secretions
atmosphere and lung alveoli
- Hemoptysis (blood tinged sputum)
Circulation - Productive Cough
- Non-Productive Cough
- The quantity of blood flowing through the lungs
- The quantity of blood that should flow in the body How to Do it?
should be approximately 4-6L every minute
Respirations
Diffusion
1. Introduce yourself and verify client identity
- The exchange of oxygen and carbon dioxide 2. Hand hygiene and infection control procedure
between the alveoli and the blood 3. Provide privacy
4. Observe/palpate and count the RR
Transport
5. Observe depth, rhythm, and character of respirations
- Carrying of oxygen and carbon dioxide In the 6. Document findings
blood and body fluid to and from the cell
BLOOD PRESSURE
ASSESSING RESPIRATION
 Blood pressure is the measure of pressure exerted
 Sites as blood flows through the artery
1. Chest wall  It is measured in terms of millimetres of mercury
2. Thorax (mm/Hg) and written in fraction form
3. Nose and mouth  NORMAL VALUE is below 120 (systolic) and
below 80 (diastolic)
ALTERED BREATHING PATTERN / SOUNDS
THE 2 BLOOD PRESSURE MEASUREMENTS
Rate
Systolic 120
- Tachypnea (increase in respiratory rate)
- Bradypnea (decrease in respiratory rate) ______
- Apnea (cessation or absence of breathing)
- Eupnea (normal breathing pattern)

Volume Diastolic 80

- Hyperventilation (you are removing too much C02 DETERMINANTS OF BLOOD PRESSURE
in your body) Pumping action of the heart
- Hypoventilation (decrease in breathing and not
enough oxygen supply) - If the heart is weak = ↓ blood pumped into arteries
Effort Peripheral vascular resistance

- Dyspnea (difficulty in breathing) - Vasoconstriction = ↑ BP

- Orthopnea (difficulty in breathing while your - Vasodilation = ↓ BP
patient is lying down) (indication that patient may
have fluid accumulation in lungs) Blood volume

Sounds - ↓ blood = low BP because of ↓ fluid in arteries

- Stridor (shrill harsh sound during inspiration) Blood viscosity

(patient might have obstruction)
- Measurement of thickness and stickiness of blood
- Crackling (snoring respiration) (obstruction in
- Proportion of RBC to plasma is high (haematocrit)
upper airway)
60-65% - (RBC INCREASED)
- Wheeze (asthma attacks, COPD) (narrowing in
- Common to patients with polycythemia
the airway)
- Elevated BV is a strong independent predicator of
- Bubbling (thick respiratory or mucus secretion)
cardiovascular events
Chest Movement - The component of the blood (does your blood
have elevated RBC, elevated Blood Glucose?)
- Intercostal retractions - These factors may lead to elevated BP

22 | P a g e
 FACTORS THAT AFFECT BP SPHYGMOMANOMETER

Age Parts of Sphygmomanometer

- Rises with age then declines due to physiologic  Bulb

changes in aging  Valve
 Cuff – covering
Exercise
 Bladder – the one inflating and deflating cuff
- Assess 20-30 minutes after  Manometer

Stress ASSESSING THE BLOOD PRESSURE

- Sympathetic nervous system stimulation = SITE

increased cardiac output
- Arm (Brachial Artery)
Gender - Thigh

- Hormonal variations METHODS

Medications DIRECT (INVASIVE)

Obesity - A catheter is inserted into the brachial, radial or

femoral artery
Diurnal variations
INDIRECT
- Lowest early in the morning and peaks at late
afternoon o Auscultation
- Observation of the readings from the
Disease process manometer in relation to the korotkoff’s
sound
- Conditions that affect cardiac output, blood o Palpation
viscosity, volume, arteries
- Uses light to moderate pressure to
palpate the pulsations of the artery as the
pressure of the cuff is released

NORMOTENSION

- Normal BP
- 1 inch above the antecubital fossa
- Inflate the cuff by pumping the bulb to about 30
mmHg above the point which the radial pulse
disappears (assist you to avoid missing an
auscultatory gap)
- Read the point closest to an even number on the
gauge
- If it is necessary to recheck, wait for 120 seconds
after deflating the cuff (2 minutes)

KOROTKOFFS SOUND

I. Clear, soft tapping that increases to a thud or loud tap

(systolic sound) (sharp tapping sounds)
II. Tapping changes to a soft, swishing sound. (longer
swishing sound)
III. Clear tapping sound returns. (crisp tap)
IV. Muffled, blowing sound (diastolic sound in children or
physically active adults). (quiet dull thudding sound)
V. Disappearance of muffled, blowing sound (second
diastolic sound). (silence as the cuff pressure drops
below diastolic pressure)

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 COMMON ERRORS
ERROR EFFECT
Bladder cuff too narrow Erroneously High
Bladder cuff too wide Erroneously Low
Arm unsupported Erroneously High
Insufficient rest before Erroneously High
assessment
Repeating assessment too Erroneously High S or D
quickly reading
Cuff wrapped Erroneously High
loosely/unevenly
Deflating too quickly Erroneously Low S or D
reading
Deflating too slowly Erroneously High D reading
Failure to use same arm Inconsistent Measurement
consistently
Arm above heart level Erroneously Low
After smoking or in pain Erroneously High
Failure to identify Erroneously Low S or D
auscultatory gap reading

How to Do it?

Blood Pressure

1. Introduce self and verify client identity

2. Hand hygiene and infection control procedure
3. Provide privacy
4. Position the client appropriately
5. Wrap the deflated cuff around arm
6. If this is a preliminary examination, perform palpatory
determination of systolic pressure
7. Position the stethoscope appropriately
8. Auscultate the client’s BP
9. If this is the initial assessment repeat on the other arm
10. Document and report pertinent findings

24 | P a g e
 NCMA121: HEALTH ASSESSMENT
PRELIMS
1st year, 2nd SEMESTER | S.Y 2021-2022
LECTURER: Ma’am Cora P. Quinto
VALIDATION OF DATA & DOCUMENTATION OF DATA
VALIDATING DATA
PURPOSE OF VALIDATION
 Is the process of confirming or verifying that the subjective
and objective data the nurse have collected are reliable and
accurate.
 The steps of validation include:
o Data Requiring Validation
 Conditions that require data to be rechecked and
validated include:
- Discrepancies or gaps between the subjective
and objective data
- Discrepancies or gaps between the client says
at one time versus another time
- Findings that are highly abnormal and/or
inconsistent with other findings
o Methods of Validation
 There are several ways to validate your data:
- Recheck your own data through a repeat
assessment
- Clarify with the client by asking additional
questions
- Verify the data with another health care
professional
- Compare your objective findings with your
subjective findings to uncover discrepancies
o Identification of Areas for Which Data are Missing
 Once an initial database is established, identify
areas for which more data are needed
 Examine data in a grouped format
DOCUMENTATION
DOCUMENT
 To complete the assessment phase, the nurse records
client’s data. Accurate documentation is essential and
should include all data collected about the client’s health
status.
 Tangible or physical evidence that a treatment, a procedure
or an assessment has been done. (serves as an evidence
that you did something to the patient).
 These are recorded in a factual manner and not interpreted
by the nurse.
Example:
 The nurse records the client’s breakfast intake
 To increase accuracy, the nurse records subjective data in
the client’s own words. Restating in other words what
someone says increase the chance of changing the original
meaning.
 Use “quotation mark” to symbolize that the statement was
verbalized by the patient.
 It is a legal document that can stand in court. This can save
your licenses. Save you from complaints. So, it is very
important that you document the things you have done to
WEEK 3
TRANSCRIBED BY: KRISTINE CALDERON, ALYSSA JIMENEZ
your patient, also, document the things that you were not
able to do to your patient.
 It should be accurate, precise, correct, honest.
DOCUMENTING DATA
 Another crucial part of the first step in the nursing process
 Categories of information on the forms are designed to
ensure that the nurse gathers pertinent information needed
to meet the standards and guidelines of the specific
institutions mentioned previously and to develop a plan of
care for the client
PURPOSE OF DOCUMENTATION
 Promote effective communication among multidisciplinary
health team members to facilitate safe and efficient client
care
 Provides the health care team with a database that becomes
the foundation for care of the client
 Helps to identify health problems, formulate nursing
diagnoses, and plan immediate and ongoing interventions
 The use of electronic health records (EHRs) also increases
the likelihood that clients received life-saving treatments and
may lower the risk of hospital acquired infections
THINGS TO CONSIDER ON DOCUMENTATION
 Legal record of patient encounter
 May be used by many professionals
 Document in a professional and legally acceptable manner
(statement should be grammatically correct with proper
spelling)
 FOLLOW INSTITUTION’S SYSTEM
 Ensure accuracy
A. Ensure correct patient record or chart (you should not
falsify your documentations)
B. Record information immediately upon completion of
patient encounter
C. Avoid distractions while documenting
D. Date and time each entry and sign your entry
 Ensure correct patient record or chart
o Record information immediately upon completion of
patient encounter
o Avoid distractions while documenting
o Date and time each entry and sign your entry
GUIDELINES FOR DOCUMENTATION
 Keep confidential all documented information in the client
record
- These are legal documents containing confidential
information especially when you are handling highly
sensitive patients or information.
- We do not leave the patient’s chart in the patient’s room
because there are relatives or other people that can
enter the room and look at the patient’s records and
that will in turn breach the patient’s confidentiality.
 Document legibly or print neatly in nonerasable ink
- Make sure that your nurse’s notes are readable so you
have to write legibly.
- Because these notes are also going to be viewed and
used by other health care workers hence why it is
25 | P a g e
 important that everyone can understand what you have CHARTING
written.  The common term used in the field of nursing when it comes
- Use of pencil is not recommended since it’s erasable to documentation
 Use correct grammar and spelling  Charting and documentation refer to the same thing
 Avoid wordiness that creates redundancy
- Less is more PURPOSE OF CHARTING
- Make your documentation simple yet precise and  It is a permanent record of patient’s information.
complete  Tracks the progress of the patient’s condition during the
- Complete doesn’t mean more hospitalization as well as the status upon discharge. It serves
 Use phrases instead of sentences to record data as an information sheet of the medications and procedures
 Record data findings, not how they were obtained rendered to the patient.
- You don’t have to narrate what you have done to your  Legal evidence for cross-examination whenever complaints
patient as this can be wordy. or malpractice claims have been sighted out.
 Write entries objectively without making premature  It serves as the evidence of continuity of care.
judgments or diagnoses  It serves as a research material for retrospective study
 Record the client’s understanding and perception of
problems TYPES OF CHARTING
 Avoid recording the word “normal” for normal findings  Narrative Charting
- Record or write the findings and not right your o Traditional form of charting
judgments - We still do this today however there are only specific
- Do not write that these are normal findings just write areas in the hospital who still use the traditional
down what you have observed and what you have charting
obtained - Usually, we do this during admission because during
 Record complete information and details for all client admission this is the time that we are going to ask the
symptoms or experiences patient the history or the history of the patient’s illness
- Do not record “client has pain in the lower back” - During admission, especially in the emergency room,
instead, record “client reports aching, burning, pain in emergency room nurses do nurses’ notes
lower back for two weeks” - Narrative charting is usually used during patient
 Include additional assessment content when applicable admission
 Support objective data with specific observations obtained o Source-oriented record
during the physical examination o Advantage is that it provides organized section for each
member of the healthcare team
ASSESSMENT SPECIFIC DOCUMENTATION GUIDLINES o Disadvantage in using this type of recording is that the
 Record pertinent positive and negative assessment data information is scattered throughout the chart
 Document any parts of the assessment that are omitted or o Example:
refused by patient  Treatment Chart
 Avoid using judgmental language  Admission sheet
 Avoid evaluative statements; cite specific statements or  Initial Nursing Assessment
actions you observe  Graphic Record
 State time intervals precisely
 Use specific measurements  Problem-oriented record
o Give focus on the problems that patients face
 Draw pictures when appropriate
o Each medical personnel can contribute and collaborate
 Refer to findings using anatomic landmarks
on the plan of care
 Use the face of a clock to describe findings that are in a o Advantage seen in this type of charting is collaboration
circular pattern among medical personnel
 Document any change in patient’s condition during a visit or o The disadvantage here is that it takes complete and on
from previous visits time assessment of problem lists
 Describe what you observed, not what you did
 SOAP formats
Examples of Vague Versus Clear and Concise o Usually used since it gives a quick look at the
Documentation of Data observation of each nurse as well as the nursing action
on each observation.
Vague Clear and Concise Documentation  S – Subjective data includes the patient’s
Documentation complaints or perception of the present problem
Memory intact Recent and remote memory intact sited.
Vital signs good Temperature: 37.2OC; PR 66; RR  O – Objective data includes the nurse’s
18; BP 120/80 observation using his or her clinical eye
Skin color normal Skin pink with consistent  A – Assessment includes the inference made by
pigmentation the nurse from the two types of data. This is the part
Appetite good Reports no change in appetite wherein the problem is stated. The nursing problem
Swelling of ankles Pitting edema 3+ of both ankles that is stated in a form of nursing diagnoses using the
lasts 10 seconds NANDA.
Voids a lot Polyuria, urinary output = 3000  P – Plan this includes the nursing actions to be
mL/day made in order to solve the stated problem. This part
can be revised.
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 o Additional entries problem or concern of the patient, if you don’t have
 SOAPIE or SOAPIER nursing diagnosis, you can focus on the exact and
- I – Intervention –This is the part wherein specific client problem, concern or event.
specific nursing actions are stated
- E – Evaluation –This is the part wherein the  The SBAR
nurse evaluates the reaction of the patient or o Situation (current situation of the patient),
progress of the problem being solved. Background (history of the patient), Assessment (will
- R – Revision – This is the section that states include your subjective and objective data),
the changes made in order to further resolve Recommendation (suggestions that can be done or
the problem. ordered)
o Example: o A model of communication
 Case: A patient with hypersensitivity reaction o One of the most common handover mnemonic models
secondary to food intake. used in health care
o S o Improve quality and patient safety outcomes when
- “My skin is so itchy, especially on the used by health team members to communicate or
skinfolds.” hand-off client information
o O o Commonly used as endorsement documentation and it
- Skin appears to be flushed with bumps. improves quality and patient safety outcomes when
Irritation noted on the armpit and inner used by a health care team member to communicate
thighs. or hand off client information
o A
- Altered comfort secondary to food
intake.
o P
- Inform the patient not to scratch the skin.
- Apply cold compress on the hot spots
- Cut nails in order to prevent skin
scratches
- Refer to the physician
- Assess for progress of skin rash
o I
- Instructed not to scratch the skin.
- Cut the fingernails short
- Applied cold compress
- Referred to the physician
o E
- “I feel more comfortable and I do not
have the urge to scratch my skin.”
o R
- Give antihistamine (Antamin) 1mg/mL as
deep intramuscular injection to left
deltoid muscle.

 Focus Charting (FDAR)

o This type of charting involves Data, Action and TELEPHONE ORDERS
Response category.  WRITE DOWN AND READ BACK!!!
o This is a client-focused charting  Should be signed by the doctor who made the order within
o Since it the client being talked about most of the 24 hours
documentation, this is a form of holistic perspective of - Do not call the doctor without the patient’s chart in front
client’s needs. of you so that if the doctor has some question, you can
o Example answer immediately
 F (Focus)
- Nursing Dx, Client Concern, S&S, Event ASSESSMENT FORMS USED FOR DOCUMENTATION
- Nursing diagnosis  Initial Assessment Form
 D (Data) o Is called a nursing admission or admission database
- Facial grimacing, graded the nape pain as 7 in o 4 types
the scale of 1 to 10 with 10 as severe pain  Open – Ended Forms (Traditional form)
- Objective and subjective data  Cued or Checklist Forms
 A (Action)  Integrated Cued Checklist
- Given Norgesic Forte per Orem as now dose.  Nursing Minimum Data Set
- Implementation (independent and dependent)
 R (Response)  Frequent or Ongoing Assessment Form
- Rated pain as 2 and able to walk on her own. o Flowcharts that help staff record and retrieve data for
- Evaluation frequent reassessments
- The difference of FDAR to SOAPIER, FDAR is not so o Examples
strict with the nursing diagnosis, it depends on the  Vital signs sheet

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  Assessment flowchart
o Emphasis is placed on quality, not quantity of
documentation
 Focused or Specialty Area Assessment Form
o Focused on one major area of the body for clients who
have a particular problem
o Examples
 Cardiovascular assessment forms
 Neurologic assessment forms

COMPUTERIZED DOCUMENTATION
Electronic Health Records (EHRs)
 Used to manage the huge volume of information required in
contemporary health care
 Can integrate all pertinent client information into one record
 Nurse’s responsibilities include storing client’s database,
add new data, create and revise care plans and document
client progress
 Makes care planning and documentation relatively easy
 Transmit information from one care setting to another

OTHER FORMS OF DOCUMENTATION

Kardex
 Widely used, concise method of organizing and recording
data about a client, making information accessible to all
health professionals
 Consists of series of cards kept in a portable index file which
is particular for a client
 Can be quickly accessed to reveal specific data
 May or may not become a part of the client’s permanent
record

Flow Sheets
 Graphic record
 Intake and Output Record
 Medication Administration Record (MAR)
 Skin Assessment Record

Nursing Discharge / Referral Summaries

 Completed when the client is being discharged and
transferred to another institution or to a home setting where
a visit by a community health nurse is required

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 NCMA121: HEALTH ASSESSMENT
PRELIMS WEEK 4
1st year, 2nd SEMESTER | S.Y 2021-2022 TRANSCRIBED BY: KRISTINE CALDERON, ALYSSA JIMENEZ
LECTURER: Ma’am Cora P. Quinto

 Between 36.3OC – 37.9OC

HOLISTIC NURSING ASSESSMENT o Tympanic membrane temperature
 Between 36.7OC – 38.3OC
A. GENERAL HEALTH STATUS  Measured in degrees
GENERAL SURVEY  Body temperature is
 The first part of the physical examination that begins the o Lowest early in the morning (4:00 AM to 6:00 AM)
moment the nurse meets the client. o Highest late in the evening (8:00 PM to 12:00 MN)
 Observations lead to clues about the health status of the o Regulated by the hypothalamus
client.
 The general survey includes observation of the client’s: PURPOSE
o Physical development and body build  To establish Baseline data for subsequent evaluation
o Gender and sexual development  To identify whether the core temperature is within normal
o Apparent age as compared to reported age range
o Skin condition and color  To determine changes in core temperature in response to
o Dress and hygiene specific therapies
o Posture and gait  To monitor clients at risk for imbalanced body temperature
o Level of consciousness
o Behaviors, body movements, and affect FACTORS THAT AFFECT HEAT PRODUCTION
o Facial expression
 BMR (Basal Metabolic Rate)
o Speech
o Rate of energy utilization in the body required to maintain
o Vital signs
essential activities
B. VITAL SIGNS o Cool someone down and their metabolic rate slow down,
heat them up and their metabolism increases up
 Are the body’s indicators of health
o A thermoneutral environment is one in which nothing
 Also known as “Cardinal Signs”
except basal metabolic rate is required to maintain core
 Common, noninvasive physical assessment procedure that body temperature at 37 degrees
most clients are accustomed to o The cooler the environment, the more your body will
o First step in physical assessment attempt to keep you warm by cranking up your
 Provide data that reflect the status of several body systems, metabolism
including but not limited to the cardiovascular, neurologic,  Muscle Activity
peripheral vascular, and respiratory systems o Increases metabolic rate
o Using large muscles to make heat rather than movement
WHEN TO ASSESS VITAL SIGNS o Strenuous exercises cause normal variations in the body
 Upon admission temperature
 A change in health status o SHIVERING (using large muscles to make heat rather
 Pre and Post Op/ Procedure than movement) IS THE MOST OBVIOUS OUTWARD
 Pre and Post medication administration SIGN
 Before and after any nursing intervention that could affect  Thyroxine (T4) output
the vital signs o A Thyroid hormone for regulation of metabolism (BMR)
o Activity, talking, gum – chewing, and anxiety affect pulse, o Increased Thyroxine output increases metabolism
respirations and blood pressure (Chemical Thermogenesis)
 ALLOW 5 minutes of REST before beginning to o Thyroid hormones affect blood vessels to determine
take VS body temperature
o Affect protein synthesis
TEMPERATURE o An overactive thyroid (HYPERTHYROIDISM) can cause
 A core body temperature between 36.5OC and 37.9OC must a person to feel too hot
be maintained for the body to function at a cellular level o An underactive thyroid (HYPOTHYROIDISM) can cause
 Approximate reading of core body temperature can be taken a person to feel too cold
at various anatomic sites but none of them is completely o Sample thyroid hormones
accurate – they are simply an approximation of the core body  Thyroxine (T4)
temperature  Triiodothyronine (T3)
o Oral temperature  T0, T1, T2 – hormone precursors – byproduct of
 Between 35.9OC – 37.5OC thyroid hormones but do not act on thyroid hormone
o Axillary temperature receptor and appear to be totally inert
 Between 35.4OC – 37.0OC  Epinephrine, Norepinephrine and Sympathetic
o Temporal artery temperature Stimulation
 Between 36.3OC – 37.9OC o Sympathetic Nervous System
o Rectal temperature o Plays important role on the maintenance of core body
temperature through thermoregulatory processes
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 o Thermoregulation is a process that allows your body to  Shivering
maintain its core temperature  Cold, pallid skin
 Fever  Cyanotic nail beds
o Increase in the body temperature’s set point  “Gooseflesh”
o Increases cellular metabolic rate  Cessation of sweating
o Increase in set point triggers increased muscle  COURSE / PLATEAU
contractions o After the core temp has reach a new set point, the person
o Can be caused by medical conditions (viral, bacterial, neither feels warn nor cold
parasitic infections) o Manifestations may include
o Pyrexia  Absence of Chills
 A body temperature above the usual range is called  Skin that feels warm
Pyrexia, Hyperthermia or Fever  Photosensitivity
 Glassy eyed appearance
TYPES OF HEAT TRANSFER  ↑ PR and RR
 Conduction  ↑ thirst
o Transfer of heat from one molecule to a molecule of lower  Dehydration
temperature  Drowsiness, restlessness, delirium
 Radiation  Loss of appetite
o Transfer of energy in the form of waves and particles  Malaise
 Convection  DEFERVESCENCE
o Is the dispersion of heat by air currents o Occurs when the cause of fever is suddenly removed
 Vaporization / Evaporation o The hypothalamus attempts to normalize the
o Is a continuous evaporation of moisture from the temperature resulting in a sudden vasodilation
respiratory tract and from the mucosa of the mouth and o This event is known as CRISIS, the FLUSH
from the skin DEFERVESCENT STAGE OF PYREXIA
o Manifestations may include
FACTORS AFFECTING BODY TEMPERATURE  Flushed skin
 Age  Sweating
o Infants and older clients are greatly influenced by  Decreased shivering
environment  Possible dehydration
 Diurnal Variations
o Temperature normally changes throughout the day NURSING INTERVENTIONS DURING FEVER
(fluctuating temperature, there is a rate or magnitude of  Monitor vital signs and skin color
change)  Monitor lab values
 Exercise  Provide adequate nutrition and fluids
o Strenuous activity = high temp  Oral hygiene
 Hormones  Tepid sponge bath
o Women = progesterone increases temp (.3-.6 C)  Dry clothing and linens
 Stress  Antipyretics
o Stimulates sympathetic nervous system = increase
metabolic activity
 Environment
o Room temp may affect assessment

TYPES OF FEVERS
 Intermittent
o Alternates at regular intervals between periods of fever
and periods of normal/subnormal temperatures.
 Remittent
o Wide range of temperature fluctuations all of which are
above normal
 Relapsing
o Short febrile periods of a few days are interspersed with
periods of 1 or 2 days of normal temperature
 Constant
o Fluctuates minimally but always remain above normal PULSE
 A shock wave produced by the contraction of the heart and
CLINICAL ONSET OF FEVER forceful pumping of blood out of the ventricles into the aorta
 ONSET / CHILL  Commonly called the arterial or peripheral pulse
o Set point increases from normal to higher than normal  Is an indirect measurement of cardiac output obtained by
o Core temperature needs time to adjust thus the body will counting the number of apical or peripheral pulse waves over
compensate by heat production response a pulse point
o Manifestations may include  A normal pulse rate for adults is between 60 and 100 beats
 ↑ heart rate per minute
 ↑RR

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ARTERIAL OR PERIPHERAL PULSE SITES - A pulse deficit results from the ejection of a
 Temporal volume of blood that is too small to initiate a
o Superior and lateral to the eye peripheral pulse wave
o Used when radial pulse is not accessible - A deficit or a discrepancy may present heart
 Carotid condition such as in atrial fibrillation
o Internal o When a discrepancy exists between the apical and radial
 Branches into the anterior and middle cerebral pulses, the deficit is assessed by simultaneously
arteries and supplies the brain measuring the apical and radial pulses for a minute
o External
 Branches into the superior thyroid, inguinal, facial, PULSE CHARACTERISTICS
occipital posterior auricular, superficial temporal, and  A normal pulse has defined characteristics: quality, rate,
maxillary arteries and supplies the thyroid, head and rhythm, and volume (strength or amplitude), and elasticity
mouth  Pulse quality refers to the “feel” of the pulse, its rhythm and
o Used during cardiac arrest/shock in adults forcefulness
 Apical  Normally, pulsation is equally strong in both wrists
o Located at the apex of the heart  Amplitude can be quantified as follows:
o Routinely used for infants and children up to 3 years of o 0 – absent
age o 1 + Weak, diminished, easy to obliterate
o Used to determine discrepancies with radial pulse o 2 + Normal, obliterate with moderate pressure
o Used in conjunction with some medications o 3 + Bounding, unable obliterate or requires firm pressure
 Brachial  Pulse rhythm
o Supplies the humerus and the muscles and skin of the o Is the regularity of the heartbeat
upper arm o There are regular intervals between beats
o Inner aspect of the biceps muscle of the arm or medially  Dysrhythmia
in the antecubital space o Arrhythmia
o Used to measure blood pressure o Irregular heart beat
o Used during cardiac arrest for infants  Pulse Volume
 Radial o Is a measurement of the strength or amplitude of force
o Runs along the radial bone, on the thumb side of the exerted by the ejected blood against the arterial wall with
inner aspect of the wrist each contraction.
o Supplies the forearm and hand on the radial side  Arterial elasticity
o Gives a good overall picture of the client’s health status o Artery feels straight, resilient, and springy
 Femoral  Bradycardia
o Passes alongside the inguinal ligament o Is a heart rate less than 60 beats per minute in an adult
o Supplies the thighs o May be normal in well – conditioned clients
o Used in cases of cardiac arrest/shock  Tachycardia
o Used to determine circulation to a leg o Is a heart rate in excess of 100 beats per minute in an
 Popliteal adult
o Passes behind the knees o May be normal in clients who have just finished
o Supplies the knees, the posterior femoral, strenuous exercise
gastrocnemius, and soleus muscles and the skin on the
back of the leg RESPIRATIONS
o Used to determine circulation to the lower leg  The act of breathing
 Posterior tibialis  Rate and character are additional clues to the client’s overall
o Medial surface of the ankle, passes behind the medial health status
malleolus
o Supplies the back of the leg and the ankle PROCESS OF RESPIRATION
o Used to determine circulation to the foot  External Respiration
 Dorsalis pedis o Interchange of o2 and co2 between the alveoli and the
o Passes over the bones of the foot, on an imaginary line pulmonary blood
drawn from the middle of the ankle to the space between  Internal Respiration
the big and second toes o Interchange of o2 and co2 between the circulating blood
o Supplies the feet (pulmonary blood) and body tissues
o Used to determine circulation to the foot  Inhalation
o Intake of air into the lungs
ASSESSING THE PULSE RATE  Exhalation
1. The nurse should begin the assessment by speaking with o Movement of air from lungs to the atmosphere
the client about the normal pulse rate.
 Ventilation
2. Palpate a peripheral pulse by placing the first two fingers on
o Movement of air in and out of the lungs
the pulse point with moderate pressure.
3. Count the rate for a full minute, noting the regularity (rhythm)
TYPES OF BREATHING
o When an irregular peripheral pulse is present, the nurse
 Costal / Thoracic
needs to assess for a pulse deficit
o External intercostal muscles
 Pulse Deficit
o Accessory muscles
- Condition in which the apical pulse rate is greater
o Chest upward then outward
than the radial pulse rate
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 o Chest expansion is centered at midpoint  Abnormally slow
o More work to be done in lifting the rib cage o Apnea
o Useful for vigorous activities  Cessation of breathing
o Usually occurs when the individual is aroused by o Eupnea
challenges or danger (tension and anxiety)  Normal breathing
 Abdominal / Diaphragmatic  Volume
o Contraction and relaxation of the diaphragm o Hyperventilation
o Movement of the abdomen  Overexpansion of the lungs, rapid deep breaths
o Diaphragm is the principal muscle of use (strong dome – o Hypoventilation
shaped sheet of muscle that separates chest cavity from  Under expansion of the lungs, shallow breaths
the abdomen  Effort
o Breath-in, diaphragm CONTRACTS – lungs expand, o Dyspnea - difficulty of breathing (DOB)
creating a partial vacuum, allows air to be drawn in o Orthopnea - DOB when lying supine
(INHALATION)  Atelectasis - partial or complete collapse of alveoli of
o Breath-out, diaphragm RELAXES – abdominal muscles lungs (insufficient O2)
contract and expel air that contains carbon dioxide  Sounds
o Diaphragmatic breathing is the most efficient because o Stridor
greater expansion and ventilation occurs in the lower part  Shrill harsh sound during inspiration – laryngeal
of the lung where blood perfusion is the greatest obstruction
o Stertor
NORMAL BREATHING IS ACCOMPLISHED BY:  Snoring or sonorous respiration – partial obstruction
1. The downward and upward movement of the diaphragm to of upper airway
lengthen or shorten the chest cavity o Wheeze
2. The elevation and depression of the ribs to increase and  High pitched musical squeak on expiration –
decrease the anteroposterior diameter of the chest cavity narrowed/partially obstructed airway (asthma)
o Bubbling
MAJOR PHYSICAL PULMONARY FUNCTIONS  Gurgling sounds – moist secretions (productive
 Ventilation cough)
o The inflow and outflow of air between the atmosphere  Chest movement
and the lung alveoli o Intercostal retractions
 Circulation  Upper airway (trachea)or small airways (bronchioles)
o The quantity of blood flowing through the lungs is are blocked
approximately 4 to 6 l/min  As a result, intercostal muscles are sucked inward
 Diffusion between the ribs
o The exchange of oxygen and carbon dioxide between the  Reduced air pressure inside chest
alveoli and the blood  A sign of a blocked airway
 Transport o Substernal retractions
o The carrying of oxygen and carbon dioxide in the blood  Beneath the breastbone
and body fluids to and from the cells  Indrawing of the abdomen just below the sternum
(breastbone)
ASSESSING RESPIRATION  Belly breathing
o Suprasternal retractions
 Normal breathing is slightly observable, effortless, quiet,
 Above the clavicles
automatic, and regular
 Secretions
 It can be assessed by observing chest wall expansion and
o Hemoptysis
bilateral symmetrical movement of the thorax
o Productive cough
 Sites o Non-productive cough
o Chest wall
o Thorax BLOOD PRESSURE
o Nose and mouth
 Blood pressure is the measure of pressure exerted as blood
flows through the artery.
How to do it?
 Measurement of the pressure of the blood in the arteries
 Place your hand over client’s wrist and observe one
when the ventricles are contracted (systolic blood pressure -
complete respiratory cycle.
SBP) and when the ventricles are relaxed (diastolic blood
 Start to count with first inspiration while looking at second pressure - DBP)
hand sweep of watch.
 It is measured in terms of millimeters of mercury (mm Hg)
 Nursing consideration and written in fraction form.
o Observe respirations without alerting the client by
 NORMAL VALUE is below 120 (systolic) and below 80
watching the chest movement while continuing to palpate
(diastolic)
the radial pulse

ALTERED BREATHING PATTERN / SOUNDS C. MENTAL STATUS

 Refers to a client’s level of cognitive functioning (thinking,
 Rate
knowledge, problem solving) and emotional functioning
o Tachypnea
(feelings, mood, behaviors, stability).
 Quick, shallow breathing
o Bradypnea

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 MENTAL HEALTH
 An essential part of one’s total health and is more than just
the absence of mental disabilities or disorders
 A state of well – being in which an individual realizes his or
her own capabilities, can cope with the normal stresses of
life, can work productively and is able to make a contribution
to his or her own community – WHO
Major areas of mental status assessment include language,
orientation, memory, and attention span and calculation.
ASSESSMENT TECHNIQUES
 Positioning
o Sitting on the examination table, wearing examination
gown
 Observe the patient
o Note hygiene, grooming, posture, body language, facial
expressions, speech, and ability to follow directions
o Abnormal findings
 Inadequate self-care, flatness of affect, and inability
to follow directions may be associated with mental
illnesses such as depression or schizophrenia
 Anormal facial expression or body language may be
reflective of neurological or psychiatric disorders
 Note the patient’ speech and language abilities
o Note rate of speech, ability to pronounce words, tone of
voice, loudness or softness of voice and ability to speak
softly and clearly
o Note patient’s choice of words, ability to respond to
questions, and ease of response made
o Abnormal findings
 Changes in speech could reflect anxiety, Parkinson’s
disease, depression or dysphasia
 Assess patient’s sensorium
o Determine the patient’s orientation to date, time, place,
as well as the need for the physical assessment
o Grade the level of alertness on a scale from full alertness
to coma
o Abnormal findings
 Neurologic disease can produce a sliding or changing
degree of alertness
 Change in the level of consciousness (LOC) may be
related to cortical or brain stem disease
 Stroke, seizure, or hypoglycemia could also
contribute to a change in the LOC
 Assess the patient’s memory
o Ask the patient’s DOB, names and ages of any children
or grandchildren, education history with dates and
events, work history with dates and job descriptions
o Abnormal findings
 Loss of long-term memory may indicate cerebral
cortex damage, which occurs in Alzheimer’s disease
 Assess the patient’s ability to calculate problems
o Start with a simple problem such as 4+3, 8÷2, and 15-4
o Abnormal findings
 Inability to calculate simple problems may indicate
the presence of organic brain disease, or it may
simply indicate lack of exposure to mathematical
concepts, nervousness, or an incomplete
understanding of the examiner’s language
- Also consider that a poor response to calculations
should not be considered an abnormal finding
 Use problems that are appropriate for the patient’s
developmental, educational, and intellectual levels
 Assess the patient’s ability to think abstractly
o Ask the patient to identify similarities and differences
between 2 objects or topics, such as wood and coal, king
and president, orange and apple
o Quote a proverb and ask the patient to explain it
 Be aware that culture and age influence the ability to
explain quotes or proverbs
o Abnormal findings
 Responses made by the client may reflect lack of
education, mental retardation or dementia
 Assess the patient’s mood and emotional state
o Observe the patient’s body language, facial expressions
and communication technique
o Abnormal findings
 Lack of congruence of facial expression and tone of
voice may occur with neurologic problems, emotional
disturbance or a psychogenic disorder
o The patient’s mood and emotions should reflect the
current situation or response to events that trigger mood
change or call for an emotional response
o Abnormal findings
 Lack of emotional response, lack of change in
emotional expression, and flat tone of voice can
indicate problems with mood or emotional responses
 Other states related to mood and emotions include
anxiety, depression, fear, anger, overconfidence,
ambivalence, euphoria, impatience and irritability
 Mood disorders include bipolar disorder, anxiety
disorders, and major depression
 Assess perceptions and thought process
o Listen to patients’ statements. It should be logical and
relevant. It should be with complete thought
o Abnormal findings
 Disturbed thought processes can indicate neurologic
dysfunction or mental disorder
o Assess the patient’s ability to make judgments
 Disturbances in sense of reality can include
hallucination and illusion
 These are associated with mental disturbances as
seen in schizophrenia
 Assess the patient’s ability to make judgments
o Determine if the patient is able to evaluate situations and
to decide on a realistic course of action
o Abnormal findings
 Impaired judgment can occur in emotional
disturbances, schizophrenia and neurologic
dysfunction
D. PSYCHOSOCIAL, COGNITIVE AND MORAL
DEVELOPMENT
 Freud Theory of Psychosexual Development
o Personality development was based on understanding
the individual life history of a person
o Stages
 Oral
- 0 – 1.5 years
 Anal
- 1.5 – 3 years
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  Phallic  Irritability
- 3 – 6 years
 Latency TYPES OF PAIN
- 6 – 11 years  Acute Pain
 Genital o Lasts only through the expected recovery period
- Adolescence o Of short duration, has limited tissue damage and
emotional response
 Erikson Theory of Psychosocial Development o Eventually resolves with or without treatment, after and
o Societal, cultural, and historical factors as well as injured area heals
biophysical processes and cognitive function influence o Complete pain relief is not always achievable, but
personality development reducing pain to a tolerable level is realistic
o Stages o Unrelieved acute pain can progress to chronic pain
 Infant  Chronic Pain
 Toddler o Pain that lasts longer than 6 months and is constant or
 Preschooler recurring with a mild-to-severe intensity
 School – age child o Leads to great personal suffering
 Adolescent o Associate symptoms of chronic pain include fatigue,
 Young adult insomnia, anorexia, weight loss, hopelessness and
 Middle – age adult anger
 Older adult
PAIN CONCEPTS
 Piaget Theory of Cognitive Development  Radiating Pain
o Physical maturity, social interaction, environmental o Perceived at the source of the pain and extends to the
stimulation and experience in general are interrelated nearby tissues
and were necessary for cognition to occur
 Referred Pain
o Stages
o Felt in a part of the body that is considerably removed or
 Sensorimotor
far from the tissues causing the pain
 Preoperational
 Concrete operational
 Persistent Pain
 Formal operational
o A pain that contributes insomnia, weight gain,
constipation, etc.
 Kohlberg Theory of Moral Development
 Sever Pain
o Individual morality has been viewed as a dynamic
o An emergency situation deserving attention and
process that extends over one’s lifetime, primary
professional treatment
involving the affective and cognitive domains in
determining what is “right” and “wrong”  Hyperalgesia
o Stages o Excessive sensitivity to pain
 Preconventional  Pain Threshold / Sensation
 Conventional o The amount of pain stimulation a person requires before
 Postconventional feeling pain
o Least level of pain that the patient is able to detect
E. PAIN: THE 5TH VITAL SIGN  Pain Tolerance
 Pain is an unpleasant sensory and emotional experience o Maximum amount and duration of pain that an individual
associated with actual or potential tissue damage, or is willing to endure
described in terms of such damage  Pain Perception
o The point which the person becomes aware of the pain
NATURE OF PAIN  Allodynia
o Pain due to a stimulus that does not normally provoke
 Pain is subjective and highly individualized
pain
 Its stimulus is physical and/or mental in nature
 Dysesthesia
 It interferes with personal relationships and influences the
meaning of life o Unpleasant abnormal sensation, imitates the pathology
 Only the patient knows whether pain is present and how the of central neuropathic pain disorder
experience feels  Nociceptive Pain
 May not be directly proportional to amount of tissue injury o Pain directly related to tissue damage and may be
somatic
 Sensitization
SIGNS AND SYMPTOMS OF PAIN o An increased sensitivity of a receptor after repeated
 Increased RR activation by noxious stimuli or nociceptor
 Increased HR  Breakthrough Pain
o A transitory increase in pain that occurs on a background
 Peripheral vasoconstriction
of otherwise controlled persistent pain
 Pallor • Elevated BP
 Bradykinin
 Diaphoresis
 Moaning o Universal stimulus for pain
 Guarding behavior  Comfort
 Restlessness o Implies renewal amplification of power

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F. VIOLENCE
 Violence is the use of physical force to harm someone, to
damage property, etc. – Merriam-Webster Online 2015
AGGRESSION
 Aggression is defined as a forceful action or procedure
(unprovoked attack) especially when intended to dominate
or master – Merriam-Webster Online 2015
Positive connotation of aggression
o Associated with the drive for success, as in aggressive
men
Negative connotation of aggression
o Often associated with the notion of aggressive women,
which violates what is considered appropriate for gender
norms in many cultures
o Also associated with aggression against family member
when one person tries to dominate or master another
DOMESTIC VIOLENCE
 Domestic violence is a pattern of abusive behavior in any
relationship that is used by one partner to gain or maintain
control over another intimate partner – US DOJ Office on
Violence against Women
5 THEORIES RELATED TO VIOLENCE FOR WHY MEN
BATTER WOMEN – MCCUE (2008)
1. Psychopathology theory
o Batterers suffer personality disorders
2. Social learning theory
o Violence is a learned behavior from childhood
3. Biologic theory
o Physiologic changes from childhood trauma, head
injuries, or through heredity cause violent behavior)
4. Family systems theory
o Violence grows through family system function, but some
criticize this theory as blaming the victim
5. Feminist theory
o Male/female inequity in patriarchal societies lead to
violence
WALKER’S CYCLE OF VIOLENCE / TENSION BUILDING OR
EXPLOSION MODEL
 Phase 1 – Criticism
o The tension-building phase
o The abuser makes unrealistic demands and when
expectations are not satisfied, criticism and/or ridicule
leads to shoving or slapping
 Phase 2 – The acute battering stage
o Triggered by something minor but results in violence
lasting up to 24 hours
o Victim rarely able to stop the abuse
 Phase 3 – The honeymoon phase
o Period of reconciliation
TYPES OF FAMILY VIOLENCE
 Physical Abuse
o Includes pushing, shoving, slapping, kicking, choking,
punching, and burning
o May also involve holding, tying, or other methods of
restraint
o Victim may be left in a dangerous place without
resources
o Abuser may refuse to help the victim when sick, injured,
or in need
 Psychological Abuse
o Aka emotional abuse
 Humiliation, intimidation, infantilization, or any other
treatment which may diminish the sense of identity,
dignity, and self-worth – Vancouver Coastal Health
(2013)
o Involves the use of constant insults or criticism, blaming
the victim for things that are not the victim’s fault, threats
to hurt children or pets, isolation from supporters (family,
friends or coworkers), deprivation, humiliation, stalking
and intimidation, and manipulation of various kinds, such
as threats of suicide
 Economic Abuse
o Aka financial abuse
 Improper exploitation of another person’s personal
assets, properties, or funds
o May be evidenced by preventing the victim from getting
or keeping a job, controlling money and limiting access
to funds, spending the victim’s money, and controlling
knowledge of family finances
 Sexual Abuse
o Involves forcing the victim to perform sexual acts against
her or his will, pursuing sexual activity after the victim has
said no, using violence during sex, and using weapons
vaginally, orally, or anally
CATEGORIES OF FAMILY VIOLENCE
 Intimate Partner Violence (IPV)
o A pattern of assaultive behavior and coercive behavior
that may include physical injury, psychologic abuse,
sexual assault, progressive isolation, stalking,
deprivation, intimidation, and reproductive coercion –
Family Violence Prevention Fund (2010)
 Child Abuse
o Physical or mental injury, sexual abuse, negligent
treatment or maltreatment of a child under the age of 18
by a person who is responsible for the child’s welfare
under circumstances that indicate that the child’s health
or welfare is harmed – The Child Welfare Information
Gateway (2008b)
o May be either by commission or by omission and is rarely
an isolated incident
o 4 broad categories of child abuse:
 Neglect
 Emotional abuse
 Sexual abuse
 Physical abuse
o Long-term consequences of child abuse and neglect
(The Child Welfare Information Gateway (2008b))
 Physical
- Chronic health conditions
- Impaired brain development
- Brain injury with head trauma
- Emotional conditions
 Psychological
- Lifelong psychological consequences eg. Low
self-esteem, depression
- Cognitive and social difficulties
 Behavioral
- Adolescent issues eg. Substance abuse,
delinquency
- Greater likelihood of being raped
- Juvenile delinquency and adult criminality
- Alcohol and drug abuse
- Greater likelihood to become abusive parents
 Societal
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 - Increased used of health care system
- Juvenile and adult criminal activity • Mental illness
- Substance abuse
- Domestic violence
- Employment problems
- Financial problems
- Absenteeism from work
 Elder Mistreatment
o Aka elder abuse
o Includes neglect, physical abuse, sexual abuse, financial
abuse, psychological abuse (including humiliation,
intimidation, and threats), exploitation, abandonment, or
prejudicial attitudes that decrease quality of life and are
demeaning to those over the age of 65 years
o Abuse may be from commission, but is frequently from
omission
o Consequences of elder mistreatment – (CDC, 2015a)
 Physical
- Injuries eg. Bruises, lacerations, head injuries,
broken bones, pressure sores
- Persistent physical pain and soreness
- Nutrition and hydration issues
- Sleep disturbances
- Increased susceptibility to new illnesses
- Exacerbation of pre-existing health conditions
- Increased risk of premature death
 Psychological
- Increased risk for developing fear and anxiety
reactions
- Learned helplessness
- Posttraumatic stress disorder
ASSESSMENT PROCEDURE
Perform General Survey
 Observe general appearance and body build
o Normal findings
 Client appears stated age, is well developed, and
appears healthy
o Abnormal findings
 Abused children may appear younger than stated
age due to developmental delays or malnourishment
 Older clients who have been abused may appear thin
and frail due to malnourishment
 Note dress and hygiene
o Normal findings
 Client is well groomed and dressed appropriately for
season and occasion
o Abnormal findings
 Poor hygiene and soiled clothing may indicate
neglect
 Long sleeves and pants in warm weather may be an
attempt to cover bruising or other injuries
 Victims of sexual abuse may dress provocatively
 Assess mental status
o Normal findings
 Client is coherent and relaxed
o Abnormal findings
 Client is anxious, depressed, suicidal, withdrawn, or
has difficulty concentrating
 Client has poor eye contact or soft passive speech
 Client is unable to recall recent or past events
 Child does not meet developmental expectations
 Evaluate vital signs
o Normal findings
 Vital signs are within normal limits
o Abnormal findings
 As with any condition of prolonged stress,
hypertension may be seen in victims of abuse
 Acute stress may result in elevated heart rate and
respiration rate
 Inspect skin
o Normal findings
 Skin is clean, dry, and free of lesions, bruises, or
burns
o Abnormal findings
 Client has scars, bruises, burns, welts or swelling on
face, breasts, arms, chest, abdomen, or genitalia,
including evidence of cigarette or cigar burns; hand
or finger patterns on arms, legs, or neck; or heating
element patterns as though pushed against a heater
or radiator
 Inspect the head and neck
o Normal findings
 Head and neck are free of injuries
o Abnormal findings
 Client has hair missing in clumps, subdural
hematomas, or rope marks or finger/hand
strangulation marks on neck, or obvious past or
present nose injuries
 Inspect the eyes
o Normal findings
 Eyes are free of injury
o Abnormal findings
 Client has bruising or swelling around eyes, unilateral
ptosis of upper eyelids (due to repeated blows
causing nerve damage to eyelids), or a
subconjunctival hemorrhage
 Assess the ears
o Normal findings
 Ears are clean and free of injuries
o Abnormal findings
 Client has external or internal ear injuries
 Assess the abdomen
o Normal findings
 Abdomen is free of bruises and other injuries, and is
nontender
o Abnormal findings
 Client has bruising in various stages of healing
 Assessment reveals intra-abdominal injuries
 A pregnant client has received blows to abdomen
 Assess genitalia and rectal area
o Normal findings
 Client’s genitalia and rectal areas are free of injury
o Abnormal findings
 Client has irritation, tenderness, bruising, bleeding, or
swelling of genitals or rectal area
 Discharge, redness or lacerations may indicate
abuse in young children
 Hemorrhoids are unusual in children and may be
caused by sexual abuse
 Extreme apprehension during this portion of the
examination may indicate physical or sexual abuse
 Assess the musculoskeletal system
o Normal findings
 Client shows full range of motion and has no
evidence of injuries
o Abnormal findings
 Dislocation of shoulder; old or new fractures of face,
arms, or ribs; and poor range of motion of joints are
indicators of abuse
 Assess the neurologic system
o Normal findings
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  Client demonstrates normal neurologic function  Those focused on the present perceive what is
o Abnormal findings happening in the present to be more important than
 Abnormal findings include tremors, hyperactive what will occur in the future
reflexes, and decreased sensations to areas of old o Space
injuries secondary to neurologic damage  Everyone who’s ever felt cramped in a crowd knows
that the skin is not the body’s only boundary. We each
G. CULTURE AND ETHNICITY wear a zone of privacy like a hoop skirt, inviting others
 Culture may be defined as a shared system of values, in or keeping them out with body language—by how
beliefs, and learned patterns of behavior. The totality of closely we approach, the angle at which we face
socially transmitted behavioral patterns, arts, beliefs, values, them, and speed with which we break a gaze –
customs, lifeways, and all other products of human work and Davis’s 1990 classic article on cultural differences in
thought characteristic of a population or people that guide personal space
their worldview and decision making – Purnell and Paulanka o Eye Contact and Face Positioning
(2008) o Body Language and Hand Gestures
 Culture is learned, shared, associated with adaptation to the o Silence
environment, and is universal.  2 types of silence
- One is simply remaining silent for long periods
PURPOSE AND SCOPE OF ASSESSMENT - The other is used to space talking between two
people carrying on a conversation
 To learn about the client’s beliefs and usual behaviors
o Touch
associated with health and illness
 Touch is very culturally based
 To compare and contrast the client’s beliefs and practices to - How much touch is comfortable and allowable,
standard Western health care and by whom, are all based on culture
 To compare the client’s beliefs and practices with those of
other persons from a similar cultural background Factors Affecting Disease, Illness, Health State
 To assess the client’s health relative to diseases prevalent  Biomedical variations
in the specific cultural group  Nutrition/dietary habits
 Family roles and organization, patterns
Cultural beliefs and values to assess include:
 Workforce issues
 Value orientation
 High-risk behaviors
 Beliefs about human nature
 Pregnancy and childbirth practices
 Beliefs about relationship with nature
 Death rituals
 Beliefs about purpose of life
 Religious and spiritual beliefs and practices
 Beliefs about health, illness, and healing
 Health care practices
 Beliefs about what causes disease
 Health care practitioners
 Beliefs about health
 Environment
 Beliefs about who serves in the role of healer or what
practices bring about healing
H. SPIRITUALITY AND RELIGIOUS
PRACTICES
Factors Affecting Approach to Providers
RELIGION
 Ethnicity
 Rituals, practices, and experiences involving a search for the
 Generational level
sacred (i.e., God, Allah, etc.) a that are shared within a
 Educational level
group.
 Religion
 Characteristics
 Previous health care experiences o Formal
 Occupation and income level o Organized
 Beliefs about time and space o Group oriented
 Communication needs/preferences o Ritualistic
o Objective, as in easily measurable (e.g., church
COMMUNICATION attendance)
All communication is culturally based
 Verbal communication can have many variations based on SPIRITUALITY
both language differences and usual tone of voice  A search for meaning and purpose in life, which seeks to
o E.g., a harsh tone of voice may be normal in some understand life’s ultimate questions in relation to the sacred.
cultures and thought to be rude in others  Characteristics
 Nonverbal communication has the most often misinterpreted o Informal
variations o Nonorganized
o Time o Self-reflection
 Different cultural groups tend to place different values o Experience
on the past versus present versus future
o Subjective, as in difficult to consistently measure (e.g.,
 Those focused on the past value practices that are
unchanged from ancestors and are often resistant to daily spiritual experiences, spiritual well-being, etc.)
new ways SPIRITUAL ASSESSMENT
 Active and ongoing conversation that assesses the spiritual
needs of the client.
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 Characteristics
o Formal or informal
o Respectful
o Non-biased
SPIRITUAL CARE
 Addressing the spiritual needs of the client as they unfold
through spiritual assessment.
 Characteristics
o Individualistic
o Client oriented
o Collaborative
MAJOR WORL RELIGIONS AND COMMON HEALTH
BELIEFS
 Christianity
o Beliefs focus around the Old and New Testaments of
the Bible and view Jesus Christ as the Savior
o Prayers may be directed to one or all of the Holy Trinity
(God, Holy Spirit, and Jesus Christ)
o Illness - Most view illness as a natural process for the
body and even as a testing of faith
o End of Life - There is belief in miracles, especially
through prayer
 Buddhism
o Suffering is a part of human existence, but the inward
death of the self and senses leads to a state beyond
suffering and existence
o Illness - Prayer and meditation are used for cleansing
and healing
o End of Life - Life is the opportunity to cultivate
understanding, compassion, and joy for self and others
- Death is associated with rebirth
 Hinduism
o Nirvana (oneness with God) is the primary purpose of
the religion
o Illness - Illness is the result of past and current life
actions (Karma)
o End of Life - Death marks a passage because the soul
has no beginning or end
 Islam
o Mohammed is believed to be the greatest of all
prophets
o Worship occurs in a mosque
o Illness - Illness is often believed to be a trial sent by
God, and the outcome depends on the person’s attitude
of pious endurance
o End of Life - All outcomes, whether death or healing,
are seen as predetermined by Allah
 Judaism
o Judaism includes religious beliefs and a philosophy for
a code of ethics with four major groupings of Jewish
beliefs (Reform, Reconstructionist, Conservative,
Orthodox)
o Illness - Restrictions related to work on holy days are
removed to save a life
o End of Life - Psalms and the last prayer of confession
(vidui) are held at bedside
ASSESSMENT PROCEDURE
 Explore the client’s religious and spiritual background
o Normal findings
 Client makes reference to involvement in religious
groups and/or spiritual practices that have provided
comfort and social support
o Abnormal findings
 Reports lost connections to religious group, while
continuing to focus on the negative aspect of
spirituality (e.g., suppressive religious rules)
 Comments and body language reveal a lack of hope
with symptoms of depression
 Observe nonverbal and verbal communication patterns in
presence of others
o Normal findings
 Eye contact is maintained (appropriate to cultural
group) with nonverbal cues correlating with
conversation
o Abnormal findings
 Client displays poor eye contact
 The presence of others strongly influences
information client shares
 Begin to focus questions
 What do you hold onto during difficult times?
 What sustains you and keeps you going?
o Normal findings
 Reports spirituality giving a sense of peace that
transcends illness or disease
 Reports that meditation and exercise facilitate a
sense of peace
 Family frequently mentioned as source of strength
and motivation
 Client places a strong emphasis on spirituality as a
guiding force in life
o Abnormal findings
 Describes no connection to others such as God,
nature, family, or peers.
 Shares pessimistic and fatalistic attitude toward
recovery
 Identifies limited coping resources with little desire to
adopt new ones
 Ask questions about family and community support:
 Do you have family support for your spiritual beliefs and
practices?
 Does your community support your spiritual beliefs and
practices?
o Normal findings
 Client relates full support for beliefs and practices (both
for health care and generally) from family and religious
leaders
 Relates no differences with community
o Abnormal findings
 Client describes disagreement among family,
religious, or community members regarding choice of
spiritually based health care decisions
 Ask transition question from organizational to personal
beliefs.
 Ask client to specify differences or similarities in own beliefs
and the beliefs of the faith or denomination with which
affiliated.
o Normal findings
 Describes personal beliefs that coincide with
denominational beliefs
o Abnormal findings
 Abnormal findings may include reporting very limited
similarities between denomination and personal
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 beliefs, past utilization of prayer and listening to
religious music, but currently has no avenue for the
fostering of spirituality
 Ask the questions:
 Has being sick (or your current situation) affected your ability
to do the things that usually help your spirituality? (Or
affected your relationship with God?)
 As a nurse, is there anything I can do to help you access the
resources that usually help you?
o Normal findings
 Client views present diagnosis of cancer as “part of
God’s will for her life” or/and desires to continue nature
walks and other spiritual practices to develop a closer
relationship with God
o Abnormal findings
 Client appears traumatized with cancer diagnosis
and views the illness as a fault of her past lifestyle or
a punishment
 Refuses visits from local clergy and hospital
chaplains
 Declines conversation and just wants to be sent
home to die
I. NUTRITIONAL STATUS
NUTRITION
 Refers to the “process by which substances in food are
transformed into body tissues and provide energy for the full
range of physical and mental activities that make up human
life” – Carpenter, 2016
 For adequate nutrition, essential nutrients—including
carbohydrates, proteins, fats, vitamins, minerals, and
water— must be ingested in appropriate amounts.
Primary Factors that are Emphasized on a Newer Evidence
for Nutrition (The Dietary Guidelines for Americans)
 Follow a healthy eating pattern across the lifespan
 Focus on variety, nutrient density, and amount
 Limit calories from added sugars and saturated fats and
reduce sodium
 Shift to healthier food and beverage choices
 Support healthy eating patterns for all
OPTIMAL NUTRITION
 The most beneficial nutritional status requires a balance of
nutrient intake to meet daily metabolic demands
 Balance of calories and exercise
MALNUTRITION
 Risk factors
o Lower socioeconomic status (SES), making nutritious
foods unaffordable
o Lifestyle of long work hours and obtaining one or more
meals from a fast-food chain or vending machine
o Poor food choices by children, teens, and adults
o Chronic dieting, particularly with fad diets, to meet
perceived societal norms for weight and appearance
o Chronic diseases (e.g., Crohn’s disease, cirrhosis, or
cancer) that may interfere with absorption or use of
nutrients
o Dental and other factors such as difficulty chewing, loss
of taste sensation, depression
o Limited access to sufficient food regardless of SES such
as being physically unable to shop, cook, or feed self
o Disorders whereby food is self-limited or refused (e.g.,
anorexia nervosa, bulimia, depression, dementia, or
other psychiatric disorders)
o Illness or trauma that increases client’s nutritional needs
dramatically but that interferes with the ability to ingest
adequate nourishment (e.g., extensive burns)
OVERNUTRITION
 Increased caloric consumption, especially of food high in fat
and sugar, with decreased energy expenditure has led to
near epidemic obesity
o Obesity is defined as excessive body fat in relation to
lean body mass
o The amount of body fat, or adipose tissue, includes
concern for both the fat distribution throughout the body
as well as the size of the fat deposits
o The health risks of obesity are numerous and include
diabetes, heart disease, stroke, hypertension, some
forms of cancers, osteoarthritis, and sleep apnea
HYDRATION
 Another important indicator of the client’s general health
status, but may be overlooked or confused with the signs and
symptoms of nutritional changes
 Signs and symptoms that may indicate changes in hydration
status
o Exposure to excessively high environmental
temperatures
o Inability to access adequate fluids, especially water
(e.g., clients who are unconscious, confused, or
physically or mentally disabled)
o Excessive intake of alcohol or other diuretic fluids
(coffee, sugar-rich and/or caffeinerich carbonated soft
drinks)
o People with impaired thirst mechanisms
o People taking diuretic medications
o Diabetic clients with severe hyperglycemia
o People with high fevers
DEHYDRATION
 Can have a seriously damaging effect on body cells and the
execution of body functions
 A chronically and seriously ill client who is not receiving
adequate fluids either orally or parenterally is at high risk for
dehydration unless monitored carefully
OVERHYDRATION
 In a healthy person is usually not a problem because the
body is effective in maintaining a correct fluid balance
 Clients at risk for overhydration or fluid retention are those
with kidney, liver, and cardiac diseases in which the fluid
dynamic mechanisms are impaired
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EVALUATING NUTRITIONAL DISORDERS
 Measure height
 Measure weight
 Determine ideal body weight (IBW) and percentage of IBW
ASSESSMENT PRCEDURE
 Observe body build as well as muscle mass and fat
distribution
o Normal findings
 In general, the normal body is proportional
 Bilateral muscles are firm and well developed
 There is equal distribution of fat with some
subcutaneous fat
 Body parts are intact and appear equal without
obvious deformities
o Abnormal findings
 A lack of subcutaneous fat with prominent bones is
seen in the undernourished
 Abdominal ascites is seen in starvation and liver
disease
 Abundant fatty tissue is noted in obesity
o Measure the client’s height by using the L-shaped
measuring attachment on the balance scale.
o Instruct the client to stand shoeless on the balance
scale platform with heels together and back straight,
and to look straight ahead.
o Raise the attachment above the client’s head.
o Then lower it to the top of the client’s head
o Record the client’s height
o Normal findings
 Height is within range for age, and ethnic and genetic
heritage
 Children are usually within the range of parents’
height
o Abnormal findings
 Extreme shortness is seen in achondroplastic
dwarfism and Turner’s syndrome
 Extreme tallness is seen in gigantism (excessive
secretion of growth hormone) and in Marfan’s
syndrome
o Level the balance beam scale at zero before weighing
the client.
o Do this by moving the weights on the scale to zero and
adjusting the knob by turning it until the balance beam
is level.
o Ask the client to remove shoes and heavy outer
clothing and to stand on the scale.
o Adjust the weights to the right and left until the balance
beam is level again.
o Record weight
 (2.2 lb. = 1 kg)
o Normal findings
 Desirable weights for men and women in BMI chart
o Abnormal findings
 Weight does not fall within range of desirable weights
for women and men
o Use this formula to calculate the client’s IBW:
 Female: 100 lb for 5 ft + 5 lb for each inch over 5 ft ±
10% for small or large frame
 Male: 106 lb for 5 ft + 6 lb for each inch over 5 ft ±
10% for small or large frame
o Calculate the client’s percentage of IBW by the
following formula:

o Normal findings

Body weight is within 10% of ideal range
o Abnormal findings
 A current weight that is 80% to 90% of IBW indicates
a lean client and possibly mild malnutrition
 Weight that is 70% to 80% indicates moderate
malnutrition; less than 70% may indicate severe
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 malnutrition possibly from systemic disease, eating
disorders, cancer therapies, and other problems.
 Weight exceeding 10% of the IBW range is
considered overweight; weight exceeding 20% of
IBW is considered obesity.
 Measure body mass index (BMI)
o Most commonly used screening method is the body
mass index (Weight-control Information Network,
2011)
o BMI is calculated based on height and weight
regardless of gender.
o It is a practical measure for estimating total body fat
and is calculated as weight in kilograms and divided by
the square height in meters.


o Normal findings

BMI is between 18.5 and 24.9
o Abnormal findings
 BMI <18.5 is considered underweight.
 BMI between 25.0 and 29.9 is considered overweight
and increases risk for health problems.
 A BMI of 30 or greater is considered obese and
places the client at a much higher risk for type 2
diabetes, cardiovascular disease, osteoarthritis, and
sleep apnea.

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