PHASES OF NURSING PROCESS: 3 types of Percussion:

1. ASSESSMENT – the first and most critical phase of 1. Direct – direct tapping of a body part with one or two
the nursing process. It gathers information about the fingertips to elicit possible tenderness.
health status of the client. 2. Blunt – used to detect tenderness over organs (e.g,
kidneys) by placing one hand flat on the body surface.
Interdependent factors that affect a person’s level of 3. Indirect – commonly used method of percussion. The
health: tapping done with this type of percussion produces a
 Mind sound or tone that varies with the density of underlying
 Body structures.
 Spirit  Auscultation – it requires the use of a
stethoscope to listen for heart sounds,
Particular body system and are broken down into four movement of blood through the
sections: cardiovascular system

 History of present health concern Example:

 Personal health history
 Family history
 Lifestyle and health practices
Types of Health Assessment:
 Initial comprehensive assessment - collection of
subjective data about the clients’ perception of their
health of all body parts or system.
 Ongoing or partial assessment – consists of data
collection that occurs after the comprehensive database
is established. This a mini overview of the client’s body
system.
 Focused or problem-oriented assessment – it is
performed when a comprehensive database exists for a
client who comes to a health care agency with specific
concerns.
 Emergency assessment – very rapid assessment
performed in life-threatening situations.
Steps of Health Assessments:
1. Collection of subjective data – integral part of
interviewing the client to obtain a nursing health
history. It consists of:
 Sensations or symptoms
 Feelings
 Perceptions
 Desires
 Preferences
 Beliefs
 Ideas
 Values
 Personal information
2. Collection of objective data – it is obtained by general
observation and by using the four examination
techniques:
 Inspection – using the sense of vision, smell,
and hearing to observe and detect any
normal or abnormal findings.
 Palpation – using parts of the hand to touch
and feel.
The fingerpads, ulnar/palmar surface, and
dorsal surface – used during palpation.
 Percussion – involves tapping body parts to
produce sound waves. The sound waves or
vibrations enable the examiner to assess
underlying structures.
o Physical characteristics (skin, color, posture)
o Body functions (heart rate, respiratory tract)
o Appearance (dress, hygiene)
3. Validation of data – crucial part of assessment and
serves to ensure that the assessment process is not
ended before all relevant data have been collected.
4. Documentation of data - it forms the database for the
entire nursing process and provides data for all other
member of the health care team.
2. Diagnosis – second phase of nursing process. It
requires the nurse to use clinical judgement. During this
phase, you recognize, analyze and synthesize cues.
Phases of the Interview:
 Preintroductory Phase – the nurse reviews the medical
record before meeting with the client
 Introductory Phase – the nurse explains the purpose of
the interview.
 Working Phase – the nurse elicits the client’s comments
about major biographical data, reason for seeking care.
 Summary and Closing Phase – the nurse summarizes
information obtain during the working phase and
validates problem and goals with client.
Communication During the Interview:
Nonverbal Communication:
 Appearance – ensure your appearance is professional
because client is expecting to see a health professional.
 Demeanor – display poise, focus on the client and
upcoming interview and assessment.
 Facial Expression – often overlooked aspect of
communication because it shows what you are truly
thinking.
 Attitude – all clients should be accepted, regardless of
beliefs, ethnicity, lifestyle and health care practices.
 Silence – periods of silence allow you and the client to
reflect and organize thoughts.
 Listening – most important skill to learn and develop
fully in order to collect complete and valid data from
your client.
Verbal Communication – essential to a client interview.

 Open-ended Questions – used to elicit the client’s

feelings and perceptions. It begins with the words
“how” or “what”.
 Close-ended Questions – to obtain facts and to focus on
specific information. It begins with the words “when”
or “did”
 Laundry list – provide client with a list of words to
choose from in describing symptoms, conditions or
feelings.
 Rephrasing – this technique helps you to clarify
information the client has stated.
 Well-Placed Phrases – example “uh-huh” “yes” or “I
agree:
 Inferring – inferring information from what the clients
tells you and what you observe in the client’s behavior
may elicit more data.
 Proving information

3 variations in communication as you interview clients:

1. Gerontological
2. Cultural
3. Emotional

8 sections of Health History:

 Biographical Data
 Reasons for seeking health care
 History of present health concern
 Personal Health History
 Family Health History
 ROS for current health problems
 Lifestyle and Health practices profile
 Developmental level

Validation of Data – the process of confirming or verifying that

the subjective and objective data you have collected are reliable
and accurate.

Making Clinical Judgment – helps the reader visualize,

understand and practice analyzing data to make clinical judgement.

Collaborative problems – defined as physiologic problems that

are at risk to occur or have occurred that require both medical and
nursing interventions to treat.

STEPS OF NURSING PROCESS:

1. Assessment – collecting subjective data and objective

data
2. Diagnosis – analyzing subjective and objective data to
make and prioritize professional clinical judgements.
3. Planning – generating solutions, developing a plan, and
determining which outcomes need to be met first
4. Implementation – taking action, prioritizing and
implementing the planned intervention.
5. Evaluation – assessing whether outcomes have been
met and revising the plan if the interventions did not
make a difference.
PRELIM REVIEWER
ASSESSING SKIN
The Skin - largest organ of the body responsible for temperature
maintenance, fluid.
3 Layers of the Skin:
1. The Epidermis - the outer layer of skin which consists
of dead, keratinized cells that render the skin
waterproof.
Keratin - a scleroprotein that is insoluble in water like hair, nails.
Stratum germinativum - the only layer that undergoes cell
division and contain melanin and keratin-forming cells.
Melanin - major determinant of skin color
2. Dermis - The inner layer of skin, also connective tissue
layer containing collagen.
Dermal Papillae - connects the dermis to the epidermis.
-create unique pattern of friction ridges
commonly known as fingerprints.
Sebaceous Glands - attached to hair follicles that secrete an oily
substance called sebum that waterproofs the hair and skin.
Sweat glands has two types:
 Eccrine Glands - located over the entire skin. Its
function is secretion of sweat and thermoregulation.
 Apocrine Glands - associated with hair follicles. It’s a
small and nonfunctional until puberty.
3. Subcutaneous Tissue - a loose connective tissue
containing fat cells. It stores fat as an energy reserve,
provide insulation.
Hair - consists of keratinized cells. It develops within a sheath of
epidermal cells called hair follicle.
Hair color varies and is determined by the type and amount of
pigment (melanin and pheomelanin)
Two types of hair:
 Vellus (peach fuzz), is a short, pale, fine, present over
much of the body.
 Terminal hair (scalp and eye-brows) - is longer,
generally darker and coarser than vellus hair.
Nails - hard, transparent plates of keratinized epidermal cells that
grow from the cuticle.
Skin Cancer -most common cancers.
Skin cancers occurs in 3 types:
1. Melanoma
2. Basal Cell Carcinoma (BCC) - most common skin cancer in
Whites
3. Squamous Cell Carcinoma (SCC) - most common in the
darker skin
Malignant Melanoma - most serious skin cancer.
Common Skin Variations:
 Freckles - flat, small macules of pigment that appear
following sun exposure.
 Vitiligo Depigmentation of the skin
 Stria - sometimes called Stretch marks.
 Seborrheic keratosis - a warty or crust pigmented
lesion
 Scar
 Mole - also called nevus, a flat or raised tan/brownish
marking up to 6 mm wide.
 Cutaneous tag - raised papule with a depressed center
 Cutaneous horn
 Cherry Angiomas - small raised spots (1-5 mm wide)
typical seen with aging.
PRIMARY SKIN LESIONS:
 Macule and Patch - small, flat nonpalpable skin color
change.
 Vesicle and Bulla - circumscribed elevated, palpable
mass containing serous fluid.
 Papule and Plaque - Elevated palpable, solid mass.
 Wheal - Elevated mass with transient borders that are
often irregular.
 Nodule and Tumor - Elevated solid palpable mass that
extends deeper into dermis than a papule.
 Cyst - Encapsulated fluid-filled or semisolid mass that
is located to the subcutaneous tissue or dermis.
 Pustule - Pus-filled vesicle or bulls. Example Acne.
SECONDARY SKIN LESIONS:
 Erosion - loss of superficial epidermis that does not
extend to the dermis.
 Scar (CICATRIX) - skin mark left after healing of
would or lesion.
 Ulcer - Skin loss extending past epidermis, with
necrotic tissue loss.
 Fissure - linear crack in the skin that may extend to the
dermis and may be painful.
VASCULAR SKIN LESIONS:
 Petechia - bound red or purple macule that is 1 to 2 mm
in size.
 Spider Angioma - Red arteriole lesion with a central
body with radiating branches.
 Ecchymosis - Round or irregular macular lesion that is
larger than petechial lesion.
 Telangiectasis (Venous Star) - Bluish or red lesion
with varying shape (spider-like or linear) found on the
legs and anterior chest.
 Hematoma - A localized collection of blood creating
an elevated ecchymosis. It is associated with trauma.
 Cherry Angioma - Papular and round, red or purple
lesion found on the trunk or extremities.
The mnemonic ABCDE - Used to detect signs of skin cancer that  Trapezius muscles - muscles extends the head and
indicate the need for further evaluation. moves the shoulder.

A – Asymmetry Eleventh Cranial nerve - responsible for muscle movements.

B - Borders Thyroid Gland - largest endocrine gland in the body

C - Color - produces thyroid hormones that increase

metabolic rate.
D - Diameter
Cricoid Cartilage - the first upper tracheal ring
E - Elevated
Thyroid cartilage - (Adam's apple) is larger and located above the
The Head 2 subsections: cricoid cartilage.
1. Cranium - protects the brain and major sensory organs. It The hyoid bone - attached to the tongue, lies above the thyroid
consists of eight bones: cartilage.
 Frontal The internal Jugular veins and Carotid arteries - located
 Parietal bilaterally, parallel and anterior to the sternomastoid muscles.
 Temporal
 Occipital Lymph nodes - filter lymph, a clear substance composed mostly of
 Ethmoid excess tissue fluid.
 Sphenoid
- produce lymphocytes and antibodies
2. Face - Facial bones give shape to the face. It consists of 14
Common lymph nodes:
bones:
 Preauricular
 Maxilla
 Postauricular
 Zygomatic (cheek)
 Tonsillar
 Inferior conchae
 Occipital
 Nasal
 Submandibular
 Lacrimal
 Submental
 Palatine
 Superficial cervical
 Vomer
 Posterior cervical
 Mandible (jaw) - not immovable
 Deep cervical
Temporal Artery - major artery located between the eye and top  Supraclavicular
of the ear.
Trigeminal Neuralgia - manifested by sharp, shooting, piercing
Parotid Glands - located on each side of the face, anterior and facial pains.
inferior to the ears, and behind mandible.
A goiter - an enlarged thyroid gland.
Submandibular - located inferior to the mandible, underneath the
base of the tongue. An abnormally small head is called Microcephaly.

The neck is composed of: Abnormalities of the Head and Neck:

 Muscles  Acromegaly - enlargement of the facial features like

nose,ears,hands and feet.
 Ligaments
 Cushing Syndrome - present with a moon-shaped face
The cervical vertebrae - (C1 through C7) located in the posterior with reddened cheeks.
neck and support cranium  Hypothyroidism/Myxedema - characterized by a dull,
puff face edema around the eyes.
The neck contained of:  Scleroderma - a tightened, hard face with thinning
facial skin
 Hyoid bone  Bell Palsy - usually begins suddenly and reaches a peak
 Several major blood vessels within 48 hours.
 The larynx  Parkinson Disease -mask-like facial appearance, along
 Trachea with a shuffling gait, rigid muscles.
 Thyroid Gland - the anterior triangle of the neck.  Simple Goiter - any enlargement of the thyroid gland
not caused by inflammation or neoplasm.
Muscles that allow movement and provide support to the head and  Cerebrovascular Accident - results in neurologic
neck: damage. The symptoms depend on what part of the
brain was affected.
 Sternomastoid - rotates and flexes the head
ASSESSING EYES
The Eyeball – located in the eye orbit and composed of 3 separate
coats or layers.
1. The external layer:
 Sclera – protective, white covering that
physically supports the internal structure of
the eye.
 Cornea – permits the entrance of light,
which passes through lens to the retina.
2. The middle layer:
 Iris – containing pigments that determine
eye color.
o Pupil – the central aperture of the
iris that controls the amount of
light entering the eye.
 Ciliary body – where the lens is attached
o Lens – refract (bend) light rays
onto the retina.
 Choroid – contains the vascularity necessary
to provide nourishment and prevents light
from reflecting internally.
3. The innermost layer
 Retina – It receives visual stimuli and sends
it to the brain.
Layers of Retina:
Rods or cones (photoreceptors) –
responsive to light.
The Eyelids (Upper and Lower) – are movable structures that
protect the eye from foreign bodies and limit the amount of light
entering the eye. It is composed of skin and two types of muscles:
 Striated and Smooth
The Upper lids – larger more mobile and contains tarsal plates
made up of connective tissue.
Tarsal Plates – contain the meibomian glands that secrete an oily
substance that lubricates the eyelid.
The eyelids join at two points:
The lateral (outer) canthus
The medial (inner) canthus – contains:
 Puncta – two small openings that allow drainage of
tears into the lacrimal system.
 Caruncle – a small, fleshy mass that contains
sebaceous glands.
Palpebral fissure – the white space between open eyelids.
Eye lashes – filter dust and dirt from air entering the eye.
Conjunctiva – a thin transparent membrane allows for inspection
of underlying tissue and protects the eye from foreign bodies.
divided into two portions:
 Palpebral portion – lines the inside of the eyelids.
 Bulbar portion – covers most of the anterior eye,
merging with the cornea at the limbus.
The lacrimal apparatus – consists of glands and ducts that
lubricate the eye.
The lacrimal gland – located in the upper outer corner of orbital
cavity just above the eye, produces tears.
The extraocular muscles - are the six muscles that attached to the
outer surface of each eye ball. It controls six directions of eye
movement.
 Rectus muscles
1. Superior
2. Inferior
3. Lateral
4. Medial
 Oblique muscles
1. Superior
2. Inferior
The Optic Disc – circular area located on the retina and it is where
the optic nerve enters the eyeball.
A visual field – refers to what a person sees with one eye.
Visual perception – occurs as light rays strike the retina.
Visual Reflexes: prevent damage to the delicate photoreceptors by
excessive light.
 The pupillary reflex – causes pupil to constrict
immediately when exposed to bright light.
 Direct reflexes
 Indirect reflexes or consensual.
 Accommodation – functional reflex allowing the eyes
focus on near objects.
Diseases:
 Glaucoma – a group of eye diseases that damage the
optic nerve, often caused by abnormally high pressure
within the eye.
 AMD – major cause of visual impairment that affects
the macula portion of the retina.
 Cataracts – leading cause of blindness in the world
today. It is clouding of the usually clear lens of the eye.
Snellen Chart – used to test distant visual acuity.
Ophthalmoscope – hand-held instrument that allows the examiner
to view the fundus of the eye.
ABNOMRAL FINDINGS:
 Myopia (Impaired far vision) – present when the
second number in test result is larger than the first.
 Presbyopia (impaired near vision) – indicated when
the client moves the chart away from the eyes to focus
on the print.
 Nystagmus – an oscillating (shaking) movement of the
eye.
 Episcleritis – noninfectious inflammation of the sclera.
 Papilledema – appears as swollen disc with blurred
margins.
 Pseudostrabismus – normal in young children, the
pupils will appear at the inner canthus due to epicanthic
fold.
ABNORMALITIES OF THE PUPILS:
 Miosis – also known as pinpoint pupils, it is
characterized by constricted and fixed pupils – possibly
a result of narcotic drugs or brain damage.
 Anisocoria – pupils of unequal size
 Mydriasis – dilated and fixed pupils, typically resulting
from central nervous system injury.
Phoria – term used to describe misalignment that occurs only
when fusion reflex is blocked.
Strabismus – a constant malalignment of the eyes.
Tropia – is a specific type of malignment
Esotropia – is an inward turn of the eye
Exotropia – an outward turn of the eye.
ASSESSING EARS
The Ear – is the sense organ of hearing and equilibrium.
Parts of the Ears:
1. The external Ear
 Auricle or Pinna – portion of the external ear and
ridges that form an irregular funnel to conduct sound
waves into the external auditory canal.
 External auditory canal – is S-shaped in the adult.
Modified sweat glands in the external ear canal secrete
Cerumen – a wax-like substance that keeps the
tympanic membrane soft.
2. The middle Ear (tympanic cavity)
- Is a small, air -filled chamber in the temporal bone. It is
separated from the tympanic membrane (eardrum)
- Tympanic (eardrum) has a translucent serve as a
partition stretched across the inner auditory canal.
Contains 3 auditory ossicles:
Malleus, Incus, Stapes – responsible for transmitting sound
waves from the eardrum to the inner ear through the oval
window.
The distinct landmarks of tympanic membrane:
 Handle and short process of the malleus – the nearest
auditory ossicle that can be seen through the translucent
membrane
 Umbo – the base of the malleus, also serving as a center
point landmark
 Cone of light - The reflection of the otoscope light seen
as a cone due to concave nature of the membrane.
 Pars flaccida – the top portion of the membrane that
appears to be less taut than the bottom portion.
 Pars tensa – the bottom of the membrane that appears to
be taut.
3. The inner Ear (labyrinth) -is fluid-filled and made up
of the bony labyrinth and an inner membranous
labyrinth.
3 parts of bony labyrinth:
 Cochlea
 Vestibule
 Semicircular canals
Spiral organ of corti – the sensory organ for hearing.
Sensory Receptors – located in the vestibule and the membranous
canals, sense position and head movements to help maintain both
static and dynamic equilibrium.
Conductive hearing – transmission of sound waves through the
external and middle ear.
- Hearing loss cause (impacted earwax, otitis media,
foreign object, perforated eardrum, drainage in the
middle ear)
Perceptive or sensorineural hearing – transmission of sound
waves in the inner ear.
- Hearing loss (organ of corti, cranial nerve VIII, or
temporal lobe of the brain.
Otorrhea (drainage of liquid from the ear) – usually indicates
infection
Otalgia (earache) – can occur with ear infections (otitis media or
external)
Tinnitus (ringing in the ears) – may be associated with excessive
earwax buildup, high blood pressure, certain ototoxic medications.
Vertigo (sensation that you or the environment around are
spinning) – may be associated with an inner ear problem.
 Subjective vertigo – when clients feel they are spinning
around
 Objective vertigo – when clients feel that the room is
spinning around them.
Otitis externa – often referred to as swimmer’s ear, can occur
when water stays in the ear canal for long periods of time.
The otoscope – a flashlight-type viewer used to visualize the
eardrum and external ear canal.
ABNORMAL FINDINGS:
 Polyp – growth on inside the ear canal due to chronic
ear infections or a skin cyst inside the ear
(cholesteatoma)
 Exostosis – known as surfer’s ear, abnormal bone
growth within the ear canal due to chronic irritation,
heredity or unknown reasons.
 Acute otitis media – note the red, bulging membrane,
decrease or absent of light reflex.
 Perforated tympanic membrane – perforation results
form rupture caused by increased pressure, usually from
untreated infection or trauma.
ASSESSING MOUTH, THROAT, NOSE, SINUSES
The mouth and throat – first part of the digestive system and
responsible for receiving food (ingestion).
The nose and paranal sinuses – first part of the respiratory
system and responsible for receiving, filtering, warming and
moistening air to be transported to the lungs.
The Mouth (oral cavity) – formed by the lips, cheeks, hard and
soft palates, uvula and the tongue and its muscles
- Beginning of the digestive tract and serves as an airway
for the respiratory tract.
The upper and lower lips – serves as a protective gateway to the
digestive and respiratory tracts.
The Tongue – is a mass of muscle, attached to the hyoid bone and
connected to the floor of the mouth by a fold of tissue called the
frenulum.
- The gums (gingiva) – are covered by mucous
membrane and normally hold 32 permanent teeth in the
adult.
- Crown – the top, visible white enameled part of each
tooth.
- Root - the portion of the tooth that is embedded in the
gums.
- Neck – where the crown and root are connected.
- Papillae – small bumps that cover the dorsal surface of
the tongue.
- Saliva – helps break down food and lubricates it.
- Amylase – digest carbohydrates.
- Open under the tongue on either side of the frenulum
through openings called Wharton duct
The Throat (pharynx) – located behind the mouth and nose and
serves as a muscular passage for food and air.
The Sinuses – located in the skull and it is a air-filled cavities
decrease the weight of the skull and act as resonance chambers
during speech.
4 Pairs of Paranasal Sinuses:
 Frontal
 Maxillary
 Ethmoidal
 Sphenoidal
Frontal sinuses (above the eyes) and Maxillary sinuses (in the
upper jaw) -are accessible to examination by the nurse.
The ethmoidal and sphenoidal sinuses – are smaller, located
deeper in the skull, and are not accessible for examination.
NOSE AND SINUSES FINDINGS:
 Epistaxis (nosebleed) can be divided into local causes
(trauma, mucosal irritation, inflammatory disease)
 Leukoplakia (chalky white raised patches) – may be a
seen in chronic irritation, heavy smoking and alcohol
use.
 Fruity or acetone breathe – is associated with diabetic
ketoacidosis.
 Nasal Mucosa – is swollen and pale pink or bluish gray
in clients with allergies. It is with upper respiratory
infections,
MOUTH AND THROAT FINDINGS:
 Dysphagia (difficult swallowing)
 Odynophagia (painful swallowing)
- May be seen with tumors of the pharynx, esophagus or
surrounding structures.
 Bruxism (grinding the teeth) – may be a sign of stress
or of slight malocclusion.

- Nasopharynx – upper part of the throat

- Oropharynx – below the nasopharynx
- Laryngopharynx – below the oropharynx
- Palatine tonsil – masses of lymphoid tissue is located
on both sides of the oropharynx.
- The lingual tonsil- lie at the base of the tongue.
- Pharyngeal tonsil (adenoids) – are found high in the
nasopharynx.
- Tonsil help protect against infection.

The Nose – it is composed of bone and cartilage and is lined with

mucous membrane.

- The external nose – consists of a bridge (upper

portion) tip, and two oval openings called Nares.
- The nasal cavity – located between the roof of the
mouth and the cranium and it also opens the
nasopharynx.
- The nasal septum contains a rich supply of blood
vessels and is known Kiesselbach area.
- Kiesselbach area – is a common site for nasal
bleeding.
- The superior, middle, and inferior turbinates are bony
lobes, sometimes called Conchae.