MODULE III

Holistic Nursing Assessment

is used in nursing to inform the nursing process and provide the

foundations of patient care. Through holistic assessment, therapeutic communication, and the

ongoing collection of objective and subjective data, nurses are able to provide improved person-

centered care to patients. A holistic approach acknowledges and addresses the physiological,

psychological, sociological, developmental, spiritual and cultural needs of the patient.

I - GENERAL STATUS-

is the first step part of head to toe examination that begins the moments of nurse meets the client. It
requires the nurse to all her observation skills while interviewing and interacting with the client. These
observation will lead to clues about the health status of the client.

The outcome of the general survey provides the nurse with an overall impression of the client whole
being.

The general survey includes observation of the clients

• Physical development and body build

• Gender and sexual development
• Apparent age as compared to reported age
• Skin condition and color
• Dress and hygiene
• Posture and gait
• Level of consciousness
• Behaviors, body movements, and effect
• Facial expression
• Speech
• Vital signs

General Physical Survey

Observe the following:

Procedure Normal Findings Deviations from Normal

 Behavior Cooperative attitude and behavior Uncooperative or bizarre,
unpredictable behavior

Mood Mild anxiety or tenseness Moderate to severe

anxiety and tenseness

Appearance Dressed for occasion Dress bizarre and

inappropriate for occasion

Body movements Coordinated; smooth and steady Uncoordinated; shaky and

unsteady

II - Mental status

• refers to a client’s level of cognitive functioning ( thinking knowledge, problem

solving) and emotional functioning (feelings, mood, behavior stability).
Mental health

• is an essential part of ones total health and is more than just the absence of mental
disabilities or disorders.
Healthy Mental Status is needed to think clearly, respond,, appropriately and function
effectively in all activities of daily living. It is reflected in once appearance, behaviors
speech, thought patterns, decision and in one relationship in home, work, social and
recreational settings.
Factors Affecting Mental Health
1. Economic and social factors, such as rapid changes, stressful work conditions and
isolation.
2. Unhealthy lifestyle choices such as sedentary lifestyle or substance abuse.
3. Exposure to violence, such as victim of child abuse
4. Personality factors such as poor decision making skills, low self concept, poor self
control,
5. Spiritual factors
6. Cultural factors
7. Changes or impairments in the structure and function of the neurologic system
Example celebral abnormalities
8. Psychosocial developmental level and issues .
Collecting Subjective Data: The nursing health History
Before asking question to determine the client mental status, explain the purpose of this
examination
1. Biographical data
2. History of present Health concern
3. Personal health history
4. Family history
5. Lifestyle and health practices
Clinical Tip: It is best to validate client response by asking additional questions, verifying data
with another health care professional, or comparing objective with subjective findings before
completing the entire assessment. If the nurse finds out that the clients thought perceptions or
level of orientation are impaired, another means of obtaining necessary subjective data must
be identified.

Collecting of Objective Data: Physical Examination

1. OBSERVE LEVEL OF CONSCIOUSNESS
Call the client name and note the response. If the client does not respond, call the name
louder.
Always begin with the least noxious stimulus: verbal, tactile to painful

• Older considerations when assessing the mental status of an older clients, be

sure to check vision and hearing before assuming that the client ha s a mental
problem.
• Older client’s response and ability to process information may be slower, he or
she is normally alert and oriented.
GLASGOW COMA SCALE- most widely used in scoring system for intensive care unit, comatose patients.
GCS score 14 indicates an optimal level of consciousness.
The client who scores 10 and lower needs emergency attention
The client with score of 7 or lower is generally considered to be a coma
2. OBSERVE POSTURE AND BODY MOVEMENTS
Be alert for tense, nervous, fidgety, and restless behavior which may seen in anxiety or
may simply reflect the clients apprehension during a physical examination.
Normal finding: the clients appears to be relaxed with shoulders and back erect when
standing or sitting.
• Older Considerations – in older adult, purposeless movement, wandering,
aggressiveness or withdrawal may indicate neurologic deficits.
3. Observe the behavior and affects

4. Observe dress, grooming and hygiene

Keep the examination setting and the reason as you note the clients degree of
cleanliness and attire.
• Older adult considerations some older adults wear excess clothing because of
slowed metabolism and loss of subcutaneous fat resulting in cold intolerance.
• Cultural considerations Asian and native americans have fewer sweat gland and
therefore less obvious body odor than most Caucasians and black africans who
have more sweat glands, additionally, some cultures do not use deodorant
5. Observe facial expressions. note particularly eye contact and effect.
Normal findings: clients maintains good eye contact, smiles and frown appropriately.
• Cultural considerations: eye contact and facial expressions such as smiling differ
in some cultures. Eye contact is often related to status or gender.
6. Observe speech
observe and listen to tone clarify and pace of speech.
Speech is in a moderate tone, clear, and with moderate pace.
 • If the client has difficulty with speech perform: ask the client to name objects
• Older adult considerations responses may be slowed but speech should be clear and moderately
paced

7. Observe mood feelings and expressions- moods and feeling often vary from sadness to joy to anger,
depending on the situation and circumstance

8. Observe thought processes and perception

Example “tell me more about what you said .”

9. Observe Cognitive abilities

a. Assess Orientation- ask the name, names of family members, time, date and
current location.
• Older consideration- may seem confused especially in a new or acute
setting but most know who and where they are and the current month
and year
b. Assess Concentration- ability to focus and stay attentive to you
• Older consideration- may like to reminisce and tend to wander
somewhat from the topic to hand.
c. Assess Recent memory- recalls recent event like “ what did you eat today”
d. Assess Remote memory- correctly recalls past event ex: “when is your birthday”.
e. Assess Use of memory to learn new information- ask the client to repeat four
unrelated words ex: rose, hammer, automobile, brown.
f. Assess Abstract reasoning – client explain similarities and differences
g. Assess Judgement- answers to questions are based on sound rationale
“ what do you do if you have pain’
h. Assess Visual perceptual and constructional ability- can copy simple figures.

Seven warning signs of ALZHEIMER DISEASE

1. Asking the same question over abd over again

2. Repeating the same story
3. Forgetting some activities
4. Losing ones ability to pay bills
5. Getting lost in familiar surrounding
6. Neglecting to bath
7. Relying on someone else, such as a spouse to make decision

Selected Nursing Diagnosis

Health promotion Diagnosis
o Readiness for enhanced health management
o Readiness for enhanced coping
Risk Diagnosis

• Risk for self directed violence

• Risk for developmental delay
Actual Diagnosis

• Anxiety related to awreness

• Impaired verbal communication
• Impaired memory
III Assessing Psychosocial, Cognitive and moral Development
PSYCHOSOCIAL

A psychosocial assessment is an evaluation of an individual's mental health and social well-being. It

assesses self-perception and the individual's ability to function in the community. The psychosocial
assessment goal is to understand the patient to provide the best care possible and help the individual
obtain optimal health.

The psychosocial assessment helps the nurse determine if the patient is in mental health or a mental
illness state. Mental health is a state of well-being where there is the ability to deal with the typical
stresses of life, works productively, and contribute to their community.

Freud theory of Psychosexual Development

Sigmund Freud- a viennese physician developed the first formal theory of personality . He originated the
concept of psychoanalysis and believed that personality development was based on understanding the
individual life history of a person.

Three Level of Awareness

1. Consciousness- refers to whatever a person is sensing, thinking about, or experiencing at any

given moment. This level to be limited since only a small amount of such thought exist at one
time
2. Preconsciousness- involves all of a person’s memories and stored knowledge that can be
recalled and brought to the conscious level
3. Unconsciousness – as the largest and most influential. This level of corresponds to socially
unacceptable sexula desires, shameful impulses and irrational wishes, as well as axieties and
fears.
3 basic structures in his anatomy of the personality

1. ID- is the inherited system. Containing the basic motivational drives for such entities as air,
water, warmth and sex, it seek instant gratification and supplies the psychic energy for ego and
superego.
• No perception of reality or morality (what is right and wrong)
2. Ego- it includes many processes such as learning, perceptions, memory, problem solving and
decision making.
• Use the variety of defence mechanism
 • It does not possess a concept of morality
3. Superego -often reffered to as the moral component of personality ( conscience ) provides
feedback to the person regarding how closely his or her behavior

Erikson Theory of Psychosocial Development

Erik Erikson-
was psychoanalysis who adapted and expanded Sigmund Freuds psychosexual theory.
Erikson theory has become known as a psychosocial theory with psychosocial being
defined as intrapersonal and interpersonal responses of a person to external events.
Erikson concluded that societal, cultural and historical factors as well as biophysical
processes and cognitive function influence personality development.
He did not strictly define chronological boundaries for his stage . He did assign selected
development levels throughout the lifespan, termed critical periods, as times when a
person possesses criteria to attempts a given development task . each person develops
at his or her rate in accordance with individual potential and experience.
Piaget Theory of Cognitive development
Dr. Jean Piaget described himself as a genetic epistemologist ( one who studies the origins of
knowledge). His theory is a description and an explanation of the growth and development of
intellectual structures. He focused on how a person learns, not what the persons learn.
Kohlberg Theory of Moral Development

• Lawrence Kohlberg, a psychologist, expanded Piaget’s thoughts on

morality; in doing so, he developed a comprehensive theory of moral
development. Recognition of the distinction between good and evil or
between right and wrong; respect for and obedience to the rules of right
conduct; the mental disposition or characteristic of behaving in a manner
intended to produce good results
IV VIOLENCE
Family violence- a situation in which one family member causes physical or emotional harm to
another family member. At the center of this violence is the abusers need to gain power and
control over the victim.

Types of Family Violence

1. Physical Abuse
- includes pushing, shoving, slapping. Kicking, choking, punching and burning. It may
also involve holding, trying or other methods of restraints. The victim may be left in a
dangerous place without resources. The abuser may involve refuse to help the victim
when sick, injured or in need. Physical abuse may also involve attacking the victim
with household item( lamps, radios, ashtrays, iron etc) or with common
weapons(knives or a gun)

2. Psychological abuse
- Involves the use of constant insults or criticism, blaming the victim for things that are
not victims faults, threats to hurt children or pets, isolation from supporters ( family,
friends, or co workers). Deprivation, humiliation, and intimidation

3. Economic abuse
- May be evidenced by preventing the victim from getting or from keeping a job,
controlling knowledge of family finances
4. Sexual abuse
- Involves forcing the victim to perform sexual acts againts his or will, pursing sexual
activity after the victim has said no, using violence during sex and using weapon
vaginally, orally and anally.

Outline the Categories of family violence

Intimate partner violence- is a pattern of assaultive behavior and coercive that may
include physical injury, psychological abuse, sexual assault, progressive isolation
staking, deprivation, intimidation and reproductive coercion.

Child Abuse- any recent act or failure on the part of a parent or caregiver that
results in death, serious physical or emotional harm, sexual abuse or exploitation, or
an act or failure to act that present an imminent risk of serious harm.
Family Violence Assessment

Subjective

1. Review the client past health history and physical examination records if
available
 2. If partner/parents/ caregiver is present at the visit observe the client interaction
with partner.
3. Perform the rest of examination without the partner, parents or caregiver present.
Ask all client:
§ Has anyone in your home ever hurt you?
§ Do you feel safe in your home?
§ Are you afraid of anyone in our home
§ Has anyone ever touched you without telling them to do so?
§ Has anyone ever threatened you?
OBJECTIVE DATA

1. General survey
( observe general appearance and body build, note dress and hygiene)
2. Assess mental status
3. Evaluate vital signs
4. Inspect skin
5. Inspect the head and neck
6. Inspect the eyes Assess the
7. Assess the ears
8. Assess the abdomen
9. Assess the genitalia and rectal ears
10. Assess the musculoskeletal system
11. Assess the neurologic system
Possible nursing diagnosis

1. Wellness Diagnosis
-Readiness for enhanced Family process
- health seeking behavior: request information related to safety from domestic violence

2. Risk Diagnosis
- Risk for impaired parent/infant/child family processes related to the presence of domestic
violence.
- Risk for violence related to the presence of poor coping mechanism and the misuse of
alcohol and illegal drugs.
3. Actual Diagnosis
- Dysfunctional grieving related to loss of ideal relationship as evidenced by refusal to discss
feeling and prolonged denial.
- Impaired parenting related to choosing to remain living in the presence of an abusive
marriage or intimate relationship

V. CULTURE and ETHNICITY

CULTURE
-the totality of socially transmitted behavioral patterns, arts, beliefs, values,
customs, lifeways, and all other products of human work and thought
 characteristic of a population or people that guide their worldview and
decision making."
Ethnicity
Characteristics that a group may share such as language, symbols,
traditions, music, religious beliefs, geographic origin, literature, and internal
sense of distinctiveness Race

CHARACTERISTIC OF CULTURE

1. Learned
- transmitted from one generation to the other
2. Shared
- norms for behaviors, values, and beliefs are shared by the cultural group

3. Associated with adaptation to environment

4. Universal
- may vary but humans cannot exist without culture
Steps to Cultural Competency

• Collect relevant cultural data of the client's presenting problem

• Self-understanding
• Identify the meaning of HEALTH to other people
• Understand the health care delivery system
• Know about social background of your patients
• Be familiar with the language people speak & resources to interpret

ASKED mnemonic - used to examine cultural competence

Awareness
Skill
Knowledge
Encounters
Desire

Cultural Awareness
- Self-examining and looking at your own cultural background
- You have to examine your own biases, prejudices and assumptions that you
make about others
- Avoid cultural imposition and be sensitive to cultural differences

Stages of cultural awareness

Unconscious Incompetence:
- aware one lacks knowledge

Conscious Incompetence:
- aware differences exist, but not knowing the differences
 Conscious Competence:
-wanting to learn, seeking it out

Unconscious Competence:
able to automatically provide care to patients from different cultures

Cultural Skill
Have communication skills to navigate cross-cultural differences

Develop communication skills that will help close the gap of cultural differences

Listen, be nonjudgemental. Be culturally sensitive when doing assessments

Be respectful, empathetic and ask patients about their health beliefs and practices.
Spend time with the patient to build trust.

Cultural Knowledge

The process of seeking and obtaining a sound educational foundation regarding

the various world views of various different cultures

Understand their world view and remember the concept of intracultural variations

Cultural Encounters

Have real experiences

Have face-to-face encounters with many patients

Purpose of Cultural Assessment

• To learn about the client's beliefs and behaviors associated with health and
illness

• To compare and contrast the client's beliefs and practices to the standard
Western care

• To compare the client's beliefs and practices with those of other persons

• To assess the client's health relative to diseases prevalent in their group

Cultural Assessment

• Adding elements of cultural assessment to the current assessment OR

conducting a specific culture assessment of beliefs and values
 includes:
• Value orientation
• Beliefs about:
- human nature
- relationship with nature
- purpose of life
- health, illness & healing
- causation of disease
- health
- role of health providers

FACTORS AFFECTING APPROACH TO PROVIDERS

• Ethnicity (both client and health care provider)
• Generational status
• Educational level
• Religion
• Previous health care experiences
• Occupation and income level
• Beliefs about time and space
• Communication needs/preferences

Factors affecting Disease, Illness, health State

• Biomedical Variation
• Nutritional/dietary habits
• Family roles and organization, patterns
• Workforce issues
• High risk behavior
• Pregnancy and spiritual beliefs and practuces
• Health care practices
• Health care practitioners
• Environment
CULTURAL VARIATIONS OF TRADITIONAL HEALERS AND PRACTICES
Health Beliefs & Practices Assessment
1. How do you define health?
2. How do you rate your health?
3. How do you describe illness?
4. What do you believe causes illness?
5. What did your mother do to keep you from
getting sick, and what home remedies did your
mother use to restore your health?
6. How do you keep yourself from getting sick, and what home
remedies do you use?

VI- SPIRITUALITY AND RELIGIOUS PRACTICES

Religion
- rituals, practices, and experiences involved in a search for the sacred
- shared within a group

Defining characteristics:
- Objective (easily measurable)
- Formal
- Organized
- Ritualistic
- Group-oriented

Spirituality

search for meaning and purpose in life

- seeks to understand life's ultimate questions in relation to the sacred
- based on self-experience
- may be disconnected from any religious institution.

Defining characteristics:
- Subjective as in difficult to consistently measure ( daily spiritual experience,
spiritual well being)
- Informal
- Non-organized
- Experience
- Self-reflection

Spiritual Activities
- search for meaning and purpose in life
- prayer
- participation in church services
- meditation
- yoga
- tai chi
- dietary restrictions
- pilgrimage
- confessions
- reflection
- forgiveness, and etc.

Spiritual Assessment

- explore the client's religious and spiritual background

- active and ongoing conversation that assesses the spiritual needs of the client
- use SPIRIT (nonformal), RCOPE, and FICA (formal)
- observe nonverbal and verbal communication patterns in the presence of others
- listen to the client's story
- focus questions
- daily spiritual experiences
- brief religious coping questionnaire

Defining characteristics
- formal/informal
- respectful
- non-biased

Spiritual Care
- addressing the spiritual needs of the client as they unfold through spiritual assessment

Defining characteristics:
- individualistic
- client oriented
- collaborative

Negative Affect of Some Religious

Christian Scientists
frequently rely on prayer alone to heal illnesses, rarely seek mainstream medical care,
and have higher rates of mortality than the general population.

Jehovah's Witnesses
refuse blood transfusions due to their beliefs that the body cannot be sustained by
another's blood and accepting a transfusion will bar the recipient from eternal salvation.

Faith Assembly of Indiana

have a negative view of modern health care and have an especially high rate of infant
mortality due to limited prenatal care.

Reffering if religious or spiritual views have the potential to compromise adequate

nursing care:
- Situation should be presented to a supervising staff member immediately.
- For complex cases to assure that appropriate measures are followed: to the ethics

committee of the institution

- For specific instructions regarding individual cases: to the institutional or
organizational handbook

Taking a Spiritual History: SPIRIT acronym

SPIRIT - Non-formal technique for spiritual assessment

Spiritual belief systems
Personal spirituality
Integration w/ spiritual community
Ritualized practices and restrictions
Implications for medical care
Terminal events planning

HOPE questions for Spiritual Assessment

H- source of hope
O- organized religion
P- personal spiritual and practices
E- effects on medical care and end of life issues

POSITIVE RELIGIOUS/SPIRITUAL COPING SUBSCALE

- I think about how my life is part of a larger spiritual force.
- I work together with God as partners to get through hard times.
- I look to God for strength, support, and guidance in crisis.

NEGATIVE RELIGIOUS/SPIRITUAL COPING SUBSCALE

- I feel that stressful situations are God's way of punishing me for my sins or lack of
spirituality.
- I wonder if God has abandoned me.
- I try to make sense of the situation and decide what to do without relying on God.

FICA - formal assessment tool used for spiritual assessment

Faith and beliefs
Importance and influence
Community
Address
VII- NUTRITIONAL STATUS

Purpose of Nutritional Assessment

- provides insight into overall health status
- Assess the risks factors of obesity( excessive body fat) and for dietary deficits
- also used to guide health promotion and disease prevention activities

Nutrition
- refers to the process by which substances in food are transformed into body
tissue and provide energy for the full range of physical and mental activities that
make up human life.
- complex processes by which nutrients - carbohydrates, protiens, fats, vitamins,
minerals, and water - are ingested, digested, absorbed, transported, used, and
then excreted.

Essential Nutrients

1. Carbohydrates
- Are referred to as either simple or complex depending on their chemical
structure.
- A healthy diet consist of 45%- 65% of carbohydrates

a. Simple carbohydrates- are sugar simple structures that raises the blood
glucose level and can be converted quickly into energy.
Ex: fruit juice

b. Complex carbohydrates- are composed of double or multiple units of

sugar and can also be used as energy source
Ex: whole grains, starchy vegetables, and fiber

2. Fiber – both soluble and especially insoluble helps to promote normal bowel
function,
Reduce the cholesterol levels, control the blood sugar levels and aid weight
management ( mayo clinic, 2015)

3. Proteins – are important in a healthy diet, which is essential for normal growth
and development.
- Made up of amino acid and are stored in muscle, skin, bone and blood,
cartilage and lymph tissue.

4. Fats – it stored in adipose tissue cell and are classified as triglycerides, which
made up 95% of fats in foods, phospholipids and sterols.
a. Saturated fats
b. Unsaturated fats
 5. Cholesterol- is a fat like substance that the liver produces. It is necessary as a
components of bile salts that aid in digestion, serves as essential element in all
cell membranes is found in the brain and nerve tissue and is essential for the
production of several hormones such as estrogen, testosterone and cortisone.

6. Vitamins -is a part of a nutritional sound diet because vitamins are required for
energy to be released from carbohydrate protein and fats.

7. Minerals- are essential in promoting growth and maintaining health: they can be
found in all body fluids and tissues.
Example: major mineral calcium, potassium, sodium
Trace mineral: fluoride, iron and zinc
8. Water- one of the our most basic nutritional needs. Water accounts to 50%- 75
% of body weight.

Hydration
- indication of general health
- most adults need 2,000 to 3,000 mL of daily water intake

Adequate hydration can be affected by:

- high environmental temps
- inability to access adequate fluids
- excessive intake of alcohol or caffeine
- impaired thirst mechanism
- taking diuretic medications
- diabetic clients with hyperglycemia
- people with high fevers

Food Safety
- Assessing how the client’s food is stored and prepared is an important
suspect of nutritional assessment and subsequent health.
The centers of Disease Control and prevention noted that there are more than
250 different food borne illnesses. Causes are infection (bacteria, viruses
and parasites) and poisoning from the contaminations with toxins or chemical.
Symptoms are nausea, vomiting, abdominal cramp and diarrhea.

Other aspects of Food Safety

a. Food allergies- symptoms of food allergy appear from the minutes to

hours of ingestion.
Symptoms of a severe or anaphylactic response to a food include
Obstructive swelling on the lips, tongue and throat,
dysphagia, cyanosis, dyspnea, hypotension, feeling faint,
confused, weak, chest pain
 b. Food intolerances- results from a digestive system irritation or when the
digestive system is unable to break down or properly digest the food. Like
lactose intolerance is the most common that include symptoms of nausea,
diarrhea, headache, irritability or nervousness.

Lifestyles
Sedentary
- lifestyle that includes only the light physical activity associated with
typical day-to-day life.

Moderately active
- lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles
per day at 3 to 4 miles per hour, in addition to the light physical activity
associated with typical day-to-day life.

Active
- lifestyle that includes physical activity equivalent to walking more than 3 miles
per day at 3 to 4 miles per hour, in addition to the light physical activity
associated with typical day-to-day life.

Anti-Inflammatory Diet
More:
- olive oil, nuts, fatty fish, leafy greens, tomatoes, and fruits. + herbs and spices

Less:
- French fries, sodas, refined carbs, lard, and processed meats.

1. Eat the rainbow

2. Restrict dairy and grains
3. Avoid red meat

Many spices and herbs are anticoagulants!

Optimal Nutritional Status
achieved when sufficient nutrients are consumed to support day to day body needs

clinical tip: advise clients to avoid simple sugar, transfat, processed foods and too many
calories.

Optimal Nutrition- is often thought t

Malnutrition
- reserves are depleted;
- at risk for impaired growth and development
- signs and symptoms may be confused with other diseases or conditions
Risk factors:
- low SES, frequent fast food use, poor food choices, chronic dieting, chronic illnesses,
eating disorders, dental problems,
- vulnerable groups; cancer, and AIDS.

Wasting syndrome / cancerous or malignant cachexia

- abnormal metabolic rate, anorexia, muscle wasting, severe weight loss, and general
decline in condition.
- is not well understood;
- combination of increased catabolism and gastrointestinal function, poor appetite,
altered metabolism, treatment related, and from psychological factors such as anxiety
and depression.

Over-nutrition
- increased caloric consumption (high fat and sugar) & decreased energy expenditure

Overwieght
- 10% over ideal body weight (IBW)

Obesity
- excessive body fat in relation to lean body mass;
- IBW over 20%
- BMI over 30

- highest in middle-aged (40-59 y.o.) Americans, especially for non-Hispanic Black,

Hispanic, non-Hispanic Whites, and Asians.
- in children: Hispanic, non-Hispanic Black.
Collecting of objective data

General routine screening

1. Observe clients general status and appearance.
2. Observe body build as well as muscle mass and fat distribution
3. Measure height and weight
4. Determine IBM and Percentage of IBW
5. Measure the BMI
6. Observe for changes hydration:
• Measure I and O
• Assess the skin turgor and moisture
• Check for edema
• Check venous filling, neck veins
• Check condition of tongue
• Check condition of eyeball and surrounding sikn
• Auscultate lung sounds
ANTHROPOMETRIC MEASUREMENTS

-when evaluating anthropometric data, base conclusions on a data cluster, not on

individual findings. Factors in any special considerations and general health status.
Although general standards are useful for making estimates, the clients overall health
and well being may be equal or more useful indications of nutritional status.

1. Measure the height

2. Measure the weight
Determine ideal body weight (IBW) and percentage of IBW

3. measure the body mass index ( BMI )are available to evaluate weight status are commonly used
screening methods.
- Is calculated base on the height and weight regardless of gender. It is practical measure for
estimating total body fat and is calculated as weight in kilogram and divided by the square in
meters.
Determine the BMI using this formula:

4. determine the waist circumference- is the most common measurement used to determine the
extent of abdominal visceral fat in relation to body fat.
Normal findings
Females : less than or equal to 35 in.
Males: less than or equal to 40 in
 Positioning of
measuring
Tape for waist
circumference

Visceral fat within the abdominal cavity increases

Health risk

5. determine Waist to hip ratio- measure the hip circumference at the largest area of the buttocks.
To obtain ratio, divide the waist measurement by the hip measurement.

Using fruit as an example this body

Shape concept.

6. Measure the mid-arm Circumference (MAC )-

To evaluate the skeletal mass and fat stores
Have the client fully extend and dangle the nondominant arm freely next to the body. Locate the
midpoint. Then mark the midpoint and measure the MAC, holding the tape measure firmly
around but not pinching the arm. Record the measurement

7. Measure the triceps skin fold thickness- to evaluate the degree of subcutaneous fat stores.
- Instruct the client to stand and hang the on dominant arm freely. Grasp the skin fold and
subcutaneous fat between the acromion process and the tip of the elbow. Pull the skin away
from the muscle. Repeat 3x and average the 3 measurement. Record the measurement in
millimeters. Record both the TSH= 15mm; 91% of standard. Standard = 16.5 ( 15/16.5=91%).
Assessing Hydration
- 1. Measure the intake and output. Measure all the fluids taken in by oral and parental
routes, through irrigation tubes as medications in solution and through tube feedings.
- 2. Weight clients at risk for hydration
- 3. Take the blood pressure with the client in lying, sitting and standing
- 4. Check the skin turgor
- 5. Check for pitting edema
- 6. Observe skin for moisture
- 7. Assess venous filling
- 8. Observe neck veins with client in the supine position then with the head elevated above
45degree
- 9. Inspect the tongue condition and furrows
- 10. Auscultate lung sounds
MODULE 4

Vital signs

-This is a common, non-invasive physical assessment procedure that most clients are
accustomed to.
- Temperature, pulse, respiration, blood pressure (B/P) & oxygen saturation are the most
frequent measurements taken by Health Care Personnel.
- Because of the importance of these measurement’s, they are referred to as Vital Signs. They
are important indicators of the body’s response to physical, environmental, and psychological
stressors.
q VS may reveal sudden changes in a client’s condition in addition to changes that occur
progressively over time. A baseline set of VS are important to identify changes in the patient’s
condition.

q VS are part of a routine physical assessment and are not assessed in isolation. Other factors such
as physical signs & symptoms are also considered.

q Important Consideration:

ü A client’s normal range of vital signs may differ from the standard range.

When to Take a vital sign

• On a client’s admission
• According to the physician’s order or the institution’s policy or standard of practice

• When assessing the client during home health visit

• Before & after a surgical or invasive diagnostic procedure

• Before & after the administration of meds or therapy that affect cardiovascular, respiratory &
temperature control functions.

• When the client’s general physical condition changes LOC, pain

• Before, after & during nursing interventions influencing vital signs

• When client reports symptoms of physical distress

Body temperature

— Core temperature – temperature of the body tissues, is controlled by the hypothalamus (control
center in the brain) – maintained within a narrow range.

— Skin temperature rises & falls in response to environmental conditions & depends on blood flow
to skin & amount of heat lost to external environment

— The body’s tissues & cells function best between the range from 36 deg C to 38 deg C

— Temperature is lowest in the morning, highest during the evening.

Types of temperature

1. tympanic temperature
- An electronic tympanic thermometer
measure the temperature of the tympanic
membrane quickly and safety. It is also a
good device in measuring core body
temperature because the tympanic
membrane is supplied by a tributary of the
artery
( internal carotid) that supply the
hypothalamus ( the body’s thermoregulatory
center).
2. ORAL TEMPERATURE
- Use an electronic thermometer with a
disposable protective probe cover. Then place
the thermometer under the tongue to the right
an left of the frenulum deep in the posterior
sublingual pocket.
Ask the client to close his or her lip around the
probe. Hold the probe until you hear a beep.
Remove the probe and dispose of its cover by
pressing the release bottom.
Reading to about 10 seconds.

3. Axillary Temperature
- Hold the glass or electronic thermometer under
the axilla firmly by having the client hold the arm
down and across the chest.

4. Temporal arterial temperature

- Remove the protective cap from the
thermometer. Place the thermometer over
the clients forehead and while pressing the
scan button., gently stroke the thermometer
across the client forehead over the temporal
artery to a point directly behind the ear. You
will hear a beeping and release the scan
button and remove the thermometer.
Ò Glass mercury – mercury expands or contracts in response to heat.
OLDER ADULT CONSIDERATION In the older adult, temperature may range from 95.0°F to 97.5°F.
Therefore, the older client may not have an obviously elevated temperature with an infection or be
considered hypothermic below 96°F.

Types of fever
1. Remittent – fluctuating but above normal
2. Intermittent –fever to normal (within 24 hours)
3. Relapsing – fever to normal (>24 hours)
4. Constant – malignant hyperthermia
Process of heat loss
1. evaporation-change from liquid into gas
2. Conduction-movement of heat or electricity through something (such as metal or water)
3. Convection-movement in a gas or liquid in which the warmer parts move up and the
colder parts move down.
 CLINICAL SIGN OF FEVER
Onset (cold or chill stage)
q Increased HR
q Increased RR and depth
q Shivering
q Pallid, cold skin
q Complaints of feeling cold
q Cyanotic nail beds
q “Gooseflesh” appearance of the skin
q Cessation of sweating
COARSE OF FEVER
— Absence of chills
— Skin that feels warm
— Photosensitivity
— Glassy-eyed appearance
— Increased pulse and respiratory rates
— Increased thirst
 — Mild-to-severe dehydration
— Drowsiness, restlessness, delirium, or convulsions
— Herpetic lesions of the mouth
— Loss of appetite (if the fever is prolonged)
— Malaise, weakness, and aching muscles

Defervescence (fever abatement)

§ Skin that appears flushed and feels warm
§ Sweating
§ Decreased shivering
§ Possible dehydration
Nursing intervention for clients with fever
1. Monitor vital signs
2. Assess skin color and temperature
3. Monitor WBC count, HCT, and other pertinent labs for indications of infection or
dehydration
4. Remove excess blankets when the client feels warm, but provide extra warmth when the
client feels chilled
5. Provide adequate nutrition and fluids.
6. Measure I and O
7. Reduce physical activity to limit heat production
8. Administer antipyretics as ordered.
9. Provide oral hygiene to keep mucous membranes moist
10. Provide TSB to increase heat loss through conduction
11. Provide dry clothing and bed linens

CLINICAL SIGNS OF HYPOTHERMIA

1. Decreased body temperature, pulse, and respirations
2. Severe shivering (initially)
3. Feelings of cold and chills
4. Pale, cool, wavy skin
5. Hypotension
 6. Decreased UO
7. Lack of muscle coordination
8. Disorientation
a. Drowsiness progressing to coma.

Nursing Intervention for clients with hypothermia

• Provide a warm environment (room temp)
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the client’s scalp with a cap or turban
• Supply warm oral or intravenous fluids
• Apply warming pads.

PULSE
- Shock wave is produced when the heart
contracts and forcefully pumps blood out of the
ventricles into the aorta. The shock wave travels
along the fibers of the arteries and is commonly
called the arterial or peripheral pulse.

Assessing Radial Pulse

Felt by palpating artery lightly against underlying bone or
muscle.

Ð Carotid, brachial, radial, femoral, popliteal,

posterior tibial, dorsalis pedis

Ò Assess: rate, rhythm, strength – can assess by using

palpation & auscultation.

Ò Pulse deficit – the difference between the radial pulse and the apical pulse – indicates a decrease
in peripheral perfusion from some heart conditions. Atrial fibrillation.
Procedure in assessing Pulse
Ò Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over an underlying
bone. Do not use your thumb (feel pulsations of your own radial
artery). Count 30 seconds X 2, if irregular – count radial for 1
min. and then apically for full minute.

Ò Apical – beat of the heart at it’s apex or PMI (point of maximum

impulse) – 5th intercostal space, midclavicular line, just below lt.
nipple – listen for a full minute “Lub-Dub”

Ð Lub – close of atrioventricular (AV) values –

tricuspid & mitral valves

Ð Dub – close of semilunar valves – aortic &

pulmonic valves

Assess: rate, rhythm, strength & tension

Ò Rate – N – 60-100, average 80 bpm

Ð Tachycardia – greater than 100 bpm

Ð Bradycardia – less than 60 bpm

Ð Rhythm – the pattern of the beats (regular or irregular)

Ò Strength or size – or amplitude, the volume of blood pushed against the wall of an artery during
the ventricular contraction

Ð weak or thready (lacks fullness)

Ð Full, bounding (volume higher than normal)

Ð Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+

Absent Weak NORMAL Full Bounding

Factors Affecting Pulse Rate

• Age.
• As age increases, the pulse rate gradually decreases.
• Sex.
• After puberty, the average male’s pulse rate is slightly lower than the female’s.
 • Exercise.
• Fever.
• Medications.
• Hemorrhage
• Stress

Normal Heart Rate

Age Heart Rate (Beats/min)

Infants 120-160

Toddlers 90-140

Preschoolers 80-110

School agers 75-100

Adolescent 60-90

Adult 60-100

Stethoscope

Ð Diaphragm – high pitched sounds, bowel, lung & heart sounds – tight seal

Ð Bell – low pitched sounds, heart & vascular sounds, apply bell lightly (hint think
of Bell with the “L” for Low)

Assessing Pulse
• Pulse Characteristics
– Rate
– Rhythm
– Quality
• Sites
• Equipment
• Methods
Reasons for Using Specific Pulse Sites Pulse Characteristics
– Rate

Pulse Site Reasons for Use

Radial Readily accessible

Temporal Used when radial pulse is not accessible

Carotid Used for infants

Used in cases of cardiac arrest
Used to determine circulation to the brain

Apical Routinely used for infants and children up to 3 yrs

Used to determine discrepancies with radial pulse
Used in conjunction with some medications

Brachial Used to measure BP

Used during cardiac arrest for infants

Femoral Used in cases of cardiac arrest

Used for infants and children
Used to determine circulation to a leg

Popliteal Used to determine circulation to the lower leg

Posterior tibial Used to determine circulation to the foot

Pedal Used to determine circulation to the foot

Older Adult considerations: the older artery may feel more rigid, hard and bent.
RESPIRATION

o Assess by observing rate, rhythm & dept

o Inspiration – inhalation (breathing in)
o Expiration – exhalation (breathing out)
§ I&E is automatic & controlled by the
medulla oblongata (respiratory center
of brain)
§ Normal breathing is active & passive
§ Women breathe thoracically, while
men & young children breathe
diaphramatically
§ Asses after taking pulse, while still holding
hand, so pt is unaware you are counting
respirations

Rate # of breathing cycles/minute (inhale/exhale-1cycle)

N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing

Abnormal increase – tachypnea

Abnormal decrease – bradypnea

Absence of breathing – apnea

Depth Amt. of air inhaled/exhaled

normal (deep & even movements of chest)

shallow (rise & fall of chest is minimal)

SOB shortness of breath (shallow & rapid)

Rhythm Regularity of inhalation/exhalation

Normal (very little variation in length of pauses b/w I&E

 Character Digressions from normal effortless breathing

Dyspnea – difficult or labored breathing

Cheyne-Stokes – alternating periods of apnea and hyperventilation, gradual increase &

decrease in rate & depth of resp. with period of apnea at the end of each cycle.

Hyperventilation or hypoventilation
Volume

Factors affecting Respirations

§ Age
§ Medications

§ Stress

§ Exercise

§ Altitude

§ Gender

§ Body Position

§ Fever

BLOOD PRESSURE

Ø Force exerted by the blood against vessel

walls. Pressure of blood within the arteries
of the body – lt. ventricle contracts– blood is
forced out into the aorta to the large arteries,
smaller arteries & capillaries.

Ø Measured in mmHg – millimeters of mercury

Ø Systolic- force exerted against the arterial

wall as lt. ventricle contracts & pumps blood
into the aorta – max. pressure exerted on
vessel wall.

Ø Diastolic – arterial pressure during

ventricular relaxation, when the heart is filling, minimum pressure in arteries.

Pulse Pressure
-difference between systolic and diastolic pressures
 Important diagnostic indicator in such conditions as increase ICP, HPN and shock

Hypotension
- abnormally low BP (below 95/60 mm Hg)
- Can result from MI, w/c dec. cardiac output or from any condition that reduces the client’s total
blood volume

Hypertension
- persistently elevated blood pressure (above 140/90 mm Hg)
- occurs when blood exerts excessive pressure against arterial walls

Orthostatic Hypotension
– drop in systolic pressure of at least 25 mm Hg or a drop in diastolic pressure of at least 10
mm Hg

Factors affecting B/P

• cardiac output
• Circulating blood Volume
• Peripheral vascular resistance
• Viscosity
• Elasticity of vessel walls

Non invasive method of B/P measurement

3 types of sphygmomanometers

1. Aneroid – glass enclosed circular gauge with needle that registers the B/P as it descends the
calibrations on the dial.

2. Mercury – mercury in glass tube - more reliable – read at eye level.

3. Electronic – cuff with built in pressure transducer reads systolic & diastolic B/P

• Cuff – inflatable rubber bladder, tube connects to the manometer, another to the bulb,
important to have correct cuff size (judge by circumference of the arm not age)

É Support arm at heart level, palm turned upward - above heart causes false low reading

§ Cuff too wide – false low reading

 § Cuff too narrow – false high reading

§ Cuff too loose – false high reading

— Do not take B/P in

Ò Arm with cast

Ò Arm with arteriovenous (AV) fistula
Ò Arm on the side of a mastectomy

Identifying the Korotkoff Sounds– series of sounds created as blood flows through an artery after it has
been occluded with a cuff then cuff pressure is gradually released.
Measuring Blood Pressure
Oxygen Saturation (Pulse Oximetry)

v Non-invasive measurement of oxygen saturation

v Calculates SpO2 (pulse oxygen saturation) reliable estimate of

arterial oxygen saturation

§ Probes – finger, ear, nose, toe

§ Patient with PVD or Raynauds syndrome – difficult

to obtain.

§ Normal – 90-100%

§ Remove nail polish

§ Wait until oximeter readout reaches constant value & pulse display reaches full
strength

§ During continuous pulse oximetry monitoring – inspect skin under the probe
routinely for skin integrity – rotate probe.

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

Preparing the client

The client should be in a comfortable sitting then explain that vital signs will be taken.

Equipment

ü Thermometer
ü Protective disposable covers for the type of
thermometer used
ü Aneroid or mercury sphygmomanometer
ü stetoscope
ü watch with second hand

1. Observe physical development, body build, and fat distribution.

2. Observe gender and sexual development. male characteristics.
3. Compare client’s stated age with her apparent age and developmental stage
4. Observe posture and gait
5. Measure body temperature
6. Measure pulse rate
7. Measure respiration
8. Measure blood pressure
 9. Assess pain

The FIFTH VITAL SIGN: PAIN

Pain – an unpleasant sensory and emotional experience which we
primarily associate with tissue damage or describe in terms of such
damage.
- It is whatever the patient says it is
- It exists whenever the patient says it does
- Subjective

Pathophysiology pain
The pathophysiologic phenomenon of pain is summarized by the processes of Transduction,
Transmission, perception and modulation
The source of pain stimulates peripheral nerve endings (nociceptors) which transmit the
sensations to the central nervous system (CNS). They are the sensory receptors that detect the
signal from the damaged tissue and chemicals released from the damaged tisuue.
Physiologic responses to Pain
o Anxiety, fear. Hopelessness, sleeplessness, thought of suicide
o Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
o Decrease in cognitive function, mental confusion, altered temperament, high
somatization and dilated pupils
o Increased heart rate; peripheral, systemic, and coronary vascular resistance; increased blood
pressure
o Increased respiratory rate and sputum retention, resulting in infection and atelectasis
o Decreased gastric and intestinal motility
o Decreased urinary output, resulting in urinary retention,
o fluid overload, depression of all immune responses
o Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons;
decreased insulin, testosterone
o Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism
o Muscle spasm, resulting in impaired muscle function and
o immobility, perspiration
Classification of pain
1. Nociceptive- represent the normal res[once to noxious insult or injury of tissues such as
skin, muscles, visceral organs, joints, tendons or bones.
2. Neuropathic pain- pain initiated or caused by a primary lesion or disease in the
somatosensory nervous system.
3. Inflammatory- a result of activation and sensitization of the nociceptive pain pathways by
a variety of medications released at a site of tissue inflammation.

Duration and Etiology

• Acute pain- usually associated with recent injury
• Chronic nonmalignant pain- usually associated with specific cause or injury and
described as a constant pain that persists for more than 6months.
• Cancer pain- often due to the compression of peripheral nerves or meninges or
from the damage of these structures following surgery, chemotherapy, radiation
or tumor growth and infiltration
• Intractable pain- defined by its high resistance to pain relief

Pain Location Classifications

Ø Cutaneous pain- skin or subcutaneous tissue
Ø Visceral tissue- abdominal cavity, thorax, cranium
Ø Deep somatic pain- ligaments, tendons, bones blood vessel and nerves
Ø Radiating pain-
Ø Referred pain
Ø Phantom pain
The Seven Dimensions of Pain
1. Physical Dimension- refers to the physiologic effect
- Includes the patient’s perception of the pain and the body’s reaction to the
stimulus.
2. Sensory Dimension- concerns the quality of pain and how severe the pain is perceived to
be. Locations, intensity and quality.
3. Behavioral Dimensions- verbal and nonverbal
4. Sociocultural Dimension- social and cultural backgrounds on the experience of pain
5. Cognitive Dimension- belief, thoughts, intention and motivations
6. Affective Dimension- feelings and emotion that results in pain
7. Spiritual Dimension- ultimate meaning and purpose attributed to pain
Collecting Subjective Data:
Pain assessment includes:
§ Location
§ Intensity
§ Quality
§ Pattern
§ Precipitating factors
§ Pain relief

To assess pain in the cognitively Impaired older adult, observe the behavior that may
indicate pain;
ü Facial expression ( frowning, grimacing )
ü Vocalization (crying, groaning )
ü Change body language(rocking guarding )
ü Behavioral change( refusing to eat )
ü Physiologic change(increase bp or heart rate)
ü Physical change( skin tears)

QUESTT Principle For Pain In Children

Q- question the child
U-Use pain rating scales
E-valuate bhavior and physiologic needs
S- Secure parents involvement
T- take cause of pain into account
T- ake action and evaluate results

HIERARCHY OF PAIN ASSESSMENT TECHNIQUES

ü Use if the client may be unable to self report pain includes unconscious
clients, intubated, elders with dementia, infants, nonverbal person
1. Self report- always try to get a self report , but note if unable and go on
to the other items.
2. Search for potential causes of pain
3. Observe for patients behavior
 4. Surrogate reporting (family members, parents, caregivers) of pain
5. Attempt an analgesic trial-

PAIN ASSESSMENT TOOL

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

1. Observe posture
2. Observe facial expression
3. Inspect joints and muscles
4. Observe skin for scars, lesions, rashes, changes or discoloration
5. Measure heart rate
6. Measure respiratory rate
7. Measure blood pressure
MODULE 5
SKIN, HAIR, NAILS
SKIN:

- Physical barrier, protects underlying tissues and structures from microorganisms,

physical trauma, radiation, dehydration.
- Temperature maintenance, fluid & electrolyte balance, absorption, excretion,
sensation, immunity and vitamin D synthesis.
- Identity to a person’s appearance.

PHYSICAL ASSESSMENT OF THE SKIN:

INSPECTION

1. Inspect general skin coloration.

*The older client’s skin becomes pale due to decreased melanin production and
decreased dermal vascularity.

*Note any odors emanating from the skin.

- a strong odor of perspiration/foul odor may indicate disorder of sweat glands, poor
hygiene may need health teaching or assistance with ADL.

ABNORMAL FINDINGS:

• PALLOR – (loss of color)

- Seen in arterial insufficiency, decreased blood supply and anemia.
- Pallid tones vary from pale to ashen without underlying pink.
• CYANOSIS – cause white skin to appear blue-tinged, especially in the perioral,
nailbed, and conjunctival areas.
Ø Central cyanosis – cardiopulmonary problem, decreased arterial oxygen
saturation, generalized, affected part is WARM

e.g., mucous membranes of the lips, tongue (oral mucosa)

Ø Peripheral cyanosis – when the hands, fingrtips, or feet turn blue, local problem
resulting from vasoconstriction or decreased blood flow (tight jewelry, cold
temp), localized, affected part is COLD, disappears upon application of
warmth.
• JAUNDICE – characterized by yellow skin tones especially in the sclera, oral mucosa,
palms, and soles.
• ACANTHOSIS NIGRICANS - roughening and darkening of skin in localized areas,
especially in the posterior neck.
2. Inspect for color variations.

Freckles – flat, small macules of pigment caused by sun exposure.

Vitiligo – discolored patches when the skin loses its pigment cells
(melanocytes). Maybe related to dysfunction of the immune system.

Striae – stretchmarks

Seborrheic keratosis, warty/crusty pigmented lesion.

Scar – area of fibrous tissue that replaces normal skin after an injury.

Mole – also called nevus. A flat or raised tan/brownish marking up to 6mm wide.

Cutaneous tags - raised yellow papules with a depressed center.

Cutaneous horn – made up of compact keratin that resembles an animal horn.

ABNORMAL FINDINGS:

RASHES – itchy, swollen/red, painful, irritated skin.

BUTTERFLY RASH across the bridge of the nose and cheeks – discoid lupus
erythematosus.

ALBINISM – a generalized loss of pigmentation

ERYTHEMA – skin redness and warmth, seen in inflammation, allergic reactions, trauma.
Maybe difficult to see in dark-skinned client but the affected skin feels swollen and
warmer.
3. Check skin integrity for any skin breakdown especially in the pressure points.
Skin breakdown – initially reddened area that may progress to serious painful
pressure ulcers.

4. Inspect for lesions. Look for abnormalities. Note color, shape, size of lesion.
Lesions –wound, injury, abrasion, ulcer. May indicate local or systemic problems.
Normal lesions maybe moles, freckles, birthmarks.

• Fungus – shine a Wood’s light (a UV light filtered with special glass) on the lesion.
Normal – lesion does not fluoresce.

Abnormal – blue-green fluorescence indicates fungal infection.

PALPATION

1. Palpate skin to assess texture.

Hypothyroidism – rough, flaky, dry skin.
Obese – often reports dry, itchy skin.
2. Palpate to assess thickness.
Very thin skin – maybe seen in clients with arterial insufficiency, or in those on steroid
therapy.
3. Palpate to assess moisture.
Diaphoresis (profuse sweating) – fever, hyperthyroidism.
Decreased moisture - dehydration, hypothyroidism.
Clammy skin – typical in shock, hypotension.

4. Palpate to assess temperature.

Cold skin – shock, hypotension
Very warm skin – febrile state, hyperthyroidism

5. Palpate to assess mobility and turgor. Ask client to lie

down, gently pinch the skin on the sternum or under
the clavicle.

Mobility – refers to how easily the skin can be pinched.

Turgor – refers to how quickly the skin returns to its

original shape after being pinched.

Decreased mobility – seen with edema.

Decreased turgor – is seen in dehydration.

6. Palpate to detect edema. Use your thumbs to press down on the skin of the feet or
ankles to check for swelling.

TESTING FOR EDEMA:

PITTING VS NON-PITTING EDEMA

PITTING – pressing the affected area displaces fluid,

leaving a finger shaped depression (pit) that
disappears within seconds.

Ex. CHF, kidney Damage, Cirrhosis

NON-PITTING – not compressible, caused by chronic

lymphedema (lymphatic obstruction) or
myxedema( (advanced hypothyroidism)

Ex. Elephantiasis,hypothyroisidm

SCALP AND HAIR:

Inspection and Palpation

1. Remove hairclip, pins, or wigs. – Inspect for general color and condition.
2. At 1-inch intervals separate the hair from the scalp and inspect and palpate for:

• Cleanliness
• Dryness, dandruff
• Oiliness
• Parasites (lice, nites)
• Lesions
• Injuries
Normal Findings:

Skull:

• Generally round, with prominences in the frontal and occipital area.

(normocephalic).
• No tenderness noted upon palpation.
Scalp:

• Lighter in color than the complexion.

• Can be moist and oily.
• No scars noted.
• Free from lice, nits, and dandruff.
• No lesions should be noted.
• No tenderness or masses on palpation.
Hair:

• Can be black, brown, or burgundy depending on the race.

• Evenly distributed covers the whole scalp.
• No evidence of alopecia.
• Maybe thick or thin, coarse, or smooth.
• Neither brittle nor dry.

*Wear gloves.

Abnormal Findings:

Excessive scaliness – dermatitis

Raised lesions – infections or tumor growth.

Dull, dry hair – maybe in hypothyroidism and malnutrition

Poor Hygiene – a need for client teaching or assistance with ADL.

Pustules with hair loss in patches – seen in tinea capitis (contagious fungal disease/scalp
ringworm).

Folliculitis – appear as pustules surrounded by erythema.

3. Inspect amount and distribution of scalp, body, axillae, and pubic hair.
Generalized hair loss –
• infection,
• nutritional deficiencies,
• hormonal disorder,
• thyroid disease
• liver disease,
• drug toxicity
• hepatic failure
 • renal failure

Patchy hair loss – scalp infection, discoid or systemic lupus erythematosus,

chemotherapy.

Hirsutism (Facial hair on females) – imbalance of adrenal hormones, steroid side effects,
Cushing’s disease.

INFANT HEAD FINDINGS:

1. MOLDING- Bones overlap due to

passing through the birth canal

2. CEPHALHEMATOMA- collection of
blood under the scalp due to trauma

3. DEPRESSED FONTANELS- Due to dehydration

 4. BULGING FONTANELS- May indicate increase in
intracranial pressure

NAILS:

INSPECT

1. Inspect nail grooming and cleanliness.

Poor hygiene – dirty, broken, or jagged fingernails, or from hobby or occupation.
2. Inspect nail color and markings.
§ Pale or cyanotic – hypoxia, or anemia

§ Splinter hemorrhages – trauma

§ Beau’s lines – (indentations or ridges across the nail plate) occur after acute illness
and eventually grow out.
§ Yellow discoloration – seen in fungal infections or psoriasis.

3. Inspect shape of nails.

§ Early clubbing (180-

degree angle with
spongy sensation) -
hypoxia
§ Late clubbing (>180
degrees angle) – hypoxia
§ Spoon nails (concave) – Iron deficiency anemia

PALPATE

1. Palpate nail to assess texture.

Thickened nails – especially toenails – decreased
circulation. Dark skinned may have thicker nails.
2. Palpate to assess texture and consistency, noting whether nailplate is attached to
nailbed.
Paronychia (inflammation) – local infection
Onycholysis (detachment of nailplate from nailbed – infections and trauma.
3. Test capillary refill in nailbeds by pressing the nail tip briefly and watching for color
change.
Greater than 2 seconds – respiratory or cardiovascular diseases that causes hypoxia.

OLDER CLIENT’S CONSIDERATIONS:

SKIN (OLDER CLIENT):

1. Older clients become pale due to decreased melanin production and

decreased dermal vascularity.
2. They may have skin lesions due to aging.
3. Their skin may feel dryer due to decreased sebum production.
4. Their skin loses its turgor because of decrease in elasticity and collagen fibers.
5. Sagging and wrinkled skin appears in the facial, breast and scrotal area.

HAIR (OLDER CLIENT):

1. Older clients have thinner hair due to decrease in hair follicles. This includes
pubic, axilla and body hair.
2. Alopecia is seen esp in men. Hair loss occurs from the periphery of the scalp and
moves to the center.
3. Elderly women may have terminal hair growth on the chin due to hormonal
changes.

NAILS (OLDER CLIENT):

1. Nails may appear thickened, yellow, and brittle because of decreased

circulation in the extremities.
Refer to book UNIT 3 SKIN, HAIR, NAILS

Abnormal Findings: Identification of Pressure Ulcer Stage

Abnormal Findings: Primary Skin Lesions

Abnormal Findings: Secondary Skin Lesions

Abnormal Findings: Vascular Skin Lesions

Abnormal Findings: Skin Cancer

Abnormal Findings: Configuration of Skin Lesions

Abnormal Findings: Common Nail Disorder

FACE:

• Observe the face for shape.

• Inspect for symmetry.
- Inspect for the palpebral fissure (distance between the eyelids); should be
equal in both eyes.
- Ask the patient to smile, there should be bilateral nasolabial fold (creases
extending from the angle of the corner of the mouth). Slight asymmetry in the
fold is normal.
- If both are met, then the face is symmetrical.
• Test the functioning of the cranial nerves that innervates the facial structures.
Cranial Nerve V (trigeminal)

1. Sensory Function
- Ask the client to close the eyes.
- Run cotton wisp over the forehead, cheek, and jaw on both sides of the
face.
- Ask the client if he/she feel it, and where she feels it.
- Check for the corneal reflex using cotton wisp.
- The normal response is blinking.
2. Motor Function
- Ask the client to chew or clench the jaw.
- The client should be able to clench or chew with strength and force.
Cranial Nerve VII (Facial)

1. Sensory Function (This nerve innervates the anterior 2/3 of the tongue).
- Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
- Normally, the client can identify the taste.
2. Motor Function
- Ask the client to smile, frown, raise eyebrow, close eye lids, whistle, or puff the
cheeks.
Normal Findings:
- Shape maybe oval or rounded.
 - Face is symmetrical.
- No involuntary muscle movements.
- Can move facial muscles at will.
- Intact cranial nerve V and VII.

EYEBROWS, EYES, AND EYELASHES

• All the structures are assessed using the modality of inspection.

Normal Findings

Eyebrows

- Symmetrical and in line with each other.

- Maybe black, brown, or blonde depending on race.
- Evenly distributed.
Eyes

- Evenly placed and in line with each other.

- Non protruding.
- Equal palpebral fissure.
Eyelashes

- Color dependent on race.

- Evenly distributed.
- Turned outward.

EYELIDS AND LACRIMAL APPARATUS

• Inspect the eyelids for position and symmetry.

• Palpate the eyelids for the lacrimal glands.
- To examine the lacrimal gland, the examiner, lightly slide the pad of the index
finger against the client’s upper orbital rim.
- Inquire for any pain or tenderness.
• Palpate for the nasolacrimal duct to check for obstruction.
- To assess the nasolacrimal duct, the examiner presses with the index finger
against the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST
THE NOSE.
- In the presence of blockage, this will cause regurgitation of fluid in the
puncta.

Normal Findings:

Eyelids
• Upper eyelids cover the small portion of the iris, cornea and sclera when eyes
are open.
• No ptosis noted (drooping of upper eyelids).
• Meets completely when eyes are closed.
 • Symmetrical.

Lacrimal Apparatus

• Lacrimal gland is normally non palpable.

• No tenderness on palpation.
• No regurgitation from the nasolacrimal duct.

Conjunctivae

• The bulbar and palpebral conjunctivae are examined by separating the eyelids
widely and having the client look up, down and each side. When separating the
lids, the examiner should exert NO PRESSURE against the eyeball; rather the
examiner should hold the lids against the ridges of the bony orbit surrounding the
eye.
Normal Findings:

• Both conjunctivae are pinkish or red in color.

• With presence of many minute capillaries.
• Moist.
• No ulcers.
• No foreign objects.

Sclerae

• The sclerae is easily inspected during the assessment of the conjunctivae.

Normal Findings:

• Sclerae is white in color (anicteric sclera)

• No yellowish discoloration (icteric sclera)
• Some capillaries maybe visible.
• Some people may have pigmented positions.
Cornea

•The cornea is best inspected by directing penlight obliquely from several

positions.
Normal Findings:

• There should be no irregularities on the surface.

• Looks smooth.
• The cornea is clear or transparent. The features of the iris should be fully visible
through the cornea.
• There is a positive corneal reflex.

Anterior Chamber and Iris

 • The anterior chamber and the iris are easily inspected in conjunction with the
cornea. The technique of oblique illumination is also useful in assessing the
anterior chamber.
Normal Findings:

• The anterior chamber is transparent.

• No noted any visible materials.
• Color of the iris depends on the person’s race (black, blue, brown, or green).
• From the side view, the iris should appear flat and should not be bulging forward.
There should be NO crescent shadow casted on the other side when illuminated
from one side.
Pupils

• Examination of the pupils involves several inspections, including assessment of

the size, shape, reaction to light is directed and is observed for direct response of
constriction. Simultaneously, the other eye is observed for consensual response of
constriction.
• The test for papillary accommodation is the examination for the change in
papillary size as it is switched from a distant to a near object.
• Ask the client to stare at the objects across the room.
• Then ask the client to fix his gaze on the examiner’s index fingers, which is placed
5 – 5 inches from the client’s nose.
• Visualization of the distant objects normally causes papillary dilation and
visualization of nearer objects causes papillary constriction and convergence of
the eye.
Normal Findings:

• Pupillary size ranges from 3 – 7mm, and are equal in size.

• Equally round.
• Constrict briskly/sluggishly when light is directed to the eye, both directly and
consensual.
• Pupils dilate when looking at distant objects.
• Pupils constrict when looking at nearer objects.
• If all of which are met, we document the findings using the notation PERRLA,
pupils equally round, reactive to light, and accommodate.

SNELLE N CHART

Cranial Nerve II (Optic Nerve)

• The optic nerve is assessed by testing for visual acuity and peripheral vision.
• Visual acuity is tested using a Snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the letter E
faces in different directions, maybe used.
 • The chart has a standardized number at the end of each line of letters, these
numbers indicates the degree of visual acuity when measured at a distance of
20 feet.
• The numerator 20 is the distance in feet between the chart and the client, or the
standard testing distance. The denominator 20 is the distance from which the
normal eye can read the lettering, which correspond to the number at the end
of each letter line; therefore the larger the denominator the poorer the vision.
• Measurement of 20/20 vision is an indication of either refractive error or some
other optic disorder.
• In testing for visual acuity you may refer to the following:
- The room used for this test should be well lighted.
- A person who wears corrective lenses should be tested with and without
them to check for the adequacy of correction.
- Only one eye should be tested at a time, the other eye should be covered by
an opaque card or eye cover, not with client’s finger.
- Make the client read the chart by pointing at a letter randomly at each line;
maybe started from largest to smallest or vice versa.
- A person who can read the largest letter on the chart (20/200) should be
checked if they can perceive hand movement about 12 inches from their
eyes, or if they perceive the light of the penlight directed to their eyes

Peripheral Vision or Visual Fields

- The assessment of visual acuity is indicative of the functioning of the macular

area, the area of central vision. However, it does not test the sensitivity of the
other areas of the retina which perceive the more peripheral stimuli. The
visual field confrontation test, provide a rather gross measurement of the
peripheral vision.
- The performance of this test assumes that the examiner has normal visual
fields, since that the client’s visual fields are to be compared with the
examiner’s.

Follow the steps on conducting the test:

- The examiner and the client sit or stand opposite each other, with the eyes at
the same, horizontal level with the distance of 1.5 – 2 feet apart.
- The client covers the eye with opaque card, and the examiner covers the
eye that is opposite to the client’s covered eye.
- Instruct the client to stare directly at the examiner’s eye, while the examiner
stares at the client’s open eye. Neither looks out at the object approaching
from the periphery.
- The examiner hold an object such as pencil or penlight, in his hand and
gradually moves it in from the periphery of both directions horizontally and
from above and below.
 - Normally, the client should see the same time the examiner sees it. The
normal visual field is 180 degrees.

CRANIAL NERVE III, IV, & VI (OCULOMOTOR, TROCHLEAR, ABDUCENS)

- All the 3 cranial nerves are tested at the same time by assessing the Extra
Ocular Movement (EOM) or the six cardinal position of gaze.

Follow the given steps:

- Stand directly in front of the client and hold a finger or a penlight about 1ft
from the client’s eyes.
- Instruct the client to follow the direction the object hold by the examiner by
eye movements only; that is without moving the neck.
- The nurse moves the object in a clockwise direction hexagonally.
- Instruct the client to fix his gaze momentarily on the extreme position in each
of the cardinal gazes
- The examiner should watch for any jerky movements of the eye (nystagmus).
- Normally, the client can hold the position and there should be no nystagmus.
Ears

- Inspect the auricles of the ears for parallelism, size, position, appearance and
skin color.
- Palpate the auricles and the mastoid process for firmness of the cartilage of
the auricles, tenderness, when manipulating the auricles and the mastoid
process.
- Inspect the auditory meatus or the ear canal for color, presence of cerumen,
discharges, and foreign bodies.
- For ADULT, pull the pinna UPWARD and BACKWARD to straighten the canal.
- For CHILDREN, pull the pinna DOWNWARD and BACKWARD to straighten the
canal.
- Perform otoscopic examination of the tympanic membrane, noting the color
and landmarks.

Normal Findings:

- The earlobes are bean shaped, parallel, and symmetrical.

- The upper connection of the ear lobe is parallel with the outer canthus of the
eye.
- Skin is same in color as in the complexion.
- No lesions noted on inspection.
- The auricles has a firm cartilage on palpation.
- The pinna recoils when folded.
- There is no pain or tenderness on the palpation of the auricles and mastoid
process.
- The ear canal has normally some cerumen of inspection.
 - No discharges or lesions noted at the ear canal.
- On otoscopic examination, translucent and pearly gray in color.

NOSE AND PARANASAL SINUSES

• The external portion of the nose is inspected for the following:

- Placement and symmetry.
- Patency of nares (done by occluding nostril one at a time, and noting for
difficulty in breathing).
- Flaring of alae nasi
- Discharge

The external nares are palpated for:

- Displacement of bone and cartilage.

- For tenderness and masses.
- The internal nares are inspected by hyperextending the neck of the client,
the ulnar aspect of the examiners hand over forehead of the client, and
using the thumb to push the tip of the nose upward while shining a light into
the nares.
Inspect for the following:

- Position of the septum.

- Check the septum for perforation. (Can also be checked by directing the
lighted penlight on the side of the nose, illumination at the other side suggests
perforation).
- The nasal mucosa (turbinates) for swelling, exudates, and change in color.

Paranasal Sinuses:

• Examination of the paranasal sinuses is indirect. Information about their condition

is gained by inspection and palpation of the overlying tissues. Only frontal and
maxillary sinuses are accessible for examination.
• By palpating both cheeks simultaneously, one can determine tenderness of the
maxillary sinusitis, and pressing the thumb just below the eyebrows, we can
determine tenderness of the frontal sinuses.

Normal Findings:

- Nose in the midline.

- No discharges.
- No flaring alae nasi.
- Both nares are patent.
- No bone and cartilage deviation noted on palpation.
- No tenderness noted on palpation.
- Nasal septum in the midline and not perforated.
 - The nasal mucosa is pinkish to red in color. (increased redness turbinates are
typical of allergy).
- No tenderness noted on palpation of the paranasal sinuses.

HEAD AND NECK

Head and neck assessment focuses on the cranium, face, thyroid gland, and lymph
node structures contained within the head and neck.

HEAD & FACE

Assessment NORMAL ABNORMAL

INSPECT HEAD Symmetric, round, erect, Acromegaly – the skull and

• Size, shape, and in midline. facial bones are larger
configuration No lesions. and thicker.

Paget’s disease of the

bone - acorn-shaped,
enlarged skull bones.

• Involuntary Still and Upright Tremors – neurologic d/o,

Movement horizontal jerking
movement.

Involuntary nodding –
Aortic insufficiency

Head tilted to one side:

- unilateral vision
- hearing deficiency
- shortening of
sternomastoid
muscle.

PALPATE HEAD Normally hard, smooth, Lesion/ lumps – recent

(WEAR GLOVES) w/o lesions. trauma or cancer.
• Consistency
INSPECT FACE • Symmetric -Asymmetry in front of
• Symmetry, features, • Round earlobes – parotid gland
movement, • Oval enlargement. (abscess or
expression, and skin • Elongated tumor)
condition • Or square
• No abnormal Unusual facial movements
movements – neurologic problem.
 Drooping of one side of
the face – stroke, Bell’s
Palsy.

Mask-like face –
Parkinson’s Disease

Cachexia (emaciation or
wasting) - “sunken” face
with depressed eyes,
hollow cheeks.

Pale, Swollen face –

nephrotic syndrome.

PALPATE TEMPORAL Elastic, non-tender Inflammation - hard, thick,

ARTERY and tender temporal
artery. Can lead to
blindness.

PALPATE THE TMJ. • No swelling, TMJ Syndrome - Limited

• Place index finger tenderness, ROM, swelling, tenderness,
over the front of crepitation w/ crepitation
each ear, ask the mov’t.
client to OPEN
mouth.

THE NECK

INSPECTION
Neck.
Slightly extend, inspect for • Symmetric Swelling, enlarged masses
symmetry, lumps, masses. • Head centered. or nodules:
• w/o bulging masses • Enlarged thyroid
Shine a light from side of gland.
neck – highlight swelling • Inflammation of
lymph nodes
• Tumor

Neck structure. Move upward Asymmetric movement.

Observe the mov’t of the symmetrically as the client
thyroid cartilage/gland as swallows.
the client is asked to
swallow a small sip of
water.

Cervical Vertebrae. C7 – visible and palpable Swelling and prominence

Flex neck of other vertebrae
• Chin to chest
• Ear to shoulder
• Twist L to R
• Twist R to L
• Backward and
forward
ROM Smooth, controlled Muscle spasms,
inflammation, or cervical
arthritis – cause stiffness,
rigidity. Limited mobility
affects ADL.

PALPATION Trachea is midline. The trachea maybe pulled

Trachea. Place finger in to one side – tumor,
sternal notch. enlargement, fibrosis.

Thyroid Gland. Midline Deviate from midline

Locate: because of masses,
Hyoid Bone: ach-shaped abnormal growth.
bone that does not
articulate directly with any
other bone, located high
in anterior neck.
Landmarks deviate from
Thyroid Cartilage: under midline.
the hyoid bone, known as
the “Adam’s apple”

Cricoid Cartilage: smaller

upper tracheal ring under
the thyroid cartilage.

AUSCULTATION
Auscultate the thyroid only No bruits are auscultated. A soft, blowing, swishing
if you noted an sound over thyroid lobes –
enlargement. Ask client to hyperthyroidism.
hold breath (to obscure
any tracheal breath
sound).
LYMPH NODES OF THE HEAD AND NECK

PALPATE: No swelling, enlargement, Abnormal if with swelling,

Preauricular Nodes (in front tenderness, hardness. enlargement, tenderness,
of ears) hardness, immobility.

Postauricular nodes
(behind ears)

Occipital (posterior base of

skull).

Tonsillar Nodes (angel of

the mandible)

Submental nodes – few cm

behind the tip of the
mandible.

Superficial cervical nodes

No enlargement or Enlargement or tenderness
Posterior cervical nodes tenderness present. is abnormal.

Deep cervical chain nodes

Supraclavicular nodes
HEAD AND NECK ABNORMALITIES

1. ACROMEGALY – enlragement of the facial features (nose,

ears) and the hands and feet. Happens when pituitary gland
produces too much growth hormone.

2. MOON-SHAPE – with reddened cheeks and

increased facial hair may indicate Cushing’s
Syndrome.

3. TIGHTENED-HARD FACE – with

thinning facial skin is seen in
scleroderma

4. EXOPTHALMOS – hyperthyroidism, outward

protrusion of the eyes.