Nursing Health Assessment

Akram Mohammad AbuSalah

BNS, MSN, Ph. D.

Islamic University of Gaza Strip

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 Chapter (1)
The Interview

Islamic University of Gaza Strip

 The first assessment begin in (1992) by American
medical association

In (1995) health assessment considered as basic human right

Preventive health care divided in three categories, primary,

secondary and tertiary prevention. Each level of prevention

is based on a thorough assessment of the client's health as
status.
Periodic health assessment needed to be performed by a

physician, or a nurse

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 Objectives of health assessment
Surveillance of health status, identification of occult disease,

screening, and follow-up care

The periodic assessment, at regular intervals

 Increasing client participation in health care

Accurately define the health and risk care needs for individuals

Health assessment is shared with the client in a clearly and

understandable manner
The client must share in decision making for his own care.

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 Types of Assessment
Comprehensive assessment: is usually the initial

assessment it very thorough and includes detailed

health history and physical examination and examine
the client's overall health status
Focused assessment : is problem oriented and may

be the initial assessment or an ongoing assessment

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 Frequency of assessment

The persons under (35) years every (4 – 5) years

 The persons from (35 – 45) every (2 – 3) years.

Persons from (45-55) years of age undergo a

thorough health assessment every year.

Persons over (55) years may needs assessment every

6 months or less

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Importance of nursing health assessment F

1. Systematic and continuous collection of client data

2. It focus on client responses to health problems

3. The nurse carefully examine the client’s body parts to
determine any abnormalities
4. The nurse relies on data from different sources which
can indicate significant clinical problems
5. Health assessment provides a base line used to plan
the clients care
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 6. Health assessment helps the nurse to diagnose
client’s problem & the intervention

7. Complete health assessment involves a more

detailed review of client’s condition

8. Health assessment influence the choice of therapies

& client's responses

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 Purposes of health assessment

1. Gather data

2. Confirm or refuse data obtained in the health history

3. To identify nursing diagnoses

4. To make clinical judgments about client's changing
health status
5.To evaluate bio-psycho-social and spiritual outcomes
of care
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 Nursing and medical diagnosis
There is a big Difference between both because:

 Nursing diagnose is independent role of the nurse

 Nursing diagnoses depends on the client's

problems/response associated with specific disorder
 Any problem in nursing diagnosis must notice from a

holistic view e.g. bio-psycho-social and spiritual

relations

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 Medical diagnoses
 Depends on clinical picture and laboratory findings

 The specialist doctor has a right to diagnose not else

Example:
- DM is medical diagnoses (hypo or hyperglycemia)
- Nursing diagnoses in this case e.g. Impaired skin integrity R/T
poor circulation, Knowledge deficit about the effects of exercise
on needs of insulin.
The difference between medical diagnosis, a collaborative
problem, and nursing diagnosis is explained with the next
table:-
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 Health Assessment
Holistic approach:

1. The interview

2. Psychosocial assessment

3. Nutritional assessment

4. Assessment of sleep-wakefulness patterns

5. The health history.

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 1. Interview

Definition: communication process focuses on the

client's development of psychological, physiological,

sociocultural, and spiritual responses, that can be

treated with nursing & collaborative interventions

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 Major purpose:
To obtain health history and to elicit symptoms and the

time course of their development. The interview

conducted before physical examination is done.

Components of nursing interview

1. Introductory phase
2. Working phase
3. Termination phase
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 1. Introductory phase:

 Introduce yourself and explains the purpose of the

interview to the client.

 Before asking questions, Let client to feel Comfort,

Privacy and Confidentiality

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 Working phase:
The nurse must listen and observe cues in addition to using critical
thinking skills to validate information received from the client.
The nurse identify client's problems and goals.

Termination phase:
1.The nurse summarizes information obtained during the working
phase
2. Validates problems and goals with the client.
3.Making plans to resolve the problems (nursing diagnosis and
collaborative problems are identified and discussed with the

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client)
 Communications techniques during interview
1. Types of questions :
 Begin with open ended questions to assess client's

feelings e.g. what, how, which“

 Use closed ended question to obtain facts e.g." when,
did…etc
 Use list to obtain specific answers e.g. "is pain sever,
dull sharp
 Explore all data that deviate from normal e.g. “increase
or decrease the problem
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 2. Types of statements to be use:
 Repeat your perception of client's response to clarify
information and encourage verbalization
3. Accept the client silence to recognize thoughts
4. Avoid some communication styles e.g.
 Excessive or not enough eye contact.

 Doing other things during getting history.

 Biased or leading questions e.g. "you don't feel bad"
 Relying on memory to recall information

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 5. Specific age variations :-
 Pediatric clients: validate information from parents.

 Geriatric clients: use simple words and assess hearing acuity

6. Emotional variations:
 Be calm with angry clients and simply with anxious and

express interest with depressed client

 Sensitive issues "e.g. sexuality, dying, spirituality" you must

be aware of your own thought regarding these things.

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 7. Cultural variations:
 Be aware of possible cultural variations in the

communication styles of self and clients

8. Use culture broker:

 Use culture broker as middleman if your client not

speak your language.

 Use pictures for non reading clients.

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 Chapter (2)
Psychosocial assessment

Islamic University of Gaza Strip

 Psychosocial assessment

Psychological assessment involves person's growth

and development throughout his life.

Discuss crises with the clients to assess relationship

between health & illness. “It depends on multiple

G&D theories e.g. Erickson, Piaget, and Freud …. etc.

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Stages of Age
 Infancy period: birth to 12 months
Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
 Early childhood Stage: It’s refers to two integrated stages of
development
Toddler: 1 - 3years.
Preschool: 3 - 6 years.
 Middle childhood 6-12 years
 Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
 Young adulthood 20-40 years
 Middle adulthood 40-65years
 Late adulthood 65 and more
 Chapter (3)
Nutritional assessment

Islamic University of Gaza Strip

 Nutritional assessment

Nutrition plays a major role in the way an

individual looks, feels,& behaves.

The body ability to fight disease greatly

depends on the individual's nutritional status

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 Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.

Components of Nutritional Assessment

1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis
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 1. Anthropometric measurement
Measurement of size, weight, and proportions of human body.

Measurement includes: height, weight, skin fold thickness,

and circumference of various body parts, including the head,

chest, and arm.
Assess body mass index (BMI) to shows a direct and continuous
relationship to morbidity and mortality in studies of large
populations. High ratios of waist to hip circumference are
associated with higher risk for illness & decreased life span.

BMI = (Wt. in kilograms) = 60 = 60 = 23.4

(High in meters) 2 (1.6)2 2.56
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BMI RANGE
Rang kg/m2 Condition
less than 16.0 Very thin
16.0 - 18.4 Thin
18.5- 24.9 Average
25–29.9 Overweight
30-34.9 Obese
≥ 35 Highly obese
2. Biochemical Measurement
Useful in indicating malnutrition or the development of

diseases as a result of over consumption of nutrients. Serum

and urine are commonly used for biochemical assessment.
In assessment of malnutrition, commonly tests include: total

lymphocyte count, albumin, serum transferrin, hemoglobin,

and hematocrit …etc. These values taken with
anthropometric measurements, give a good overall picture
of an individual's skeletal and visceral protein status as well
as fat reserves and immunologic response.
3. Clinical examination
Involves, close physical evaluation and may

reveal signs suggesting malnutrition or over

consumption of nutrients.
Although examination alone doesn't permit
definitive diagnosis of nutritional problem, it
should not be overlooked in nutritional assessment

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Nutritional assessment technique for clinical examination

A. Types of information needed

 Diet: Describe the type: regular or not, special,

"e.g. teeth problem, sensitive mouth.

 Usual mealtimes: How many meals a day:

when? Which are heavy meals?

 Appetite: "Good, fair, poor, too good".

 Weight: stable? How has it changed?

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 Food preferences: e.g." prefers beef to other meats"

 Food dislike: What & Why? Culture related?

 Usual eating places: Home, snack shops, restaurants.

 Ability to eat: describe inabilities, dental problems: "ill

fitting dentures, difficulties with chewing or swallowing

 Elimination" urine & stool: nature, frequency problems

 Exercise & physical activity: how extensive or deficient

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Psycho social - cultural factors: Review any thing which can

affect on proper nutrition

Taking Medications which affect the eating habits

Laboratory determinations e.g.: “Hemoglobin, protein,

albumin, cholesterol, urinalyses"
Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and
determine the nutritional diagnosis and nutritional plan of
care.
Imbalanced nutrition: Less than body requirements, related
to lack of knowledge and inadequate food intake
Risk for infection, related to protein-calorie malnutrition
 B. Signs & symptoms of malnutrition
Dry and thin hair
Yellowish lump around eye, white rings around both
eyes, and pale conjunctiva
Redness and swelling of lips especially corners of mouth
Teeth caries & abnormal missing of it
Dryness of skin (xerosis): sandpaper feels of skin
Spoon shaped Nails " Koilonychia “ anemia
Tachycardia, elevated blood pressure due to excessive
sodium intake and excessive cholesterol, fat, or caloric
intake
Muscle weakness and growth retardation

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 4. Dietary analysis
Food represent cultural and ethnic background and socio-
economic status and have many emotional and
psychological meaning
Assessment includes usual foods consumed & habits of

food
The nurse ask the client to recall every thing consumed
within the past 24 hour including all foods, fluid, vitamins,
minerals or other supplements to identify the optimal meals
 Should not bias the client's response to question based on
the interviewer's personal habits or knowledge of
recommended food consumption
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 Diseases affected by nutritional problems

1- Obesity: excess of body fat.

2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.

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 Chapter (4)
Sleep-wakefulness patterns

Islamic University of Gaza Strip

 Assessment of sleep-wakefulness patterns
Normal human has “homeostasis” (ability to
maintain a relative internal constancy)
Any person may complain of sleep-pattern
disturbance as a primary problem or secondary
due to another condition
1/4 of clients who seek health care complain of a

difficulty related to sleep

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Factors affecting length and quality of sleep

1. Anxiety related to the need for meeting a tasks, such as

waking at an early hour for work.
2. The promise of pleasurable activity such as starting a
vacation.
3. The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as diseases
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 Good sleep depends on the number of awakenings and

the total number of sleeping hours

The nurse can assess sleep pattern by doing interview

with the client or using special charts or by EEG

Disorders related to sleep

1.Sleep disturbances affects family life, employment, and
general social adjustment

2. Feelings of fatigue, irritability and difficulty in concentrating

3. Difficulty in maintaining orientation

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4. Illusions, hallucination (visual & tactile )
5. Decreased psychomotor ability with decreased incentive to
work

6. Mild Nystagmus

7. Tremor of hands

Increase in gluco-corticoid and adrenergic hormone secretion

9. Increase anxiety with sense of tiredness

10. Insomnia "short end sleeping periods“

11. Sleep apnea "periodic cessation of breathing that occurs

during sleep
 12. Hypersomnia: "sleeping for excessive periods” the
sleep period may be extended to 16-18 hours a day
13. Peri-hypersomnia. "Condition that is described as an
increased used for sleep "18-20 hours a day" lasts for
only few days
14. Narcolepsy "excessive day time drowsiness or
uncontrolled onset of sleep.
15. Cataplexy: abrupt weakness or paralysis of voluntary
muscles e.g. arms, legs & face last from half second to
10 minutes, one or twice a year
16. Hypnagogic hallucinations: " Disturbing or
frightening dream that occur as client is a falling a
sleep
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 Assessment of sleep habits
Let the client record the times of going to sleep and
awakening periods, including naps.
Allow client to described their sleep habits in their own words

You can ask the following questions:

How have you been sleeping?‖
Can you tell me about your sleeping habits?"
Are you getting enough rest?"
Tell me about your sleep problem"
Good History includes: a general sleep history,
psychological history, and a drug history
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 Chapter (5)
Nursing Health History

Islamic University of Gaza Strip

Definition of Health History

Systematic collection of subjective

data which stated by the client,
and objective data which observed
by the nurse
That using to determine a client
functional health pattern status.

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Phases of taking health history

Two phases:-

The interview phase which elicits the

information (primary sources)

The recording phase (secondary sources).

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Guidelines for Taking Nursing History

Private, comfortable, and quiet

environment.

Allow the client to state problems and

expectations for the interview.
Orient the client the structure, purposes,
and expectations of the history.

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Guidelines for Taking Nursing History cont..

Communicate and negotiate priorities

with the client

Listen more than talk.

Observe non verbal communications e.g.

"body language, voice tone, and
appearance".

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 Guidelines for Taking Nursing History cont..

Review information about past health history

before starting interview.
Balance between allowing a client to talk in an
unstructured manner and the need to structure
requested information.
Clarify the client's definitions (terms &
descriptors)
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Guidelines for Taking Nursing History cont..

Avoid yes or no question (when detailed

information is desired).
Write adequate notes for recording?
Record nursing health history soon after
interview.

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 Types of Nursing Health History

Complete health history: taken on initial visits

to health care facilities.
Interval health history: collect information in
visits following the initial data base is collected.
Problem- focused health history: collect data
about a specific problem

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 Components of Health History
1-Biographical Data: This includes
Full name
Address and telephone numbers (client's permanent
contact of client)
Birth date and birth place.
Sex
Religion and race.
Marital status.
Social security number.
Occupation (usual and present)
Source of referral.
Usual source of healthcare
Source and reliability of information.
Date of interview.
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 2- Chief Complaint: “Reason For Hospitalization

Examples of chief complaints:

Chest pain for 3 days.

Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Pap smear needed.
Physical examination needed for camp.
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SYMPTOM ANALYSIS
P Q R S T
a. Provocative or Palliative
First occurrence :
 What were you doing when you first experienced or
noticed the symptom?
 What to trigger it ? stress? Position?, activity?
 What seems to cause it or make it worse? For a
psychological symptom .
 What relieves the symptom : change diet? Change
position ? Take medication ? Being active?
Aggravation: what makes the symptom worse?
SYMPTOM ANALYSIS

P Q R S T
b. Quality Or Quantity
QUALITY:

 How would you describe the symptom- how it feels, looks, or

sounds?
QUANTITY:

 How much are you experiencing now?

 Is it so much that it prevents you from performing any activity?

SYMPTOM ANALYSIS
P Q R S T
C. Region Or Radiation

Region :
 Where does the symptom occur?

Radiation :
 Does it travel down your back or arm, up your neck or
down your legs?
SYMPTOM ANALYSIS
P Q R S T

d. Severity scale
Severity
 How bad is symptom at its worst?

Course
 Does the symptom seem to be getting better, getting

worse?
SYMPTOM ANALYSIS
P Q R S T
e. Timing
Onset :
 On what date did the symptom first occur
Type of onset :
 How did the symptom start sudden? Gradually?
Frequency :
 How often do you experience the symptom ; hourly ? Daily ?
Weekly? monthly
Duration :
 How long does an episode of the symptom last
 3-History of present illness

Gathering information relevant to the

chief complaint, and the client's
problem, including essential and
relevant data, and self medical

treatment.
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 Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date, gradual
or sudden, duration, frequency, location, quality,
and alleviating or aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".

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 4- Past Health History:
The purpose: (to identify all major past
health problems of the client)
This includes:
Childhood illness e.g. history of rheumatic
fever.
History of accidents and disabling injuries
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 Past Health History. Cont…

History of hospitalization (time of

admission, date, admitting complaint,
discharge diagnosis and follow up care.
History of operations "how and why this
done"
History of immunizations and allergies.
Physical examinations and diagnostic
tests.

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 5-Family History

The purpose: to learn about the general health of

the client's blood relatives, spouse, and
children and to identify any illness of
environmental genetic, or familiar nature that
might have implications for the client's health
problems.
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 Family History. Cont…

Family history of communicable diseases.

Heredity factors associated with causes of some diseases.

Strong family history of certain problems.

Health of family members "maternal, parents, siblings,

aunts, uncles…etc.".

Cause of death of the family members "immediate and

extended family".

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 6-Environmental History:
Purpose
“To gather information about surroundings
of the client", including physical,
psychological, social environment, and
presence of hazards, pollutants and safety
measures."

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 7- Current Health Information
The purpose is to record major current health related
information.

Allergies: environmental, ingestion, drug, other.

Habits "alcohol, tobacco, drug, caffeine"

Medications taken regularly "by doctor or self prescription

Exercise patterns.

Sleep patterns (daily routine).

The pattern life (sedentary or active)

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 8- Psychosocial History:

Includes:
How client and his family cope with
disease or stress, and how they responses
to illness and health.
You can assess if there is psychological or
social problem and if it affects general
health of the client.

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 9- Review of Systems (ROS)

Collection of data about the past and the

present of each of the client systems.
(Review of the client’s physical, sociologic,
and psychological health status may identify
hidden problems and provides an opportunity
to indicate client strength and disabilities
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Physical Systems
Which includes assessment of:-
General review of skin, hair, head, face, eyes, ears,
nose, sinuses, mouth, throat, neck nodes and breasts.
Assessment of respiratory and cardiovascular system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal system.
Assessment of endocrine system.
Assessment of heamatoboitic system.
Assessment of social system.
Assessment of psychological system.
 10- Nutritional Health History

“Discussed Before”

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 11- Assessment of Interpersonal Factors.
This includes :-
Ethnic and cultural background, spoken language, values,
health habits, and family relationship.

Life style e.g. rest and sleep pattern

Self concept perception of strength, desired changes

Sexuality developmental level and concerns

Stress response coping pattern, support system,

perceptions of current anticipated stressors.
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 Chapter (6)
Functional Health Pattern

Islamic University of Gaza Strip

 Definition of (NANDA)

The North American Nursing Diagnosis Association

(NANAD 1994) defines a nursing diagnosis as “A
clinical judgments about individual, family or
community response to actual and potential health
problems and life responses”

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Functional health pattern (NANDA)
1- Health Perception-Health Management Pattern
2- Nutritional—Metabolic Pattern
3- Elimination Pattern
4- Activity—Exercise Pattern
5- Sexuality—Reproduction Pattern
6- Sleep—Rest Pattern
7- Sensory—Perceptual Pattern
8- Cognitive Pattern
9- Role—Relationship Pattern
10- Self-Perception-Self-Concept Pattern
11- Coping-Stress Tolerance Pattern
12- Value—Belief Pattern
Health Perception-Health Management
Pattern
1- Determine how the client perceives and manages his
or her health.
2- Compliance with current and past nursing and,
medical recommendations.
3- The client's ability to perceive the relationship
between activities of daily living and health.
Subjective Data
Client's Perception of Health:
Describe your health.
Client's Perception of Illness
Describe your illness or current health problem.
Health Management and Habits
Tell me what you do when you have a health problem.
Compliance with Prescribed Medications and Treatments
Have you been able to take your prescribed medications?
If not, what caused your inability to do so?

Objective Data
Refer to General Physical Survey
Associated Nursing Diagnoses
Wellness Diagnoses
Effective Management of Therapeutic Regimen
Risk Diagnoses
Risk for Injury
Risk for Suffocation
Risk for Trauma
Actual Diagnoses
Altered Growth and Development
Ineffective Management of Therapeutic Regimen: Individual
Ineffective Management of Therapeutic Regimen: Family
Ineffective Management of Therapeutic Regimen:
Community Noncompliance.
Nutritional-Metabolic Pattern
Assessing the client's nutritional-metabolic pattern is to
determine the client's dietary habits and metabolic needs. The
conditions of hair, skin, nails, teeth and mucous membranes
are assessed.

Subjective Data
Dietary and Fluid Intake
Describe the type and amount of food you eat at breakfast, lunch, and
supper on an average day
Do-you take any vitamin supplements? Describe.
Do you find it difficult to tolerate certain foods? Specify.
Do you ever experience nausea and vomiting? Describe.
Do you ever experience abdominal pains? Describe
Condition of Skin
Describe the condition of your skin.
How well and how quickly does your skin heal?
Do you have any skin lesions? Describe-
Do you have any itching? What do you do for relief?

Condition of Hair and Nails

Have you had difficulty with scalp itching or sores?
Do you use any special hair or scalp care products?
Have you noticed any changes in your nails? Color Cracking?
Shape? Lines?
Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or drinking habits?
Explain.
Have you noticed any voice changes?

Objective Data
Assess the client's temperature, pulse, respirations, and height
and weight.
Wellness Diagnoses
0pportunity to enhance nutritional metabolic pattern

Opportunity to enhance effective breastfeeding

Opportunity to enhance skin integrity

Risk Diagnoses
Risk for Altered Body Temperature

Hypothermia

Risk for Infection

Risk for altered nutrition less than body requirements .

Risk for Aspiration
Actual Diagnoses
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Altered Oral Mucous Membrane
Impaired Skin Integrity.
Elimination Pattern

Adequacy of the client's bowel and bladder.

The client's bowel and urinary habits.

Bowel or urinary problems

Use of urinary or bowel elimination devices.

 Subjective Data

Bowel Habits
How frequent are your bowel movements?

Do you use laxatives? What kind and how often do you use
them?

Do you use enemas or suppositories? How often and what kind?

Do you have any discomfort with your bowel movements?

Describe.
Bladder Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with urinating:
 Pain? Blood in urine? Difficulty starting a stream?
Incontinence? Voiding frequently at night? Voiding
frequently during day? Bladder infections?
 Have you ever had a urinary catheter? Describe. When?
How long?

Objective Data
Refer to abdominal assessment, and the rectal assessment.
Associated nursing-Diagnoses

Wellness Diagnoses

Opportunity to enhance adequate bowel elimination pattern

Opportunity to enhance adequate urinary elimination pattern

Risk Diagnoses

Risk for constipation

Risk for altered urinary elimination

Actual Diagnoses
Altered Bowel Elimination Constipation

Diarrhea

Bowel Incontinence

Altered Urinary Elimination Patterns of Urinary Retention

Total Incontinence

Stress Incontinence
Activity-Exercise Pattern

Activities of daily living, including routines of exercise,

leisure, and recreation.

Activities necessary for personal hygiene, cooking, shopping,

eating, maintaining the home, and working.

An assessment is made of any factors that affect or interfere

with the client's routine activities of daily living.
Subjective Data
Describe your activities on a normal day. (Including hygiene
activities, eating activities.)
Do you have difficulty with any of these self-care activities? Explain.
Does anyone help you with these activities? How?
Do you use any special devices to help you with your activities?
Does your current physical health affect any of these activities e.g.
dyspnea, shortness of breath, palpations, chest pain. pain, stiffness,
weakness)? Explain.

Occupational Activities
Describe what you do to make a living.
Do you feel it has affected your health?
How has your health affected your ability to work?
Objective Data
Refer to Thoracic and Lung Assessment
Cardiac Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment.

Associated Nursing Diagnoses

Wellness Diagnoses
Opportunity to enhance effective cardiac output
Opportunity to enhance effective self-care activities
Opportunity to enhance adequate tissue perfusion Opportunity
to enhance effective breathing pattern
Risk Diagnoses
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function

Actual Diagnoses
Activity Intolerance
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Disuse syndrome
Impaired Physical Mobility
Inability to Sustain Spontaneous Ventilation
Altered Tissue Perfusion
Sexuality-Reproduction Pattern

Subjective Data
1- Female
Menstrual history:

Last cycle begin?

Duration ?

Any change or abnormality ?

Describe any mood changes or discomfort before, during, or

after your cycle
Obstetric history
How many times have you been pregnant?

Describe the outcome of each of your pregnancies.

If you have children, what are the ages and sex of each?

Explain any health problems or concerns you had with each

pregnancy. If pregnant now .
Contraception
What do you or your partner do to prevent pregnancy?

Describe any discomfort or undesirable effects this method produces.

Have you had any difficulty with fertility? Explain

Special problems
Do you have or have you ever had a sexually transmitted
disease? Describe.

Describe any pain, burning, or discomfort you have while

voiding.

Objective Data
Refer to Breast Assessment, d Abdominal Assessment, and
urinary-Reproductive Assessment
Associated nursing Diagnoses

Wellness Diagnosis:

Opportunity to enhance sexuality patterns

Risk-Diagnosis
Risk for altered sexuality pattern

Actual Diagnoses

Sexual Dysfunction, Altered Sexuality Patterns

Sleep-Rest Pattern
Subjective data

Sleep Habits:
How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep?
Remaining asleep? Do you ever feel fatigued after a sleep
period?
Sleep Aids
What helps you to fall asleep? medications? reading?
relaxation technique? Watching TV? Listening to music?
Objective Data
1. Observe appearance

a. Pale b. Puffy eyes with dark circles

2. Observe behavior

a. Yawning

b. Dozing during day

c. Irritability

d. Short attention span

Associated nursing Diagnoses

Wellness Diagnosis:
Opportunity to enhance sleep
Risk Diagnosis
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleep Pattern Disturbance.
Sensory-Perceptual Pattern
Subjective Data
Describe your ability to see, hear, feel, taste, and smell.
Describe any difficulty you have with your vision, hearing, and
ability to feel (e.g., touch, pain, heat, cold), taste (salty, sweet,
bitter, sour), or smell.
Pain Assessment
Complete Symptom Analysis
Special Aids:
What devices (e.g., glasses, contact lenses, hearing aids)
Describe any medications you take to help you with these
problems.
Objective Data
Refer to the section on Nose and Sinus Assessment, Eye
Assessment, and Ear Assessment.
Associated Nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain
Actual Diagnoses
Pain
 Cognitive Pattern
Subjective Data
Ability to Understand:
Explain what your doctor has told you about your health.

Ability to Communicate:
Can you tell me how you feel about your current state of health?

Ability to Remember:
Are you able to remember recent events and events of long
ago? Explain.

Ability to Make Decisions:

Describe how you feel when faced with a decision.
Objective Data
Refer to the Mental Status Assessment

Associated nursing Diagnoses

Wellness Diagnosis: Opportunity to enhance cognition
Risk Diagnosis: Risk for altered thought processes
Actual Diagnoses:
Acute confusion
Chronic Confusion
Knowledge Deficit (Specify)
Impaired Memory
 Role-Relationship Pattern
Subjective Data

Perception of Major Roles and Responsibilities in Family

Describe your family.
Are there any major problems now?

Perception of Major Roles and Responsibilities at Work

Describe your occupation.
What is your major responsibility at work?

Perception of Major Social Roles and Responsibilities

Describe your neighborhood and the community in which you
live.
Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.

Associated Nursing Diagnoses

Wellness Diagnoses:
Opportunity to enhance effective relationships
Opportunity to enhance effective communication
Risk Diagnoses:
High risk for Loneliness
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
Impaired Verbal Communication
Impaired Social Interaction: Social Isolation
 Coping-Stress Tolerance Pattern
Subjective Data
Perception of Stress and Problems in Life
Describe what you believe to be the most stressful situation
in your Life.
How has your illness affected the stress you feel?
Coping Methods and Support Systems:
What do you usually do first when faced with a problem?
What helps you to relieve stress and tension?
Do you use medication, drugs, or alcohol to help relieve
stress? Explain.
Objective Data
Refer to the Mental Status Assessment.
Associated nursing Diagnoses

Wellness Diagnoses
Opportunity to enhance effective individual coping.
Opportunity to enhance family coping

Risk Diagnoses:
Risk for self-harm
Risk for suicide

Actual Diagnoses:
Ineffective Individual Coping
Ineffective Family Coping: Disabling
 Value-Belief Pattern
Subjective Data
Values, Goals, and Philosophical Beliefs

Religious and Spiritual Beliefs:

Are there certain health practices or restrictions that are important
for you to follow while you are ill or hospitalized? Explain.
Objective Data
Observe religious practices
Bible , clergy
Observe client's behavior for signs of spiritual distress
Anxiety, Anger , Depression , Doubt, Hopelessness and
Powerlessness
Associated Nursing Diagnoses

Wellness Diagnosis:

Potential for Enhanced Spiritual Well-Being

Risk diagnosis:

Risk for spiritual distress

Actual Diagnosis:

Spiritual disturbance (distress of the human spirit).

 Chapter (7)
Physical Assessment Techniques

Islamic University of Gaza Strip

 Indications for the Physical Exam
Routine screening

Eligibility prerequisite for health insurance, military

service, job, sports, school

Admission to a hospital or long term care facility

112
 STEPS OF ASSESSMENT
Think

Organize
Don’t forget…Nutrition / Height & Weight
Environment:

Accommodate special needs (cultural sensitivity)

Equipment - clean surface & clean equipment Room - quiet,

warm & well lit

Maintain privacy

Observe & Listen

113
 DON’T FORGET
REVIEWING GENERAL INFORMATION

INTRODUCTION TO CLIENT

OBTAINING THE HEALTH HISTORY

PAIN ASSESSMENT

THIS IS KEY TO HOLISTIC APPROACH

114
 Physical Assessment

There are four techniques to use in performing physical

assessment: 1.Inspection

2. Palpation

3. Percussion

4. Auscultation

Note: there are five addition skill known as olfaction

115
116
 1. Inspection:
Inspection is defined as “the use of the senses of vision,
smell and hearing to observe the normal condition or any
deviations from normal of various body parts.”
The nurse inspects or looks body parts to detect normal

characteristics or significant physical sings.

Inspection helps to know normal characteristics before

trying to distinguish abnormal findings in different ages.

The quality of an inspection depends on the nurse's

willingness to spend time doing a thorough job.

117
Inspection
Use vision, hearing & smell

Always first

Look for symmetry

Use good lighting

Use good exposure

118
 Principles of Accurate Inspection
 Good lightening either day light or artificial light is suitable.

 Expose body parts being observed only.

 look before touching.

 warm room for examination of the client “not cold not hot".

 Observe for color, size, location, texture, symmetry, odors, and

sounds.
 Compare each area inspected with the opposite side of body if
possible.
 Use pen light to inspect body cavities.
119
Palpation
Touch & feel with hands to determine:
 Texture – use fingertips (roughness, smoothness).
 Temperature – use back of hand (warm, hot, cold).
 Moisture (dry, wet, or moist).
 Organ location and size
 Consistency of structure (solid, fluid, filled)

Slow and systematic

Light to deep
Light palpation (tenderness)
Deep palpation (abdominal organs/masses)
 Principles for Accurate Palpation
 Examiner finger nails should be short.

 Use sensitive part of the hand.

 Light Palpation precedes deep palpation.

 Start with light then deep palpation

 Tender area are palpated last

 Tell client to take slow deep breath to enhance muscle relaxation.

 Examine condition of the abdominal organs

 Depressed areas must be approximately “2cm”

 Assess turger of skin measured by lightly grasping the body part

121 with finger tips.

 Light palpation

122
 Deep palpation

123
Percussion
Tap a portion of the body to elicit tenderness that varies with the
density of underlying structures.
Percussion denotes location, size and density of underlying
structures, percussion requires dexterity.
Methods of percussion:
Direct method: involving striking the body surface directly
with one or two fingers.
Indirect method: performed by placing the middle finger of the
examiner’s non dominant hand “pleximeter hand” firmly
against the body surface with palm and fingers remaining
off the skin, and the tip of the middle finger of the
dominant hand “plexor” strikes the base of the distal joint
of the pleximeter. Use a quick & sharp stroke
 Percussion

125
Description of sounds
Sound produced by the body is characterized by
intensity, frequency, duration and quality.
Intensity, or loudness, associated with physiologic sound
is low; thus, the use of the stethoscope is needed.
Frequency, or pitch, of physiologic sound is in reality
“noise” in that most sounds consist of a frequency
spectrum as opposed to the single-frequency sounds that
we associate with music or the tuning fork.
Duration relates to the time elapsed from the beginning
of the sound till the end of the sound.
Quality of sound relates to overtones that allow one to
distinguish between different sounds.
126
 Sounds produced by percussion
Sound Intensity Pitch Duration Quality Example
Tympany Loud High Moderate Drum like Large
pneumothorax

Resonance Moderate Low Long hollow Normal lung

to loud
Hyper- Very loud Very Longer Booming Emphysematous
resonance low than lung
resonance
Dullness Soft to High Moderate Thud like Liver
moderate
Flatness Soft High Short Flat Muscle

127
Five percussion sounds produced in different body regions

1. Resonant – normal lung

2. Hyper resonant: it’s a louder and lower pitched than resonant sounds. Normally
heard in children and very thin adults , and abnormally in emphysema

3. Tympany : A hollow drum-like sound produced when a gas-containing cavity

is tapped sharply. Tympany is heard if the chest contains free air
(pneumothorax) or the abdomen is distended with gas air filled (stomach)

4. Dull or thud like sounds are normally heard over dense areas such as the heart
or liver. Dullness replaces resonance when fluid replaces air-containing lung
tissues, such as occurs with pneumonia, pleural effusions, or tumors

5. Flat: shown in no air areas such as thigh muscle, bone and tumor
Auscultation
“To listen for various breath, heart, and bowel sounds”

Direct or immediate auscultation is accomplished by

the unassisted ear that is without amplifying
device. This form of auscultation often involves
the application of the ear directly to a body surface
where the sound is most prominent.

Mediate auscultation: the use of sound augmentation

device such as a stethoscope in the detection of
body sounds.
 Auscultation
Listening to body sounds

Movement of air (lungs)

Blood flow (heart)

Fluid & gas movement (bowels)

Remember the sound changes in

the abdomen…

130
 HOW TO BEGIN…
Positions for physical exam

Using a stethoscope:

Longer the tube – more sound has to travel

Hold diaphragm firmly against client’s skin (NOT

THROUGH CLOTHING)
If using bell – less pressure

Warm in your hands first!

Listen / Concentrate on the sounds

131
 Olfaction
Another skill that used during assessment, certain alteration is
body function create characteristic body odors, smelling can
detect abnormalities that unrecognized by other means.

Assessment of characteristic odors:

Alcohol odor from oral cavity means ingestion of alcohol.
Ammonia from urine means urinary tract infection.
Body odor from skin, particularly in areas where body
parts rub together means poor hygiene, excess
perspiration (bromidrosis).

132
Feces odor from wound site means wound abscess, but if this
odor from vomitus this means bowel obstruction, and if the
odor from rectal area this means fecal incontinence.
Foul–smelling stools in infant from stool means mal
absorption syndrome.
Halitosis from oral cavity means poor dental and oral
hygiene, gum disease.
Sweet, fruity ketones from oral cavity may be from diabetic
acidosis.
Musty odor from casted body part means infection inside

cast.
Fetid odor from tracheostomy or mucous secretions means
infection of bronchial tree (pseudomonas bacteria).
Basic Guidelines for physical Assessment
1. Obtain a nursing history and survey
2. Maintain privacy.
3. Explain the procedure
4. Always inspect, palpate, percuss, and then auscultate
except abdominal start with auscultate
5. Compare symmetrical sides
6. If abnormality (Symptom analysis )
7. Client teaching
8. Allow time for client’s questions.

"Remember:
Remember the most important guideline for adequate physical
assessment is conscious, continuous practice of physical
assessment skills".
Variation in physical assessment of the
pediatric client.
Sequence of physical assessment is dependent upon

the developmental level of the client.

Allowing time for interaction with the child prior to

beginning the examination helps to reduce fears.

In certain age groups, portions of assessment will

require physical restraint of the client with the help of

another adult.
Distraction and play should be intermingled throughout
the examination to assist in maintaining rapport with the
pediatric client.
Involving assistance from the child’s significant
caregiver may facilitate a more meaningful examination
of the younger client.
The examiner should be prepared to alter the order of the
assessment and approach to the child based on the
child’s response.
Protest or an uncooperative attitude toward the examiner
is a normal finding in children from birth to early
adolescence, throughout parts or even all the assessment
process.
Variations for physical assessment of the
geriatric client.
Remember: normal variation related to aging may be
observed in all parts of the physical examination.
Dividing the physical assessment into parts in order to

avoid fatigue in the older client.

Provide room with comfortable temperature and no drafts.
Allow sufficient time for client to respond to directions.

If possible assess the elderly clients in a setting where they

have an opportunity to perform normal activities of daily

living in order to determine the client’s optimum potential.
 Chapter (8)
Vital Signs and General Assessment

Islamic University of Gaza Strip

 Vital signs and general assessment
Equipment needed:
Balance scale.
Tape measure.
Thermometer.
Sphygmomanometer.
Stethoscope.

Subjective Data:
Reason for seeking health care and major concern about
current health, current age, height, and weight, recent weight
changes, fever, history of hypertension, hypertension,
difficulty breathing, changes impulse or heart rate.
139
Objective Data:
Observe client from head to toe to note any gross abnormalities

in appearance or behaviors.
Assess vital signs, temperature, pulse, respirations, and blood

pressure to detect any severe deviations and to acquire base line

data.
Weight the client and measure for height with shoes, and heavy

clothing removed.

140
Vital signs (assessment) include:
Assessment of temperature, pulse, respiration and blood
pressure are known as life signs.
Vital signs are indicators of the body’s physiologic status and
response to physical, environmental and physiologic stressors.
Vital signs reveal the client’s current ability to maintain body
temperature regulation, to maintain local and systemic blood
flow, and to provide oxygenation of body tissues.
A. Temperature
Body temperature is difference between heat produced and heat
lost. The hypothalamus acts as the body's thermostat to maintain
between the body's heat-producing function (metabolism,
shivering, muscle contraction, exercise and thyroid activity) and
heat losing methods (radiation, convection)
141
Method of measurement
a. Oral b. Rectal c. Axillary d. Forehead e.Tympanic
Remember
Routinely, where accuracy is not crucial, an oral temp will
sufficient.
Rectal temperature is the most accurate.
Unless contraindicated a rectal temperature is often preferred.

Factors influencing of temperature

Biologic rhythms
Gender: women has greater fluctuations in body temperature than
men because change of hormones
Environmental effect (hot, cold), Physiologic change(exercise)
Drugs and Age (child have slightly higher normal temperature,
elderly people have decrease body temperature).
B. Pulse
The pulse reflects the force of the heart contracting. Also reflects
stroke volume, the mount of blood ejected with each contraction.
A pulse deficit (a difference between the apical and radial pulse rate)
Factors influencing of pulse
1. Pain 2. Emotion 3. Exercise
4. Prolong heat application
5. Decrease BP, and increase temperature.
6. Poor oxygen in the blood.
Remember
Palpate the radial pulse and count for at least "30" second.
If the pulse is irregular, count for full minute and note the number of
irregular beats per minute.
Note is the pulse against your finger strong or weak (Amplitude of
rhythm)
 Rhythm: regular or irregular
Amplitude of rhythm
Absent 0
Thready 1
Weak 2
Normal 3
Bound 4

Site of pulse
Temporal, Carotid, Brachial, Radial, Femoral, Dorsalis
Pedis , Popliteal, Posterior Tibia and Apical.
N.B pulse rate is "60-100 b/m" regular in rhythm. The
normal pulse rate varies from a low of 50 bpm in healthy,
athletic young adults to rates well in excess of 100 bpm after
144 exercise or during times of excitement
145
C. Respiration:
Count the number of respiration (rate), in full minute Respiration:
normally "16-20 breath/minute" (for healthy adult person).
Note rhythm (regular or irregular) and depth of breathing
(reflects the tidal volume, described as shallow or deep
breathing).

Factors influencing of reparation

1. Age
Newborn 35 breath / minute ,
1 year 30 breath / minute ,
6 year 21 breath / minute,
10 year 19 breath / minute ,
18 year 16-18 breath / minute
2. Any disease 3. Exercise 4. Emotion
D. Blood pressure:
Measure Blood Pressure in both arms.
Pulse pressure: the difference between the systolic and the
diastolic pressures (normally is 30 to 40 mm Hg)
Palpate the systolic pressure before using the stethoscope in
order to detect an auscultatory gap.
Apply cuff firmly, if too tight (small) it will give falsely
high reading.
Use cuff in appropriate size.
Note position of client when measuring blood pressure.
Monitor blood pressure after client is seated or supine
quietly for "10" minute.
Repeat after two minutes. Then repeat with client standing.
 Factors influencing the BP
1. Age
Newborn 40 mmHg/systolic / 20 diastole
1 month 84/54 mmHg
1 year 95 /65 mmHg
6 year 105 / 65 mmHg
10 – 13 year 120 / 80 mmHg
14- 17 year 120/80 mmHg
18 year 120/80 mmHg
Normal range 100 – 140mmHg (systolic) and from 60-90
mmHg/( diastolic)
2. Sex 3. Emotion 4. Position: Laying down
4. After meal 5. Exercise
148
 Instrumentation used in assessment
Instruments, or “equipments” used during physical assessment
should be readily accessible, clean, in proper working order.
Ophthalmoscope: "lighted instrument for visualization of the
eye".
Otoscope: for examination of the ear.
Snellen eye chart: used as a screening test for vision.
Nasal speculum: used for assessment of the nose.

Vaginal speculum: examination of the vaginal canal and

cervix.
Tuning fork: for testing auditory function and vibratory
perception.
Percussion hammer: “reflex hammer” used to test reflexes
149 and determine tissue density.
150
Positions
Each position has it's specialty for parts of examination. Draping
during assessment is used to prevent unnecessary exposure.
Drapes may be paper, cloth, or bed linens

I. Sitting position
Areas Assessed:
Head and neck, back, posterior thorax and lungs, anterior thorax
and lungs, breasts, axially, heart, vital signs, and upper extremities
Rationale:
Sitting upright provides full expansion of lungs and provides
better visualization of symmetry of upper body parts.
Limitations:
Physically weakened client may be unable to sit. Examiner should
use supine position with head of bed elevated instead.
II. Supine position
Areas Assessed: Head and neck anterior thorax and lungs,
breasts, axillae, heart, abdomen, extremities, and pulses
 Rationale: This is most normally relaxed position. It prevents
contracture of abdominal muscles and provides easy access to pulse
sites.
 Limitations: If client becomes short of breath easily, examiner
may need to raise head of bed.

III. Dorsal position:

Areas Assessed: Head and neck, anterior thorax and lungs,
Breasts, axillae and heart.
Rationale: Clients with painful disorders are more comfortable
with knees flexed.
Limitations: Position is not used for abdominal assessment
because it promotes contracture of abdominal muscles
IV. Lithotomy position:
Areas Assessed: Female genitalia and genital tract
Rational: This position provides maximal exposure of genitalia and
facilitates insertion of vaginal speculum.
Limitations:
Lithotomy position is embarrassing and uncomfortable, so examiner
minimizes time that client spends in it. Client is kept well draped.
Client with severe arthritis or other joint deformity may be unable to
assume this position.

V. Sims’ position:
Areas Assessed: Rectum and vagina
Rationale: Flexion of hip and knee improves exposure of rectal
area.
Limitations:
Joint deformities may hinder client’s ability to bend hip and knee.
VI. Prone position:
 Areas Assessed: Musculoskeletal system
 Rationale:
This position is used only to assess extension of hip joint.
 Limitations:
This position is intolerable for client with respiratory
difficulties.

VII. Knee-chest position:

Areas Assessed: Rectum.
Rationale: This position provides maximal exposure of rectal area.
Limitations:
This position is embarrassing and uncomfortable.
Clients with arthritis or other joint deformities may be unable to
assume this position.
155
 Chapter (9)
Assessment of Skin, Hair and Nails

Islamic University of Gaza Strip

Structure of the Integument
 The skin is the largest organ of the body comprising 15 percent of
total body weight.
 Layers of the skin
A. Epidermis B. Dermis C. Subcutaneous tissue
Epidermal appendages
 Hair
 Nails
 Glands: two types of skin glands:
1. Sweat Gland
Eccrine sweat glands: are widely distributed and open directly
onto the skin surface
Apocrine sweat glands: open into hair follicle in axillary and genital
areas
2. Sebaceous glands: Produce sebum(oily secretion)
158
 Functions of skin and epidermal appendages
Barrier to water and electrolyte loss

Regulation of body heat

Sensory organ for touch, temperature, and Pain

Production of protective skin film by eccrine and

sebaceous glands
Participation in production of vitamin

Wound repair

159
 Assessing the Integument
1. Subjective data
Skin infection, rashes, lesions, itching.

Precipitating factors: stress, weather, drugs

Changes in skin color, lesions

Amount of sun exposure

Scalp lesions, itching, and infections.

Changes in texture and amount of hair.

Changes in nails and cuticles nail breaking

160
2. History of current symptom
Are you having experience of skin problem, such as rashes, lesion
Describe any birthmarks, tattoos, or moles
Have you noticed any changed in your ability to feel pain,
pressure, light touch, or temperature changed?
Have you had any hair loss or change in the condition of your
hair?
Have you had any change in the condition or appearance of your
nails?
Describe any previous problem within the skin, hair or nails ( past
history)
Have you ever had any allergic skin reaction to food, medication,
plants?
Has anyone in your family had a recent illness, rash, or other skin
problem? (Family history)
3. Physical Assessment
Equipment
Penlight Tongue depressor Centimeter rule Gloves
Magnifying glass Flashlight Wood’s lamp

Technique to examination of skin

Inspection Palpation
Inspections and palpation of skin
Color Moisture Temperature
Thickness
Turgor Vascular changes Edema
Lesions
Skin odors are usually noted in the skin fold.
162
163
Inspection color of skin
Skin color varies from body part to body part and from person

to person.
Assessment first involves area of skin not exposed to the sun
e.g. palms of the hands.
Pallor easily perceived in the buccal “mouth” mucosa
particularly in individuals with dark skin.
Cyanosis readily seen in area of least pigmentation e.g. lips,
nail beds conjunctiva and palm.
Jaundice or Yellow seen in client’s sclera.

Erythema may indicate circulatory changes

164
165
 Palpation moisture of skin
Skin is normally smooth and dry.
Skin folds e.g. axillae are normally moist.
In presence of lesions or ooze fluid, nurse must wear gloves
to prevent exposure to infections drainage
Moisture indicates:
1- Degree of client’s hydration
2- Condition of the outer lipid layer of the skin surface
Dry (xerosis): Vitamin A def. and Myxedema
Oily: Acne

166
 Palpation of Temperature
Temperature of skin depends on the amount of blood
circulating through dermis.
Generalized warmth: (Fever, Hyperthyroidism)

Local warmth: (Inflammation)

Coolness: (Hypothyroidism, Frost bite, Hypothermia, Shock,

Low cardiac output)

Palpation of skin with dorsum of the hand.

Assessment of skin is critical point in some conditions such

as: after cast application, or after vascular surgery.

167
 Palpation of Texture
Texture of skin normally smooth, soft and flexible

If any abnormalities in texture found you must ask the client

is he exposed to any recent injury to the skin?

Nurse determines whether the client’s skin is smooth or

rough, thin or thick, tight or supple (flexible).

Very Soft: (Thyrotoxicosis)

Tight: (Scleroderma = hard skin)

Rough: (Hypothyroidism)

168
 Palpation of Turgor
Turgor: is the skin elasticity
diminished by edema or
dehydration.
Assessment of turgor done by
pinching skin between the
thumb and forefinger and
released.
Normally skin return
immediately to its position.
Failure of this process means
dehydration.
Decrease in turgor predisposes
the client to skin breakdown.
Palpation of Vascularity
 Vascularity: Assessment of circulation of skin E.g. petechiae may
indicate serous blood clotting disorders, drug reactions or liver
disease.
Inspection and Palpation of Edema
 Edema : "Build up of fluid in tissues“
 Inspected for location, color, and shape.
 Palpates areas of edema to determine mobility, consistency, and
tenderness
Inspection and Palpation of Lesions
 Normally skin free of lesions except common freckles.
 If lesion present, inspection must done for distribution, arrangement,
morphology, color and size
 Palpation for lesion’s mobility, contour (flat, raised or depressed) and
consistency (soft or hard are indicated).
 Cancerous lesions frequently undergo changes in color and size.
Hair and Scalp
Assessment done for distribution, thickness, texture, and
lubrication of the hair.
Some events which affect the distribution of hair over the body

e.g. client with hormone disorders, woman with hirsutism

Amount of hair covering extremities may be reduced as a result of

aging and arterial insufficiency especially in lower limbs.

Scaliness or dryness of the scalp is frequently caused by dandruff

or psoriasis.

171
 Nails Assessment
Nails reflect an individual's
general state of health, state of
nutrition, and occupation.
Nails are normally transparent,
smooth, and convex, with a nail
bed angle of about 160 degrees.
The surrounding cuticles are
smooth, intact and without
inflammation.
Nail bed is normally firm on
palpation.
Nails normally grow at a constant
rate.
 Abnormal condition of nail
Anonychia: complete absence of nails

Platunychia: flatting nails

Koilonychia : nails like spoon shape (iron deficiencies anemia)

Racket nail: fattened and expanded nails

Onycholysis: separation of nail form nail bed (thyrotoxicosis)

Melanoychia: presence of brown color in nails plate

Paronychia: inflammation of tissue surrounding the nail

173
174
 Chapter (10)
Assessment of respiratory system

Islamic University of Gaza Strip

 Anatomy of Respiratory System
The lung is a two cone-shaped, elastic structure suspended within
the thoracic cavity.
Lung are paired, they are not complete symmetric, the right lung

contain three lobe, whereas the left lung contain only two lobes.
The apex of each lung extended slightly above the clavicle, where

the base is at the level of diaphragm

The thoracic cavity contains the nasopharynx, larynx, trachea,

bronchi, bronchioles, alveoli.

The thoracic cavity is lined by a thin, double- layered serous

176 membrane collectively called the pleural membrane

177
178
Assessment of respiratory system
Subjective data: the nurse must ask the client about:-
Coughing (productive, non productive)

Sputum (type & amount)

 Allergies, dyspnea or SOB (at rest or on exertion).

Chest pain, history of asthma, bronchitis, emphysema, tuberculosis.

Cyanosis, pallor.

 Exposure to environmental inhalants (chemicals, fumes).

History of smoking (amount and length of time)

179
 Technique for Respiratory Exam
Before beginning, if possible:

Quiet environment

Proper positioning (patient sitting for posterior thorax exam,

supine for anterior thorax exam)

Expose skin for auscultation

Patient comfort, warm hands and diaphragm of stethoscope, be

considerate of women (drape sheet to cover chest)

After that the nurse should apply the four techniques;

180 Inspection, Palpation, Percussion and Auscultation

Initial Respiratory Survey (Inspection)
Observe the patient’s breathing pattern
Rate (normal vs. increased/decreased)
Depth (shallow vs. deep)
Effort (any sign of accessory muscle use, inspect neck)
Assess the patient’s color
Cyanosis
Normal Respiratory Rates
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-age child 18-30
Adolescent 12-16
Adult 16-20
181
Inspection and assessment of respiration patterns
Assess the skin and overall symmetry and integrity of the thorax.
Assess thoracic configuration.
Client must be uncovered to the waist, and in sitting position
without support.
Observation of skin may give you knowledge about nutritional
status of the client.
Anterior- posterior diameter of thorax in normal person less than
the transverse diameter = (1:2).
Assess for abnormality of configuration, e.g. pigeon chest,
funnel chest, spinal deformities.
Assess ribs and inter spaces on respiration – may give
information about obstruction in air flow e.g. bulging of inter
spaces on expiration may be from obstruction to air out flow
“tumor, aneurysm, cardiac enlargement”
 Assess pattern of respiration
Normally: men and children – breathe diaphragmatically
and Women breathe thoracically or costally.
Tachypnea: respiratory rate over than 20/m for adult.

Bradypnea: respiratory rate less than 10/m.

Palpation: palpate areas of chest especially areas of

abnormalities.
If clients complains: all chest areas must palpated carefully

for tenderness, bulges, or any movements

183
 Assess thoracic expansion:
Anterior: put your hands over anterior-lateral chest and
thumbs extended along costal margin pointing to xiphoid
process.
Posterior: thumbs placed at level of T 10 with palms
placed on posterior-lateral chest.
By two ways you feel amount of thoracic expansion
during quiet and deep breathing, and symmetry of
respiration between left and right hemi thoraces.
Assessment of fremitus: which is vibration perceptible on
palpation"
In subcutaneous emphysema: you must palpate the tissue,
audible cracking sounds are heard – these sounds are
184 termed Crepitation
185
Percussion of chest:
 Done to determine relative amounts of air, liquid, or solid material in
the underlying lung, and to determine positions and boundaries of
organs.
 Percussion done for posterior and anterior and lateral aspects of chest
with all directions, and with about “5”cms intervals.
Auscultation:
 To obtains information about the function of respiratory system & to
detect any obstruction in the passages.
 Instruct the client to breathe through the mouth more deeply and
slowly than in usual respiration and then to hold the breath for a few
seconds at the end of inspiration to increase intrapleural pressure and
reopen collapsed alveoli.
 Auscultate all areas of chest for at least one complete respiration: 12
anterior locations and 14 posterior locations
 Auscultate symmetrically: Should listen to at least 6 locations
anteriorly and posteriorly
187
 Breathe sounds: are analyzed according to pitch, intensity,
quality, and relative duration of inspiratory and expiratory
phases.
Bronchial breathe sounds: are normally heard over
manubrium of sternum
If heard over lung tissue – indicate pathologic condition,
these sounds “high-pitched loud sounds with decrease
inspiratory and lengthened increase expiratory phases.
Absent or decreased breath sounds can occur in:
 Foreign body.
 Bronchial obstruction.
 Shallow breathing.
 Emphysema
188
 Breath Sounds
Normal breath sounds are distinguished by their location over a
specific area of the lung and are identified as tracheal, vesicular,
bronchovesicular, and bronchial (tubular) breath sounds as the
next:
1. Tracheal
Very loud, high pitched sound
Inspiratory = Expiratory sound duration
Heard over trachea in the neck
2. Bronchial
Loud, high pitched sound
Expiratory sounds > Inspiratory sounds
Heard over manubrium of sternum
If heard in any other location suggestive of consolidation
189
 3. Bronchovesicular
Intermediate intensity, intermediate pitch
Inspiratory = Expiratory sound duration
Heard best 1st and 2nd ICS anteriorly, and between scapula
posteriorly
If heard in any other location suggestive of consolidation

4. Vesicular
Soft, low pitched sound
Inspiratory > Expiratory sounds
Major normal breath sound, heard over most of lungs

190
Adventitious Breath Sounds
An abnormal condition that affects the bronchial tree and alveoli
may produce adventitious (abnrmal= addtional) sounds.
Adventitious sounds are divided into two categories: discrete,
noncontinuous sounds (crackles) and continuous musical sounds
(wheezes) as the next:

1. Crackles (Rales)
Discontinuous, intermittent, nonmusical, brief sounds. Heard
more commonly with inspiration
Classified as fine or coarse
Its may associated with Prolonged recumbency
Crackles caused by air moving through secretions and collapsed
alveoli and associated with the following conditions: pulmonary
edema, early CHF, and pnumonia
191
 2. Wheeze
Continuous, high pitched, musical sound, longer than crackles
Whistle quality, heard during expiration, however, can be
heard on inspiration
Produced when air flows through narrowed airways
Associated conditions: asthma, chronic bronchitis, and COPD

3. Rhonchi
Similar to wheezes (subtype of wheeze)
Low pitched, snoring quality, continuous, musical sounds
Implies obstruction of larger airways by secretions
Associated condition: acute bronchitis

192
4. Stridor
 Inspiratory musical wheeze
 Loudest over trachea
 Suggests obstructed trachea or larynx
 Medical emergency requiring immediate attention
 Associated condition
 inhaled foreign body

5. Pleural Friction Rub

 Pleural friction rubs are specific examples of crackles. Discontinuous
or continuous brushing sounds
 It is a loud dry, cracking or grating sound indicating of pleural
irritation, heard over lateral and anterior lung in sitting position that
heard during both inspiratory and expiratory phases
 Occurs when pleural surfaces are inflamed and rub against each other
 Associated conditions as pleural effusion, Pneumonothorax
Medical conditions associated with decreased or absent of
breath sounds
Asthma
COPD
Pleural Effusion: fluid accumulating within the pleural space
Pneumothorax: caused by accumulation of air or gas in the
pleural space.
ARDS( adult respiratory distress syndrome)
Atelectasis : is defined as a state in which the lung, in whole
or in part, is collapsed or without air entery

Five Main Symptoms of Respiratory Disease

Cough Sputum Pain
Breathlessness Wheeze
 Chapter (11)
Head Assessment, face and neck

Islamic University of Gaza Strip

Assessment of the Head
Inspects the size, shape, and contour of head.
The skull is generally round with anterior & posterior prominences.
Large infant's head may be hydrocephalus.
Large adult's head & facial bones resulting of acromegaly.
Palpates the skull for nodules or masses
Assessment of the eye 
Assess external eye structures and pupils, visual acuity, ocular
movements, Peripheral vision.
Assessment of external eye structures: position and alignment of
eyes, eye brow, eye lids, eye lashes, lacrimal glands, pupils and iris.
Assessment of pupils done by using penlight which produce
constriction of pupils to show accommodation and convergence of
pupils.
Assess internal eye structures e.g. iris , retina, macula etc
Consider the following Factors:
 Age use of corrective lens, artificial eye, allergies, pain, visual
disturbances
 Health related factors such increase Blood Pressure, or Diabetes
mellitus
Using the following equipment to assess the eyes:
 Eye chart (Snellen chart), Chart or newsprint.
 Cover card.
 Penlight, and ophthalmoscope
Ask the client about history of previous eye surgery,
trauma, use of corrective glasses or contact lenses, blurred
vision, Diplopia, strabismus, recent changes in vision, date
of previous vision test, allergies, eye redness, and frequent
197
watering discharge
Assess Visual Acuity:
Done by placing the client 20 feet
from the Snellen eye chart and
testing each eye alone.
Assess extra ocular movements by
asking client to hold his head and
follow movements of your
forefinger.
Assess peripheral vision: “Visual
fields”
 Hemianopsia: blindness of 1/2 field
in one or both eyes.
 Quadrantanopsia: blindness of 1/4 of
visual field in one or both eyes.
 Ascotoma: Island like blindness in
visual field
Ear Assessment
Take history of ear surgery, trauma, frequent infection, ear
pain, drainage, hearing loss, tinnitus, vertigo, ototoxic
medications, and last hearing examination
Assess client in sitting position & inspects the auricle’s
placement, size, symmetry, and color.
Redness: sign of inflammation or fever. Color of ears must be
the same as of the face.
Pallor: indicate frost bite.
Palpate the auricles for texture, tenderness, and skin lesion.
If client complains of pain: pull the auricle and press on the
tragus and behind the ear over the mastoid process if pain
increase, means external ear infection, if pain is not increase,
means middle ear infection may be present.
199
 Inspection the ear canal for size and discharge.
Assessment of cerumen if it is yellow or green may indicate
infection.
Assessment of hearing acuity: done simply by identification
of voice tones, with the client repeating testing words spoken
by the nurse (whisper test)
N.B: deeper structure and middle ear can be observed only by
otoscope.
Whisper Test (patient with normal acuity can correctly
repeat what was whispered)
Weber Test (uses bone conduction to test lateralization of
sound by a tuning fork)
Rinne Test (useful for distinguishing between conductive
and sensorineural hearing losses)
200
Weber Test: A tuning fork, set in motion by grasping it firmly by its stem
and tapping it on the examiner’s hand, is placed on the patient’s head.
 A person with normal hearing will hear the sound equally in both ears or
describe the sound as centered in the middle of the head.
 In an abnormal patient, the sound is heard louder in one ear
(lateralization).

Rinne Test
 The examiner shifts the stem of a vibrating tuning fork between two
positions: 2 inches from the opening of the ear canal (for air conduction)
and against the mastoid bone (for bone conduction). Patient is asked to
indicate which tone is louder or when the tone is no longer audible.
 Normally, sound heard by air conduction is audible longer and louder than
sound heard by bone conduction.
 With a conductive hearing loss, bone-conducted sound is heard longer
than air-conducted sound
 With a sensorineural hearing loss, air-conducted sound is audible longer
than bone conducted sound.
202
The Otoscope Examination
 Using the Otoscope :
 Otoscope should be held in the examiner’s right hand, in a pencil-
hold position, with the bottom of the scope pointing up. This
position prevents the examiner from inserting the otoscope too far
into the external canal. Choose the largest appropriate speculum
 Using the opposite hand, the auricle is grasped and gently pulled
upper and back to straighten the canal in the adult, while pulled
down and back in infant and child ( <3 age )
 The External Canal :
 Redness / swelling / lesion / foreign body / discharge
 Tympanic Membrane :
 Color / character / perforation
 The healthy tympanic membrane is shiny, translucent , pearl-gray
color
203  Cone-shaped light reflex
204
Assessment of the nose
Functions of the nose
1. Identify odors (upper 1/3 of septum)
2. Air passageway (obligate in newborns)
3. Air conditioning: humidify, warms/cools air, cleans and
filters air of
dust and most bacteria and voice resonance
Inspect and Palpate
External Nose
1) Symmetric, in the midline, skin lesion, pain

205
 Nostril patency:
Inspect & observe symmetry, inflammation & deformity.
In case of swelling or deformities of nose, the nose is
palpated gently for tenderness, swelling and underlying
deviations.
Normally the external nose is symmetrical, strait, non tender,
and without discharge.
Assess mucosa which is normally pink in color.
Yellowish or greenish discharge – means sinus infection.
 Pale mucosa with clear discharge – means allergy.
For client with NGT, nurse should routinely checks for local
breakdown of skin “Excoriation” of the nostril that
characterized by redness and sloughing of the skin
206
Assessment of the sinuses
Frontal and maxillary sinuses are examined for pain and edema.
Palpate sinuses both frontal (below the eyebrow) and maxillary
(below cheekbones) for tenderness, which verbalized by client
during exam.
Percuss sinuses for resonance which is normally hollow tone, and
noting abnormality e.g. flat, dull tone elicited or expresses pain on
percussion
Transillumination sinusitis: is the transmission of light through
tissues of the body. A common example is the transmission of a
flash of light through fingers, producing a red glow. This is
because red blood cells absorbed other colors of the beam and
transmitted only the red component. Absence of light indicates
mucosal thickening or the cavity is likely contain fluid or pus
sinuses
207
208
Assessment of Mouth and pharynx
1. Assessment of oral cavity can be made during administration of
oral hygiene.
Lips – inspected for color, texture, hydration, contour, and lesions.
Inner and buccal mucosa, Gums and teeth inspected for color,
hydration, texture and lesions e.g. ulcers, abrasions or crusts.
Tongue and floor of mouth can carefully inspect.
Assessment of palate “soft and hard” by extending client’s
backward, assessment for color, shape, texture, and extra bony
prominences or defects
2. Assessment of Pharynx
Assessment for pharynx done: by using tongue depressors.
Pharyngeal tissues are normally pink and smooth.
Edema, ulceration, or inflammation indicates infections or
abnormal lesions
210
Assessment of Neck
Assessment done by inspection and palpation that the client
placed in a sitting position
Assess neck muscles, trachea, thyroid gland, carotid arteries and
jugular veins, cervical lymph nodes and cervical vertebrae.
Assess neck size and position of trachea and thyroid
Assess range of motion by asking the client to tilt the head
backward and side to side
Assess lymph nodes and venous distention.
Normally:
Neck should be symmetrical with full range of motion.
No neck vein distention should be visible.
Inspect and palpate cervical vertebrae
Assess the posterior aspects of the neck for symmetry, tenderness,
masses or swelling.
 Thyroid gland is assessed by palpation, observation and
auscultation.
 Normal thyroid gland is not palpable. The isthmus is the only
portion of the thyroid that is normally palpable
 Palpation – for gland itself. If enlargement of thyroid gland is
detected, the area over the gland is auscultated for a bruit
 Bruit: vibrations sound of blood flow through arteries. In enlarged
gland, heard with the diaphragm of stethoscope (This abnormal
finding)

212
Trachea
 Trachea normally centered; (at the suprasternal notch)
 The cartilages should be smooth, non tender and move easily under
examiner’s fingers when the client swallow
 Palpation done by placing the thumb and forefinger on each side of
the trachea
Assessment of the lymphatic system
 Lymphatic System consists of a network of collecting ducts, lymph
fluids e.g. spleen, thymus, tonsils, adenoids--- etc
Functions of lymphatic system
 Movement and transportation of lymphocytes
 Production of lymphocytes.
 Production of antibodies.
 Phagocytosis
 Absorption of fat and fat soluble substances.
 Enlargement of lymph node: provides early indication of infection or
malignancy.
Examination of lymphatic System : 2 steps
 Firstly inspection for enlarged lymph nodes, skin lesions and edema
 Secondly palpating gently the lymph nodes areas using pads of "2, 3, 4"
fingers in gentle circular motion.
 Press lightly and then increasing pressure gradually.
 Move skin lightly over the under lying tissues & not moving the examining
fingers over the skin.
 Large nodes due to malignancy are generally not tender vary in size, hard,
asymmetrical
Some Areas of lymph nodes
 Pre auricular: in front of the ear.
 Mastoid or posterior auricular – behind the ear. Above the mastoid process.
 Occipital – at the base of skull posterior.
 Parotid – near the angle of the jaw.
  Sub-mandibular – midway between
angle of jaw and the tip of the
mandible.
 Submentum – in the midline posterior
to the tip of the mandible.
 Anterior superficial nodes – in the
anterior triangle of the neck.
 Posterior cervical nodes – in the
posterior triangle of the neck.
 Deep cervical nodes – very deep and
difficult to be examine.
 Supra clavicular or scalene nodes – In
the angle formed by clavicle and
Sternocleidomastoid muscle.
 Axilla, breast & Lower extremity
(inguinal and popliteal nodes)
215
 Chapter (12)
Assessment of the breast

Islamic University of Gaza Strip

 Assessment of the breast
The breasts, or mammary glands, are highly specialized
glands, which extend laterally from edges of the sternum to
the anterior axillary fold.
They are located between the third and seventh ribs on the
anterior chest wall. Each breast is divided into 15 to 20
irregularly shaped lobes separated by fibro elastic and adipose
tissues. The areola is a roughened, segmented, circular
formation, which surround the nipple.
Subjective data
Tenderness, pain, swelling, or change in size of breasts.
Change in position of nipple or nipple discharge.
Presence of cysts, lumps, and lesions.
History of prior breast surgery
217
Female breast:
Inspection: Best done in sitting position with arms relaxed at sides
Carefully observe the breasts for symmetry. The normal breasts
may be slightly different in size. If necessary, reassure the patient
that any difference in size is normal.
Inspect Areola and nipples for position, pigmentation, inversion,
discharge, crusting & masses.
Examine the breast tissue for size, shape, color, and contour
Assess level of breasts, notes any retractions or dimpling of the
skin.
Ask client to elevate her hands over her head, repeat the
observation.
Ask client to press her hands to her hips and repeat observation.
Inspect the axilla for: rashes, signs of infection and unusual
218 pigmentation
Palpation: Best done in recumbent position:
Raise the arm of client on the side of the breast being palpated
above client’s head.
Palpate the breast from less painful or less diseased area (Use
on palpation palmer aspects of the fingers in a rotating motion,
compressing the breast tissue against the chest wall, this is done
quadrant by until the entire breast has been palpated.
Note skin texture, moisture, temperature, or masses.
Gently squeeze the nipple and note any expressible discharge.
"Normally not present in non lactating women".
Repeat examination on the opposite breast & compare findings.
If mass is palpated, its location, size, shape, consistency,
mobility and associated tenderness are reported
Remember the breast may feel slightly more fibrotic or be
somewhat tender just prior to or during the menses.
 Male Breast:
Examination of male breast can be brief and should never
be omitted.
Observe nipple & areola for ulceration, nodules, swelling
or discharge
Instruct the patient to raise both arms, exposing the skin of
the axilla. Carefully inspect the axilla for: rashes, signs of
infection and unusual pigmentation
Palpate the areola for nodules or tenderness

220
 Chapter (13)
Assessment of Cardiovascular System

Islamic University of Gaza Strip

Anatomy of the Heart
Right Atrium
Right Ventricle
Left Ventricle
Left Atrium
Superior and Inferior Vena Cava
Pulmonary Artery
Pulmonary Vein
Aorta

TWO PUMPS
Right side pumps blood to
lungs
Left side pumps blood to body
FOUR VALVES
Two Atrioventricular Valve (AV)
Tricuspid Valve (right atrioventricular valve)
 Mitral (left atrioventricular valve)
Two Semilunar Valve (SL)
 Aortic valve (left semilunar valve)
 Pulmonary valve (right semilunar valve)

Subjective data:
1. Assessment of chief complaints:
Chest pain: location, quality, duration & associated symptoms.
Irregular heart beat: too fast, jump etc.

223
 2. Assessment of risk factors:-
Ask about history of hypertension, diabetes, and rheumatic fever
Ask about family history of heart attack, hypertension, stroke, and
diabetes
Describe your nutritional intake: high cholesterol, triglyceride
level.
Do you smoke? How much? And for how long?
How do you view yourself? What do you do to relax?
How many hours a day do you work? How do cope with stress.
Exercise: what do you do for exercise? How often?
Pain in calves, feet, buttocks or legs? What aggravates the pain
(walking, sitting long periods, standing long periods, sleep) what
relieves the pain “elevating legs, rest, lying down”.
In what type of chair does client usually sit?
Does he/she cross legs frequently?
224
Inspection:
Assessment the client must be is in supine or sitting positing

according to his health

By inspection and palpation you may detect ventricular
hypertrophy.
Use source of light to inspect subtle movements in chest e.g.:

pulsation, retraction etc.

Apical pulse in left fifth intercostal space, if deviation in site

observed may indicate cardiac enlargement 6th intercostal space.

Retractions may be seen around site of apical pulse, marked

retraction may indicate pericardial disease.

225
Palpation (supine position)
Palpate from apex, moving to external border to base
Detect abnormalities in site of palpation and abnormal sounds
especially for thrill “abnormal flow of blood”
Describe in terms: locations of pulsation in relation to mid-
sternal, mid-clavicular or axillary lines.
Palpation of apical pulse, strength differs from thin person to
obese.
Conditions such as anxiety, anemia, fever, and
hyperthyroidism may increase in force and duration of apical
pulse (you feel lifting sensation under your fingers).
Palpation of pulse at base of the heart (putting your hand at
second left intercostal spaces at sternal borders).

Percussion: “not used in cardiac assessment”

Auscultation:
All heart sounds are generally low pitched “low frequency” and
difficult for the human ear to hear.
Auscultation can be started from base to apex or from apex to the base.
Assess:
 Rate and rhythm of the heart beat.
Concentrates initially on sound "1", noting its intensity and variations,
possible duplication and effects of respiration.
Sound 1 caused by the closing of the tricuspid and mitral valves.
Systole begins with Sound "1" & extends to Sound "2"
Then listen to Sound "2" for same characteristics.
Sound "2": results from closing of the aortic & pulmonary valves
Diastole begins with Sound "2" and extends to next Sound "1"
Sound "2" louder than Sound "1" at the base of heart, and is lighter
than Sound "1" at the apex.
Finally listen for extra sounds and for murmurs
Sound "3": During diastole, rapid filling and distention of
ventricles occur causes vibrations of ventricular walls"
and this known as sound "3" ". Sound "3" best heard at
the apex with bell of stethoscope. Its indicate
Pathological alterations in ventricular filling in early
diastole. it represents a normal finding in children
Sound "4": occur after Sound "3" (late diastolic filling),
occur from vibrations of ventricular wall or vibrations of
the valves. It’s usually associated with cardiac disease,
often that with altered ventricular compliance
Gallop Sound: a gallop characterized by the
superimposition of abnormal third and fourth heart
sounds, usually indicative of myocardial disease.
 Heart murmurs (abnormal sounds produced by
vibrations within the heart or in the walls of large
vessels “during systole or diastole”.
Murmurs occurrence result from valve defects,
changes in the blood vessels or an increased flow of
blood through a normal structure (eg, with fever,
pregnancy, hyperthyroidism).

Special maneuvers for vascular assessment

Check for deep phlebitis by quickly squeezing calf
muscles against tibia (normally no pain)
Check Homan's sign by extending leg and dorsi-
flexing foot (normally no pain).
229
 Arterial and venous insufficiency of lower extremities

230
 Chapter (14)
Assessment of the abdomen

Islamic University of Gaza Strip

Assessment of the abdomen
The abdomen is the largest body
cavity that extends from the
diaphragm inferiorly to the inlet
of the true pelvis. Its contents
are partially protected:
Superiorly by the lower ribs.
 Posterior by the lumbar
vertebra.
Laterally by the iliac bones

Abdomen Regions
Divisions of the abdomen
Four Quadrants.
Nine regions.
Locating Abdominal Structure By Quadrant
1. Right Upper Quadrant (RUQ)
Ascending and transverse colon
Duodenum Gallbladder
Liver , head of pancreas Right of adrenal gland
The small intestine or ileum in all quadrant
Right kidney (upper pole) and right ureter

2. Right Lower Quadrant (RLQ)

Appendix
Ascending colon , Cecum
Right kidney lower pole
Right ovary and tube, right ureter, and right spermatic cord
233
3. Left Upper Quadrant (LUQ) contains of:
Left of adrenal gland
Left kidney (upper pole)
Left ureter Pancreas (body and tail)
Spleen Stomach
Transverse ascending colon

4. Left Lower Quadrant (LLQ) contains of:

Left kidney (lower pole)
Left ovary and tube
Left spermatic cord
Sigmoid colon
5. Midline
Balder , Uterus , Prostate gland
Assessment Procedures
Subjective data: ask the client about:
 Nutritional history: appetite, weight loss or gain.
 Gastro intestinal symptoms: dysphagia, nausea, vomiting, and indigestion.
 Bowel habits: pattern, and stool characteristics.
 Pain: location, quality, pattern, and relationship to ingestion of food.
 Use of medications: Aspirin, Anti inflammatory drugs, and steroids.
 Gastro intestinal diagnostic tests and surgeries.
 The client is placed in the supine position, with small pillows under the
head and knees.
 The abdomen is exposed from the breast to the symphysis pubis
 Start assessment with inspection, auscultation, then percussion and
palpation.
 Stand the client right side and carry out assessment systematically,
beginning with the left upper quadrant. The bladder should be empty.
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Inspection:
 Under source of light you see exactly changes in contours.
 Assess the presence or absence of symmetry, distention, masses, visible
peristaltic waves and respiratory movement.
 Inspect the abdominal skin for pigmentation e.g. jaundice, lesions,
striae scars, dehydration, general nutritional status and condition of
umbilicus, this give information about general state health
 Contour of the normal abdomen is described as: flat, rounded, or
scaphoid. Normally contour is description of the profile line from the
rib margin to the pubic bone.
 Flat contour seen in the muscularly competent and well nourished
individual.
 Rounded abdomen: Normally in infant and toddler, but in the adult
caused by poor muscle tone and excessive Subcutaneous fat deposition.
 Scaphoid contour “Concave in horizontal line” seen in thin clients of all
ages.
 Inspect for respiratory movements especially for retraction of the
abdominal wall on inspiration which is called "Czerny's sign
“associated with some Central Nervous System diseases such as
chorea”
Auscultation:
Auscultate peristaltic sounds which are normally high pitched.
Listen for at least "5" minutes before concluding that no bowel
sounds are present. "Peristaltic sounds may be quite irregular".
Duration of single sound may be less than a second or more than
it.
Stimulation of peristalsis may be achieved by flicking the
abdominal wall with a finger “direct percussion
Auscultate vascular sounds: Loud bruits detected over the aorta
may indicate presence of an aneurysm; the aorta is auscultated
superior to the umbilicus
Listen for Peritoneal friction rub over the area of liver and spleen
e.g. spleen infection, abscess or tumor: best heard over the lower
rib cage in the anterior axillary line. (rough grating sound like
sound of two pieces of leather being rubbed together).
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Percussion:
To detecting fluid or gaseous distention and masses and assessing
solid structures within the abdomen.
Percussion of one for each quadrant to assess areas of tympany
and dullness. Potentially painful areas are always Percuss last
Percussion allows you to identity borders of the liver to detect
organ enlargement.
To detect liver size, start percussion at the right iliac crest and
proceeds up ward on the right mid-clavicular line, when dullness
occur this is the lower border of the liver.
To detect upper border of the liver percuss, down from the nipple
along mid-clavicular line, then dullness occur “upper border” may
be found in (5,6,7) intercostals space, distance between points
lower and upper is (6-12cm). Diseases e.g. cirrhosis, cancer, and
hepatitis cause liver enlargement

Stomach position:
With percussion you can locate the tympanic air bubble of the
stomach by percussing over the left lower anterior rib cage.
Kidney Tenderness:
 In sitting or erect position, use direct or indirect percussion to assess
for kidney inflammation.
 Use ulnar surface of the partially closed fist and percuss the costo-
vertebral angle at the scapular line.
 If the kidneys are inflamed, client feels tenderness during percussion

Palpation:
 Detect abdominal tenderness and noting the quality of abnormal
distensions or masses.
 During palpation assess for muscular resistance, distention,
tenderness and superficial organs or masses.
 Assess for distended bladder if client has inability to void (Bladder
lies normally below the umbilicus and above symphysis pubis).
 In deep palpation depress hands (2.5-7.5 cm), "1-3 inch" Deep
palpation never used over a surgical incision or tender organs, or
masses.
 If tenderness present, check for rebound tenderness, if it was positive
indicated peritoneal irritation e.g. appendicitis
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Palpation of liver:
Right upper quadrant under the rib cage
Place your left hand under client’s posterior thorax at the 11 th
and 12th ribs and by your right hand palpate in and up to feel
the liver’s edge as the client inhales.
G.B normally not felt and if distended it felt under liver and
may indicate cholecystitis.
Palpation of spleen:
Generally not palpable in normal adult person, but in case of
spleen enlargement you can palpate it below costal margin.

240
Assessment of the anus and recto sigmoid region
 Events required rectal examination:
 Abdominal pain
 Alternation in bowel habits.
 Anal pain, anal spasm.
 Anal itching or burning.
 Black tary stool.
 Rectal bleeding.
 Positions for rectal examinations:
 Left lateral or SEM's position.
 Knee- chest position
 Standing position, most common use for prostate gland examination.
 Lithotomy position
 Squatting position.
 In all positions, before examination wear two gloves
Inspection:
 Spread buttocks carefully with both hands to examine the anus and
skin around it which is more pigmented, moist, and hairless.
 Assess lesions, scars, or inflammation, peri-rectal abscess, fissures,
piles, fistula opening, tumor and rectal prolapsed.
 Ask the client to strain down ward as in defecation.
 Inspect for pilonidal sinus or cyst at the sacro- coccygeal area, and
give description

Palpation: (PR examination)

 Spread the buttocks apart with your non dominant hand. Gloved
index gently placed against the anal verge, and with firm pressure
in direction of umbilicus as the rectal sphincter relaxes. Ask client
to lighten the sphincter around your finger to examine muscle
strength.
 Mucosa of the anal canal is palpated for tumor or polyps.
 Assess normal cervix in female which felt as small round mass
during P.R examination
242
Common diseases can be detected during rectal examination:
Pilonidal cyst or sinus.
Pruritus anus
Rectal tenesmus:.
Fecal impaction
Anal fissure
Fistula in anus
Hemorrhoids: External painful & internal painless unless
complicated.
Rectal polyps
Rectal prolapse: e.g. in case of internal hemorrhoids
Anal incontinence.
Abscesses or masses e.g. Ischio rectal abscess, peri rectal
obstruction
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 Chapter (15)
Assessment of musculo-skeletal system

Islamic University of Gaza Strip

 The primary structures of the musculoskeletal system are the
bones, muscles, cartilage, ligaments, tendons and joints.
 The bony skeleton provides a sturdy framework to support body
structures. The bone matrix stores calcium, phosphorus,
magnesium and fluoride.
 In addition, the red bone marrow located within bone cavities
produces red and white blood cells in a process of hematopoiesis.
 There are 206 bones in the human body, divided into four
categories.
 Long bones (eg, femur)
 Short bones (eg, metacarpals)
 Flat bones (eg, sternum)
 Irregular bones (eg, vertebrae)
 Assessments are made of muscles, bones and joints. When
assessing the musculoskeletal system keep in mind that injury or
inflammation of any part of the system can cause pain, stiffness, or
an alteration in motor strength or mobility.
245
 Musculoskeletal assessment is conducted from head to toe
with inspection and palpation
Assessment of musculo-skeletal system done firstly when the
client walks, moves in bed or performs any type of physical
activity.
The nurse usually assesses the musculoskeletal system for:
Muscle – size, contractures, tremors, muscle tonicity,
smoothness of movement and muscle strength.
Bones – skeletal structure, tenderness, edema
Joints – swelling, tenderness, smoothness of movement,
crepitation, nodules, range of motion.

246
Terms used to describe joint movement:
Flexion – bend that decrease angle between bones
Extension – straightening a limb to increase the angle of joint
Abduction – moving a limb away from the body’s midline
Adduction – moving a limb towards the body or beyond it
Internal rotation – turning a body part towards midline
External rotation – turning a body part away from midline
Circumduction – circular movement of a body part
Supination – turning the palm upwards
Pronation – turning the palm downwards
Inversion – turning the hand or foot inward
Eversion – turning the hand or foot outward

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Musculoskeletal Assessment
Subjective data:
Observer gait and posture as client walks into room. Normally
the client walks with arms swinging freely at sides and the
head and the face leading the body.
Pain: assess pain at rest, with exercise, changes in shape or
size of an extremity, changes in mobility to carry out activities
of daily living, sports, and works.
Stiffness of joint
Decreased or altered or absent sensations.
Redness or swelling of joints.
History of fractures and orthopedic surgery.
Occupational history

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Objective data
 Determine range of motion, muscle strength and tone, joint and
muscle condition.
 Muscle problems commonly are manifestations of neurological
disease, so you must do neurological assessment simultaneously.
 Joints vary in their degree of mobility, range from freely movable
e.g. knee, to slightly movable joints e.g. the spinal vertebra.
 During assessment of muscle groups: assess muscle weakness, or
swelling, and size, then compare between sides. Joints should not
be forced into painful positions.
 Loss of height is frequently the first clinical sign of osteoporosis.
Small amount of height loss expected with aging.
 Ask client to put each joint through its full range of motion, if there
is weakness, gently supporting & moving extremities through their
Range of motion, to assess abnormalities.
 Normal joints are non tender, without swelling and move freely.
 In elderly joints often become swollen & stiff, with reduced range
of motion, resulting from cartilage erosion and fibrosis of synovial
membranes
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 Chapter (16)
Assessment of Neurological system

Islamic University of Gaza Strip

Assess this system when doing physical examination e.g. cranial
nerve function can be testing during the survey of the head and
neck.
The neurological assessment consists of six parts: (mental status,
cranial nerves, sensory functions, motor function, cerebellar
function, reflexes).
Subjective data:
Loss of consciousness, dizziness, and fainting.
Headache: precipitating factors and duration.
Numbness and tingling or paralysis or neuralgia.
Loss of memory, confusion, visual loss, blurring, and pain.
Facial pain, weakness, twitching, speech problems e.g. aphasia.
Swallowing problems and drooling.

251 Neck weakness or spasm


Mental and emotional
Mental and emotional status is observed as the nursing history
is collected, and by simply interacting with client, e.g.
“Nursing care plan”
Level of consciousness
Level of consciousness ranges from full a wakening,
“alertness” to unresponsiveness to any form of external
stimuli.
Alert client responds to questions spontaneously.
Assess level of consciousness by using Glasgow coma scale

252
 Glasgow coma scale

253
 Assessment of behavior and Appearance
 Behavior, mood, hygiene, grooming and choice of dress reveal
pertinent information about client’s mental status.
 Appearance reflects how a client feels about the self.
 Personal hygiene such as unkempt hair, a dirty body, or broken, dirty
fingernails should be noted.
 Language: Assess ability of individual to understand spoken or
written words & how he speak or writes.
 Assess intellectual function, which includes: memory “recent,
immediate, past”, knowledge, abstract thinking, association and
judgment.
Assess for sensory function:
 Assess sensitivity to light touch “cotton”
 Assess sensitivity to pain “pinprick”
 Assess sensitivity to vibrations “tuning fork”
 Assess sensitivity to positions.
254 Don’t forget comparing both sides of body

 Chapter (17)
Assessment of Urinary System

Islamic University of Gaza Strip

 The main function of urinary system is regulation of the fluid and
electrolytes composition of the body fluids and removal of metabolic
end products from the blood
Nursing History:
 Normal voiding pattern and frequency (oliguria – urinary urgency –
poyluria – anuria - dysuria –hematuria - enuresis)
 Appearance of the urine, urine culture and any recent changes
(amount – color). Normal colure yellow-straw
 Family history of kidney problems (polycystic kidney and all types of
hereditary nephritis are genetically transmitted, kidney and bladder
calculi
 The present illness such as pain or burning sensation, UTI, an ostomy.
 Past history and current problems with urination: (syphilis, gonorrhea,
sexual transmitted disease STD) DM and HTN .
 Factors influencing the elimination pattern

256 Medications: Diuretics, Psychotropic agents , Anti-hypertensive


 Medical Terms related to urinary system
Dysuria: painful or difficult voiding
Hematuria: red blood cells in the urine
Urgency: strong desired to urinate due to inflammation in
bladder , prostate , urethra
Polyuria: abnormal large volume of urine voided in given
time = 2500ml
Oliguria: small volume of urine between 100-500 ml
Anuria: absence of urine in bladder less than 50 ml
Enuresis: involuntary voiding during sleeping.

257
Physical Assessment of Urinary System
 Inspection
 Inspection including examination of abdomen and urethral meatus.
 Auscultation including renal arteries
 Percussion includes the kidneys to detect tenderness
 Palpation to detect any mass, lumps, tenderness
Percussion of the kidney
 To detect areas of tenderness by costovertebral test, normally will
feel a thudding sensation or pressure but not tenderness
Palpation of kidney
 Contour, size, tenderness, and lump.
 In adult normal the kidneys not be palpable because of their
location deep with abnormal.
 Elderly the right kidney is slightly lower than the left, it may be
easier to palpate
258
Percussion of the bladder
 Percuss the area over the bladder (5cm) above the symphysis pubis.
 To detect difference in sound, percuss toward the base of the bladder.
 Percussion normally produces a tympanic sound
Palpation of bladder
 Normally feel firm and smooth.
 In adult bladdre may not be palpable
Inspection of the urethral meatus
 Look for swelling, discharge and inflammation
Assessment of Urine
 Urine assessment includes:
 Measure volume of urine
 Inspect colour, clarity, and volume
 Test the specific gravity, glucose, ketone bodies and blood and pH
 Normal urine volume 1-2 litter per 24 hours (normal adult)

259
Color: typically yellow-straw but varies according to recent diet
and concentration of the urine. Drinking more water generally
tends to reduce the concentration of the urine and therefore
cause it to have a lighter color. (The converse is also true.)
Smell: Generally fresh urine has a mild smell but aged urine has
a stronger odor, similar to that of ammonia.
The smell urine may provide health information. For example,
urine of diabetics may have a sweet or fruity odor due to the
presence of ketones.
Acidity: PH is a measure of the acidity ( or alkalinity0 of a
solution. PH is a measure of the activity of hydrogen ions (H+)
in a solution
95% Water, 5% chemical solutes. Urea from breakdown of
amino acids (protein) to give ammonia + C02 giving urea and
creatinine from breakdown of creatine phosphate in muscle

260
Collection of urine samples
 All urine tests are ideally performed on fresh specimemens:
 Urine container has been adequate protection agonist bacterial
contamination and chemical deterioration
 Identification or labeled should be provided.
 The patient should then be gowned for the physical examination
 Bring it into the dry room
 Urine specimens should collect from the patient means of the clean
–catch midstream technique.
 All specimens should be refrigerated as soon as possible they are
obtained . to avoid shifted the PH of urine to alkaline because
contamination of urea- splitting bacteria from the environment
Consider the Developmental Stages
 Pediatric: difficulties, crying, change in urinary in childhood).
 Pregnant: Pain during urination, normal increase urine in volume
and frequency and decrease urine specific gravity
 Elderly: how much and how type of liquid do you drink in the
evening? do you ever lose of control of your bladder
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 The End

262